Asian Journal of Psychiatry 31 (2018) 43–48

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Electroconvulsive Therapy among Elderly patients: A study from Tertiary T

care centre in north India
⁎
Sandeep Grover , Ashirbad Satapathy, Subho Chakrabarti, Ajit Avasthi
Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: This retrospective study aimed to evaluate the effectiveness and safety of ECT among elderly patients
Electroconvulsive therapy receiving electroconvulsive therapy (ECT).
Elderly Methods: During the study period of January 2008 to May 2017, 151 patients aged ≥60 years received ECT and
Effectiveness they formed the study sample. Data on patients aged 19 to 59 years for the period of 3 years (2014–2016) was
also extracted for comparison purposes.
Results: The mean age of the elderly subjects was 65.8 years. In contrast to the young patients, elderly patients
who received ECT more often had diagnosis of affective disorder, especially unipolar depression. Compared to
young patients, elderly patients had higher prevalence of physical comorbidity with one third having more than
one physical illness. The most common reason for use of ECT among elderly was poor response to medications
(62.3%), followed by requirement of early response (49.6%). Four-fifth (80.8%) of the elderly patients showed
≥50% reduction in the symptoms with ECT. In terms of side effects, acute blood pressure changes were seen in
40.3% of patients during the ECT procedure and about half of the patients reported cognitive disturbances.
Conclusion: Present study suggests that ECT can be safely used among elderly patients, especially those with
depressive disorders, not responding to medications.

1. Introduction
Electroconvulsive therapy (ECT) is possibly the only treatment
modality in psychiatry, which has survived the test of time and over the
years, the technical aspects of use of ECT have improved. Despite this,
efficacy/effectiveness of ECT has never been in doubt (Moser et al.,
2005). Various controversies and negativistic opinion about ECT has led
to decline in use of ECT in developed countries and it is one of the last
resort treatments for various psychiatric disorders (Glen and Scott,
1999). In terms of trends for use of ECT, data from the developed
countries suggest that elderly form a large proportion of patients re-
ceiving ECT. Different surveys from countries like United States, United
Kingdom and Australia suggest that about one fourth to half of the
patients receiving ECT are aged above 65 years (Pippard and Ellam,
1981; ECT survey England, 1999; Reid et al., 1998; Kramer, 1999;
Prudic et al., 2001; Wood and Burgess, 2003, Chanpattana, 2007). Data
also suggest that elderly are 2 to 7 times more likely to receive ECT,
compared to subjects belonging to other age groups (Duffett et al.,
1999; Olfson et al., 1998). The indications for use of ECT among elderly
are similar to those in adult population, but it is primarily used for
management of depressive disorders (Benbow, 2005; Rabheru, 2001;
Flint and Gagnon, 2002). Some of the authors suggest that higher use of
ECT among elderly may be attributed to poor efficacy of medications in
this population, especially, in elderly patients with depression, espe-
cially those with vascular depression; poor tolerability to medications
due to pharmacokinetic changes, medical comorbidities and better ef-
ficacy of ECT in elderly patients with depression, compared to adult
patients (Kerner and Prudic, 2014). ECT is considered as a low-risk
procedure among elderly with various medical disorders (Kelly and
Zisselman, 2000) and the cognitive side effects of ECT among elderly
are considered to be usually transient and not severe (Geduldig and
Kellner, 2016). In terms of efficacy, ECT has not only been shown to be
efficacious in management of acute phase of depression among elderly,
but has also been shown to be efficacious and safe as continuation and
maintenance ECT (Van Schaik et al., 2012). The response and remission
rate with ECT among elderly with acute depression vary from 50 to
84%, with higher response rate among those with psychotic depression
and higher age (Kelly and Zisselman, 2000; O’Connor, 2002; Flint and
Rifat, 1998).
Compared to West, ECT is more frequently used in developing
countries like India and China with increasing trends in last few dec-
ades (Xiang et al., 2015). Elderly form the third largest group, after

⁎
Corresponding author.
E-mail address: drsandeepg2002@yahoo.com (S. Grover).

https://doi.org/10.1016/j.ajp.2018.01.004
Received 23 November 2017; Received in revised form 29 December 2017; Accepted 22 January 2018
1876-2018/ © 2018 Elsevier B.V. All rights reserved.
S. Grover et al.
those aged 45 to 64 years and 25 to 44 years (Chanpattana et al., 2005).
However, data in terms of use of ECT among elderly from devel-
oping countries is sparse (Jain et al., 2008; Zhang et al., 2015). A ret-
rospective study from India showed that elderly (≥60 years) form 15%
of all patients who receive ECT. The most common indication for ECT
among elderly was severe depression not responding to adequate psy-
chotropic medications. Two-third of the elderly patients who received
ECT had comorbid medical illnesses. In terms of effectiveness, 70% of
patients showed more than 50% reduction in symptomatology with
better response rate among those with inadequate response to anti-
depressant medications prior to starting ECT. Presence of medical co-
morbidities was associated with higher risk of development of cognitive
side effects (Jain et al., 2008). A large sample (N = 2339) retrospective
study of elderly (≥60 years) patients from China demonstrated that
28.1% of elderly inpatients received ECT, with most common indica-
tions for use of ECT being major depression, followed by bipolar dis-
order and schizophrenia. Compared to those who did not receive ECT,
elderly patients who received ECT more often belonged to those aged
60–64 years, had high risk of suicide, lower risk of falls at the time of
admission, lower use of mood stabilizers and antidepressants, lack of
health insurance, a diagnosis of major depression and comorbid med-
ical disorders (Zhang et al., 2015).
Considering the sparsely available data on use of ECT among elderly
patients from developing countries, there is a need to expand the lit-
erature. The present retrospective study aimed to evaluate the effec-
tiveness and safety of ECT among elderly.
2. Material and methods
This retrospective study was conducted at a multi-specialty tertiary
care hospital in north-India. The study was approved by the ethics
committee of the institute.
The hospital provides both outpatient and inpatient services to the
patients seeking mental health care. On an average, about
10,000–14,000 new patients seek psychiatric treatment every year, and
about 200 patients are admitted to the inpatient unit. There is no se-
parate geriatric inpatient unit and elderly patients admitted in the same
unit as the adult patients. Whenever a new patient attends the psy-
chiatry services, she/he is initially evaluated by a senior resident
(equivalent of a registrar) or a consultant and the treatment is initiated
based on diagnosis as per the International Classification of Diseases,
10th revision (ICD-10) and the patient is given an appointment for
detailed evaluation. At the time of detailed evaluation, patient is in-
itially seen by a trainee resident (Junior Resident), who collects in-
formation from the patient, family, reviews the available treatment
records (both psychiatric and medical) and then the case is discussed
with a consultant. Based on the available information, a diagnosis is
arrived at and the treatment plan is formulated. Most of the patients are
managed with pharmacotherapy and psychological interventions. In
very few selected cases, ECT is offered.
All patients who are administered ECT receive bilateral modified
ECT. ECT is administered to both inpatients and outpatients. The de-
cision to administer ECT is usually taken by the consultant-in-charge of
the case, in consultation with other treating team members. In few
complicated cases, a second opinion is often sought from other con-
sultant.
ECT is usually advised based on the patient’s clinical status, severity
of symptoms, response to other treatment and past history. Once ECT is
considered as a treatment, patient and family members are approached
and explained about the need for the ECT and procedure of ECT. They
are also provided with an information booklet, which is in the local
language, to read and clarify their queries. Once, they agree for ECT, a
written informed consent is obtained from the patient and/or family
members accompanying the patients, who are actively involved in
taking care of the patient. Patients who agree to undergo ECT are
evaluated physically, undergo necessary investigations and are
44
Asian Journal of Psychiatry 31 (2018) 43–48
evaluated by the anaesthetist for their fitness to undergo ECT. If the
patient is considered to be fit for ECT, then they are administered ECT
by using an indigenously manufactured machine (Medicaid Systems,
Chandigarh, India). All patients undergo, bilateral, brief-pulse, mod-
ified ECT. The ECT machine delivers constant energy, however, it has
the provision for adjusting the duration of current passed (0.1 s to upto
5 s), frequency (settings of 20, 40, 50, 60, 70, and 90 Hz), and the pulse
width (0.1, 0.2, 0.5, 1, 1.2, and 1.5 s). The machine also has a provision
for Electroencephalographic monitoring; however this is not done
routinely. Usually, the frequency (70 Hz) and pulse width (1 s) are kept
constant and the duration of current is adjusted. In elderly subjects, the
first stimulus is given at 0.6 s. If the patient does not have an effective
seizure (motor seizure of 15-s duration), the duration of current passed
is increased and a maximum of 3 stimuli are given in an ECT session. In
subsequent sessions, the electrical dose is adjusted to compensate for
the rise in the seizure threshold. ECT is given three times a week
(Monday, Wednesday, and Saturday) by a trainee resident under the
supervision of a senior resident and a consultant. The anaesthesia team
includes a trainee resident, a senior resident, a consultant and a tech-
nician. Pre-medication for ECT involves use of atropine (0.2–0.3 mg)/
glycopyrrolate (0.2–0.3 mg). Induction is usually done by thiopental
sodium (150–450 mg) with occasional patient given propofol
(60–100 mg). For muscle relaxation, succinylcholine (30–60 mg) is
used. All the patients are adequately oxygenated prior to giving elec-
trical stimulus. The seizure duration is recorded on the basis of the cuff
method and a motoric seizure of at least 15 s is considered to be an
indicator of effective ECT. Patients receiving ECT are usually evaluated
on the standardized scales such as the Hamilton Depression Rating
Scale (HDRS), the Young Mania Rating Scale, Geriatric Depression
Rating Scale and the Brief Psychiatric Rating Scale for the level of im-
provement.
In general sedative/hypnotic agents are withdrawn prior to ad-
ministration of ECT. Other medications are also withdrawn, if these are
considered to interfere with ECT. Some of the patients who have not
responded to an adequate antidepressant trial, undergo change of an-
tidepressant, prior to or after the starting of ECT. Patients are kept
fasting for the overnight, prior to ECT. However, patients are allowed to
take their antihypertensive medications and other essential medications
on the day of ECT. Data of all the patients receiving ECT is entered into
an ECT register and patient treatment records. The ECT registered is
reviewed weekly for completeness.
For this study, the ECT register for the period of January 2008 to
May 2017 was screened to identify patients aged ≥60 years at the time
of administration of ECT. Treatment records of the identified patients
were reviewed to extract the ECT details for this study. Additionally,
data pertaining to sociodemographic variables, clinical variables and
other treatment were extracted from these records. During this period,
151 patients aged ≥60 years received ECT and they formed the study
sample for this study. Data on patients aged 19–59 years for the period
of 3 years (2014–2016) was also extracted for comparison purposes. All
data were initially extracted by A.S. and subsequently randomly cross-
checked by S.G. for accuracy.
Data was analysed by using SPSS-16 version. Categorical variables
were analysed in the form of frequency and percentages. Continuous
variables were evaluated in the form of mean and standard deviations.
Comparisons were done by Chi-square test and t-test.
3. Results
3.1. Study sample and demographic profile
During the study period of total 151 patients aged ≥60 year were
given ECT during the study period. The mean age of patients was 65.8
years (SD, 5.18 years; range, 60–81 years) with only only-fourth
(N = 35; 23.2%) of patients being aged ≥70 years. The mean duration
of education of patients was 8.42 (SD −6.14). Higher proportion of the
S. Grover et al. Asian Journal of Psychiatry 31 (2018) 43–48

Table 1
Profile of patients receiving ECT.

Variables Mean (SD)/ Frequency (%) N = 151 Mean (SD)/ Frequency (%) N = 365 T-test/Chi-square test (P-value)

Age in years 65.80(5.18), 36.8 (11.07) 31.87 (p < 0.001)***

Range: 60–81 Range 19–59
Mean years of education(SD), Range 8.42(6.14) 10.41 (4.6) 4.03 (p < 0.001)***
Range: 0–23 Range 0–24
Gender
Male 86(57%) 200 (54.8%) 0.202 (p = 0.65)
Female 65(43%) 165 (45.25)
Treatment setting
Inpatient 88 (58.3%) 175 (47.9%) 4.56 (0.03)*
Outpatient 63 (41.7%) 190 (52.1%)
Diagnosis
Affective Disorders 141 (93.4%) 237 (64.9%) 44.11 (p < 0.001)***
Psychotic disorders 10 (6.6%) 128 (35.1%)
Diagnosis
Schizophrenia 6(3.9%) 115 (31.5%) 45.1 (p < 0.001)***
BPAD, Current episode depression 21(13.9%) 44 (12.0%) 0.33 (p = 0.56)
BPAD, Current episode mania 6 (3.9%) 31 (8.5%) 3.27 (p = 0.07)
RDD, Current episode depression 67(44%) 78 (21.4%) 27.96 (p < 0.001)***
First Episode Depression 48(31.7%) 86 (23.6%) 3.76 (p = 0.05)*
Psychosis NOS 1(0.6%) 3 (0.8%) FE = 1.00
Schizoaffective disorder 1(0.6%) 3 (0.8%) FE-1.00
Organic psychosis 2(1.2%) 3 (0.8%) FE = 0.63
Acute and transient Psychosis – 2 (0.5%) FE = 1.00
Index episode
Depression with psychotic symptoms 79 (52.3%) 113 (35.9%) 20.85 (p < 0.001)***
Depression without psychotic symptoms 56 (37.1%) 94 (25.75%) 6.65 (p < 0.001)***
Mania with psychotic symptoms 5 (3.3%) 21 (5.75%) 1.33 (p = 0.25)
Mania without psychotic symptoms 1 (0.7%) 10 (2.73%) 1.32 (p = 0.25)
Psychosis 10 (6.6%) 128 (35.1%) 44.11 (p < 0.001)***
Onset
Acute 22(14.6%) 62 (17%) 1.40 (0.49)
Subacute 22(14.6%) 64 (17.5%)
Insidious 107(71%) 239 (65.5%)
Mean duration of current symptoms in month 9.29 (11.64) 30.3 (46.4) U = 21588 (p = 0.013)*
Course of symptoms
Worsening 117 (77.5%) 294 (80.5%) 0.27 (p = 0.87)
Steady 13 (8.6%) 29 (7.9%)
Fluctuating 19 (12.6%) 42 (11.5%)
Physical co morbidities
Hypertension 79 (52.31%) 22 (6%) 145.39 (p < 0.001)***
Diabetes Mellitus 33 (21.85%) 7 (1.9%) 54.88 (p < 0.001)***
Coronary Artery Disease 3 (2%) 1 (0.3%) FE = 0.07
Chronic Obstructive Pulmonary Disease 3 (2%) – FE = 0.02*
Bronchial asthma 2 (1.3%) – FE = 0.08
Hypothyroidism 5 (3.3%) 10 (2.7%) 0.124 (p = 0.72)
Others 13 (8.6%) 29 (7.9%) 0.06 (p = 0.80)
More than one 40 (26.5%) 19 (5.2%) 19.36 (p < 0.001)***
Nil 45 (29.8%) 277 (75.8%) 96.70 (p < 0.001)***
Mood stabiliser
Lithium 8 (5.3%)
Valproate 11 (7.3%)
Oxcarbazepine 1 (0.7%)
Lamotrigine –
Antidepressants
Tricyclic Antidepressant 10 (6.6%)
Selective serotonin Reuptake Inhibitor 36 (23.8%)
Venlafaxine 49 (32.4%)
Mirtazapine, others 28 (18.5%)
Antipsychotics
Risperidone 10 (6.6%)
Olanzapine 52 (34.4%)
Quetiapine 32 (21.2%)
Clozapine 2 (1.3%)
Aripiprazole 2 (1.3%)
Ziprasidone 1 (0.7%)
Trifluoperazine 1 (0.7%)
Haloperidol –
More than one antipsychotic –
Benzodiazepines
Lorazepam 15 (9.9%)
Clonazepam 42 (27.8%)
Nitrazepam 4 (2.6%)
Zolpidem 5 (3.3%)
Eszopiclone 1 (0.7%)
(continued on next page)

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S. Grover et al. Asian Journal of Psychiatry 31 (2018) 43–48

Table 1 (continued)

Variables Mean (SD)/ Frequency (%) N = 151 Mean (SD)/ Frequency (%) N = 365 T-test/Chi-square test (P-value)

Others 1 (0.7%)
Anticholinergics
Trihexyphenidyl 3 (2%)
Phenergan 6 (4%)

patients (N = 88; 58.3%) were inpatients at the time of starting of ECT Table 2
and for remaining patients (N = 63; 41.7%), ECT was started on the ECT profile of the study sample.
outpatient basis. Men (n = 86; 57%) outnumber women (n = 65; 43%)
Variables Mean (SD)/ Frequency (%) N=151
slightly (Table 1).
During the 3 year period (2014–2016), 365 patients aged 19 to 59 Past history of Use of ECT-Yes 43 (28.5%)
years received ECT and this sample formed the control group. As ex- Response to ECT in the past
Satisfactory 41 (27.15%)
pected, compared to the elderly group, patients in the control group
Non-Satisfactory 2 (1.3%)
were significantly younger, had higher number of years of formal REASON FOR ECT
school education and were more often outpatients at the time of re- Poor response to medication 94(62.3%)
ceiving ECT. Contraindication to medication 14(9.2%)
Poor oral intake 36(23.8%)
Suicidality 68(45%)
3.2. Clinical profile Requirement of early response 75(49.6%)
ECT as treatment of choice 72(47.6%)
The most common diagnosis in the elderly group was Recurrent Catatonic symptoms 17(11.2%)
Psychomotor retardation 27(17.8%)
Depressive Disorder, current episode depression (N = 67; 44%), and Mean number of ECT 8.04(3.36)
this was followed by first episode depression (N = 48; 31.7%) and bi- Range: 1–22
polar affective disorder, current episode depression (N = 21; 13.9%). Overall improvement
Overall in 93.4% of elderly cases, ECT was administered for patients None 6 (4 %)
< 25% 6 (4%)
with affective disorders (Table 1), predominantly for depression
25–50% 17 (11.3%)
(N = 135; 89.4%). More than half of the elderly patients with depres- > 50% 122 (80.8%)
sion (N = 79; 58.5%) had psychotic symptoms at the time of adminis- Overall Improvement for Depression
tration of ECT (Table 1). In majority of the patient the index episode for None 4 (3.0%)
which ECT was considered had insidious onset and the mean duration < 25% 5 (3.7%)
25–50% 11 (8.1%)
of current episode was 9.29 (SD-11.64) months. In three-fourth of the > 50% 115 (85.2%)
cases, the course of the current episode was worsening. More than two- Immediate complications
third (N = 106; 70.2%) of the patients had at least one comorbid Acute blood pressure changes 61(40.3%)
physical illness, with hypertension being the most common physical ECG changes 8 (5.3%)
Hypoxia 1 (0.7%)
comorbidity, seen in more than half (52.31%) of cases. About one-
Others 8 (5.3%)
fourth of the patients had ≥1 physical comorbidity (Table 1). Among More than one 1 (0.7%)
the various antidepressants, about one-third of the patients were re- None 71 (47.0%)
ceiving venlafaxine at the time of receiving ECT and one-fifth of them Complications
were receiving a selective serotonin reuptake inhibitor (SSRI) (Table 1). Aches & pains 11 (7.3%)
Injuries 8 (5.3%)
Few patients (13.2%) were receiving mood stabilizers at the time of
Physical complications 8 (5.3%)
administration of ECT. About two-third (N = 100; 66.2%) of cases were Cognitive decline 74(49%)
receiving antipsychotics with olanzapine being the most common agent Delirium 8 (5.3%)
(Table 1). Less than half of the patients were also prescribed benzo- Switch 0
Reasons for stopping ECT
diazepines, with clonazepam being the most common agent. A small
Response plateaued in last 2 ECTs 127 (84.1%)
proportion of patients were receiving anticholinergics (Table 1). Complications 2 (1.3%)
In contrast to the young patients, elderly more often had diagnosis Contraindication for further ECT 3 (2.0%)
of affective disorder, especially unipolar depression. Mean duration of No Improvement 16 (10.6%)
current episode was significantly shorter for the elderly group.
Compared to young patients, elderly patients more often had comorbid
physical illnesses, including hypertension, diabetes mellitus, chronic per the rating scales in the elderly group was 66.34% (SD-23.24; range
obstructive pulmonary disease and more than one physical co- 0 to 100%), with higher reduction in those having poor response to
morbidity. pharmacological treatment (74.29; SD-17.58).
The percentage reduction in symptomatology in the first episode
depression group was 65.34% (SD 25.89; range 0–100) and for RDD
3.3. ECT profile group was 68.1% (SD-20.2). About half (N = 69; 51.1%) of the patients
achieved remission (HDRS of ≤7) and another 24 patients had HDRS
As shown in Table 2, the most common reason for considering ECT ≤10 (17.8%) at the end of ECT.
in the elderly group was poor response to medications and this was When further analysis was carried, 80.45% (70 out of 87) of patient
followed by reasons like requirement of early response, ECT was con- with depression who had not responded to pharmacotherapy achieved
sidered as a treatment of choice and presence of suicidality. The mean remission with ECT, whereas 93.75% (45 out 48) who had no history of
number of ECTs administered per patient were 8.04 (SD 3.36) with a poor response to medications achieved remission, with no significant
range of 1 to 22. In terms of improvement, more than four-fifth of the difference between the two groups.
patients (N = 122; 80.8%) had more than 50% reduction in the When the response rate was evaluated for patients with and without
symptoms with ECT and another 11.3% had 25–50% reduction in hypertension, the mean symptom reduction was similar among those
symptoms with ECT (Table 2). Mean reduction in symptomatology as

46
S. Grover et al.
with and without hypertension (t = 0.05; p = 0.96).
In terms of immediate complications, acute blood pressure changes
were seen in 40.3% of patients during the ECT procedure. Other less
common complications which were seen during the administration of
ECT included electrocardiogram (ECG) changes (Table 2). In terms of
post-procedure complications, cognitive decline was noted in about half
of the patients. Other less frequent complaints included aches and pains
and delirium.
4. Discussion
There is limited data on use of ECT among elderly from developing
countries. Although ECT is used more liberally used in India (Jain et al.,
2008), compared to some of the developed countries, data on use of
ECT among elderly is limited. The present study attempted to expand
this limited literature. The mean age of the study sample in the present
study was 65.8 years with maximum age being 81 years. This finding is
similar to the previous study from India (Jain et al., 2008) and suggests
that age is not a barrier in using ECT among elderly. Existing literature
suggests that ECT has been safely used in patients as old as 100 years
(O’Reardon et al., 2011). Considering the findings of the present study
and existing literature, it can be said that clinicians should not withhold
the use of ECT only on the consideration of age.
In the present study, males outnumbered females among patients
who received ECT. This finding is again in concordance with the pre-
vious study from India (Jain et al., 2008) and other developing coun-
tries like Thailand. However, studies from developed countries suggests
that elderly women outnumber elderly men in receiving ECT (Kramer,
1999; Duffett et al., 1999; Reid et al., 1998). These gender differences
in use of ECT in developing countries and developed countries could
possibly be due to male forming significantly larger proportion of el-
derly seeking treatment in our set-up (Grover et al., 2012). An inter-
esting fact observed in the present study was that about two-fifth of the
elderly received ECT as outpatients. Although, when compared to adult
population, this proportion was less, but this finding reflect that ECT
can also be used safely in outpatients.
In the present study, majority (93.4%) of the patients who received
ECT were diagnosed with mood disorder, with about 90% being diag-
nosed with depression. Studies from various parts of the World, in-
cluding India, also suggest that depression is the most common in-
dication of use of ECT among elderly (Chanpattana et al., 2005).
However, when this diagnostic profile was compared with adult pa-
tients, it is evident that among adult patients a significantly higher
proportion of patients receive ECT for psychotic disorders and this
finding is supported by the previous study from India (Jain et al., 2008).
In terms of specific reasons for use of ECT, about two-third of the
patients had not responded to the medication prior to being considered
for ECT. Other common indications for use of ECT were requirement of
early response, ECT considered as treatment of choice and presence of
suicidality. These indications for use of ECT are consistent with the
existing literature (Jain et al., 2008; Benbow, 2005; Rabheru, 2001;
Flint and Gagnon, 2002) and recommendations for use of ECT as made
by various organizations (APA Practice Guideline, 2010; RCPsych
Special Committee of ECT, 2005). In the present study, elderly patients
received a mean of 8 ECTs, and this is similar to the existing studies
(Jain et al., 2008).
In the present study, significantly high proportion of elderly patients
who received ECT had comorbid physical disorders, with hypertension
being the most common, followed by diabetes mellitus. Few patients
also had other comorbid physical illnesses like coronary artery disease,
chronic obstructive pulmonary disease, bronchial asthma and hy-
pothyroidism. The safe use of ECT in presence of physical illnesses
suggests that with proper precautions, ECT can be used safely in pa-
tients with various physical illnesses. Recommendations made by dif-
ferent organizations (APA Practice Guideline, 2010; RCPsych Special
Committee of ECT, 2005) also suggest that there are no absolute
47
Asian Journal of Psychiatry 31 (2018) 43–48
contraindications to use of ECT in presence of various physical illnesses.
In the present study, 80.8% of elderly patients showed response to
ECT, defined as reduction in symptom score by at least 50% in specific
rating scales. When the same was evaluated for patients with depres-
sion, the percentage rose to 85.2%. In terms of various types of de-
pression, the percentage reduction in symptomatology in the first epi-
sode depression group was 65.34% and for RDD group was 68.1%. In
the present study half (51.1%) of the patients achieved remission
(HDRS of ≤7) and another 17.8% patients had HDRS score ≤10 at the
end of ECT. Existing data on use of ECT among elderly suggest that
70–90% of the elderly respond adequately to ECT (Jain et al., 2008,
Benbow, 2005; O’Connor et al., 2001; Tew et al., 1999). Present study
provides further support to the effectiveness of ECT among elderly
patients with depression and suggests that ECT must be considered as a
viable treatment option for management of depression among elderly,
when they fail to respond to pharmacotherapy.
Further, in the present study, symptom reduction did not differ
among those with and without hypertension. It is well known that el-
derly patients with vascular depression do not respond well to phar-
macotherapy (Alexopoulos et al., 1997). If one considers hypertension
as a proxy variable for vascular depression in elderly, it can be said that
ECT may be viable treatment option among elderly depressed patients
with vascular depression, who do not respond to pharmacotherapy.
In terms of immediate complications 40.3% of patients experienced
acute blood pressure changes during one of the ECT session and other
immediate complications included ECG changes. However, in none of
the patients these changes led to stoppage of treatment. In terms of
delayed complications about half of the patients experienced transient
cognitive deficits. Existing literature on cognitive deficits with use of
ECT among elderly suggests that ECT is associated with increased rates
of inter-ictal and post-ictal cognitive deficits, but over the time period
(i.e., about 6 months), cognitive deficits either remain same or reduce
(Kumar et al., 2016). Other complications included aches and pains,
delirium, dental injuries and other physical complications. This profile
of side effects is consistent with the existing literature (Tomac et al.,
1997; Gormley et al., 1998). When compared with the previous study
from India, in the present study, higher proportion of patients experi-
enced cognitive deficits. This could be possibly be due to better doc-
umentation rather than true difference in the prevalence of cognitive
deficits.
Present study is limited by the retrospective study design. Further,
present study reflects the ECT practices at one centre and these cannot
be generalized to all the centres across the country, due to hetero-
geneity in the treatment settings across the country.
To conclude, present study suggests that ECT can be safely used
among elderly patients, especially those with depressive disorders, not
responding to medications. Further present study suggest that response
rate with ECT is similar among patients with and without hypertension.
Further, present study suggests that ECT can also be administered safely
as an outpatient treatment for elderly, if proper precautions are ex-
ercised. ECT is associated with transient side effects which improve
with time. Accordingly, ECT must be considered as a viable treatment
option for elderly patients with depression, not responding to various
pharmacological agents. However, all elderly must undergo thorough
evaluation prior to use of ECT.
Conflict of interest
None.
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