What used to be called infelicitously “electroshock” therapy continues to be a highly effective treatment for severe endogenous depression and can also be used to interrupt manic episodes. The technique is relatively simple and, in properly supervised clinics, quite safe. The patient is anesthetized by an intravenous injection of a short-acting barbiturate, benzodiazepine, or propofol, and is also medicated with a muscle relaxant (succinylcholine). In the conventional method, an electrode is placed over each temple and a current of about 400 mA and 70 to 120 V is passed between them for 0.1 to 0.5 s. The machine itself has as the essential element a large capacitor that is discharged to produce an electrographic seizure. The succinylcholine prevents strong and injurious muscle spasms. The patient is awake within 5 to 10 min and is up and about in 30 min. The mechanism by which ECT produces its effects is unknown. Treatments are usually given every other day for 6 to 14 sessions. The only absolute contraindication is the presence of increased intracranial pressure, as may occur with a neoplasm or intracranial hematoma. Whether epilepsy is precipitated or worsened by ECT is still debated but the presence of epilepsy is generally considered a contraindication. This treatment should also be used cautiously in the presence of uncontrolled systemic hypertension or with a known sensitivity to the anesthetic agents that are used as premedication.
The major drawback of ECT is the production of a transient impairment of recent memory for the period of treatment and for the days that follow, the degree of impairment related to the number of treatments given. Placing both electrodes on the nondominant side (unilateral ECT) or using lower amounts of current and a briefer pulse rather than a sine wave produces less memory disturbance and has been adopted because it is almost as effective against the depression.
With the recognition that transcranial magnetic motor stimulation sometimes produced an elevation of mood, its use as a substitute for ECT is being introduced. The magnetic technique has the advantage of being free of any but minor physical effects, and because it produces no loss of consciousness, anesthesia and neuromuscular paralysis are not needed. Brief pulses of high-frequency stimuli are used. Few controlled studies have as yet been performed and this technique could conceivably replace ECT, but the initial sense is that it is not as effective against severe or prolonged depressions and probably not at all for catatonia. Related methods, such as direct current stimulation of the cortex have met with mixed but generally negative results (Brunoni et al).
Until the advent of the antidepressant drugs, ECT was the treatment of choice for the agitated depression of middle and late life and for catatonia. Following a course of 6 to 14 treatments, close to 90 percent of patients recovered within 2 months or less. Prior to the use of ECT, this type of depression might last for 2 years or longer before remission or suicide occurred. In cases of catatonia or severe psychotic depression most psychiatrists favor the initial use of one of the newer antipsychosis agents, followed by a trial of an antidepressant before resorting to ECT. Following ECT therapy, maintenance therapy with an antidepressant or lithium is necessary to prevent relapse. Deep brain stimulation is under study for refractory depression.
Treatment of Bipolar Disease