Treatment of Mood Disorders: Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is an often-used modality in the treatment of mood disorders with comorbid medical problems. ECT generally has been reserved for patients in whom adequate trials of pharmacological agents have not been successful or in those in whom a quick clinical response is necessary because of the severity of the mood symptoms. Concern for the safety of ECT in the elderly and medically ill, specifically for fear of adverse cardiac effects, has in the past limited its use. Previous studies have shown mortality of ECT to be approximately two deaths per 100,000 treatments. Despite this evidence, concerns for the safety of cardiac patients and other fragile, medically ill patients persist. Although absolute contraindications do not exist, a complete pre-ECT evaluation has been shown to reduce serious complications. Several other studies have shown that neither low left ventricular ejection fraction nor valvular heart disease is a contraindication in treatment of depression with ECT. A complete medical evaluation of those patients of whom there are concerns for significant coronary disease or potential for ischemic events can markedly reduce any complications. This would include stress testing when clinically indicated and often a 3-month waiting period for patients post MI. This waiting period is essentially a recommendation and in cases of severe depression may be reduced.

Electrically induced seizures are associated with increases in both parasympathetic and sympathetic tone, which induce marked, though transient, changes in cardiac output, pulse, blood pressure, and a variety of generally brief disturbances in cardiac rhythm. Cardiac monitoring during the ECT procedure is highly recommended in all patients, but especially in those patients considered at high risk. For patients found to have significant sympathetic response leading to cardiac irritability, β-blockade with newer more cardioselective agents such as labetalol has helped to reduce this response. A framework of relative contraindications determines eligible candidates. Patients at high risk of cardiac complication include those with severe or unstable symptoms of active coronary heart disease. Other relative contraindications include unstable vascular aneurysm, recent intracerebral hemorrhage, evolving retinal detachment, pheochromocytoma, or other situations with high anesthesia risk. Close monitoring of an electrocardiogram and vital signs during and after treatment may be all that is required for the safe treatment of depression in these patients.