Electroconvulsive therapy (ECT) is a highly effective intervention for severe major depression (American Psychiatric Association Committee on Electroconvulsive Therapy, 2001). ECT is most often used because pharmacotherapy has failed. In certain clinical situations, however, ECT is the initial treatment of choice. Ten to fifteen percent of patients with major depression fail to respond to antidepressants. Such outcomes may persist despite adequate treatment with multiple classes of antidepressant drugs (Rush et al., 2006) and other pharmacologic augmentation strategies (eg, the addition of lithium to an antidepressant). Eventually, social relationships and work performance decline as patients lose hope and other depressive symptoms worsen in intensity. ECT should be strongly considered for such patients because many may fully recover with it. Those with an episodic, rather than chronic, course of depressive disorder are most likely to respond. Patients with persistent suicidal intention or actions are often given ECT as primary treatment because it would be dangerous to undergo a potentially prolonged series of medication trials while the patient remained at risk of self-injury. Similarly, those with severe inanition, psychomotor retardation, and depressionrelated immobility are usually treated with ECT first, to avoid medical complications such as aspiration, atelectasis, pneumonia, other infections, decubitus ulcers, and venous thrombosis. In both of these classes of patients, ECT is much more likely than antidepressants to rapidly improve depressive symptoms. Although delusionally depressed patients may respond to a combination of an antidepressant and neuroleptic, they are more likely to respond to ECT and to do so rapidly. The mental suffering associated with depressive delusions (eg, of hopelessness, criminality, bodily decay, or self-loathing) is often unbearable, and the patient’s response to such beliefs may make behavior impulsive and unpredictable. ECT is the treatment of choice to accelerate recovery and enhance patient safety. Catatonic patients almost always respond quickly to ECT and should be treated with it early. Although a minority of catatonics have a sustained positive response to benzodiazepines, this improvement is usually transient, and ECT is then required. Other medications are rarely effective. Retarded and agitated forms of catatonia are dangerous for the patient, and effective treatment with ECT should not be delayed.
The Longitudinal Joint Effect of Obesity and Major Depression on Work Performance Impairment
