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DAILY / MAY 22, 2019  
Psychiatric News Update
 

Panelists Discuss Difficult ECT Questions, From Patient Selection to Treatment Completion

Keith Rasmussen
A middle-aged woman with a history of depressive behaviors and borderline personality traits walks into her psychiatrist’s office and requests electroconvulsive therapy (ECT). What should the psychiatrist do? This scenario and many others were discussed as part of an interactive session that explored the diagnostic criteria to identify patients who are suitable ECT candidates. The Wednesday session was led by members of the Mayo Clinic’s psychiatry faculty.

The scenarios covered many aspects of ECT practice: patient selection, informed consent, anesthesiology considerations, electrode placement, whether to taper/discontinue medications, and the transition from acute care to maintenance ECT.

“There are a lot of considerations, but I think patient selection is the hardest part of the process,” said Keith Rasmussen, M.D., who led the discussion with Simon Kung, M.D., and Teresa Rummans, M.D. Rasmussen highlighted the four core disorders in which an ECT decision is easy: catatonia, delirious mania, an acute schizophrenia exacerbation, and psychotic depression. Beyond that, the broad range of depressive criteria and the interaction of depression with other illnesses poses many challenges, even in suicidal patients.

“Over the years, lore has been passed down that ECT helps prevent suicide,” Rasmussen said. “But not all suicidality is created equal.” Many patients who may initially appear to have major depressive disorder might have adjustment disorder with depressed features or borderline personality disorder, for which ECT may not work.

A further consideration is the eagerness of patients. As was pointed out, the woman in the case study noted above requested ECT prior to any discussion with the psychiatrist. “Patients who request this therapy often have strong expectations for how it will work,” Rasmussen said, which could be troublesome if it doesn’t. Also, some eager patients have a somatization syndrome and just want to be treated for the sake of treatment.

Once the process gets under way, the decisions tend to be more manageable—if still very debatable. There was much lively discussion about whether ECT electrodes should be placed on one side (unilateral) or both sides (bilateral) of the head. Rasmussen noted that extensive research to date still reports that unilateral and bilateral are equally effective at alleviating depressive symptoms, though bilateral is far more popular despite the slightly higher risk of memory loss.

Rasmussen, who acknowledged he is a strong believer in bilateral treatments, suggested that rating scale scores used in research studies do not capture all the nuances of depression recovery and that patients in research trials do not bear similarity to those seen in real-world clinics. “However, if a patient was fully cognizant and expressed specific concerns about memory impairment, then I would go with the unilateral,” he said.

The session finished with a flourish, as the last case study included another well-debated topic: the use of lithium during and after ECT treatment for patients already on lithium. Studies have suggested that lithium can increase risks of confusion and delirium when taken alongside ECT, though taking patients off lithium may switch them to mania during the course of treatment. The room was evenly split between continue, discontinue, or continue at a reduced dose, which highlights how difficult a decision this can be.

For his part, Rasmussen believes that patients with bipolar disorder should be on some type of mood stabilizer during ECT and patients already on lithium can remain on maintenance treatment. Patients who are not in need of immediate care can be switched to another medication before starting ECT, but since many of the patients he treats with ECT are seriously ill or potentially suicidal, waiting is not an option.

Once acute ECT sessions are completed, lithium augmented with an antidepressant has been shown to help prevent relapse in patients with unipolar depression—the data are strong in this regard. But there are few post-ECT data on lithium, so for patients with bipolar depression who were taking another mood stabilizer while undergoing ECT, there is no compelling evidence to switch them to another mood stabilizer, said Rasmussen.

(Image: David Hathcox)

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