Electroconvulsive therapy (ECT) is an effective treatment for certain people with severe or life-threatening mental disorder. The Mental Health Commission (2015) defines ECT as “a medical procedure in which an electric current is passed briefly through the brain via electrodes applied to the scalp to induce generalised seizure activity. The person receiving treatment is placed under general anaesthetic and muscle relaxants are given to prevent body spasms. Its purpose is to treat specific types of major mental illnesses. A programme of ECT refers to no more than 12 treatments prescribed by a consultant psychiatrist.”¹

Notwithstanding the considerable evidence base supporting the use of ECT, the treatment remains commonly misunderstood.²

The purpose of this article is to:

• Summarise key clinical features of depression, especially severe depression for which ECT might be considered 
• Provide an overview of management of depression across all treatment modalities including ECT 
• Outline the specific recommendations of the National Institute for Health and Care Excellence (NICE) following its extensive, objective review of evidence regarding ECT 
• Present relevant conclusions about the use of ECT in Ireland.

Clinical features of depression

Depression is a common, disabling mental illness. The life-time prevalence of major depressive disorder in the general population is 10-17%, and the 12-month prevalence is 3-7%. The point-prevalence (the number of people with depression at any given moment in time) varies significantly across Europe, as certain areas report a relatively high prevalence (eg. 15% in urban UK, 9% in urban Ireland) and others a low prevalence (eg. 2% in urban Spain). Overall, prevalence is higher in women (10%) than men (7%).³

Depression accounts for 65% of all referrals from primary care to psychiatry outpatient services and 17% of mental health presentations to emergency departments. There is a 30% 12-month prevalence of depression among all individuals attending the emergency department regardless of reason for presentation, especially among those with lower education, smoking, anxiety, chronic fatigue and back problems. Almost one in four individuals who present with acute chest pain fulfil criteria for depression. Among medical and surgical hospital inpatients, there is an 8-22% prevalence of depression. 

In England depression and anxiety account for 26% of all admissions to psychiatric hospitals, with a median inpatient stay of 14 days. In Ireland, depressive disorder was the most common psychiatric admission diagnosis in 2014, accounting for 27% of all psychiatric admissions, and yielding the highest admission rate of any diagnosis, at 105 per 100,000 population.⁴ This compares with an admission rate of 77 per 100,000 for schizophrenia, which accounted for 20% of admissions.

Diagnosing depression can be challenging. The International Classification of Diseases (10th Edition) (ICD-10)⁵ outlines useful diagnostic criteria to guide practitioners, focusing on symptoms such as depressed mood, loss of interest and enjoyment, and reduced energy, leading to increased fatigability and diminished activity. There may also be tiredness after only slight effort, as well as:

• Diminished concentration and attention
• Diminished self-esteem and self-confidence
• Ideas of guilt and/or unworthiness
• Bleak and/or pessimistic views of the future
• Ideas and/or acts of self-harm or suicide
• Disturbances of sleep
• Diminished appetite.

According to ICD-10, these symptoms should last for two weeks, but shorter periods are reasonable if the symptoms have rapid onset or are especially severe. According to ICD-10, depression can be mild, moderate or severe. Mild depression is characterised by at least two of the following three symptoms: depressed mood, loss of enjoyment and interest, and increased fatigability. In addition to these, two of the other symptoms outlined above should be present, although not to an intense degree.⁵

Moderate depression features two of the three key symptoms, as well as three or (preferably) four of the other symptoms outlined above. These symptoms are commonly present to a marked degree; they may or may not be accompanied by somatic symptoms; and they result in considerable difficulty with normal domestic, occupational or social activities.

Severe depression, with which ECT is most commonly associated, is diagnosed when all three of the key symptoms are present, plus at least four of the other symptoms (outlined above), some of which should be present to a severe intensity. As with mild and moderate depressive episodes, symptoms should be present for two weeks, although especially severe symptoms of rapid onset may merit a diagnosis of severe depressive episode before two weeks, in certain cases. Severe depression may also be accompanied by psychotic symptoms, such as delusions, hallucinations or depressive stupor. Delusions, if present, tend to focus on negative ideas, possibly related to poverty, sin, imminent disasters or other negative themes. Hallucinations are also generally unpleasant; eg. accusatory voices or rancid odours. Psychomotor retardation may be a feature, progressing to stupor in certain especially severe cases. ECT can be highly effective in such cases, and can provide lasting benefit.

Differential diagnosis of depression depends on the precise symptoms that the patient displays, but may commonly include adjustment disorder, anxiety disorder and, at the severe end of the spectrum, bipolar disorder, schizoaffective disorder and organic disorders. In cases of depressive stupor, differential diagnoses include catatonic schizophrenia, organic stupor and dissociative stupor.  Recurrent depressive disorder is diagnosed if there are repeated depressive episodes without episodes of mania (which might point to a diagnosis of bipolar affective disorder rather than unipolar depression).

Management of depression 

As with all mental disorders, treatment of depression is based on a bio-psychosocial approach: biological interventions include administration of psychotropic medications, treatment of comorbid medical or substance-related disorders and, in certain cases, ECT.

Antidepressant medications are the psychotropic medications most commonly used in the management of depression. The widely-used Maudsley Trust Prescribing Guidelines in Psychiatry (12th Edition) recommend selective-serotonin reuptake inhibitors as first-line treatments for moderate or severe depression.⁶ Choice of medication will depend on severity of the depressive episode, the individual’s treatment history, likely therapeutic effects of the proposed medication, potential adverse effects, discontinuation phenomena, estimated time to response, and patient preference.  

Approximately two-thirds of patients respond to the first antidepressant prescribed. In these patients, the medication should be continued for six to nine months after recovery from a single depressive episode. For individuals who have experienced multiple depressive episodes, there is evidence to support continuation of treatment for up to two years. If there is no or insufficient therapeutic response to the first antidepressant prescribed after four weeks, it is recommended to assess adherence and either increase dose or switch to a different anti-depressant after an appropriate period. In the event of sub-optimal therapeutic response after a second anti-depressant, alternative treatment strategies may be required. These may include augmentation with additional psychotropic medications (eg. lithium) or ECT.  

Psychological treatments for depressive episode include supportive psychotherapy, cognitive behaviour therapy, interpersonal psychotherapy, brief therapies and a range of other approaches. Cognitive behaviour therapy (CBT) is the most commonly used approach and focuses on the use of cognitive strategies (ie. strategies related to thinking patterns) and behavioural strategies (ie. strategies related to actions and behaviours), in an effort to re-frame depressive cognitions, enhance adaptive coping strategies, and reduce symptoms. There is strong evidence that CBT is highly effective in the management of depressive episode, generalised anxiety disorder, panic disorder, social phobia and post-traumatic stress disorder, among other conditions. For some patients with mild or moderate depression, the benefits of CBT may exceed the benefits of anti-depressant medications.

There is also a key role for social interventions in depression at all levels of severity, owing to strong relationships between depressive symptoms, stressful life-events and poor social support. Specific social interventions include providing pragmatic social support (eg. in relation to benefits or housing), increasing social engagement and developing befriending services for individuals who are isolated or poorly-integrated in their communities.

Combinations of therapies are likely to be required for many patients; eg. CBT and antidepressant medications. In 2009, NICE in the UK emphasised the importance of ‘person-centred care’ that takes into account the needs and preferences of patients.⁷ In this context, it is not widely acknowledged outside of psychiatry that one of the common reasons for treatment with ECT is that patients with depression or their families actively ask for it: having benefited from the treatment in the past, many patients pro-actively request ECT again if depression recurs, often many years or even decades later.

ECT: NICE recommendations

For cases of severe, difficult-to-treat depression, ECT may be considered. Despite widespread misunderstandings about ECT, it is, when used correctly, a safe, effective treatment for certain people with severe or life-threatening mental disorder with certain, specific clinical features. Anyone who has experienced or witnessed severe depression will be aware that any treatment that offers hope of genuine improvement is worth its weight in gold. Against this background, what is the evidence to support the use of ECT in contemporary psychiatric practice?

NICE, following an extensive and objective review of evidence, recommends ECT for the management of severe depressive illness, prolonged or severe episodes of mania, or catatonia, once certain conditions are met.⁸ According to NICE, ECT should be used for fast and short-term improvement of severe symptoms once all other treatment options have failed, or when the situation is life-threatening. Particular caution is advised in pregnant women and older or younger patients.⁸

Sensibly, NICE recommends that a risk-benefit assessment be performed for each patient, including risks associated with the anaesthetic, risks stemming from other illnesses, possible adverse effects of ECT (eg. memory problems), and risks of not having treatment. During a course of treatment, the patient should be re-assessed after every session of ECT, especially for signs of memory loss. More than one course of ECT should be considered only in patients with severe depressive illness, catatonia or mania and who have previously had good responses to ECT. ECT should not be used in the long-term to prevent recurrence of depressive illness or in the general management of schizophrenia. 

This advice from NICE, clear and direct, is also evidence-based and pragmatic, and offers excellent guidance for practitioners, patients and families who are considering ECT. Further reliable information is available on the websites of the College of Psychiatrists of Ireland (www.irishpsychiatry.ie) and Royal College of Psychiatrists (www.rcpsych.ac.uk).

Conclusions: ECT in Ireland 

In November 2015, the Mental Health Commission published important data about the use of ECT in Ireland. It reported that, in 2013, the overall use of ECT in Ireland increased by 2%.⁹ In 14.5% of ECT programmes, which involve up to 12 separate treatments of ECT, one or more of those treatments was administered without the patient’s consent. Overall, there were 46 programmes of ECT where one or more treatments was administered without consent: in all but one of these 46 programmes, at least one consultant psychiatrist indicated that the person lacked the mental capacity to give consent (eg. owing to severe depression).⁹

Of the total of 257 individuals who received ECT in Ireland in 2013, the majority were female (63%) and the average age was 60 years (range: 18-93). The most common indication was depression (82% of programmes of ECT), with resistance to medication the most common specific indication for this particular treatment (63%).⁹

Most importantly, in more than 90% of programmes of treatment, ECT resulted in an improvement in the condition of the patient. These figures are consistent with the NICE recommendations on ECT and provide further confirmation that ECT, when used correctly, remains an effective treatment for refractory depression.

References

• Mental Health Commission. The Administration of Electro-Convulsive Therapy in Approved Centres: Activity Report 2013. Dublin: Mental Health Commission, 2015
• Shorter E, Healy D. Shock Therapy. New Brunswick, New Jersey and London: Rutgers University Press, 2007
• Ayouso Mateos JL, Vasquez-Barquero JL, Dowrick C, Lehtinen V, Dalgard OS, Casey P, Wilkinson C, Lasa L, Page H, Dunn G, Wilkinson G, ODIN Group. Depressive disorders in Europe: prevalence from the ODIN study. Br J Psychiat 2001; 179: 308-316
• Daly A, Walsh D.  Activities of Irish Psychiatric Units and Hospitals 2014. Dublin: Health Research Board, 2015
• World Health Organization. International Classification of Diseases (10th Edition). Geneva: World Health Organization, 1992
• Taylor D, Paton C, Kapur S. The Maudsley Trust Prescribing Guidelines in Psychiatry (12th Edition). Chichester, West Sussex: Wiley Blackwell, 2015
• National Institute for Clinical Excellence. Depression: The Treatment and Management of Depression in Adults. London: National Institute for Clinical Excellence, 2009
• National Institute for Health and Care Excellence (NICE). Guidance on the Use of Electroconvulsive Therapy (www.nice.org.uk/guidance/ta59)
• Mental Health Commission. Use of seclusion, restraint and ECT all increased in 2013 according to the Mental Health Commission. Dublin: Mental Health Commission, 2015