Technique for performing electroconvulsive therapy (ECT) in adults
- Charles Kellner, MD
Charles Kellner, MD
- Professor of Psychiatry
- Icahn School of Medicine at Mount Sinai
- Section Editors
- Peter P Roy-Byrne, MD
Peter P Roy-Byrne, MD
- Editor-in-Chief — Psychiatry
- Section Editor — Depressive Disorders
- Professor of Psychiatry and Behavioral Sciences
- University of Washington School of Medicine
- Stephanie B Jones, MD
Stephanie B Jones, MD
- Editor-in-Chief — Anesthesiology
- Section Editor — Anesthesia with Comorbid Non-Cardiopulmonary Conditions
- Associate Professor of Anesthesia
- Harvard Medical School
Electroconvulsive therapy (ECT) is practiced widely in the United States and the rest of the world . It is used mainly to treat severe depression, but is also indicated for patients with other conditions, including bipolar disorder, schizophrenia, schizoaffective disorder, catatonia, and neuroleptic malignant syndrome.
There is no question about the efficacy and safety of ECT. Nevertheless, it remains controversial and stigmatized because of misinformation and outdated perceptions about how the treatment is performed.
The goal of ECT is to produce a generalized cerebral seizure under general anesthesia. The technique affects the rate of remission with ECT, which varies from 20 to 80 percent in research studies using different procedures . However, response and remission rates in clinical practice, using standard techniques, are at the higher end of that range.
The technique for performing ECT is reviewed here. An overview of ECT, the indications for treating unipolar major depression with ECT, the efficacy of ECT for treating unipolar depression, and medical consultation for ECT are discussed separately.
- Lisanby SH. Electroconvulsive therapy for depression. N Engl J Med 2007; 357:1939.
- American Psychiatric Association Task Force on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. American Psychiatric Association, Washington, DC 2001.
- Kellner, CH, Pritchett, JT, Beale, MD, Coffey, CE. Handbook of ECT, American Psychiatric Press, Inc., Washington, DC 1997.
- Kellner CH. Brain stimulation in psychiatry: ECT, DBS, TMS, and other modalities, Cambridge University Press, Cambridge, United Kingdom 2012.
- Kellner CH, Tobias KG, Wiegand J. Electrode placement in electroconvulsive therapy (ECT): A review of the literature. J ECT 2010; 26:175.
- Bjølseth TM, Engedal K, Benth JŠ, et al. Clinical efficacy of formula-based bifrontal versus right unilateral electroconvulsive therapy (ECT) in the treatment of major depression among elderly patients: a pragmatic, randomized, assessor-blinded, controlled trial. J Affect Disord 2015; 175:8.
- Kellner CH, Farber KG. The Role of Bilateral ECT When Right Unilateral ECT Is Inferior. Am J Psychiatry 2016; 173:731.
- Lapidus KA, Kellner CH. When to switch from unilateral to bilateral electroconvulsive therapy. J ECT 2011; 27:244.
- UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361:799.
- Kellner CH, Knapp R, Husain MM, et al. Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial. Br J Psychiatry 2010; 196:226.
- Scott AI. Electroconvulsive therapy, practice and evidence. Br J Psychiatry 2010; 196:171.
- Semkovska M, Landau S, Dunne R, et al. Bitemporal Versus High-Dose Unilateral Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A Pragmatic, Randomized, Non-Inferiority Trial. Am J Psychiatry 2016; 173:408.
- Rosa MA, Rosa MO, Daltio CS, et al. Open trial on the efficacy of right unilateral electroconvulsive therapy with titration and high charge. J ECT 2006; 22:237.
- Krystal AD, Holsinger T, Weiner RD, Coffey CE. Prediction of the utility of a switch from unilateral to bilateral ECT in the elderly using treatment 2 ictal EEG indices. J ECT 2000; 16:327.
- Sackeim HA, Dillingham EM, Prudic J, et al. Effect of concomitant pharmacotherapy on electroconvulsive therapy outcomes: short-term efficacy and adverse effects. Arch Gen Psychiatry 2009; 66:729.
- Dunne RA, McLoughlin DM. Systematic review and meta-analysis of bifrontal electroconvulsive therapy versus bilateral and unilateral electroconvulsive therapy in depression. World J Biol Psychiatry 2012; 13:248.
- Semkovska M, Keane D, Babalola O, McLoughlin DM. Unilateral brief-pulse electroconvulsive therapy and cognition: effects of electrode placement, stimulus dosage and time. J Psychiatr Res 2011; 45:770.
- Sackeim HA, Prudic J, Devanand DP, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000; 57:425.
- Sackeim HA, Prudic J, Fuller R, et al. The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology 2007; 32:244.
- Tor PC, Bautovich A, Wang MJ, et al. A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression. J Clin Psychiatry 2015; 76:e1092.
- Petrides G, Fink M. The "half-age" stimulation strategy for ECT dosing. Convuls Ther 1996; 12:138.
- Petrides G, Braga RJ, Fink M, et al. Seizure threshold in a large sample: implications for stimulus dosing strategies in bilateral electroconvulsive therapy: a report from CORE. J ECT 2009; 25:232.
- McCall WV, Reboussin DM, Weiner RD, Sackeim HA. Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy: acute antidepressant and cognitive effects. Arch Gen Psychiatry 2000; 57:438.
- Lisanby SH, Devanand DP, Nobler MS, et al. Exceptionally high seizure threshold: ECT device limitations. Convuls Ther 1996; 12:156.
- Bergsholm P, Gran L, Bleie H. Seizure duration in unilateral electroconvulsive therapy. The effect of hypocapnia induced by hyperventilation and the effect of ventilation with oxygen. Acta Psychiatr Scand 1984; 69:121.
- Kellner C, Li D, Maron L. Anesthesia for electroconvulsive therapy. In: Electroconvulsive and Neuromodulation Therapies, Swartz C (Ed), Cambridge University Press, Cambridge 2009. p.412.
- Sullivan PM, Sinz EH, Cain J, et al. A retrospective comparison of remifentanil versus methohexital for anesthesia in electroconvulsive therapy. J ECT 2004; 20:219.
- Lihua P, Su M, Ke W, Ziemann-Gimmel P. Different regimens of intravenous sedatives or hypnotics for electroconvulsive therapy (ECT) in adult patients with depression. Cochrane Database Syst Rev 2014; :CD009763.
- Torda TA, Graham GG, Warwick NR, Donohue P. Pharmacokinetics and pharmacodynamics of suxamethonium. Anaesth Intensive Care 1997; 25:272.
- Mayur PM, Gangadhar BN, Janakiramaiah N, Subbakrishna DK. Motor seizure monitoring during electroconvulsive therapy. Br J Psychiatry 1999; 174:270.
- Datto C, Rai AK, Ilivicky HJ, Caroff SN. Augmentation of seizure induction in electroconvulsive therapy: a clinical reappraisal. J ECT 2002; 18:118.
- Devanand DP, Decina P, Sackeim HA, Prudic J. Status epilepticus following ECT in a patient receiving theophylline. J Clin Psychopharmacol 1988; 8:153.
- Yonkers KA, Wisner KL, Stowe Z, et al. Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry 2004; 161:608.
- Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry 1994; 45:444.
- Lakshmana R, Hiscock R, Galbally M, et al. Electroconvulsive therapy in pregnancy. In: Psychopharmacology and Pregnancy: Treatment, Efficacy, Risks, and Guidelines, Galbally M, Snellen M, Lewis A. (Eds), Springer, Berlin 2014. p.209.
- American Psychiatric Association. Use of electroconvulsive therapy in special populations. In: The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging, Second Edition, American Psychiatric Association, Washington, DC 2001. p.31.
- Rabheru K. The use of electroconvulsive therapy in special patient populations. Can J Psychiatry 2001; 46:710.
- Kim DR, Snell JL, Ewing GC, O'Reardon J. Neuromodulation and antenatal depression: a review. Neuropsychiatr Dis Treat 2015; 11:975.
- Anderson EL, Reti IM. ECT in pregnancy: a review of the literature from 1941 to 2007. Psychosom Med 2009; 71:235.
- PRE-ECT ORDERS
- TREATMENT PROTOCOL
- PHYSIOLOGIC MONITORING
- ELECTRODE PLACEMENT
- Standard choice
- Side effects
- Stimulus type
- Stimulus dose
- ANESTHESIA TECHNIQUE
- Anticholinergic medication
- Anesthetic medication
- Muscle relaxation medication
- Cardiovascular medication
- SEIZURE DURATION
- Managing missed or short seizures
- INFORMATION FOR PATIENTS
- OUTSIDE SOURCES OF PATIENT EDUCATION