When Is ECT Right for Your Patients With Depression?

Depression constitutes the most common psychopathological indication for electroconvulsive therapy (ECT). Yet selecting which patients to treat with ECT is a difficult challenge. ECT is not prescribed for every patient with depression for several reasons: It is time consuming, expensive, uncomfortable from a side-effect standpoint, and not readily available in many locales.

In this article, I will review some variables that help predict ECT outcomes and present an algorithm to assist psychiatrists in deciding which patients are candidates for ECT. Of note, this discussion pertains solely to depression and not to other conditions that can be treated with ECT, such as schizophrenia, mania, or catatonia.

Who Responds Best to ECT?

Demographic variables such as age, gender, ethnicity, and socioeconomic status are not associated with differential ECT response. A recent meta-analysis in the Journal of Clinical Psychiatry found that shorter depressive episode duration correlated with better response, arguing for earlier rather than later treatment with ECT. That and another meta-analysis in the Journal of Clinical Psychopharmacology found higher ECT response rates among patients who had responded to antidepressant treatment than for those who had been treatment refractory. However, both groups experienced good ECT response rates, so there is no reason to deny ECT to medication-refractory patients who otherwise are good candidates.

Psychotic depression is often considered an indication for first-line treatment with ECT. Patients with melancholic depression have not emerged in modern datasets as responding better than those with non-melancholic depressions. Patients with bipolar depression do not respond differentially to ECT from those with unipolar depression.

Suggested Algorithm for Depressed Patients and ECT Selection

The first step in considering ECT is to ensure that patients definitively meet the criteria for a major depressive episode. Patients whose dysphoria is better accounted for by another condition—common ones being anxiety, eating disorders, and personality disorders—should not be treated with ECT. Other conditions that on first blush may mimic major depression but do not respond to ECT include adjustment disorder with depressed mood, dysthymic disorder, and depressive disorder not otherwise specified (NOS). It is not uncommon for patients in a dysphoric crisis, even with suicidal ideations, to be admitted to a psychiatric hospital but not meet the criteria for a major depressive episode. Additionally, patients with chronic generalized anxiety, in the face of increased life stressors, often end up decompensating and looking depressed, but careful history taking may reveal an exacerbation of the anxiety disorder, which does not respond well to ECT.

After ensuring patients have a major depressive episode, the next step is to deduce whether psychotic features such as psychotic depression are present. If so, then ECT is the treatment of choice, as pharmacologic treatment is not very effective for psychotic depression even when an antidepressant is combined with an antipsychotic medication.

For patients with nonpsychotic depression, the decision to use ECT is based on the degree of functional impairment due to the depressive episode, the presence or absence of suicidality, previous treatment for the current episode, and degree of comorbid psychopathology. If patients are impaired enough to require inpatient admission, then ECT is indicated. Patients who have suicidal thoughts or behaviors should be treated with ECT as well, but the caveat here is that the suicidality should be part of the depressive episode. Patients whose suicidality is related to borderline or another personality disorder or to a non-mood mental disorder probably will not respond well to ECT.

Degree of medication resistance is probably the most uncertain and common confounding issue pertaining to selection of ECT as the modality. There is no fixed, agreed-upon number of failed antidepressant trials that lead to a recommendation for ECT. What can be said is that at some point, especially with outpatients who have been depressed a long time and have taken several medications, psychiatrists need to consider discussing ECT as a possibility and see if patients are willing to consider it. Perhaps, as a general rule of thumb, broach ECT with patients after two aggressive but unsuccessful medication attempts.

The heavier the burden of comorbid psychopathology, the less optimal the ECT response generally will be because even if ECT helps depressive symptoms, the manifestations of other disorders will still be present. In particular, patients with borderline personality disorder should not be treated with ECT if the psychopathology can be accounted for by that condition. Rather, treat with ECT only if a clear, separate, debilitating major depressive episode is diagnosed and medication treatment either has not worked or the patient is hospitalized and suicidal because of the depression.

On a final note, even if ECT helps the depression, psychiatrists need to understand that after treatment is complete, patients will return to their “normal” borderline self with all the attendant chaos and mood unpredictability that come with it. ■