Electroconvulsive therapy, or ECT, is a treatment for severe forms of mental illness that involves the use of a brief, controlled electrical current to intentionally produce a seizure within the brain. This seizure is thought to bring about biochemical changes in the brain that can lead to reduced psychiatric symptoms. This intervention has been around since the late 1930s and, in recent years, it has gained in popularity as an effective treatment modality in psychiatry.1

ECT Indications for Use

Over the past 30-plus years, the literature has shown ECT to be effective in treating several psychiatric disorders, including:

  • All types of major depressive episodes, with remission rates of 80% to 90% in primary major depressive episodes;2 the method is especially effective in treating melancholic depression.
  • Acute catatonic features or delusions in individuals with schizophrenia3
  • Acute mania, with reported improvement in approximately 80% of patients experiencing manic episodes due to bipolar disorder;4 note, however, that ECT should only be used in those who are intolerant of or refractory to medication and should not be used if the patient is also taking lithium or other mood stabilizers5
  • Schizophrenia – when there is a history of a favorable response to ECT, an abrupt psychotic exacerbation, or schizophrenia with positive, affective, or catatonic features;6 interestingly, a combination of antipsychotic medication and ECT may provide better treatment outcomes and prevent relapse7
  • Schizoaffective disorder – when the patient does not respond well to psychopharmacology

ECT does not appear to be effective in the treatment of dysthymia, anxiety, substance use (SUD, AUD), eating, or personality disorders.8

ECT Treatment Course

When a patient is referred for ECT, the practitioner should conduct a thorough evaluation including taking the patient’s psychiatric history, medical history, and medication list. With this information, a physician can confirm whether ECT is indicated and make modifications to the procedure to minimize any risks (see clinical considerations below).

Once a patient is identified as a good candidate for ECT based on their diagnosis, the next step is to determine the timing of treatment in the course of the disease. ECT may be used as a first- or second-line treatment

First-line approaches for electroconvulsive therapy are indicated in four types of situations:

  1. In an urgent situation when a rapid response is necessary
  2. When ECT is less risky than other treatment alternatives
  3. When the patient has a history of responding better to ECT than other treatments
  4. When the patient prefers ECT over other treatment modalities

Second-line approaches for electroconvulsive are indicated when:

  1. The patient has a poor response or intolerance to other treatment alternatives
  2. The patient’s clinical condition has deteriorated to the point that there is an urgent need for a rapid response

ECT in Psychiatric Care: Clinical Considerations

Remission Focus

It is also crucial to note that ECT only induces a remission of an episode of illness. ECT maintenance therapy may be required if there is a recurrence of symptoms

Age-Related Indications

The use of ECT in children and adolescents is rare. However, diagnostic indications for ECT in minors appear to be the same as those for adults.9 The American Psychiatric Association (2001) recommends that prior to use, clinicians obtain a second opinion from an experienced child and adolescent psychiatrist, and two such opinions if the patient is under age 12.

Although ECT use in geriatric patients is generally safe,10 certain factors must be considered before the administration of treatment. Due to the age of these individuals, there is a higher likelihood of ECT-related complications such as cognitive loss. Additionally, older patients often have a higher seizure threshold, meaning that a higher electrical stimulus intensity may be required.

Medical Comorbidities

Certain cardiovascular and musculoskeletal medical conditions may increase the risk of negative outcomes during ECT. These include: intracranial hemorrhage, stroke, recent myocardial infarction, unstable angina, heart failure, and vertebral fracture. The practitioner should also examine the patient’s scalp for cranial defects that may interfere with electrode placement.11 Specialists should be consulted to weigh in on specific issues when needed. Outside of this, ECT is generally considered to be safe for patients with no cardiac disease.12

In addition, some conditions require accommodations for the procedure. For example, individuals with diabetes should be treated as early in the day as possible to limit issues with diet. The use of a glucose IV drip is common for patients with diabetes who have a long wait before treatment. Due to the increased seizure risk that comes with hypoglycemia, diabetic patients’ blood glucose should be measured 30 minutes prior to ECT.13

When treating patients with epilepsy, anticonvulsant medication should be withheld until after ECT treatments to maximize the procedure’s effectiveness. Blood levels of anticonvulsant medication should be measured before each ECT session.

Pregnant patients can undergo ECT but it is advised that an obstetrician is consulted prior to initiating treatment.14

Current Medications

As indicated, the patient’s medication list should be reviewed carefully. Drugs that can raise the seizure threshold for ECT include lithium, benzodiazepines, and anticonvulsants. Hydroxyzine or diphenhydramine should be used instead of benzodiazepines for sedation during the procedure for this reason.15 Theophylline can also create additional risk during ECT, as it can increase the likelihood of status epilepticus.16

Handedness

Finally, the patient’s handedness should be noted, as this will guide electrode placement.

Laboratory Tests to Conduct Before Administering ECT

In addition to taking the patient’s medical history, certain laboratory and imaging tests may be necessary – depending on the patient’s history and comorbidities – before ECT treatment can begin. Specifically, these may include:17

Bloodwork

  • CBC, BMP, TSH
  • liver function tests
  • drug levels (including lithium, valproic acid, and carbamazepine)
  • prothrombin time
  • partial thromboplastin time

Imaging

  • ECG
  • chest X-ray
  • neuroimaging
  • electroencephalogram

Other

  • neuropsychological testing

Apnea; Anesthesia Response

An anesthesia evaluation should also be obtained prior to ECT, due to the use of muscular relaxation and general anesthesia during the procedure. The practitioner should document any prior problems with anesthesia as prolonged apnea may occur during ECT in patients with pseudocholinesterase deficiency. Apnea may occur due to impaired metabolism of succinylcholine used during ECT. If the patient has a family history of prolonged apnea due to this deficiency, the patient’s pseudocholinesterase activity should be tested prior to ECT.1

Patient Education: What They Need to Know Before ECT Treatment1

Electroconvulsive therapy is typically administered three times per week. To produce a therapeutic effect, there is generally a series of 6 to 12 seizure treatments. A single treatment session usually lasts 1 hour; this includes time spent in the treatment room and in recovery.

ECT is performed in a hospital setting due to the anesthetic given but patients can go home the same day. During the actual treatment, patients are monitored by a team of doctors. A blood pressure cuff will be applied and a number of electrodes will be placed.

After the anesthetic and muscle relaxer are given, a controlled electrical stimulus, lasting a fraction of a second to several seconds will be applied across two electrodes. During this time, vitals and brain waves are monitored. A few minutes after the seizure, patients will be transported to a recovery room.

Although ECT can be effective, it does not prevent the recurrence of additional episodes of psychiatric illness. Therefore, to remain in remission, maintenance sessions will likely be necessary. The frequency of sessions depends on several factors, including cognition, level of severity, and practical considerations. However, a general schedule may consist of weekly ECT sessions for 1 month, then every other week for 2 months, then monthly.

Clinical Takeaways from the Resident Authors

The biggest barrier to administering ECT may be in those patients who are afraid of the ECT process; they usually reference how it is portrayed in the media. To overcome this, it is helpful to have an in-depth discussion with the patient about ECT before the treatment (see patient education above) to address their overall concerns in advance.

More insights from psychiatry residents in our early career psychiatrist section.

 

References
Last Updated: Jun 15, 2021