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The goals of the pre-electroconvulsive therapy (ECT) evaluation are to (1) determine if ECT is indicated, (2) establish baseline measures of efficacy and cognitive side effects, (3) identify and treat any medical conditions that may increase the risk of medical or cognitive side effects from ECT, (4) initiate the process of informed consent, and (5) begin preparation of the patient and family/significant other for the procedure. These goals are accomplished in part by a complete medical and neuropsychiatrie history interview and examination, by the appropriate use of medical consultation and laboratory studies, and by a supportive and empathetic approach to informing the patient and family/significant other about the experience of ECT
INDICATIONS FOR ECT
The primary indications for ECT include major depression, mania, mixed affective states, dysthymia, affective disorders secondary to medical conditions, schizophrenia (with prominent affective symptoms), and the syndrome of catatonia.15 Typically, ECT is administered for these conditions after drug therapy has failed or has been poorly tolerated. In the following situations, ECT should be considered a first-line treatment for these conditions: when the severity of the psychiatric or medical condition dictates a need for a rapid, definitive response (eg, severe suicidal ideation, lethal catatonia, severe inanition) and when the risks of ECT are less than those of other treatments (eg, in the elderly or during the first two trimesters of pregnancy). Additionally, ECT should be considered a first-line treatment when a previous episode responded well to ECT or poorly to other treatments and also if it is the patient's preference.2 Finally, ECT is effective for delirium from various etiologies (including some cases of neuroleptic malignant syndrome), as well as for the motor manifestations of Parkinson's disease.3,6
These indications are identified through a thorough and detailed neuropsychiatrie history interview and examination. The neuropsychiatrie evaluation also affords an opportunity to determine the patient's handedness, an issue of relevance to nondominant (for language) unilateral electrode placement. Patients should be questioned about which hand they use to write, throw a ball, and use scissors, as well as which leg is used to kick a ball and which eye is used to sight a gun. Formal assessment tools of handedness are also available.7 The majority of right-handed and left-handed individuals will be left-brain dominant for language (about...