correspondence

Electroconvulsive Therapy for Depression

To the Editor: Lisanby (Nov. 8 issue)1 reports,
in her Clinical Therapeutics article, on the use of
electroconvulsive therapy (ECT) in patients with
depression. ECT is rarely recommended in patients with schizophrenia (except for those with
acute catatonia). In the guidelines of the German
Medical Association, ECT is restricted as a treatment for patients with depression who have psychotic and suicidal symptoms.2 Modern ECT protocols for investigating the use of ECT in patients
with schizophrenia are limited. To date, data are
available from only 26 studies with a total of
798 such patients.3 However, it is noteworthy that
short-term responses are promising, and common
predictors of a response to ECT in both schizophrenic and affective disorders, such as delusions
and hallucinations, have been reported. Although
these observations have led to recommendations
to preferentially use ECT in certain subtypes of depression, such a syndromal approach is lacking in
schizophrenia. Future investigations may lead to
a broadening of ECT indications to include specific subtypes of schizophrenia.
Michael Dettling, M.D.
Ion Anghelescu, M.D.
Malek Bajbouj, M.D.
CharitUniversity Medicine Berlin
14050 Berlin, Germany
michael.dettling@charite.de
1. Lisanby SH. Electroconvulsive therapy for depression. N Engl

J Med 2007;357:1939-44.
2. Hoppe J-D, Scriba PC. Stellungnahme zur Elektrokrampftherapie (EKT) als psychiatrische Behandlungsmanahme. (Accessed January 17, 2008, at http://www.bundesaerztekammer.
de/downloads/EKT.pdf.)
3. Tharyan P, Adams CE. Electroconvulsive therapy for schizophrenia. Cochrane Database Syst Rev 2005;2:CD000076.

To the Editor: Lisanby notes that the efficacy of

ECT is affected by a variety of factors. The depth
of anesthesia induced by premedication and anesthetic drugs can also influence the effectiveness
of this therapy. For this reason, the electroencephalographic (EEG) bispectral index (BIS), a multivariate scale that reflects the level of anesthesia
in anesthetized patients, has become an important factor that predicts seizure activity and treatment success. White et al. found that EEG BIS
values obtained after induction of anesthesia (pre-

ECT BIS) and at the end of ECT (post-ECT BIS)

correlate with the duration of motor and EEG seizure activity in patients with glycopyrrolate and
methohexital anesthesia.1 This finding has been
reproduced with thiopental anesthesia.2 Sartorius et al. found a significant negative correlation
between the number of ECT sessions needed to
achieve full remission and pre-ECT BIS values.3
These studies support routine use of pre-ECT BIS
in patients with depression who are receiving
treatment with ECT.
Cesar Augusto Guevara-Cuellar, M.D.
Carlos Andres Pineda-Caar, M.D.
University of Valle
25360 Cali, Colombia
cesarguevara75@yahoo.com
1. White PF, Rawal S, Recart A, Thornton L, Litle M, Stool L.

Can the bispectral index be used to predict seizure time and

awakening after electroconvulsive therapy? Anesth Analg 2003;
96:1636-9.
2. Ochiai R, Yamada T, Kiyama S, Nakaoji T, Takeda J. Bispectral index as an indicator of seizure inducibility in electroconvulsive therapy under thiopental anesthesia. Anesth Analg 2004;
98:1030-5.
3. Sartorius A, Muoz-Canales EM, Krumm B, et al. ECT anesthesia: the lighter the better? Pharmacopsychiatry 2006;39:201-4.

To the Editor: The electrical craniofacial stimulation and the induced seizure from ECT have
clinically important cardiovascular effects1,2 not
discussed in the article by Lisanby. During and immediately after application of the electrical stimulus, severe bradycardia is common, with heart rates
in the 20-beats-per-minute range for a few seconds.
Sinus tachycardia, with rates often greater than
120 to 140 beats per minute, becomes the typical
rhythm as the seizure develops. When the seizure
ends, short-lived sinus bradycardia, with rates in
the 40s and 50s, is frequent. Arterial systemic
blood pressure increases during the seizure, with
systolic values frequently exceeding 200 mm Hg.
Diastolic values are increased as well. Arterial hypertension slowly resolves over a period of 10 to 20
minutes after the ECT session. Intravenous drugs
such as esmolol and propofol are often used to
limit seizure-induced hypertension. These cardiovascular effects might complicate the clinical
decision regarding the use of ECT in the elderly
patient described in the vignette. A vigilant anesthesiologist, pre-ECT clinical selection and eval-

n engl j med 358;6 www.nejm.org february 7, 2008

The New England Journal of Medicine

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Copyright 2008 Massachusetts Medical Society. All rights reserved.

645

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n e w e ng l a n d j o u r na l

uation, intravenous access, and frequent measurements of blood pressure, in addition to the
oxygen-saturation and cardiac-rhythm monitoring
mentioned in the article, are essential to the safety
of ECT.
Andrea Torri, M.D.
Massachusetts General Hospital
Boston, MA 02114
atorri@partners.org

Stephen Seiner, M.D.

McLean Hospital
Belmont, MA 02478
1. Welch CA, Drop LJ. Cardiovascular effects of ECT. Convuls

Ther 1989;5:35-43.
2. Ding Z, White PF. Anesthesia for electroconvulsive therapy.
Anesth Analg 2002;94:1351-64.

of

m e dic i n e

cite studies showing associations among BIS score,

seizure duration, and outcome. Seizure duration,
in isolation, is no longer considered a reliable
indicator of the efficacy of ECT.1 The study4 of
BIS score and outcome was an open study in
which concomitant medications were not controlled. Controlled, randomized studies are needed to confirm these promising results and to
determine whether approaches to monitor and
adjust the depth of anesthesia may improve the
outcome with ECT.
Torri and Seiner highlight the acute cardiovascular effects of ECT. Thorough medical evaluation, with special attention to cardiovascular
history, is an important part of the pre-ECT
evaluation.1 Frequent assessment of heart rate
and blood pressure during ECT is standard to
identify any potential cardiovascular complications.1 Most of the heart-rate and blood-pressure
changes seen with ECT are transient and frequently do not require intervention. In addition,
many centers use small doses of atropine to prevent bradycardia. Short-acting beta-blockers and
calcium-channel blockers are quite effective in
mitigating the peaks of heart rate and blood pressure during and after the seizure, if they become
severe or prolonged. Of course, proper patient selection and careful monitoring during and after
the treatment are important for optimal ECT
practice, especially in treating the elderly.

The author replies: Although this Clinical

Therapeutics article focuses exclusively on the use
of ECT in the treatment of major depression,
Dettling and colleagues correctly point out that
ECT has been used in the treatment of schizophrenia.1,2 Schizophrenia is included as a principal diagnostic indication for ECT in the report of
the American Psychiatric Associations Task Force
on Electroconvulsive Therapy. ECT has been reported to be helpful in the treatment of depression in the context of schizophrenia and also in
the treatment of medication-resistant psychotic
symptoms. Furthermore, there is a reported synergy between ECT and atypical neuroleptics in
the treatment of refractory psychosis.3 This is an
Sarah H. Lisanby, M.D.
application of ECT that could benefit from furUniversity College of Physicians and Surgeons
ther research to identify the clinical role of ECT Columbia
New York, NY 10032
in schizophrenia and develop effective strategies depression@columbia.edu
to maintain a benefit in the treatment of this dis1. American Psychiatric Association Committee on Electroconorder.
vulsive Therapy. The practice of electroconvulsive therapy: recGuevara-Cuellar and Pineda-Caar raise the ommendations for treatment, training, and privileging. 2nd ed.
important point that the depth of anesthesia can Washington, DC: American Psychiatric Association, 2001.
affect the outcome of ECT. Anesthestics that raise 2. Tharyan P, Adams CE. Electroconvulsive therapy for schizophrenia. Cochrane Database Syst Rev 2005;2:CD000076.
the seizure threshold may necessitate higher elec- 3. Havaki-Kontaxaki BJ, Ferentinos PP, Kontaxakis VP, Paplos
trical dosages to ensure optimal efficacy, espe- KG, Soldatos CR. Concurrent administration of clozapine and
cially for unilateral ECT. Guevara-Cuellar and electroconvulsive therapy in clozapine-resistant schizophrenia.
Clin Neuropharmacol 2006;29:52-6.
Pineda-Caar suggest that EEG BIS may be useful 4. Sartorius A, Muoz-Canales EM, Krumm B, et al. ECT anesin titrating the depth of anesthesia for ECT. They thesia: the lighter the better? Pharmacopsychiatry 2006;39:201-4.

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n engl j med 358;6 www.nejm.org february 7, 2008

The New England Journal of Medicine

Downloaded from nejm.org on November 6, 2015. For personal use only. No other uses without permission.
Copyright 2008 Massachusetts Medical Society. All rights reserved.