• Document: VO- PMHP Treatment Guideline 102: Electroconvulsive Therapy (ECT)
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VO- PMHP Treatment Guideline 102: Electroconvulsive Therapy (ECT) Diagnostic Guidelines: Introduction: Electroconvulsive Therapy has been in continuous use for more than 60 years. The clinical literature establishing its efficacy in specific disorders is among the most substantial for any medical procedure. The decision to recommend the use ECT derives from a risk/benefit analysis for the specific patient. This analysis considers the diagnosis of the patient and the severity of the presenting illness, the patient’s treatment history, the anticipated speed of action and efficacy of ECT, the medical risks and anticipated adverse side effects. These factors should be considered against the likely speed of action, efficacy, and medical risks of alternative treatments in making a determination to use ECT. These Guidelines are taken from the APA Guidelines published in November 2000, which should be reviewed for further details. Indications for Use Primary Use: ECT is a major treatment in psychiatry with well-defined indications. It should not be reserved for use only as a “last resort”. The likely speed and efficacy of ECT are factors that influence its use as a primary intervention. Particularly in major depression and acute mania, substantial clinical improvement often occurs soon after the start of ECT. When a rapid or a higher probability of response is needed, as when patients are severely medically ill or at risk to harm themselves or others, primary use of ECT should be considered. Other considerations for the first-line use of ECT involve the patient’s medical status, treatment history, and treatment preference. A second psychiatric opinion from a physician not involved with the administration of the proposed ECT is required for authorization of this treatment modality for ValueOptions Tennessee Prepaid enrollees. Secondary Use: The most common use of ECT is with patients who have not responded to other treatments. During the course of pharmacotherapy, lack of clinical response, intolerance of side effects, deterioration in the psychiatric condition, or the appearance of suicidality are reasons to consider the use of ECT. Major Diagnostic Considerations Major Depression Mania Schizophrenia and Related Psychotic Disorders- ECT is usually considered for psychotic patients who have not responded to trials of medications. The best response to ECT in this population is noted when the duration of illness from initial onset is short; when psychotic symptoms in the present episode have an abrupt or recent onset; with catatonia present; or when there has been a favorable response to ECT in the past. Medical Conditions Associated with Substantial Risk There are no absolute medical contraindications to ECT. It is more pertinent to think in terms of degree of risk relative to potential benefits of ECT. There are some specific conditions that may be associated with substantially increased risk. These are: ¾ Unstable or severe cardiovascular conditions such as recent myocardial infarction, congestive heart failure, and severe valvular cardiac disease. ¾ Aneurysm or vascular malformation that might be susceptible to rupture with increased blood pressure. ¾ Increased intracranial pressure, as may occur with some brain tumors or other space-occupying Page 1 of 5 lesions. ¾ Recent cerebral infarction. ¾ Pulmonary conditions such as severe chronic obstructive pulmonary disease, asthma, or pneumonia. ¾ Anesthetic risk rated as ASA level 4 or 5. Treatment Guidelines: Use of Medical and Psychotropic Medications During ECT All medications should be reviewed as part of the pre-ECT evaluation. In general, it is advisable to discontinue or reduce the dose of most psychotropic agents prior to ECT, although this should not prevent the institution of ECT treatment in a timely fashion. This is especially true for medications that may increase morbidity or decrease efficacy of ECT (i.e. benzodiazepines and most sedative hypnotics, anticonvulsants, lithium). Patients on antidepressants may continue the course of therapy, as co-administration of moderate doses of antidepressant is unlikely to contribute substantially to morbidity. There may even be a synergistic effect with the co-administration of antipsychotic medication and ECT. The medications administered before ECT on treatment days should be clearly specified. Procedure for ECT Pre-ECT Evaluation: Although components of the evaluation for ECT will vary on a case-by-case basis, each facility should have a minimal set of procedures to be undertaken in all cases. These include: ¾ Psychiatric history and examination to determine the indication for ECT, including previous response to ECT if pertinent. ¾ A medical evaluation to define risk factors ¾ An evaluation by an individual privileged to administer ECT with a note in the clinical record summarizing the indications and potential risks for the specif

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