W h e n A l l El s e Fa i l s

The Use of Electroconvulsive Therapy for

Conditions Other than Major Depressive Episode

Peter B. Rosenquist, MD*, Nagy A. Youssef, MD,

Sandarsh Surya, MBBS, William V. McCall, MD, MS

KEYWORDS
 Electroconvulsive therapy  Indications  Schizophrenia  Bipolar disorder  Mania
 Post-traumatic stress disorder  Catatonia

KEY POINTS
 Draft guidance prepared by the FDA Office of Device Evaluation for the first time specifies
a labeled indication for ECT, restricted to major depressive episode, but ECT practitioners
may appropriately provide treatment of other “off-label” conditions.
 Limited evidence supports the inclusion of ECT in the treatment guidelines for treatment-
resistant schizophrenia, bipolar mania, and mixed states and catatonia.
 Use of ECT in PTSD and Parkinson disease is encouraging; however, the overall body of
evidence is insufficient to support use of ECT as a primary intervention in these conditions
because of limited research, sample size, and design limitations. However, there is no
rationale for foregoing ECT treatment of another primary indication if comorbid with these
conditions, because anecdotal evidence suggests there may be symptomatic improve-
ment and no clear evidence for harm.

INTRODUCTION

In 1938, the US Congress passed the Food, Drug and Cosmetic Act, which gave the
Food and Drug Administration (FDA) the authority to oversee and ensure the safety of
products meant for human consumption. That same year, the Italians, Ugo Cerletti and

Dr P.B. Rosenquist discloses current research funding from NIMH (R01MH09S776A1), American
Foundation for Suicide Prevention, Lumosity Corporation (66324S-13), Merck (8S0073-9), ALS
Association, GlaxoSmithKline, Harvard Stem Cell Institute, Neurologic Clinical Research Insti-
tute (701419-18), and MECTA Corporation (72200S-2). Dr N.A. Youssef discloses current research
supported by American Foundation for Suicide Prevention (DIG-0-087-13), Merck, MECTA Cor-
poration, ABR Corporation, and Veterans Administration. Dr S. Surya has no disclosures. Dr W.
V. McCall discloses current research support from NIMH, American Foundation for Suicide Pre-
vention, Merck, and MECTA Corporation.
Department of Psychiatry and Health Behavior, Medical College of Georgia at Augusta Univer-
sity, Augusta, GA, USA
* Corresponding author. 997 Street Sebastian Way, Augusta, GA 30912.
E-mail address: [email protected]

Psychiatr Clin N Am - (2018) -–-

https://doi.org/10.1016/j.psc.2018.04.002 psych.theclinics.com
0193-953X/18/ª 2018 Elsevier Inc. All rights reserved.
2 Rosenquist et al

Lucio Bini, collaborated to develop electroconvulsive therapy (ECT). In 1976, the Dal-
kon Shield intrauterine device injured at least 900,000 women in the United States,
which aided passage of the Medical Device Regulation Act bringing medical devices
under the purview of the FDA. Accordingly, ECT was afforded “grandfather” status
and classified as a class III (highest risk) device until 2015 when the FDA Office of De-
vice Management proposed new rules for the reclassification of ECT devices as class
II (intermediate risk) in recognition of the large body of evidence with regard to its
safety.1 The draft guidance prepared by the FDA Office of Device Evaluation for the
first time specified a labeled indication for ECT, restricted to major depressive episode
associated with unipolar or bipolar disorder, and for those “patients 18 years of age
and older who are treatment-resistant, or who require a rapid response due to the
severity of their psychiatric or medical condition.” The guidance identifies several pop-
ulations for which there is “Lack of evidence for efficacy or safety”, including, schizo-
phrenia, schizophreniform disorder, schizoaffective disorder, and bipolar mania or
mixed states.”2
Although product labeling is an important mechanism for promoting safe and effec-
tive products, the FDA does not define scope of practice. It is therefore understood
that physicians may prescribe treatments that are off-label in accordance with profes-
sional judgment. This practice is widespread and generally accepted. A recent survey
indicated that in a group of commonly used medications in an office-based practice,
21% were for an off-label use, although of concern was the survey’s judgment that
73% of those medications had poor or no scientific support for the stated indication.3
Given the high frequency of treatment resistance across the full spectrum of mental
disorders, it is likely that the judicious off-label use of ECT will continue. The impecca-
ble clinician will consult the evidence, document the rationale, and communicate un-
certainties as part of the informed consent process.
In this review, we examine certain conditions that are considered off-label indica-
tions for ECT under the proposed FDA reclassification, namely schizophrenia, bipolar
mania, catatonia, Parkinson disease (PD), and post-traumatic stress disorder (PTSD).
We weigh the published evidence to address two main questions: whether the evi-
dence supports the use of ECT, and what recommendations may be offered as to
how ECT should be used.

SCHIZOPHRENIA

Among the off-label indications for ECT, schizophrenia emerges as the most time-
honored, has the largest empirical basis, and correspondingly greater inclusion in
published treatment guidelines. However, there remain sufficient criticisms regarding
the evidence base to give pause to clinicians and those who define the coverage pol-
icy for national health services and private insurance. The Schizophrenia Patient Out-
comes Research Team: Updated Treatment Recommendations make no mention of
ECT.4 In the most recent versions of World Federation of Societies of Biological Psy-
chiatry Guidelines, ECT achieved a low-ranking recommendation as a treatment
option, reserved for treatment-resistant schizophrenia as an add-on to antipsychotic
treatment and for schizophrenia with catatonic features.5 The United Kingdom Na-
tional Institute for Health and Care Excellence guideline on the use of ECT6 concluded
that there was insufficient evidence to endorse the general use of ECT in the manage-
ment of schizophrenia but did allow that ECT might be effective in acute episodes of
schizophrenia with catatonic features, might reduce the likelihood of relapses, and
that the combination of ECT and pharmacotherapy might be more effective than phar-
macotherapy alone.
 The Use of Electroconvulsive Therapy 3

Similar reserved endorsements emerged from a Cochrane review of randomized

controlled trials (RCTs) of ECT for schizophrenia.7 The authors note that most studies
favor real ECT and suggest that ECT resulted in fewer relapses and a greater likelihood
of being discharged from the hospital. In eight RCTs (n 5 419 patients) that directly
compared ECT with antipsychotic medications, the results favored medications, but
importantly when ECT was added to antipsychotics the combination was superior
to antipsychotics alone. ECT was considered an option when the treatment aim
was rapid global improvement and symptomatic reduction, and for patients whose ill-
nesses had shown only a limited response to medication alone.
A gold standard for clinical trials involving devices in the modern era includes
a sham arm to compare with the active device. Table 1 compares the sham-
controlled published RCTs that reveal small sample sizes; heterogeneous approaches
to patient selection, diagnosis, and outcome assessment; and ECT technique.8–13 All
studies included concurrent antipsychotic pharmacotherapy equally to all groups, so
these studies are best characterized as ECT plus pharmacotherapy versus pharmaco-
therapy alone (sham ECT). Overall, ECT outperformed sham ECT in four of six trials,
despite short treatment courses.
Several controlled trials have addressed the possible limitation of inadequate dura-
tion of ECT treatment, in the context of antipsychotic drug failure. Chanpattana and
coworkers14 studied a group of patients who had failed to respond during an acute
exacerbation of psychosis to a minimum of two antipsychotics from at least two
different classes, each equivalent to 750 mg chlorpromazine equivalents daily. Pa-
tients had a baseline Brief Psychiatric Rating Scale (BPRS) score of at least 35, and
more than a 2-year duration of illness. In recognition of the chronic nature of the illness,
the study used a two-phase design. The first phase was an open-label acute trial of
ECT/antipsychotic medication in combination, followed by a 3-week stabilization
period during which ECT was tapered. Responders who sustained improvement dur-
ing the stabilization period were then randomized in a 6-month continuation phase to
receive either treatment alone or in combination. In the acute phase 114 patients with
schizophrenia were enrolled. The study also controlled antipsychotic doses, with all
patients receiving flupenthixol, 12 mg/d, in the first week and increased as tolerated
to 24 mg/d in the second week, while receiving bitemporal (BT) brief pulse ECT at
threshold three times a week. ECT was continued until patients achieved the response
criteria (defined a priori as a reduction in the BPRS to 25 or less) or received a
maximum of 20 treatments at which time they were declared nonresponders. A total
of 101 patients completed the study with 58 responders and 43 nonresponders. Base-
line BPRS scores before/and after treatment were 49.1 ( 9.6)/18.7 ( 7.2) in re-
sponders and 51.4 ( 9.4)/39.4 ( 8.3) in nonresponders (P<.001). The average
number of ECT treatments for responders was 13.9 ( 4.8), and nonresponders
received 20.4 ( 0.8) treatments. In this study, and a subsequent larger study by
the same authors (N 5 293; 54.6% responders), responders were characterized as
younger, with less extensive family history of schizophrenia, shorter durations of pre-
sent episode and total illness, higher rates of psychiatric admission, more paranoid
type, lower baseline negative symptoms, and higher baseline Global Assessment of
Functioning score compared with nonresponders.15
In a randomized, single-blind study, Petrides and colleagues16 focused on
treatment-resistant patients with schizophrenia on a stable dose of clozapine for
at least 8 weeks, with persistent psychotic symptoms (12 in the BPRS psychosis
subscale) and no current mood symptoms. Patients were subsequently randomized
to receive 8 weeks of BT ECT (3 times a week for the first 4 weeks, then twice a
week for 4 weeks) in addition to clozapine or to continue with clozapine treatment
 4
Rosenquist et al
Table 1
Randomized, controlled studies of ECT in schizophrenia

Study Randomized Comparison Sample Diagnostic Criteria ECT Technique Outcome Measures Main Results
Brandon et al,8 BL ECT 1 antipsychotic Inpatients with Present State Sine wave ECT of Blind ratings: MASS Patients receiving real
1984 (n 5 9) vs sham schizophrenia, Examination unspecified ECT had significantly
“Leicester Trial” ECT 1 antipsychotic referred for ECT dosage twice per greater improvement
(n 5 8) No change in week, for a total in MASS at 2 (P 5 .02)
antipsychotic of 8 treatments and 4 (P 5 .05) wk
permitted during No difference between
4-wk study phase groups at extended
Chlorpromazine 12- and 28-wk
equivalents follow-up
273 mg in
simulated ECT
group, 317 mg in
real ECT
Sarkar et al,9 BL ECT 1 haloperidol Inpatients with DSM-III-R per Sine wave fixed BPRS; clinician Both groups improved
1994 (n 5 15) vs sham schizophreniform Research dosage BT ECT global rating over treatment course;
ECT 1 haloperidol disorder Diagnostic Criteria for a fixed weekly for 6 wk, no significant
(n 5 15) (illness <2 mo); course of 6 and at 6 mo difference between
confirmation of treatments groups at any time
schizophrenia at point
6 mo in 29/30
patients
Ukpong et al,10 BL (n 5 9) 1 antipsychotic ECT-naive patients ICD-10 Brief pulse fixed Blinded (single Both groups improved in
2002 vs sham with dosage BT ECT rater) ratings first 2 wk, with no
ECT 1 antipsychotic schizophrenia of 3 d/wk, for a BPRS; CGI-S and significant difference
(n 5 7) <2 y duration, total of 6 Scale for between groups at any
onset before 45 y treatments Assessment of time point
(mostly inpatients) Negative
Chlorpromazine Symptoms at 2, 4,
equivalent dose of 6, 8, 12, 16, and
300 mg daily 20 wk
 Masoudzadeh Sham ECT 1 clozapine vs Treatment-resistant DSM-IV criteria RUL ECT for 12 PANSS All groups improved;
& Khalilian,11 ECT alone with sham schizophrenia confirmed by two sessions given 3 ECT 1 clozapine group
2007 clozapine vs (failure to respond psychiatrists times per week significantly improved
ECT 1 clozapine (n 5 6 to 2 adequate for 4 wk compared with other
each group) antipsychotic groups (see text for
trials) additional details)
Abraham & ECT (n 5 11) vs simulated Inpatients or Research Diagnostic 8 ECT twice weekly BPRS and CGIs ECT superior to simulated
Kulhara,12 ECT (n 5 11) outpatients with Criteria for 4 wk administered ECT at all time points
1987 All patients received schizophrenia; (electrode q 2 wk for (CGI) and for first 12 wk
trifluoperazine, 20 mg age of onset <40 y; placement 26 wk (BPRS)
daily ECT naive; illness unspecified)
not >2 y
Goswami BT ECT (n 5 15 vs sham Outpatients with DSM-IV Brief pulse BT ECT BPRS and CGI at ECT superior to sham ECT
et al,13 2003 ECT (n 5 10) schizophrenia, at 50%–200% of baseline, weekly after 2 wk
unresponsive to 3 seizure over 4 wk; No difference in CGI
courses of 2 threshold, rehospitalization Rehospitalization rate
different classes of duration >25 s rate 20% for ECT and 70%
neuroleptic thrice-weekly; for sham group
(1000-mg minimum of 6 tx,
chlorpromazine maximum and

The Use of Electroconvulsive Therapy

equivalents) in range
past 5 y, receiving unspecified
neuroleptic at
minimum of 500
CPZ equivalents
for duration of
study

Abbreviations: BPRS, Brief Psychiatric Rating Scale; BT, bitemporal; CGI, clinical global impression scale; CPZ, chlorpromazine; DSM-IV, Diagnostic and Statistical
Manual-fourth edition; ICD, International Classification of Diseases; MASS, Montgomery Asberg Schizophrenia Scale; PANSS, Positive and Negative Syndrome
Scale; RUL, right unilateral.

5
6 Rosenquist et al

for 8 weeks. Patients in the pharmacotherapy-only arm who did not respond after
8 weeks were crossed over to the ECT arm and received the combination treatment
for another 8 weeks in an open trial. The study used two levels of response: 20%,
and 40% reduction in the psychosis items of BPRS. There were no responders in
the pharmacotherapy group as defined by 20% reduction of the psychosis sub-
scale, compared with 12 of 20 (60%; P<.001) in the ECT 1 clozapine group. There
were 10 of 20 (50%; P<.001) responders in the ECT 1 clozapine group meeting the
40% reduction criterion. For those who did not respond to 16 weeks of clozapine
treatment crossed over to the combination there were 11 of 15 (73.3%) responders
when response was defined as 20% reduction and 6 of 15 (40%) when 40% was
used.

Choice of Electrode Placement

Questions remain regarding optimal ECT technique particularly about electrode
placements. An early randomized comparison of unilateral dominant (n 5 18),
unilateral nondominant (n 5 17), and BT (n 5 19) ECT for outpatients with schizo-
phrenia showed no difference between groups in BPRS total scores or in the
proportion of patients achieving 50% or greater reduction after a minimum of six
ECT administered or at completion of treatment (average number of treatments,
eight for unilateral and 9.4 for bilateral).17 Phutane and colleagues18 compared
the speed of therapeutic response and cognitive adverse effects for patients ran-
domized to receive bifrontal (BF) (n 5 62) versus BT (n 5 60) ECT administered
at 1.5 times seizure threshold and with 1.5-ms pulse width setting, thrice-weekly
with the total number of ECT treatments administered decided by the referring psy-
chiatrist. Primary efficacy was determined by a response criterion of 40% reduction
of total BPRS score. After six ECT sessions, 27/43 (63%) of BF met criteria
as compared with 5/38 (13.2%) of patients administered BT ECT. By the end of
the treatment course, 41/43 (95.3%) and 30/38 (78.9%) achieved response criteria
for BF and BT ECT, respectively. Significant differences in favor of the BF
group were found for recent memory, serial subtraction, digit span, and total
controlled word association test. The authors conclude that BF offers significant
advantages in speed and likelihood of clinical response and a more benign cogni-
tive outcome.

Electroconvulsive Therapy for Maintenance

Two controlled trials have addressed the question of maintenance ECT (MECT) in
schizophrenia. The earlier described study by Chanpattana and coworkers14 used a
second phase, during which continuation ECT was given weekly to patients who
responded in the acute phase for 1 month (four treatments) and then biweekly for
5 months (10 treatments). Fifty-one patients were enrolled and 45 completed the sec-
ond phase of the study. Among the completers, significantly more maintained remis-
sion after 6 months in the combined MECT 1 flupenthixol group (60%), whereas 93%
relapsed in the MECT-alone and the flupenthixol-alone groups.
Yang and colleagues19 conducted a randomized comparison of MECT 1 risperi-
done versus risperidone alone in 62 patients with schizophrenia who were ECT re-
sponders. MECT was used weekly in the first month, twice in the second month,
and monthly thereafter for the remainder of 1 year (16 total treatments). Patients
in the MECT group had a significantly lower relapse rate (only 4/27 relapsed) and
longer relapse-free survival time (11 months) compared with medication control
subjects (14/26 relapsed; seven relapsed in first 6 months and seven in second
6 months).
 The Use of Electroconvulsive Therapy 7

MANIA

ECT appears in the treatment algorithm for mania within the treatment guidelines of
many professional bodies. Mania is recognized by the National Institute for Health
and Care Excellence6 as an indication for ECT, which states that ECT may be
used to treat a prolonged or severe manic episode. A recent international survey
of professional organizations with published guidelines for the treatment of mania
showed that seven of nine organizations listed ECT as an option for the second-
line treatment of mania.20 For those organizations endorsing ECT, it was generally
reserved for severe and/or treatment-resistant cases. ECT was not a recommended
treatment by any of the international bodies for maintenance therapy for bipolar
disorder.
A 2011 review on ECT and bipolar disorder reported on 28 clinical trials (mostly un-
controlled, nonrandomized, and not blinded). The range of clinical response in these
trials was broad, from 48.1% to 100%.21 The variability in response could be
explained by nonstandard means of diagnosis, changes over time in the frequency
of treatment-resistant mania, lack of blinding, variability in psychometric instruments,
and different definitions of response. Given that the cited studies dated back to 1942,
there were also important differences in ECT technique. For all these reasons these
studies are difficult to interpret. A more recent naturalistic report using prospective
systematic measurement in treatment-resistant patients noted 75% response rate
for six patients with mania and 72.9% response rate for 55 bipolar patients in mixed
state.22
We located six RCTs of ECT in mania (Table 2).23–28 These dated from 1987 to 2009
and would meet most definitions of modern ECT and modern clinical trial methodol-
ogy. None of the studies would meet modern definitions of large RCT, therefore all
the results must be interpreted with caution. Inclusion criteria generally required a
high severity of illness, and the patients were treated in an inpatient setting, in those
instances when setting was specified. The mean number of ECT sessions was in
the seven to nine range. Most, but not all studies reported their results categorically
as responder versus nonresponder status. Of those studies that reported responder
rates, there were 121 patients assigned to various forms of ECT, with an overall
72.7% response rate. Two of the RCTs explicitly required that the patient demonstrate
treatment resistance before entering their studies. Notably, response rates were high
and comparable with those reports that did not require treatment resistance for inclu-
sion. Response rates were generally calculated at the end of ECT or within a week af-
ter the conclusion of the ECT course, so longer-term outcomes were generally not
reported from these RCT.
The study by Sikdar and coworkers26 is the only sham-controlled ECT study in
mania, and shows an overwhelming advantage for real ECT 1 lithium versus sham
ECT 1 lithium. Four of the RCTs performed various comparisons of BF versus BT,
versus right unilateral (RUL), versus left unilateral ECT. Although differences in setting
invalidate the simple combination of results across the studies, the overall impression
is that bilateral forms of ECT are more reliable in their antimanic effect than any form of
unilateral ECT. Contrasts of BT versus BF ECT suggest that BF electrode placement
works faster and has fewer global cognitive side effects than BT ECT. Finally, the sole
RCT contrasting different stimulus doses found no advantage for high-dose versus
barely suprathreshold BT ECT. The Schnur and colleagues30 study also provided
data on symptom profiles that predicted ECT response in mania, reporting that signs
and symptoms of anger, irritability, and suspiciousness were predictors of nonre-
sponse. However, the authors rightfully note that their small total sample size of 18
 8
Table 2

Rosenquist et al
Randomized, controlled studies of ECT in mania

Randomized Diagnostic
Study Comparison Sample Criteria ECT Technique Outcome Measures Main Results
Milstein et al,23 BL (n 5 11) vs initial Inpatients with mania DSM-III per Brief pulse 3 times per Semiblind ratings of Patients who started
1987 RUL a switch to BL or mixed state Research week MRS with BL had
(n 5 6) Score 7 on the manic Diagnostic No discussion about Also, CGI, Global numerically superior
portion of the Criteria stimulus dosing Assessment Scale results at the end of
Severity of Depression wk 2 for CGI (P<.05),
and Mania Scale Global Assessment
PRN neuroleptic Scale (P<.05), and
allowed 200–400 PCZ MRS
equivalents Statistical significance
No requirement for not reported for MRS
treatment resistance
Small et al,24 1988 ECT (n 5 17) vs Li1 Inpatients with mania DSM-III per RUL with possibility Semiblind ratings of 81% improvement in
(This study is (n 5 17) or mixed state Research switch to BL (average MRS MRS seen in Li1
derivative of Score 7 on the manic Diagnostic 9 sessions) Calculated % patients vs 95%
Milstein et al, portion of the Criteria Brief pulse 3 times per improvement improvement in ECT
above) Severity of Depression week from baseline patients, P<.05
and Mania Scale No discussion about
PRN neuroleptic stimulus dosing
allowed 200–400 PCZ
equivalents
No requirement for
treatment resistance
Mukherjee et al,25 BL (n 5 4), RUL MMS 30 and met RDC DSM-III Brief pulse at 150% of Blind measurement Rates of response:
1988 (n 5 8), LUL (n 5 5) criteria for manic seizure threshold, of MMS; BL: 4/7
episode 3 d/wk, or 5 d/wk recovery 5 no RUL: 5/8
All participants had longer meets RDC LUL: 2/5
failed 3 wk of criteria for mania Change in MMS scores:
lithium and/or BL: 40.4%
antipsychotic RUL: 37.4%
LUL: 44.8%
 Sikdar et al,26 1994 ECT 1 CPZ Inpatients with mania, DSM-III-R Eight sessions of BL Blind measurement 12/15 in ECT group vs
600 mg (n 5 15) vs and baseline MRS 14 sinewave vs of MRS; 1/15 in sham group
sham ECT 1 CPZ anesthesia without recovery 5 MRS recovered
600 mg (n 5 15) ECT <6 P<.001
Hiremani et al,27 BF (n 5 17) vs BT Inpatient with mania, DSM-IV Stimulus dose 1.5X Blind ratings of BF group improved
2008 (n 5 19) ECT including 6 who were seizure threshold, 3 YMRS faster than BT group
treatment resistant times per week with a A 50% reduction (P<.03)
Mean haloperidol dose brief pulse constant from baseline in By end of treatment,
BF group 5 43.8 mg, current device (mean YMRS 5 response response to
and BT of 7.5–7.6 sessions) BF 5 87.5% and
group 5 96.4 mg BT 5 72.2%
Barekatain et al,28 BF (n 5 14) vs BT Inpatients with DSM-IV DSM-IV Stimulus dose 1.5X Blind ratings of No difference between
2008 (n 5 14) mania per Mini seizure threshold YMRS groups in YMRS
Participants were International with a brief pulse A 50% reduction scores (exact rates of
allowed Neuropsychiatric device from baseline in response not
lorazepam, 1-mg Interview YMRS 5 response reported), but MMSE
equivalents per Medication resistance Cognition is scores were higher at
day not required for entry measured with the end of ECT in
MMSE those assigned to BF
Mohan et al,29 Titrated BT ECT, Inpatients older than DSM-IV BT brief pulse ECT Blind ratings of Barely suprathreshold

The Use of Electroconvulsive Therapy

2009 followed by BL 18 y with a manic (mean of 7.6 sessions YMRS and CGI response 5 92%, and
ECT at barely episode, with for both groups) A 50% reduction 2.5X threshold
suprathreshold YMRS 26 from baseline in response 5 91.7%
(n 5 26) and 2.5X All patients were YMRS 5 response No difference between
threshold (n 5 24) treatment resistant, Also measured groups in any
and received MMSE, cognitive measure
risperidone autobiographical
6–8 mg/d or memory, and
olanzapine Wechsler
15–30 mg/d Memory Scale

Abbreviations: BT, Bitemporal; DSM-IV, Diagnostic and Statistical Manual-fourth edition; LUL, left unilateral; MMS, Modified Mania Scale; MMSE, Mini-mental
status exam; MRS, Mania Rating Scale; RDC, Research diagnostic criteria; RUL, right unilateral; YMRS, Young Mania Rating Scale.

9
10 Rosenquist et al

patients limits the utility of their findings. The impressions from these six RCTs are
echoed in other reviews on this topic.31

Treatment Considerations
The risk of a switch from depression to mania is always present in the application of
ECT in patients with bipolar disorder. The risk is reported at 24%, and although
some advocate for continuing ECT and treating through the mania, others have sug-
gested suspending ECT and resuming intensive pharmacotherapy.32
There are no logical objections to the use of antipsychotics during a course of ECT
for mania, but there are theoretic objections to the use of anticonvulsants and lithium.
Remarkably, most patients can experience a successful course of ECT despite
ongoing use of an anticonvulsant mood stabilizer.33 Early reports on the combination
of lithium and ECT presented concerns about long ECT seizures and aggravated
cognitive problems.34 However, the rate of lithium-related problems was reported
as zero in 90 consecutive patients with mania receiving lithium concurrently with
ECT.35 The modern practice of ECT would expect the administration of at least one
antimanic psychotropic in conjunction with a course of ECT for mania.
It is unknown how often treatment resistance develops in an episode of mania.
Ciapparelli and colleagues36 defined treatment-resistant mixed mania as failure to
respond to at least 16 weeks of two or more mood stabilizers and antipsychotics. In
their recent series of 41 treatment-resistant patients with mixed mania, the authors re-
ported a 56% response rate with a mean of 7.2 sessions of BL pulse ECT.

POST-TRAUMATIC STRESS DISORDER

Many patients with PTSD do not achieve full remission from current pharmacotherapy
and psychotherapy and ECT has sometimes been used in these cases.37 However,
there are no RCTs that examine the role of ECT in PTSD and PTSD is still not a recog-
nized indication for ECT in any published treatment guideline.38 A retrospective chart
review by Watts39 examined the use of ECT for treatment of PTSD in 26 military vet-
erans who had major depression and PTSD. All patients started with RUL ECT (at 2.5
times seizure threshold). Five patients did not respond to RUL ECT and were switched
to BT ECT after session 8. Patients had significant reduction in the symptoms of major
depression and “some amelioration in PTSD symptoms." There was a mean reduction
in PTSD symptoms after treatment (P<.001). However, only 35% of patients had
greater than or equal to 20% reduction in symptoms. The main limitations of this study
were that it was retrospective, a small sample size, and lack of non-ECT control.
In another retrospective study, Ahmadi and colleagues40 compared patients with
comorbid PTSD and major depressive disorder who received BF ECT (n 5 92) with
matched patients who did not receive ECT (n 5 3393). ECT was administered
thrice-weekly. Improvement in PTSD and major depressive disorder symptoms was
assessed using clinical global impression scale (CGI). There was statistically signifi-
cant improvement in the ECT (90%) group, compared with the antidepressant medi-
cations group (50%; P 5 .001).
The most recent clinical trial is an open-label study by Margoob and coworkers.41
Twenty civilians were enrolled with severe, chronic, treatment-resistant PTSD (failure
to respond to an adequate trial of four antidepressants or more, and 12 sessions of
cognitive behavior therapy). Six sessions of bilateral ECT were given to all 20 outpa-
tients twice-weekly. The stimulus intensity was barely suprathreshold. PTSD symptom
severity was primarily measured with the Clinician-Administered PTSD Scale (CAPS).
Secondary outcome measures were the Montgomery-Asberg Depression Rating
 The Use of Electroconvulsive Therapy 11

Scale (MADRS) and the clinical global impression-severity scale (CGI-S). Seventeen
participants completed the study. Mean CAPS scores for all the sample decreased
by 34% (P<.001), and MADRS decreased by 51.1% (P<.001). The authors reported
that the correlation between improvement in CAPS and MADRS was low. These
data seem encouraging; however, the overall body of evidence is insufficient to sup-
port routine use of ECT for PTSD because of limited research, small sample size, and
design limitations. These encouraging early studies warrant replication in an RCT,
especially for treatment-resistant PTSD.

CATATONIA

Catatonia is a neuropsychiatric condition characterized by wide range of psychomotor

abnormalities ranging from stupor to marked agitation that is, referred to as catatonic
excitement. Untreated catatonia can lead to poor outcomes because of poor nutri-
tional status of these individuals, increased risk of venous thrombosis, decubitus ul-
cers, and pneumonia caused by immobility.42 On the contrary, catatonic excitement
and combativeness can pose risk of injury to self and others. Hence, catatonic state
frequently represents a psychiatric emergency. Fortunately, benzodiazepines or bar-
biturates are effective in up to 60% to 80% of cases.43 Although ECT is an effective
treatment of catatonic syndrome there are no RCTs and it is most often considered
when there is a poor response to medication or in cases where the condition is at
risk of severe physiologic detriment, such as malignant catatonia.44 McCall45 demon-
strated that only 10 of 20 patients with catatonia demonstrated a significant initial
improvement in speech and behavior (score of 4 or 5 on CGI scale; “definite and sus-
tained” or “dramatic”) when administered intravenous amobarbital at an average
dosage of 4.8 mg/kg. However, 19 of 20 patients ultimately had resolution of catatonic
features with continued treatment using a combination of medication and ECT.
Most published studies of ECT for catatonia include patients with demonstrated
refractoriness to benzodiazepines. However, in a study with algorithmic approach of
treatments offered to patients with catatonic symptoms, ECT emerged as clearly
more beneficial than the alternatives. Patients not responding to one treatment were
offered the alternatives sequentially with some provision for patient and family prefer-
ence. The first treatment options were benzodiazepines or ECT, second options were
antipsychotic or ECT, third options chlorpromazine or ECT, and the final option was
ECT alone. Authors report an overall efficacy rate of 100% for ECT in comparison
with chlorpromazine 68%, risperidone 26%, haloperidol 16%, and benzodiazepines
2%.46 BT ECT was used in this study and the frequency of the treatments was three
times weekly with a mean of 8.8 treatments. The low efficacy of benzodiazepines in
this study was likely caused by low dosage (eg, 3 mg oral lorazepam) as regulated
by the Japan Ministry of Health, Labor and Welfare.
Medda and colleagues47 treated 26 patients with bipolar disorder with catatonia
features with ECT. These patients were resistant to pharmacotherapy including loraz-
epam at doses of 6 to 24 mg/d. A total of 21 of the 26 patients (80.8%) were classified
as responders and required a mean of 10.2  3 treatments. Compared with baseline
scores, there was 82% reduction in Bush-Francis Catatonia rating scale scores48 and
50% reduction in global severity of the illness, general psychopathology, and psy-
chotic symptoms. ECT seemed safe for the patients in this study, with many individ-
uals classified as having high burden of medical comorbidity.
When benzodiazepine treatment does not result in complete remission, they may
still be combined with ECT, although concerns have long been raised about their
impact on seizure threshold and seizure duration.49 In a prospectively identified
12 Rosenquist et al

case series of five patients with catatonia, Petrides and colleagues50 report that loraz-
epam became effective at the same or at lower doses after the ECT was initiated
because of lack of response with lorazepam treatment. Also, in two cases, addition
of lorazepam enhanced the therapeutic response of ECT suggesting a synergistic rela-
tionship between lorazepam and ECT when treating catatonic syndrome.
Rasmussen and colleagues51 noted that benzodiazepine response rate is dimin-
ished when catatonia is present with schizophrenia. This may also be true for ECT.
In a study of five patients with catatonia secondary to schizophrenia and four patients
with catatonia secondary to a mood disorder, patients with mood disorder showed
greater clinical improvement and required fewer treatments overall.52
Other studies paint a more positive picture of the role of ECT in the care of patients
with catatonia associated with schizophrenia. In a 1-year outcome study, Suzuki and
colleagues53 examined 11 consecutive patients with catatonic schizophrenia referred
for acute ECT after failing to respond to other treatments, including benzodiazepines
in 10 cases. ECT was administered acutely thrice-weekly for a mean of 9.9  1.3 treat-
ments. All 11 patients met criteria for a clinical response with a score of less than 25 on
BPRS. In a subsequent pharmacotherapy maintenance study, the same ECT re-
sponders were assessed weekly using BPRS for 48 weeks or until they met criteria
for relapse or recurrence (defined as BPRS score of >37 on 3 consecutive days).
Relapse occurred in seven patients (63.6%) and all in the first 6 months.54 Patients
who relapsed in the phase 2 study were retreated with acute ECT treatments and
all seven patients responded to the second course of acute ECT (mean of
12.3  3.9 treatments). Finally, the responders were then treated with a fixed regimen
of continuation ECT combined with pharmacotherapy. Continuation ECT was admin-
istered for 6 months with four ECT sessions at weekly intervals followed by four ECT
sessions administered every 2 weeks, and the final three ECT sessions were given
every 4 weeks. Four out of these seven patients relapsed in 1-year follow-up including
one drop-out.55
Catatonia is associated with grave complications and treatment should be prompt.
One study provides a glimpse into how this may not be adequately addressed in some
settings. In a population of heterogeneous cases, 13 patients with benign catatonia,
11 with malignant catatonia, and 10 patients with neuroleptic malignant syndrome
were studied retrospectively.56 Overall response to treatment was encouraging,
because 58% showed complete remission and 18% reached partial remission with
benzodiazepines and/or ECT. In medication-resistant patients treated with ECT,
50% of patients recovered completely. Strikingly, the time lag reported in this study
between the onset of catatonic symptoms and first-line treatment targeting catatonia
was 15  36 days and the time lag between first and the second line of ECT treatment
was found to be 27  46 days.

PARKINSON DISEASE

PD is a neurodegenerative movement disorder characterized by resting tremor, rigid-

ity, bradykinesia, and postural instability associated with loss of the dopaminergic
nigrostriatal neurons and decreased striatal levels of dopamine. Depression is a com-
mon nonmotor feature of this illness in up to 40% of patients.57 Studies of the effect of
ECT in animal models58 and humans59 consistently suggest enhancement of dopa-
mine activity. Benefits of ECT in PD came to light in the 1970s when patients treated
with ECT for depression with comorbid PD showed improvement in motor symptoms
of PD.60 Borisovskaya and colleagues61 recently published a systematic review of 43
published studies and recommended that ECT be included in guidelines for treatment
 The Use of Electroconvulsive Therapy 13

of patients with PD. Their analysis included 116 patients with depression and PD, and
found that depression improved in 93.1% and when motor symptom severity was re-
ported, 83% of patients were deemed improved.
In a double-blind controlled study, patients with treatment-resistant PD showing se-
vere “on-off” phenomenon with pronounced “off” periods, patients treated with ECT
significantly prolonged the duration of “on” phase compared with the sham ECT. In
the open-label part of the study, severity of parkinsonian symptoms as measured
on Webster scale and time and number of steps required to walk 10 m improved. How-
ever, the benefits of the treatment were short lived between 2 and 3 weeks.62 The
improvement of movement disorders with ECT is sometimes attributed to the
improvement in the depression that is frequently comorbid in patients with PD, but
in this study the sample consisted of patients with PD without depressive illness.
The durability of antiparkinsonian effects of ECT is variable but time-limited. An
open-label study included seven patients ages between 61 and 73 years old with ma-
jor depression and PD. After two treatments there was significant improvement in mo-
tor functions (rigidity, gait, tremor, bradykinesia, and postural instability) in five of the
seven patients. Two of the patients developed dyskinetic movements that improved
after reduction in doses of dopaminergic drugs. The duration of improvement varied
from 1 to 6 months after cessation of ECT.63 In another open-label study examining
16 patients with advanced PD with comorbid depression, the antiparkinsonian effect
lasted a few days to 4 weeks in eight patients, 3 to 5 months in seven patients, and
18 months in one patient.64
The existing evidence suggests ECT does have a role in the treatment of PD, not
only for the treatment of depression associated with PD, but also for improving the
motor symptoms of PD

OVERALL SUMMARY/FUTURE DIRECTIONS

ECT is remarkably effective over a broad spectrum of neuropsychiatric conditions and

should not be limited to major depression alone. The ECT research agenda is similarly
broad and ultimately will be driven by the developing understanding of its mechanism
of action. Where the literature is sparse, and the need is acute, off-label prescribing
must proceed with caution, and not overly impeded by regulatory bodies.

REFERENCES

1. McDonald WM, Weiner RD, Fochtmann LJ, et al. The FDA and ECT. J ECT 2016;
32(2):75–7.
2. U.S. Department of Health and Human Services Food and Drug Administration.
Electroconvulsive therapy (ECT) devices for class II intended uses. Rockville
(MD): 2015. Available at: https://www.gpo.gov/fdsys/pkg/FR-2015-32592.pdf.
Accessed May 1, 2018.
3. Radley DC, Finkelstein SN, Stafford RS. Off-label prescribing among office-
based physicians. Arch Intern Med 2006;166(9):1021–6.
4. Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Out-
comes Research Team (PORT): updated treatment recommendations 2009.
Schizophr Bull 2010;36(1):94–103.
5. Hasan A, Falkai P, Wobrock T, et al. World Federation of Societies of Biological
Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 1:
update 2012 on the acute treatment of schizophrenia and the management of
treatment resistance. World J Biol Psychiatry 2012;13(5):318–78.
14 Rosenquist et al

6. National Institute for Health and Clinical Excellence. NICE technology appraisal
guidance No.59: The clinical effectiveness and cost effectiveness of electrocon-
vulsive therapy (ECT) for depressive illness, schizophrenia, catatonia and mania.
2003. Available at: https://www.nice.org.uk/guidance/ta59. Accessed May 1,
2018.
7. Tharyan P, Adams CE. Electroconvulsive therapy for schizophrenia. Cochrane
Database Syst Rev 2005;(2):CD000076.
8. Brandon S, Cowley P, McDonald C, et al. Leicester ECT trial: results in schizo-
phrenia. Br J Psychiatry 1985;146:177–83.
9. Sarkar P, Andrade C, Kapur B, et al. An exploratory evaluation of ECT in
haloperidol-treated DSM-IIIR schizophreniform disorder. Convuls Ther 1994;
10(4):271–8.
10. Ukpong DI, Makanjuola RO, Morakinyo O. A controlled trial of modified electro-
convulsive therapy in schizophrenia in a Nigerian teaching hospital. West Afr J
Med 2002;21(3):237–40.
11. Masoudzadeh A, Khalilian AR. Comparative study of clozapine, electroshock and
the combination of ECT with clozapine in treatment-resistant schizophrenic pa-
tients. Pak J Biol Sci 2007;10(23):4287–90.
12. Abraham KR, Kulhara P. The efficacy of electroconvulsive therapy in the treat-
ment of schizophrenia. A comparative study. Br J Psychiatry 1987;151:152–5.
13. Goswami U, Kumar U, Singh B. Efficacy of electroconvulsive therapy in treatment
resistant schizophrenia: a double-blind study. Indian J Psychiatry 2003;45(1):
26–9.
14. Chanpattana W, Chakrabhand ML, Sackeim HA, et al. Continuation ECT in
treatment-resistant schizophrenia: a controlled study. J ECT 1999;15(3):178–92.
15. Chanpattana W, Chakrabhand ML. Combined ECT and neuroleptic therapy in
treatment-refractory schizophrenia: prediction of outcome. Psychiatry Res
2001;105(1–2):107–15.
16. Petrides G, Malur C, Braga RJ, et al. Electroconvulsive therapy augmentation in
clozapine-resistant schizophrenia: a prospective, randomized study. Am J Psy-
chiatry 2015;172(1):52–8.
17. Doongaji DR, Jeste DV, Saoji NJ, et al. Unilateral versus bilateral ECT in schizo-
phrenia. Br J Psychiatry 1973;123(572):73–9.
18. Phutane VH, Thirthalli J, Muralidharan K, et al. Double-blind randomized
controlled study showing symptomatic and cognitive superiority of bifrontal
over bitemporal electrode placement during electroconvulsive therapy for schizo-
phrenia. Brain Stimul 2013;6(2):210–7.
19. Yang Y, Cheng X, Xu Q, et al. The maintenance of modified electroconvulsive
therapy combined with risperidone is better than risperidone alone in preventing
relapse of schizophrenia and improving cognitive function. Arq Neuropsiquiatr
2016;74(10):823–8.
20. Parker G, Graham R, Tavella G. Is there consensus across international evidence-
based guidelines for the management of bipolar disorder? Acta Psychiatr Scand
2017;135:515–26.
21. Versiani M, Cheniaux E, Landeira-Fernandez J. Efficacy and safety of electrocon-
vulsive therapy in the treatment of bipolar disorder. J ECT 2011;27(2):153–64.
22. Perugi G, Medda P, Toni C, et al. The role of electroconvulsive therapy (ECT) in
bipolar disorder: effectiveness in 522 patients with bipolar depression, mixed-
state, mania and catatonic features. Curr Neuropharmacol 2017;15:359–71.
23. Milstein V, Small J, Klapper M, et al. Uni- versus bilateral ECT in the treatment of
mania. Convulsive Ther 1987;3(1):1–9.
 The Use of Electroconvulsive Therapy 15

24. Small J, Klapper M, Kellams J, et al. Electroconvulsive treatment compared with

lithium in the management of manic states. Arch Gen Psychiatry 1988;45:727–32.
25. Mukherjee S, Sackeim H, Lee C. Unilateral ECT in the treatment of manic epi-
sodes. Convulsive Ther 1988;4(1):74–80.
26. Sikdar S, Kulhara P, Avasthi A, et al. Combined chlorpromazine and electrocon-
vulsive therapy in mania. Br J Psychiatry 1994;164:806–10.
27. Hiremani R, Thirthalli J, Tharayil B, et al. Double-blind randomized controlled
study comparing short-term efficacy of bifrontal and bitemporal electroconvulsive
therapy in acute mania. Bipolar Disord 2008;10:701–7.
28. Barekatain M, Jahangard L, Haghighi M, et al. Bifrontal versus bitemporal electro-
convulsive therapy in severe manic patients. J ECT 2008;24(3):199–202.
29. Mohan T, Tharyan P, Alexander J, et al. Effects of stimulus intensity on the efficacy
and safety of twice-weekly, unilateral electroconvulsive therapy (ECT) combined
with antipsychotics in acute mania: a randomised clinical trial. Bipolar Disord
2009;11:126–34.
30. Schnur D, Mukherjee S, Sackeim H, et al. Symptomatic predictors of ECT
response in medication-nonresponsive manic patients. J Clin Psychiatry 1992;
53(2):63–6.
31. Mukherjee S, Sackeim H, Schnur D. Electroconvulsive therapy of acute manic ep-
isodes: a review of 50 years’ experience. Am J Psychiatry 1994;151(2):169–76.
32. Lee J, Arcand A, Narang P, et al. ECT-induced mania. Innov Clin Neurosci 2014;
11(11–12):27–9.
33. Rubner P, Koppi S, Conca A. Frequency of and rationale for the combined use of
electroconvulsive therapy and antiepileptic drugs in Austria and the literature.
World J Biol Psychiatry 2009;10:836–45.
34. el-Mallakh R. Complications of concurrent lithium and electroconvulsive therapy:
a review of clinical material and theoretical considerations. Biol Psychiatry 1988;
23(6):595–601.
35. Volpe F, Tavares A. Lithium plus ECT in mania in 90 cases: safety issues.
J Neuropsychiatry Clin Neurosci 2012;24(2):E33.
36. Ciapparelli A, Dell’Osso L, Tundo A, et al. Electroconvulsive therapy in
medication-nonresponsive patients with mixed mania and bipolar depression.
J Clin Psychiatry 2001;62:552–5.
37. Berger W, Portella CM, Fontenelle LF, et al. Antipsychotics, anticonvulsants, anti-
adrenergics and other drugs: what to do when posttraumatic stress disorder
does not respond to selective serotonin reuptake inhibitors? Rev Bras Psiquiatr
2007;29(Suppl 2):S61–5 [in Portuguese].
38. Youssef NA, McCall WV, Andrade C. The role of ECT in posttraumatic stress dis-
order: a systematic review. Ann Clin Psychiatry 2017;29(1):62–70.
39. Watts BV. Electroconvulsive therapy for comorbid major depressive disorder and
posttraumatic stress disorder. J ECT 2007;23(2):93–5.
40. Ahmadi N, Moss L, Simon E, et al. Efficacy and long-term clinical outcome of co-
morbid posttraumatic stress disorder and major depressive disorder after elec-
troconvulsive therapy. Depress Anxiety 2016;33(7):640–7.
41. Margoob MA, Ali Z, Andrade C. Efficacy of ECT in chronic, severe, antidepres-
sant- and CBT-refractory PTSD: an open, prospective study. Brain Stimul 2010;
3(1):28–35.
42. McCall WV, Mann SC, Shelp FE, et al. Fatal pulmonary embolism in the catatonic
syndrome: two case reports and a literature review. J Clin Psychiatry 1995;56(1):
21–5.
16 Rosenquist et al

43. Wijemanne S, Jankovic J. Movement disorders in catatonia. J Neurol Neurosurg

Psychiatry 2015;86(8):825–32.
44. Fink M, Taylor MA. The catatonia syndrome: forgotten but not gone. Arch Gen
Psychiatry 2009;66(11):1173–7.
45. McCall WV. The response to an amobarbital interview as a predictor of thera-
peutic outcome in patients with catatonic mutism. Convuls Ther 1992;8(3):
174–8.
46. Hatta K, Miyakawa K, Ota T, et al. Maximal response to electroconvulsive therapy
for the treatment of catatonic symptoms. J ECT 2007;23(4):233–5.
47. Medda P, Toni C, Luchini F, et al. Catatonia in 26 patients with bipolar disorder:
clinical features and response to electroconvulsive therapy. Bipolar Disord
2015;17(8):892–901.
48. Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized ex-
amination. Acta Psychiatr Scand 1996;93(2):129–36.
49. Boylan LS, Haskett RF, Mulsant BH, et al. Determinants of seizure threshold in
ECT: benzodiazepine use, anesthetic dosage, and other factors. J ECT 2000;
16(1):3–18.
50. Petrides G, Divadeenam KM, Bush G, et al. Synergism of lorazepam and electro-
convulsive therapy in the treatment of catatonia. Biol Psychiatry 1997;42(5):
375–81.
51. Rasmussen SA, Mazurek MF, Rosebush PI. Catatonia: our current understanding
of its diagnosis, treatment and pathophysiology. World J Psychiatry 2016;6(4):
391–8.
52. Escobar R, Rios A, Montoya ID, et al. Clinical and cerebral blood flow changes in
catatonic patients treated with ECT. J Psychosom Res 2000;49(6):423–9.
53. Suzuki K, Awata S, Matsuoka H. Short-term effect of ECT in middle-aged and
elderly patients with intractable catatonic schizophrenia. J ECT 2003;19(2):
73–80.
54. Suzuki K, Awata S, Matsuoka H. One-year outcome after response to ECT in
middle-aged and elderly patients with intractable catatonic schizophrenia.
J ECT 2004;20(2):99–106.
55. Suzuki K, Awata S, Takano T, et al. Continuation electroconvulsive therapy for
relapse prevention in middle-aged and elderly patients with intractable catatonic
schizophrenia. Psychiatry Clin Neurosci 2005;59(4):481–9.
56. Tuerlings JH, van Waarde JA, Verwey B. A retrospective study of 34 catatonic pa-
tients: analysis of clinical care and treatment. Gen Hosp Psychiatry 2010;32(6):
631–5.
57. Tandberg E, Larsen JP, Aarsland D, et al. The occurrence of depression in Par-
kinson’s disease. A community-based study. Arch Neurol 1996;53(2):175–9.
58. Landau AM, Chakravarty MM, Clark CM, et al. Electroconvulsive therapy alters
dopamine signaling in the striatum of non-human primates. Neuropsychopharma-
cology 2011;36(2):511–8.
59. Baldinger P, Lotan A, Frey R, et al. Neurotransmitters and electroconvulsive ther-
apy. J ECT 2014;30(2):116–21.
60. Lebensohn ZM, Jenkins RB. Improvement of Parkinsonism in depressed patients
treated with ECT. Am J Psychiatry 1975;132(3):283–5.
61. Borisovskaya A, Bryson WC, Buchholz J, et al. Electroconvulsive therapy for
depression in Parkinson’s disease: systematic review of evidence and recom-
mendations. Neurodegener Dis Manag 2016;6(2):161–76.
 The Use of Electroconvulsive Therapy 17

62. Andersen K, Balldin J, Gottfries CG, et al. A double-blind evaluation of electro-

convulsive therapy in Parkinson’s disease with "on-off" phenomena. Acta Neurol
Scand 1987;76(3):191–9.
63. Douyon R, Serby M, Klutchko B, et al. ECT and Parkinson’s disease revisited: a
"naturalistic" study. Am J Psychiatry 1989;146(11):1451–5.
64. Fall PA, Ekman R, Granerus AK, et al. ECT in Parkinson’s disease. Changes in
motor symptoms, monoamine metabolites and neuropeptides. J Neural Transm
Park Dis Dement Sect 1995;10(2–3):129–40.