Posted by OldSchool on March 23, 2002, at 15:04:53
In reply to Re: Anyone had success with ECT?, posted by Elizabeth on March 23, 2002, at 13:00:10
> Hi everyone. I was just looking through this thread concerning indications for ECT.
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> It's true that ECT is mainly reserved for situations when medications don't work. ECT is very effective for major depression *in general*. However, it's more effective for some types of depression than others.
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> The main types of depression for which ECT is known to be especially effective are severe depressions with melancholic and/or psychotic features. These types of depression usually (not always) respond well to medications, though (in the case of psychotic depression, an antipsychotic drug is almost always necessary in addition to an antidepressant). ECT is sometimes used when the risk of suicide and/or starvation (or serious malnutrition) is immediate enough that it would be too dangerous to wait for an antidepressant to start working. (There are also some rapid-acting medications, such as antipsychotics, benzodiazepines, stimulants, and opioids, that may be used temporarily to keep the depression under control while waiting for an antidepressant to work.) In the past ECT has been used when medications were contraindicated for safety reasons; because of the discovery of safer ADs, I don't think that this situation comes up much anymore. (In the past, MAOIs were sometimes used as an alternative when TCAs were contraindicated, since MAOIs do not cause the potentially dangerous cardiovascular side effects that are seen with TCAs. If antidepressant medication in general was contraindicated -- for example, in pregnancy -- or if MAOIs didn't work, ECT was often used.)
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> Atypical depressions and depressions associated with personality disorders are frequently resistant to usual medication treatments; such depressions can be very severe, as well. But ECT is generally *not* an effective treatment for these types of depression. ECT is similarly ineffective for dysthymia (which, although not severe, can cause quite a bit of impairment and is sometimes refractory to medication treatments).
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> Many depressions don't meet the criteria for "melancholic" or for "atypical" features. It's not clear how well ECT works in these cases; because they are so heterogeneous, it's probably impossible to make any prediction. My guess is that it would be worth trying ECT in severe refractory cases of "undifferentiated" depression [not a technical term, just my word for it], particularly if the depression has features that somewhat resemble melancholia (e.g., melancholic-like neurovegetative signs with reactive mood).
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> In addition to depression, ECT is used to treat bipolar disorder (including mania) and schizophrenia. In bipolar disorders, ECT can be used to quiet down an acute manic or mixed episode (something that often can't wait; mixed states, in particular, are associated with a high degree of suicidality), as well as relieving depression (although, interestingly, ECT can trigger mania or hypomania when used to treat bipolar depression -- I think it's less likely to than antidepressants are, tho'). We don't have much information on the use of ECT for rapid-cycling bipolar disorder. Using ECT to treat episodes in bipolar disorder can be awkward since you can't take anticonvulsants while having ECTs!
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> ECT is effective for catatonic states, which occur in both mood disorders and schizophrenia and which aren't always treatable with medications.
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> In schizophrenia, ECT works best if the illness has been of brief duration, rather than chronic. ECT is used sometimes as an adjunct to antipsychotic medication in partial responders; by itself, it's less effective than antipsychotic drugs.
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> It's not clear when, if ever, bilateral ECT should be tried before unilateral.
It might be true that atypical depression doesnt respond as well to ECT. I agree the kind of depression ECT works best for is mood disorders with psychotic features. Or classic severe melancholia depression (endogenous depression). But in the real world, if you dont respond well to meds and get a referral for ECT, I dont think most shock docs differentiate that much between atypical depression and the other more conventional depression types. They just wanna shock you...period.I doubt most shock consultations the docs go thru a big long list of things like you just posted. You might know more about this than the docs do in some cases because of your readings. You know how it is in the real world, if you dont respond to meds you just get shocked, period.
As far as bilateral, its definitely better to start off with if you have psychotic features with your mood disorder. Also remember bilateral doesnt require an initial titration the first time like unilateral requires. Thus with unilateral, your first treatment is wasted. Bilateral is more effective, but has more memory side effects. Bifrontal ECT is supposed to be the best of both worlds, having effectiveness comparable to bilateral, but without the severe memory loss side effects of bilateral.
Old School
poster:OldSchool
thread:97068
URL: http://www.dr-bob.org/babble/20020322/msgs/99667.html