Correspondence
Electroconvulsive Therapy for Depression
N Engl J Med 2008; 358:645-646February 7, 2008
- Article
To the Editor:
Lisanby (Nov. 8 issue)1 reports, in her Clinical Therapeutics article, on the use of electroconvulsive therapy (ECT) in patients with depression. ECT is rarely recommended in patients with schizophrenia (except for those with acute catatonia). In the guidelines of the German Medical Association, ECT is restricted as a treatment for patients with depression who have psychotic and suicidal symptoms.2 Modern ECT protocols for investigating the use of ECT in patients with schizophrenia are limited. To date, data are available from only 26 studies with a total of 798 such patients.3 However, it is noteworthy that short-term responses are promising, and common predictors of a response to ECT in both schizophrenic and affective disorders, such as delusions and hallucinations, have been reported. Although these observations have led to recommendations to preferentially use ECT in certain subtypes of depression, such a syndromal approach is lacking in schizophrenia. Future investigations may lead to a broadening of ECT indications to include specific subtypes of schizophrenia.
3 ReferencesMichael Dettling, M.D.
Ion Anghelescu, M.D.
Malek Bajbouj, M.D.
Charité–University Medicine Berlin, 14050 Berlin, Germany
michael.dettling@charite. de 1
Lisanby SH . Electroconvulsive therapy for depression. N Engl J Med 2007;357:1939-1944
Full Text | Web of Science | Medline2
Hoppe J-D, Scriba PC. Stellungnahme zur Elektrokrampftherapie (EKT) als psychiatrische Behandlungsmaßnahme. (Accessed January 17, 2008, at http://www.bundesaerztekammer.de/downloads/EKT.pdf.)
3
Tharyan P ,Adams CE . Electroconvulsive therapy for schizophrenia. Cochrane Database Syst Rev 2005;2:CD000076-CD000076
Medline
To the Editor:
Lisanby notes that the efficacy of ECT is affected by a variety of factors. The depth of anesthesia induced by premedication and anesthetic drugs can also influence the effectiveness of this therapy. For this reason, the electroencephalographic (EEG) bispectral index (BIS), a multivariate scale that reflects the level of anesthesia in anesthetized patients, has become an important factor that predicts seizure activity and treatment success. White et al. found that EEG BIS values obtained after induction of anesthesia (pre-ECT BIS) and at the end of ECT (post-ECT BIS) correlate with the duration of motor and EEG seizure activity in patients with glycopyrrolate and methohexital anesthesia.1 This finding has been reproduced with thiopental anesthesia.2 Sartorius et al. found a significant negative correlation between the number of ECT sessions needed to achieve full remission and pre-ECT BIS values.3 These studies support routine use of pre-ECT BIS in patients with depression who are receiving treatment with ECT.
3 ReferencesCesar Augusto Guevara-Cuellar, M.D.
Carlos Andres Pineda-Cañar, M.D.
University of Valle, 25360 Cali, Colombia
cesarguevara75@yahoo.com 1
White PF ,Rawal S ,Recart A ,Thornton L ,Litle M ,Stool L . Can the bispectral index be used to predict seizure time and awakening after electroconvulsive therapy? Anesth Analg 2003;96:1636-1639
CrossRef | Web of Science | Medline2
Ochiai R ,Yamada T ,Kiyama S ,Nakaoji T ,Takeda J . Bispectral index as an indicator of seizure inducibility in electroconvulsive therapy under thiopental anesthesia. Anesth Analg 2004;98:1030-1035
CrossRef | Web of Science | Medline3
Sartorius A ,Munoz-Canales EM ,Krumm B , et al. ECT anesthesia: the lighter the better? Pharmacopsychiatry 2006;39:201-204
CrossRef | Web of Science | Medline
To the Editor:
The electrical craniofacial stimulation and the induced seizure from ECT have clinically important cardiovascular effects1,2 not discussed in the article by Lisanby. During and immediately after application of the electrical stimulus, severe bradycardia is common, with heart rates in the 20-beats-per-minute range for a few seconds. Sinus tachycardia, with rates often greater than 120 to 140 beats per minute, becomes the typical rhythm as the seizure develops. When the seizure ends, short-lived sinus bradycardia, with rates in the 40s and 50s, is frequent. Arterial systemic blood pressure increases during the seizure, with systolic values frequently exceeding 200 mm Hg. Diastolic values are increased as well. Arterial hypertension slowly resolves over a period of 10 to 20 minutes after the ECT session. Intravenous drugs such as esmolol and propofol are often used to limit seizure-induced hypertension. These cardiovascular effects might complicate the clinical decision regarding the use of ECT in the elderly patient described in the vignette. A vigilant anesthesiologist, pre-ECT clinical selection and evaluation, intravenous access, and frequent measurements of blood pressure, in addition to the oxygen-saturation and cardiac-rhythm monitoring mentioned in the article, are essential to the safety of ECT.
2 ReferencesAndrea Torri, M.D.
Massachusetts General Hospital, Boston, MA 02114
atorri@partners.org Stephen Seiner, M.D.
McLean Hospital, Belmont, MA 024781
Welch CA ,Drop LJ . Cardiovascular effects of ECT. Convuls Ther 1989;5:35-43
Medline2
Ding Z ,White PF . Anesthesia for electroconvulsive therapy. Anesth Analg 2002;94:1351-1364
CrossRef | Web of Science | Medline
Author/Editor Response
Although this Clinical Therapeutics article focuses exclusively on the use of ECT in the treatment of major depression, Dettling and colleagues correctly point out that ECT has been used in the treatment of schizophrenia.1,2 Schizophrenia is included as a principal diagnostic indication for ECT in the report of the American Psychiatric Association's Task Force on Electroconvulsive Therapy. ECT has been reported to be helpful in the treatment of depression in the context of schizophrenia and also in the treatment of medication-resistant psychotic symptoms. Furthermore, there is a reported synergy between ECT and atypical neuroleptics in the treatment of refractory psychosis.3 This is an application of ECT that could benefit from further research to identify the clinical role of ECT in schizophrenia and develop effective strategies to maintain a benefit in the treatment of this disorder.
Guevara-Cuellar and Pineda-Cañar raise the important point that the depth of anesthesia can affect the outcome of ECT. Anesthestics that raise the seizure threshold may necessitate higher electrical dosages to ensure optimal efficacy, especially for unilateral ECT. Guevara-Cuellar and Pineda-Cañar suggest that EEG BIS may be useful in titrating the depth of anesthesia for ECT. They cite studies showing associations among BIS score, seizure duration, and outcome. Seizure duration, in isolation, is no longer considered a reliable indicator of the efficacy of ECT.1 The study4 of BIS score and outcome was an open study in which concomitant medications were not controlled. Controlled, randomized studies are needed to confirm these promising results and to determine whether approaches to monitor and adjust the depth of anesthesia may improve the outcome with ECT.
Torri and Seiner highlight the acute cardiovascular effects of ECT. Thorough medical evaluation, with special attention to cardiovascular history, is an important part of the pre-ECT evaluation.1 Frequent assessment of heart rate and blood pressure during ECT is standard to identify any potential cardiovascular complications.1 Most of the heart-rate and blood-pressure changes seen with ECT are transient and frequently do not require intervention. In addition, many centers use small doses of atropine to prevent bradycardia. Short-acting beta-blockers and calcium-channel blockers are quite effective in mitigating the peaks of heart rate and blood pressure during and after the seizure, if they become severe or prolonged. Of course, proper patient selection and careful monitoring during and after the treatment are important for optimal ECT practice, especially in treating the elderly.
4 ReferencesSarah H. Lisanby, M.D.
Columbia University College of Physicians and Surgeons, New York, NY 10032
depression@columbia.edu 1
American Psychiatric Association Committee on Electroconvulsive Therapy. The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging. 2nd ed. Washington, DC: American Psychiatric Association, 2001.
2
Tharyan P ,Adams CE . Electroconvulsive therapy for schizophrenia. Cochrane Database Syst Rev 2005;2:CD000076-CD000076
Medline3
Havaki-Kontaxaki BJ ,Ferentinos PP ,Kontaxakis VP ,Paplos KG ,Soldatos CR . Concurrent administration of clozapine and electroconvulsive therapy in clozapine-resistant schizophrenia. Clin Neuropharmacol 2006;29:52-56
CrossRef | Web of Science | Medline4
Sartorius A ,Munoz-Canales EM ,Krumm B , et al. ECT anesthesia: the lighter the better? Pharmacopsychiatry 2006;39:201-204
CrossRef | Web of Science | Medline
