Electroconvulsive Therapy: Indications
General Issues
When Is ECT Indicated?

Indications for any treatment are governed by two types of considerations: the presence of an episode of a disorder for which the treatment has demonstrated efficacy, and the circumstances during such an episode when the treatment should be used. The second, more generic, type of consideration will be dealt with first.

A referral to ECT can be made on either a primary or a secondary basis. In the first case, the choice is made because of the existence of any of the following criteria: 1) there is an urgent need (either psychiatrically or medically) for a rapid response; 2) treatment alternatives are associated with a higher risk than is ECT; 3) there is a history of preferential response to ECT; or 4) the patient has expressed a preference for ECT.

Most patients, however, will be referred for ECT on a secondary basis, using the following criteria: 1) lack of adequate response or demonstrated intolerance to treatment alternatives, or 2) deterioration of the patient’s condition to the point at which criteria for primary use are met. A critical issue here is how treatment resistance is determined. In general, it is best to make this decision on an individual basis, taking factors such as symptom severity, level of functional impairment, and risks into account in addition to the number, duration, type, and dosage of prior drug trial.

Does ECT Produce a Cure?
When successful, a course of ECT induces a remission in an episode of illness; it does not in itself produce a “cure,” any more than does a course of antidepressant, antimanic, or antipsychotic medication that is stopped once remission has occurred. For most patients referred for ECT, a high risk of relapse or recurrence exists, particularly during the first year, and careful attention to continuation or maintenance therapy, using psychotropic medication or ECT, is an essential component of the overall treatment plan.

What Is the Role of ECT in Treatment of Children and Adolescents?

Although there is no relationship between diagnostic indications and patient age, in general ECT is rarely used in children and uncommonly used in adolescents, and in these groups it is used only when medication resistance has been clearly established. The use of ECT in these age groups has been so low in recent decades that the contemporary literature, particularly for prepubescent patients, consists primarily of anecdotal reports of its use as a last resort.

This situation, which may reflect a relative underutilization, appears to be due to a number of factors, including general reluctance to use “drastic measures” in such patients, concern about increased potential for adverse cerebral effects in this age group (although there are no clinical data to support this contention), lower incidence of applicable disorders in this population, and, in some states, regulations preventing use of ECT in patients below a certain age (e.g., at the time of this writing, age 16 in Texas). Fully informed consent may also be problematic with children and adolescents, and practitioners should be aware of pertinent regulations governing the age of consent for medical procedures. Because of the relative lack of experience in the field with ECT in children and adolescents, the American Psychiatric Association Committee on ECT (2000) recommendations call for second opinions from psychiatrists not otherwise involved in the case who are experienced in treating children or adolescents (one such individual for patients ages 13-17 years and two for patients age 12 or under). Guidelines for the use of ECT in adolescents have recently been proposed by the American Academy of Child and Adolescent Psychiatry.

How Is ECT Used in Treatment of the Elderly?

No one is “too old” for ECT. Although risks associated with ECT increase with age, they also do so for all viable treatment alternatives, possibly at a higher rate. Furthermore, it is important to recognize that these risks are related to concurrent medical disease and not to age itself (Weiner et al. 2000). For that matter, ECT appears to be associated with a lower mortality rate than otherwise treated elderly patients with severe depressive illness (Philibert et al. 1995). Given prevailing risk-benefit considerations and the high degree of functional impairment associated with many major depressive episodes occurring in late life, it is not surprising that elderly patients account for a greater fraction of overall ECT use than they did in the past (34% in 1986 vs. 24% in 1980) (Thompson et al. 1994). There are also reports that elderly patients are more likely to respond to ECT than are younger patients (Sackeim 1998), but these findings cannot yet be considered definitive. However, it is clear that age does have certain implications regarding ECT technique, because pharmacological agents used with the procedure are subject to age-dependent changes in tolerance and metabolism, and because seizure threshold rises with age.