Faculty Bibliography

Electroconvulsive therapy (ECT), which has been in use for 75 years, is an important treatment for severe and treatment-resistant depression. Although it is acknowledged as the most effective acute treatment for severe mood and psychotic disorders, it remains controversial because of misperceptions about its use and lack of familiarity among health care professionals about modern ECT technique. The authors present an illustrative case of a patient for whom ECT is indicated. They review the basic and clinical science related to ECT's mechanism of action and discuss clinical issues in the administration of a course of ECT, including the consent process.

Since its introduction in 1938, electroconvulsive therapy (ECT) has remained an important treatment for selected serious neuropsychiatric illnesses and continues to be one of the most effective treatments in psychiatry. ECT has evolved into a technically sophisticated procedure with a proven track record of safety. For this review, the authors relied heavily on the database from the APA Task Force Report on ECT (2001), updated with additional searches of computerized literature databases for the period 1999-2003. The review is necessarily a selective one, given the exponential growth of literature in the field. The authors attempt to summarize key areas of ECT practice, informed by relevant research findings and expert consensus when applicable. The authors also point out areas of controversy and gaps in our present knowledge. Although this review summarizes the scientific literature about the use of ECT generally, emphasis is given to describing literature pertaining to the treatment of geriatric patients when such information is available or when older patients or the disorders from which they suffer merit special consideration.

OBJECTIVE: Traditionally, it has been widely assumed that the likelihood of response to ECT is independent of the adequacy of previous treatment with antidepressant medications. However, recent research has raised the possibility that medication-resistant patients with depression have a poorer clinical ECT outcome than patients who have not failed previous adequate medication trials. METHOD: Medication resistance of 100 patients with primary, unipolar, nonpsychotic major depression was evaluated during the index episode with the Antidepressant Treatment History Form. Patients were recruited and treated with ECT at three sites; standardized ECT and clinical assessment procedures were used. Clinical outcome was assessed immediately and 1 week after completion of the ECT course. RESULTS: Patients who previously had failed one or more adequate antidepressant medication trials were less likely to respond to subsequent ECT than patients not known to be medication resistant. This finding held within each study site, whether clinical response was assessed categorically or in terms of the magnitude of symptomatic improvement and after the authors accounted for other potential predictors of clinical outcome. Resistance to heterocyclic antidepressants predicted poorer outcome after ECT, while resistance to selective serotonin reuptake inhibitors and monoamine oxidase inhibitors did not show significant predictive relations. CONCLUSIONS: While a substantial percentage of medication-resistant patients respond to ECT, clinical outcome in this group is inferior to that of patients without established medication resistance. The predictive power of medication resistance is generalizable across diverse clinical settings, particularly for heterocyclic antidepressants, which perhaps suggests an overlap in the mechanisms of actions of ECT and this medication class.

Benzodiazepines (BZD) possess anticonvulsant properties that may potentially elevate seizure threshold, inhibit seizure propagation, and alter some of the neurobehavioral effects of electroconvulsive shock (ECS) in animal models. Nevertheless, considerable controversy exists regarding the clinical impact of oral BZD use during electroconvulsive therapy (ECT). The existing literature is contradictory, and all studies attempting to address this topic suffer from important design flaws. Most studies are retrospective and some address only seizure duration. Also, studies examining treatment outcome are difficult to compare because of differing types and dosages of BZD, varied electrode placement and stimulus energy, and lack of information about the relationship of the stimulus energy to the patients' seizure thresholds. While firm conclusions must await further studies, limited data suggest that BZD have the potential to shorten seizure duration and decrease treatment efficacy, particularly with unilateral ECT.

The selection of an electroconvulsive therapy (ECT) device from the more than 10 American-made models can be a difficult endeavor. This article is meant to be a single source of basic descriptions of these ECT devices. The information provided will allow the ECT clinician to be aware of the important issues involved in the selection of an ECT device and to become familiar with the basic features of each model.

Recently, Medcraft Corporation, a well-known U.S. manufacturer of electroconvulsive therapy (ECT) equipment, introduced a new bidirectional brief-pulse model. This machine offers some features that are not currently available on most other ECT devices. In particular, the clinician determines how much stimulus energy the patient receives by setting joules, leading the duration of the electrical stimulation to vary up to 6 s, depending on the patient's dynamic impedance, and the set energy and current levels. The machine is battery powered, completely isolating it from wall current. We summarize our experience with this device, reviewing its features, safety, practicality, and cost.