Medical consultation for electroconvulsive therapy
- Anjala Tess, MD
Anjala Tess, MD
- Assistant Professor in Medicine
- Harvard Medical School
- Gerald W Smetana, MD
Gerald W Smetana, MD
- Professor of Medicine
- Harvard Medical School
Electroconvulsive therapy (ECT) is a commonly performed procedure in the United States. Use of ECT is rising, and psychiatrists often request medical evaluation before ECT since many eligible patients are elderly with multiple medical comorbidities. This topic review will discuss the use, indications, anesthetic technique, procedure, and morbidity of ECT, as well as risk assessment and strategies to reduce the risk of the procedure.
INDICATIONS FOR ECT
The primary indication for ECT is for the treatment of major depression that is refractory to antidepressant medications . Indications listed in the American Psychiatric Association guidelines for the treatment of patients with major depressive disorder include depression with psychotic features, catatonia, persistent suicidal intent, food refusal leading to nutritional compromise or dehydration, and pregnancy and other situations where a rapid antidepressant response is required (table 1) . The report also recommends ECT for patients who have previously shown a positive response to it and for those who have medical conditions that prevent the use of antidepressant medications. The Canadian Psychiatric Association clinical guidelines for the treatment of depressive disorders suggest similar indications . (See "Unipolar major depression in adults: Indications for and efficacy of electroconvulsive therapy (ECT)" and "Unipolar depression in adults: Treatment of resistant depression".)
Other psychiatric conditions for which ECT is effective include bipolar depression and mania .
TECHNIQUE AND ANESTHESIA
ECT is usually administered two or three times per week for a total of 6 to 12 treatments. The treatment typically causes a 30 to 60 second generalized tonic clonic seizure, an effect that is essential to the success of ECT. The patient is preoxygenated with supplemental oxygen (2 L/min) via nasal cannula while the procedure is being set up. Prophylactic beta blockers may be administered immediately before or during ECT to blunt the hypertensive, tachycardic response to the seizure. The anesthesia of choice is methohexital. Other induction agents include propofol, etomidate, and ketamine. Skeletal muscle relaxation is used during ECT to minimize the motor seizure and prevent musculoskeletal injury. The standard agent is succinylcholine via intravenous infusion. (See "Technique for performing electroconvulsive therapy (ECT) in adults".)
MORBIDITY AND MORTALITY
Clinicians should be aware of certain potential side effects or complications of ECT. (See "Overview of electroconvulsive therapy (ECT) for adults", section on 'Adverse effects'.)
- Fink M, Taylor MA. Electroconvulsive therapy: evidence and challenges. JAMA 2007; 298:330.
- Canadian Psychiatric Association, Canadian Network for Mood and Anxiety Treatments (CANMAT). Clinical guidelines for the treatment of depressive disorders. Can J Psychiatry 2001; 46 Suppl 1:5S.
- Fink M. Indications for the use of ECT. Psychopharmacol Bull 1994; 30:269.
- American Psychiatric Association, Weiner RD, Coffey CE. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging, 2nd ed., American Psychiatric Association, 2001.
- McCall WV. Asystole in electroconvulsive therapy: Report of four cases. J Clin Psychiatry 1996; 57:199.
- Kaufman KR. Asystole with electroconvulsive therapy. J Intern Med 1994; 235:275.
- Burd J, Kettl P. Incidence of asystole in electroconvulsive therapy in elderly patients. Am J Geriatr Psychiatry 1998; 6:203.
- Larson G, Swartz C, Abrams R. Duration of ECT-induced tachycardia as a measure of seizure length. Am J Psychiatry 1984; 141:1269.
- Abrams R. Electroconvulsive Therapy, 2nd ed., Oxford University Press, New York 1992.
- Dec GW Jr, Stern TA, Welch C. The effects of electroconvulsive therapy on serial electrocardiograms and serum cardiac enzyme values. A prospective study of depressed hospitalized inpatients. JAMA 1985; 253:2525.
- Fuenmayor AJ, el Fakih Y, Moreno J, Fuenmayor AM. Effects of electroconvulsive therapy on cardiac function in patients without heart disease. Cardiology 1997; 88:254.
- McCully RB, Karon BL, Rummans TA, et al. Frequency of left ventricular dysfunction after electroconvulsive therapy. Am J Cardiol 2003; 91:1147.
- Gerring JP, Shields HM. The identification and management of patients with a high risk for cardiac arrhythmias during modified ECT. J Clin Psychiatry 1982; 43:140.
- Zielinski RJ, Roose SP, Devanand DP, et al. Cardiovascular complications of ECT in depressed patients with cardiac disease. Am J Psychiatry 1993; 150:904.
- Rice EH, Sombrotto LB, Markowitz JC, Leon AC. Cardiovascular morbidity in high-risk patients during ECT. Am J Psychiatry 1994; 151:1637.
- Tess AV, Smetana GW. Medical evaluation of patients undergoing electroconvulsive therapy. N Engl J Med 2009; 360:1437.
- Knaudt PR, Connor KM, Weisler RH, et al. Alternative therapy use by psychiatric outpatients. J Nerv Ment Dis 1999; 187:692.
- Patra KK, Coffey CE. Implications of herbal alternative medicine for electroconvulsive therapy. J ECT 2004; 20:186.
- Devanand DP, Decina P, Sackeim HA, Prudic J. Status epilepticus following ECT in a patient receiving theophylline. J Clin Psychopharmacol 1988; 8:153.
- Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2009; 120:e169.
- Abrams R. The mortality rate with ECT. Convuls Ther 1997; 13:125.
- Dolinski SY, Zvara DA. Anesthetic considerations of cardiovascular risk during electroconvulsive therapy. Convuls Ther 1997; 13:157.
- Applegate RJ. Diagnosis and management of ischemic heart disease in the patient scheduled to undergo electroconvulsive therapy. Convuls Ther 1997; 13:128.
- Nurenberg JR. Intravenous nitroglycerine in the management of posttreatment hypertension during electroconvulsive therapy. J Nerv Ment Dis 1991; 179:291.
- Avramov MN, Stool LA, White PF, Husain MM. Effects of nicardipine and labetalol on the acute hemodynamic response to electroconvulsive therapy. J Clin Anesth 1998; 10:394.
- van den Broek WW, Leentjens AF, Mulder PG, et al. Low-dose esmolol bolus reduces seizure duration during electroconvulsive therapy: a double-blind, placebo-controlled study. Br J Anaesth 1999; 83:271.
- Howie MB, Black HA, Zvara D, et al. Esmolol reduces autonomic hypersensitivity and length of seizures induced by electroconvulsive therapy. Anesth Analg 1990; 71:384.
- Howie MB, Hiestand DC, Zvara DA, et al. Defining the dose range for esmolol used in electroconvulsive therapy hemodynamic attenuation. Anesth Analg 1992; 75:805.
- Dannon PN, Iancu I, Hirschmann S, et al. Labetalol does not lengthen asystole during electroconvulsive therapy. J ECT 1998; 14:245.
- Decina P, Malitz S, Sackeim HA, et al. Cardiac arrest during ECT modified by beta-adrenergic blockade. Am J Psychiatry 1984; 141:298.
- Wulfson HD, Askanazi J, Finck AD. Propranolol prior to ECT associated with asystole. Anesthesiology 1984; 60:255.
- Castelli I, Steiner LA, Kaufmann MA, et al. Comparative effects of esmolol and labetalol to attenuate hyperdynamic states after electroconvulsive therapy. Anesth Analg 1995; 80:557.
- Kovac AL, Goto H, Arakawa K, Pardo MP. Esmolol bolus and infusion attenuates increases in blood pressure and heart rate during electroconvulsive therapy. Can J Anaesth 1990; 37:58.
- Mayur PM, Shree RS, Gangadhar BN, et al. Atropine premedication and the cardiovascular response to electroconvulsive therapy. Br J Anaesth 1998; 81:466.
- Stoudemire A, Knos G, Gladson M, et al. Labetalol in the control of cardiovascular responses to electroconvulsive therapy in high-risk depressed medical patients. J Clin Psychiatry 1990; 51:508.
- Boere E, Birkenhäger TK, Groenland TH, van den Broek WW. Beta-blocking agents during electroconvulsive therapy: a review. Br J Anaesth 2014; 113:43.
- McCall WV, Shelp FE, Weiner RD, et al. Effects of Labetalol on Hemodynamics and Seizure Duration During ECT. Convuls Ther 1991; 7:5.
- Kellner CH, Pritchett JT, Beale MD, Coffey CE. Handbook of ECT, American Psychiatric Press Inc, 1997.
- Zhang Y, White PF, Thornton L, et al. The use of nicardipine for electroconvulsive therapy: a dose-ranging study. Anesth Analg 2005; 100:378.
- de Silva RA, Bachman WR. Cardiac consultation in patients with neuropsychiatric problems. Cardiol Clin 1995; 13:225.
- Magid M, Lapid MI, Sampson SM, Mueller PS. Use of electroconvulsive therapy in a patient 10 days after myocardial infarction. J ECT 2005; 21:182.
- Mueller PS, Barnes RD, Varghese R, et al. The safety of electroconvulsive therapy in patients with severe aortic stenosis. Mayo Clin Proc 2007; 82:1360.
- Rayburn BK. Electroconvulsive therapy in patients with heart failure or valvular heart disease. Convuls Ther 1997; 13:145.
- Rivera FA, Lapid MI, Sampson S, Mueller PS. Safety of electroconvulsive therapy in patients with a history of heart failure and decreased left ventricular systolic heart function. J ECT 2011; 27:207.
- Dolenc TJ, Barnes RD, Hayes DL, Rasmussen KG. Electroconvulsive therapy in patients with cardiac pacemakers and implantable cardioverter defibrillators. Pacing Clin Electrophysiol 2004; 27:1257.
- Pinski SL, Trohman RG. Implantable cardioverter-defibrillators: implications for the nonelectrophysiologist. Ann Intern Med 1995; 122:770.
- Saito S. Anesthesia management for electroconvulsive therapy: hemodynamic and respiratory management. J Anesth 2005; 19:142.
- Smith LH, Hughes DJ, Hastings DW, Alpers J. Electroshock treatment in the psychoses. Am J Psychiatry 1942; 98:558.
- Maltbie AA, Wingfield MS, Volow MR, et al. Electroconvulsive therapy in the presence of brain tumor. Case reports and an evaluation of risk. J Nerv Ment Dis 1980; 168:400.
- Dressler DM, Folk J. The treatment of depression with ECT in the presence of brain tumor. Am J Psychiatry 1975; 132:1320.
- Mattingly G, Figiel GS, Jarvis MR, Zorumski CF. Prospective uses of ECT in the presence of intracranial tumors. J Neuropsychiatry Clin Neurosci 1991; 3:459.
- Fried D, Mann JJ. Electroconvulsive treatment of a patient with known intracranial tumor. Biol Psychiatry 1988; 23:176.
- Zwil AS, Bowring MA, Price TR, et al. Prospective Electroconvulsive Therapy in the Presence of Intracranial Tumor. Convuls Ther 1990; 6:299.
- Patkar AA, Hill KP, Weinstein SP, Schwartz SL. ECT in the presence of brain tumor and increased intracranial pressure: evaluation and reduction of risk. J ECT 2000; 16:189.
- Zwil AS, Pelchat RJ. ECT in the treatment of patients with neurological and somatic disease. Int J Psychiatry Med 1994; 24:1.
- Hsiao JK, Messenheimer JA, Evans DL. ECT and Neurological Disorders. Convuls Ther 1987; 3:121.
- Murray GB, Shea V, Conn DK. Electroconvulsive therapy for poststroke depression. J Clin Psychiatry 1986; 47:258.
- Martin M, Figiel G, Mattingly G, et al. ECT-induced interictal delirium in patients with a history of a CVA. J Geriatr Psychiatry Neurol 1992; 5:149.
- Price TR, McAllister TW. Safety and Efficacy of ECT in Depressed Patients with Dementia: A Review of Clinical Experience. Convuls Ther 1989; 5:61.
- Nelson JP, Rosenberg DR. ECT Treatment of Demented Elderly Patients with Major Depression: A Retrospective Study of Efficacy and Safety. Convuls Ther 1991; 7:157.
- Durr AL, Golden RN. Cognitive effects of electroconvulsive therapy: a clinical review for nurses. Convuls Ther 1995; 11:192.
- Beach TP, Stone WA, Hamelberg W. Circulatory collapse following succinylcholine: report of a patient with diffuse lower motor neuron disease. Anesth Analg 1971; 50:431.
- Liu S, Modell JH. Anesthetic management for patients with postpolio syndrome receiving electroconvulsive therapy. Anesthesiology 2001; 95:799.
- Gyermek L. Increased potency of nondepolarizing relaxants after poliomyelitis. J Clin Pharmacol 1990; 30:170.
- Gahr M, Connemann BJ, Freudenmann RW, Schönfeldt-Lecuona C. Safety of electroconvulsive therapy in the presence of cranial metallic objects. J ECT 2014; 30:62.
- Netzel PJ, Mueller PS, Rummans TA, et al. Safety, efficacy, and effects on glycemic control of electroconvulsive therapy in insulin-requiring type 2 diabetic patients. J ECT 2002; 18:16.
- Bleich S, Degner D, Scheschonka A, et al. Electroconvulsive therapy and anticoagulation. Can J Psychiatry 2000; 45:87.
- Mehta V, Mueller PS, Gonzalez-Arriaza HL, et al. Safety of electroconvulsive therapy in patients receiving long-term warfarin therapy. Mayo Clin Proc 2004; 79:1396.
- Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:703.
- INDICATIONS FOR ECT
- TECHNIQUE AND ANESTHESIA
- MORBIDITY AND MORTALITY
- Cardiovascular effects
- Central nervous system and other effects
- ROLE OF THE MEDICAL CONSULTANT
- Preprocedure evaluation
- Strategies to reduce the risk of cardiac complications
- - Postprocedure hemodynamic changes
- - Prophylactic beta blockers
- - Other prophylactic medications
- Coexisting cardiac disease
- - Hypertension
- - Coronary heart disease
- - Heart failure and valvular disease
- - Pacemakers and implantable defibrillators
- Coexisting pulmonary disease
- Coexisting neurologic and neurosurgical disease
- - Brain tumors
- - Stroke
- - Dementia
- - Neuromuscular disease
- - Epilepsy
- - Cranial metallic objects
- INFORMATION FOR PATIENTS