Clinical Pearls & Morning Reports
Electroconvulsive therapy (ECT) has been an essential treatment for severe mood and psychotic disorders for many decades, and its use is supported by evidence of efficacy and safety. The duration of benefit from ECT varies across patients. Read the NEJM Review Article here.
Q: Are novel treatments for depression replacing ECT at this time?
A: Over the past 15 years, new treatments — for example, vagus-nerve stimulation, transcranial magnetic stimulation, and intranasal administration of esketamine — have been approved for use in depression. Trials comparing new treatments directly with ECT have been inadequate, and none of these approaches have been considered a replacement for ECT in severely depressed and certain psychotic patients.
Q: Is the use of ECT widespread?
A: A study has shown that ECT has been underused. Furthermore, ECT is less accessible to uninsured or underinsured patients and those receiving care in public hospitals than to other patient populations, it has been underused in some large health care systems, it has been limited to inpatient settings, and it is less accessible to minority racial or ethnic groups than to other groups. Stigma and lack of knowledge have constrained the use and acceptance of ECT.
A: In 2018, the Food and Drug Administration (FDA) reclassified ECT devices from class III (high risk) to class II (moderate risk, requiring special controls) for use in the treatment of severe major unipolar or bipolar depressive episodes or catatonia in persons 13 years of age or older, whose disorder is “treatment resistant or who require a rapid response due to the severity of their psychiatric or medical condition.” These stipulations are analogous to the “on label” uses of drugs. The FDA did not define the terms “severe” and “treatment resistant” and did not specify the circumstances under which a rapid response might be required. The FDA also did not rule on other uses of ECT in practice, leaving them to clinical judgment. ECT has been tested for other conditions, including bipolar disorder (manic or mixed states), schizophrenia, and Parkinson’s disease, according to narrative reviews and meta-analyses. There have been reports of uncontrolled, off-label use of ECT for the treatment of self-injurious behaviors due to autism, behavioral and psychological symptoms of dementia, and status epilepticus. However, these reports are preliminary. The use of ECT in patients with these conditions cannot be endorsed at this time because the evidence base remains too small.
A: The estimated mortality with ECT is approximately 2.1 deaths per 100,000 treatments. The most frequent complications are acute cardiopulmonary events, which have been estimated to occur in less than 1% of treatments. Serious adverse events associated with ECT, which are rare, include cardiac arrhythmias with or without hemodynamic changes, respiratory distress, prolonged apnea, aspiration, prolonged paralysis, and prolonged seizures. Common but minor side effects include headache, jaw soreness, myalgias, postprocedure nausea and vomiting, and fatigue, all of which are self-limited or require only symptomatic treatment. Patient, provider, and public concerns about cognitive impairment remain obstacles to the use of ECT. The contemporary practice of ECT results in fewer cognitive side effects than treatments in the past. Cognitive effects vary among patients and ECT techniques. It has not been possible to predict how an individual patient may be affected, but most patients have mild or moderate cognitive side effects, which usually resolve within days to weeks after the completion of the ECT course. In rare cases, an acute confusional state or delirium develops, requiring interruption or cessation of the treatment course.