Electroconvulsive Therapy: Case Examples

Case 1
Ms. A, a 48-year-old right-handed woman, was referred for evaluation for a refractory major depressive episode. The present episode of illness, which had begun 6 months previously after the death of Ms. A’s father, was characterized by a pervasive sadness; a lack of interest in nearly everything; anorexia, with resultant weight loss (20 pounds over the previous 3 months, from an original weight of 130); difficulty staying asleep; and decreased libido. Ms. A stated that she would be better off dead. Her attending psychiatrist attempted trials of imipramine, fluoxetine, and a combination of fluoxetine and lithium. Each trial lasted more than 5 weeks, but none was associated with any more than a mild transient improvement. The psychiatrist also saw Ms. A weekly for insight-oriented psychotherapy but found that she “was too depressed to focus” on what he was saying. There was a history of several previous episodes with similar presentations, but these had responded to antidepressant medications. The initial diagnosis on evaluation was a severe major depressive disorder with melancholic features.

Treatment alternatives consisted of another medication trial or ECT. These choices were discussed in detail with Ms. A and her husband, and the couple agreed that ECT would be preferable “because these drugs just don’t seem to work anymore.” The pre-ECT evaluation was benign, and Ms. A was begun on a course of RUL ECT at a rate of three treatments per week on an outpatient basis. She tolerated the procedure well, without adverse effects, and after three treatments began to show more interest in her family and also reported improvement in her sleep and appetite. After seven treatments Ms. A was clearly back to her premorbid status, and the ECT was stopped. She was then given paroxetine and valproate, neither of which she had taken previously, and was referred back to her regular attending psychiatrist. After 6 months she was still asymptomatic.

Case 2
Mr. B, a 72-year-old right-handed man, was being treated for a major depressive episode. He was transferred from the inpatient service of a freestanding psychiatric hospital because of serious medical comorbidity (severe coronary artery disease) and deterioration in his overall condition. Mr. B had been well until 3 months before admission. At the time of his transfer, his psychiatric presentation was characterized by intense dysphoria, inability or unwillingness to answer questions, severe motor retardation, a belief that he had committed terrible deeds and should be punished, and refusal to eat. Although he had been hospitalized in the initial facility for a week, no antidepressant medications had been initiated because of the staff’s concern about his medical condition. Medically, Mr. B’s coronary artery disease was characterized by angina on exertion, which required standing doses of antianginal medication, and a cardiac ejection fraction of 30% (indicating a severe level of dysfunction). The preliminary diagnosis was major depression with psychotic features.

Because of the gravity of Mr. B’s presentation, a referral for ECT on a primary basis was indicated. Although a cardiology consultation corroborated the level of cardiac dysfunction, the consultant also agreed that Mr. B’s mental condition represented an even greater risk than proceeding with ECT. Mr. B was not able to follow a discussion on ECT by the attending psychiatrist and indicated that he did not want treatment or food because he deserved to die. He was not believed to have the capacity for providing informed consent, and a guardianship procedure was begun. Mr. B’s son was appointed guardian and provided surrogate informed consent.

Mr. B received his routine antianginal agent 2 hours before ECT and was further premedicated with labetalol 5 mg iv, given 2 minutes before anesthesia induction. Because of the urgent need for a rapid response, he was administered BL ECT at a rate of three treatments per week. Mr. B tolerated the procedure well, except for some transient premature ventricular contractions lasting 2 minutes postictally. These contractions were prevented during successive treatments by an increase in the labetalol dose. After three treatments, a clear improvement in Mr. B’s symptoms was noted, along with some confusion lasting between treatments. Decreasing the rate of treatments to two per week allowed continued improvement with only mild levels of confusion and amnesia. After a total of six treatments Mr. B was back to his premorbid state. His son described Mr. B’s response as “being brought back from the dead.” Mr. B was given nortriptyline on discharge from the hospital. He remained well at 1-year follow-up.

Case 3
Ms. C was a 58-year-old right-handed woman with a long history of recurrent major depression. After numerous unsuccessful trials of various antidepressant medications, both alone and in combination, her prior three episodes had led to referrals for BL ECT. These courses of treatment were associated with a marked improvement and were well tolerated except that the patient experienced a moderate transient memory impairment. After each course of ECT, the last one of which ended 5 months previously, she was given continuation pharmacotherapy, which was of only transient benefit. No medical risks were present on pre-ECT evaluation during the last of the three episodes.

Because of her recent history of good response but memory disturbance with prior ECT, Ms. C was referred for a course of RUL ECT treatments to reduce the risk of cumulative cognitive morbidity. However, little therapeutic response was evident after the sixth treatment, in contrast to what had been observed during her previous BL ECT courses. She was switched to BL ECT and began to show improvement after two further treatments. During the tenth treatment it was noted that Ms. C’s EEG seizure duration had fallen to 22 seconds, despite the use of maximum electrical stimulation. Beginning at the eleventh treatment, her anesthetic agent was switched from methohexital to ketamine, which was associated with a 100% increase in seizure duration. Ms. C continued to improve and reached a therapeutic plateau after a total of 13 treatments.

Because of her history of rapid relapse, Ms. C was referred for continuation ECT, for which she provided informed consent. Treatments were begun at the rate of one per week for 4 weeks, followed by one every 2 weeks for an additional 4 weeks, one per 3 weeks for the next 6 weeks, and then monthly. Throughout this period, Ms. C remained in clinical remission without adverse effects. After 12 months on continuation ECT, the treatments were stopped, with close follow-up maintained. At her most recent visit, 6 months later, at which time Ms. C was still taking no psychotropic medications, she was still noted to be euthymic.

Case 4
Mr. D was a 42-year-old right-handed man with a history of recurrent manic episodes. His most recent episode, characterized by delusions of grandeur, racing thoughts, flight of ideas, and driving at excessive speeds, was unresponsive to a combination of lithium, carbamazepine, and haloperidol. Because of the severity of the presentation and the lack of response to medication, Mr. D was referred for a course of BL ECT, to which he provided informed consent. No medical risks were present. The lithium was stopped, the carbamazepine was withdrawn over a period of a week, and the haloperidol dose was reduced. Mr. D received a total of eight BL ECT treatments, following which he was in clinical remission. He was discharged from the hospital and was given a combination of lithium and sodium valproate. When last seen, 8 months later, he remained euthymic.

Conclusions
ECT is the most effective treatment available for severe episodes of major depression and mania. In most cases it is well tolerated and is not associated with significant adverse effects. After a decline of many years, the utilization rate for ECT appears to have leveled out, possibly because of the growing acceptance of a treatment that has undergone considerable methodological improvement over time. Recently, there has been an increased interest in the use of C/M ECT, as concern about the failure of medication prophylaxis in medication nonresponders has mounted. Given this situation, it is likely that ECT will continue to play a significant role in psychiatric practice for years to come.

References