1. Aetna considers electroconvulsive therapy (ECT) medically necessary for members diagnosed with any of the following conditions.
   
   
   1. Major depression (unipolar, bipolar, or mixed episode), or
   2. Mania, or
   3. Catatonia, or
   4. Certain acute schizophrenic exacerbations.

   Note: More than 20 sessions of ECT in a treatment series is rarely medically necessary.
   

2. Aetna considers multiple monitored ECT experimental and investigational because its effectiveness has not been established.
   
   

3. Aetna considers ECT experimental and investigational for the treatment of body dysmorphic disorder, obsessive-compulsive disorder, and all other indications (except for those stated in policy section I) because its effectiveness for these indications has not been established.  

Electroconvulsive therapy (also known as electroshock therapy) involves the intentional induction of generalized seizures by administering electrical impulses to the anesthetized patient. Treatments are typically administered by a psychiatrist and an anesthesiologist or anesthetist.

ECT is generally administered in an inpatient setting, but can be administered on an outpatient basis in a facility with treatment and recovery rooms. ECT is usually administered two or three times a week, although ECT may be administered daily if tolerated.

The primary indication for ECT is major depressive disorder. ECT is usually considered when medications fail, cannot be tolerated, or may be dangerous, but it is a first-line treatment for severely depressed patients who require a rapid response because of a high suicide or homicide risk, extreme agitation, life-threatening inanition, psychosis, or stupor. The average course of treatment for depression is 6 to 12 treatments, but some patients may require as many as 20 treatments.

ECT has been found to be as or more effective than lithium in the treatment of manic episodes and is also a potential treatment for patients experiencing mixed episodes. ECT is generally reserved for those patients with bipolar disorder who are unable to safely wait until a medication becomes effective, who are not responsive to or unable to safely tolerate one of the effective medications, is preferred by the patient in consultation with the psychiatrist, or who have had a good response to ECT in the past. The number of ECT treatments reported to be effective for mania has ranged from 8 to 20.

ECT is not effective for chronic schizophrenia. However, ECT may be effective for psychotic schizophrenic exacerbations when affective symptomatology is prominent, in catatonic schizophrenia, and when there is a history of a prior favorable response to ECT. Schizophrenia may require 17 or more ECT treatments.

A small number of ECT treatments often reverse catatonia, a nonspecific symptom that can occur in mood disorders, schizophrenia, cognitive disorders, and medical and neurological illnesses. Up to 12 treatments may be required in some patients.

There is very limited evidence that ECT is effective for delirium. In addition, there may be considerable risks with ECT in medically unstable patients. For these reasons, the American Psychiatric Association (APA) (1999) concluded that ECT “has not been shown to be an effective treatment for general cases of delirium.” The APA recommends that ECT be “considered only rarely for patients with delirium due to specific etiologies such as neuroleptic malignant syndrome and should not be considered initially as a substitute for more conservative and conventional treatments.”

A few clinicians have reported the successful use of ECT in severe obsessive-compulsive disorder (OCD), anorexia nervosa, atypical psychosis, cycloid psychosis, epilepsy with alternating psychosis, and chronic pain disorder, but those disorders are not usually considered indications for ECT. Electroconvulsive therapy is not an effective treatment for body dysmorphic disoder, dysthymic disorder, neuroses, dissociative disorders, hypochondriasis, conversion disorder, substance-related disorders, and personality disorders.  Dell'Osso and colleagues (2005) noted that in addition to pharmacological, behavioral, and neurosurgical interventions, different brain stimulation methods such as transcranial magnetic stimulation, deep brain stimulation, as well as ECT have been examined in treatment-resistant patients with OCD. However, available data about the use of these techniques in OCD treatment are quite limited in terms of sample size and study design, given the difficulty in conducting standard blinded trials for these procedures. Furthermore, none of the mentioned treatments has received approval for the treatment of OCD from the Food and Drug Administration. This is in agreement with the observation of Schruers et al (2005) who stated that serotonin reuptake inhibitors augmentation strategies with a variety of drugs and ECT have demonstrated results in individual cases, but no conclusive evidence has been found in placebo-controlled trials. In addition, the National Institute for Health and Clinical Excellence (NICE, 2006) guidelines on OCD stated that there is insufficient evidence on which to base a recommendation for the use of ECT in the treatment of OCD, especially given potential associated risks with ECT. Furthermore, the NICE report stated that there is no evidence that ECT or psychosurgery is beneficial in treating patients with body dysmorphic disorder.

Clinical experience suggests that ECT be continued until the patient has shown a maximal response; there is no evidence that administering one or two additional treatments results in a better outcome. Indeed, increased confusion from additional treatments may produce clinical deterioration. ECT is discontinued in patients who have had a partial but substantial improvement but show no change after two more treatments and in patients who have not responded at all after 6 to 10 treatments.

Prophylactic ECT may be needed for patients who do not tolerate or respond to prophylactic medications or who respond better to ECT. After remission, prophylactic ECT treatments are initially administered at weekly intervals, and the frequency of treatments is usually decreased gradually to once a month or less. Treatment has been continued for periods of four or six months to five years or longer; some patients apparently require indefinite prophylactic ECT.

Relative contraindications to ECT include space-occupying lesions of the brain, high intracranial pressure, intracerebral bleeding, recent myocardial infarction, retinal detachment, pheochromocytoma, high anesthesia risk, adolescents and children, or a significant medical illness in which risk outweighs potential benefit.

In multiple monitored electroconvulsive therapy (MMECT), a patient undergoes ECT in the usual manner, but before regaining consciousness, undergoes another session of ECT designed to elicit a second (or additional) seizure. The effectiveness of MMECT has not been established. The National Institutes of Health 1985 Consensus Development Conference Statement on ECT states that “Multiple monitored ECT (several seizures during a single treatment session) has not been demonstrated to be sufficiently effective to be recommended…”.

Appendix

Selection Criteria for ECT:

1. Member has one of the qualifying psychiatric conditions listed in the policy section above; and
2. Member is at least 12 years of age; and 

3. One of the following criteria is met: 

   1. Member is unresponsive to effective medications, given for adequate dose and duration, that are indicated for the member's condition (e.g., antidepressants, antipsychotics, etc., as appropriate); or   
   2. Member is unable to tolerate effective medications or has a medical condition for which medication is contraindicated; or 
   3. Member has had favorable responses to ECT in the past, or 
   4. Member is unable to safely wait until medication is effective (e.g., due to life-threatening inanition, psychosis, stupor, extreme agitation, high suicide or homicide risk, etc.); or  
   5. Member is experiencing severe mania or depression during pregnancy; or
   6. Member prefers ECT as a treatment option in consultation with the psychiatrist.