Safety considerations for outpatient electroconvulsive therapy

As electroconvulsive therapy (ECT) requires general anesthesia and is associated with both cognitive and non-cognitive side effects, careful consideration must be given to the safety aspects of providing ECT on an outpatient basis. Drawing upon published literature and their clinical experience administering outpatient ECT, the authors propose best practices for safely providing ECT to outpatients. They review criteria for selecting patients for outpatient ECT as well as treatment and programmatic issues. The authors highlight the importance of educating referring clinicians as well as patients and their families about factors involved in the safe delivery of ECT for outpatients. Fiscal considerations and the drive toward reduced length of stay are prompting insurers and caregivers to choose outpatient over inpatient ECT. For each patient, such a choice merits a careful analysis of the risks of outpatient ECT, as well as the implementation of measures to ensure patient safety.     

Electroconvulsive treatment of neuroleptic malignant syndrome: a review and report of cases.

OBJECTIVE: Neuroleptic malignant syndrome (NMS) is a potentially lethal adverse effect of neuroleptic medication, with no satisfactory treatment currently available. Electroconvulsive therapy (ECT) has been anecdotally reported to be effective in its treatment. We review 45 published case reports of ECT for NMS and describe nine new cases, to examine its effectiveness, the likelihood of adverse reactions, and the theoretical implications of such treatment. METHOD: The authors used Medline to identify reports in the English literature where ECT was used in cases of suspected NMS. In addition, the charts of patients referred to the second author for treatment of NMS were reviewed and cases in which ECT used were identified. RESULTS: The case reports suggest that ECT is effective in many individuals with NMS, even when drug therapy has failed. The response is usually apparent after a few treatments, generally up to six. The response is not predictable on the basis of age, gender, psychiatric diagnosis or any particular feature of NMS including catatonia. Electroconvulsive therapy is a relatively safe treatment in NMS, although the risk of cardiovascular complications should be considered. Malignant hyperthermia due to the anaesthesia associated with ECT has not been reported in patients with NMS, and succinylcholine has been used safely with the exception of one report of fever and raised creatine kinase levels and another report of hyperkalemia. CONCLUSIONS: Electroconvulsive therapy is the preferred treatment in severe NMS, cases where the underlying psychiatric diagnosis is psychotic depression or catatonia, and in cases where lethal catatonia cannot be ruled out. The effectiveness of ECT for the treatment of NMS has theoretical implications for the relationship between NMS and catatonia, and the possible pathophysiological mechanisms that underlie these disorders.     

Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: a review of the literature

Electroconvulsive therapy (ECT) is well established as a safe and effective treatment for several psychiatric disorders. Responsiveness to ECT does not abate with age, and data indicate that the use of ECT in the treatment of psychiatric disorders in the elderly persons has increased in recent decades. Special consideration must be given to the baseline cognitive abilities of an elderly patient prior to treatment with ECT. Much of the literature on the use of ECT in the elderly persons has focused on the treatment of mood disorders, whereas less research has been devoted to its use in the treatment of other psychiatric conditions. Although depressive syndromes remain the most common indication for ECT in the elderly persons, clinicians treating elderly patients should remain aware of the safety and efficacy of this treatment modality with other psychiatric disorders. This review examines the literature on the use of ECT in elderly patients with some common neuropsychiatric disorders including catatonia, bipolar mania, schizophrenia, dementia with behavioral disturbance, and Parkinson's disease.     

Clinical significance of the interaction between lithium and a neuromuscular blocker

Reports of delayed recovery from anesthesia by patients concurrently receiving lithium carbonate and a neuromuscular blocker have been followed by a recommendation to avoid such a combination and, hence, concurrent treatment with lithium and electroconvulsive therapy (ECT). The authors review the literature and their clinical experience with such a drug combination at one psychiatric hospital. They conclude that the clinical and experimental findings to date are insufficient to warrant proscribing the combination of lithium and ECT on the basis of possible potentiation of neuromuscular blockade by lithium.     

Electroconvulsive therapy in myasthenia gravis.

BACKGROUND: Myasthenia gravis (MG) is a neuromuscular disease sometimes associated with severe psychiatric complications. The use of electroconvulsive therapy (ECT) in MG raises certain challenges. METHODS: We describe a patient with MG and a steroid-induced major depressive episode with psychotic features treated with ECT. We also review the literature on similar cases and on the safety of ECT with muscle relaxation in this condition. RESULTS: The use of ECT in patients with MG is a viable therapeutic option when psychiatric complications secondary to MG or its treatment do not respond to psychotropic medications. CONCLUSION: ECT with muscle relaxants could be administered safely, with appropriate precautions kept in mind.     

ECT and intracranial vascular masses

In 1990, the APA Task Force on ECT cited no "absolute" contraindications to ECT but "Substantial Risk" to be associated with ECT for patients with space occupying or other cerebral lesions with increased intracranial pressure and with bleeding or otherwise unstable vascular aneurysm or malformation. These findings indicate that patients with intracranial vascular masses are at increased risk for serious morbidity and mortality. Several authors have reported performing ECT in patients with intracranial vascular masses without adverse events by monitoring blood pressure both with and without pharmacologic intervention. Given the relatively recent change in practice of considering ECT for patients with intracranial vascular masses and the few number of cases thus far reported, we present a review of the existing literature and two additional cases of ECT performed with good result and no adverse events. With the cases we have presented, the literature now contains eight cases of ECT performed in patients with intracranial vascular masses, none of which had adverse outcomes. While such numbers do not establish unequivocal safety in this population, and the individual ECT practitioner must continue to make a risk/benefit analysis on a case-by-case basis, this report adds to the growing literature on the safety and efficacy of ECT for such patients.     

Successful ECT in a patient with intracranial venous angioma

The 1990 American Psychiatric Association (APA) Task Force report on electroconvulsive therapy (ECT) suggests that there is an increased risk of complications in patients with intracranial vascular masses. There have been only a few published reports on the use of ECT in these patients. In this case report, an additional case is described that used ECT in the treatment of major depression in a 72-year-old patient with a venous angioma involving the left cerebellum. Brain imaging studies, neurosurgery, cardiology, and orthopedic consultations were obtained prior to ECT. Blood pressure was monitored closely throughout the course of ECT. Prior to each ECT, antihypertensive medication was given in addition to other pretreatment medications. Consistent with previously published reports, the patient did not experience any neurological deterioration or adverse effects. A brief review of the literature on the use of ECT in patients with venous angioma and other intracranial vascular masses is presented.     

The Use of ECT and MST in treating depression

Electroconvulsive therapy (ECT) has been used clinically since 1938. Its most common use is in the treatment of depression: first line treatment where rapid recovery is a priority, but more frequently as an effective treatment for patients who do not respond to pharmacological and psychological approaches. Whilst it is widely hailed as an effective treatment, concerns about its effect on cognition remain. The development of magnetic seizure therapy (MST) over the past decade has attempted to devise a therapy with comparable efficacy to ECT, but without the associated cognitive side effects. The rationale for this is that MST uses magnetic fields to induce seizures in the cortex, without electrical stimulation of brain structures involved with memory. MST has been used successfully in the treatment of depression, yet there is a dearth of literature in comparison with ECT. We present a systematic review of the literature on ECT (from 2009–2011) and MST (from 2001–2011).     

The use of ECT and MST in treating depression

Electroconvulsive therapy (ECT) has been used clinically since 1938. Its most common use is in the treatment of depression: first line treatment where rapid recovery is a priority, but more frequently as an effective treatment for patients who do not respond to pharmacological and psychological approaches. Whilst it is widely hailed as an effective treatment, concerns about its effect on cognition remain. The development of magnetic seizure therapy (MST) over the past decade has attempted to devise a therapy with comparable efficacy to ECT, but without the associated cognitive side effects. The rationale for this is that MST uses magnetic fields to induce seizures in the cortex, without electrical stimulation of brain structures involved with memory. MST has been used successfully in the treatment of depression, yet there is a dearth of literature in comparison with ECT. We present a systematic review of the literature on ECT (from 2009-2011) and MST (from 2001-2011).     

Effective use of electroconvulsive therapy in late-life depression.

OBJECTIVE: To review literature pertaining to the efficacy, safety, and tolerability of electroconvulsive therapy (ECT) in treating late-life depression. METHOD: We undertook a literature review with an emphasis on research studies published in the last 10 years. RESULTS: There is a positive association between advancing age and ECT efficacy. Age per se does not necessarily increase the risk of cognitive side effects from ECT, but this risk is increased by age-associated neurological conditions such as Alzheimer's dementia and cerebrovascular disease. With appropriate evaluation and monitoring, ECT can be used safely in patients of very advanced age and in those with serious medical conditions. Several technical factors, including dose of electricity relative to a patient's seizure threshold, position of electrodes, frequency of administration, and total number of treatments, have an impact on the efficacy and cognitive side effects of ECT and need to be taken into account when administering ECT. Naturalistic studies have found that 50% of more of patients have a relapse of depression within 6 to 12 months of discontinuing acute ECT. CONCLUSIONS: In recent years, there has been substantial progress in our understanding of the effect of technical factors on the efficacy and cognitive side effects of ECT. When administered in an optimal manner, ECT is a safe, well-tolerated, and effective treatment in older patients. Relapse of depression after response to ECT remains a significant problem, and there is a need for further research into the prediction and prevention of post-ECT relapse.     

ECT post eye surgery: two cases and a review of the literature

Little is known about the safety of electroconvulsive therapy (ECT) following any surgical procedure. We present two cases of elderly patients who required treatment with ECT shortly after eye surgery. One patient received ECT 12 days post cataract surgery. The other patient received ECT 1 week post vitrectomy on one eye, and then a few years after that she received ECT 2.5 weeks post cataract surgery on the other eye. There were no complications or adverse events for either patient. We review the existing literature on the effects of ECT on intraocular pressure and discuss the implications on patients who have recently undergone ophthalmic surgery.     

Electroconvulsive therapy in movement disorders: an update

Electroconvulsive therapy (ECT) is a well-recognized treatment for psychiatric illness, primarily depressive disorders. Its use in patients with neurological illnesses is steadily increasing. Older reviews indicate that ECT may also benefit Parkinson's disease and similar movement disorders independent of its effects on comorbid psychiatric disorders. In this updated review, recent literature regarding ECT and movement disorders is summarized from 1990 to 2000. Considerable evidence indicates that ECT improves motor symptoms of Parkinson's disease in patients with and without mood disorders. A few case reports, ranging from one to six patients per disorder, suggest that ECT may ameliorate the motor symptoms of other movement disorders. ECT affects a variety of neurotransmitters that play a role in these diseases. Limitations of current reports are reviewed, and recommendations for further investigation are made.     

Electroconvulsive therapy in the very old

At least one study has questioned the safety of electroconvulsive therapy (ECT) in the very old. In this study, the authors reviewed a 5-year experience with ECT at two university psychiatric services for patients 75 years of age or older. Both outcomes and complications were reviewed. Nineteen of 22 patients (86.3%) were ECT responders. Five patients (22.7%) suffered complications which varied from minor to substantial. ECT was found to be an effective and reasonably safe treatment for depression in the very old.     

Is electroconvulsive therapy effective for the depressed patient with comorbid borderline personality disorder?

Among the more common current indications for electroconvulsive therapy (ECT) is treatment-resistant depression. Treatment resistance is correlated with a number of factors, including the presence of comorbid personality disorders, such as borderline personality disorder (BPD). A detailed review of the literature was undertaken and very few reports or studies have dealt specifically with ECT in borderline patients. Thirteen original reports on ECT outcome in personality disordered patients were identified. Depressed patients with a personality disorder, particularly BPD, may have a poorer outcome on some measures. However, the available data suggests that depression in these patients can be effectively treated with ECT. The depressed, borderline patient appears to have two distinct disorders, one which is responsive to ECT and the other which is not. Unfortunately, the literature is limited by lack of rigorous randomized treatment studies, lack of long-term follow-up, and other methodological weaknesses. Clinical guidelines are suggested.     

Treatment Choice in Neuroleptic Malignant Syndrome

A literature review of patients with symptomatic neuroleptic malignant syndrome (NMS) treated with electroconvulsive therapy (ECT) yielded 26 cases, to which we add five cases. ECT was associated with a positive outcome in 26 of 31 cases with one unclear outcome and a poor outcome in four cases, including two deaths. ECT appeared to be effective in eight of nine patients previously treated with dantrolene and/or bromocriptine; no difference in time to apparent response was seen between those treated with medication first and those undergoing ECT first. The mean time to clinical response after the first ECT was 1.46 +/- 2.38 days, with 19 of 20 having a clinical response by 72 h. The possible relationship of ECT to the two deaths is discussed. Given this experience, the suggested treatment sequence is medication (dantrolene or bromocriptine) for 48 h; if no clinical response is seen, ECT should be initiated. ECT may be used earlier in response to specific clinical situations.     

Morbidity and mortality in the use of electroconvulsive therapy

There are a few large studies of the morbidity and mortality of electroconvulsive therapy (ECT). To add data to this literature, we performed a retrospective review of all the patients who underwent ECT at our institution between January 1, 1988, through December 31, 2001. We identified 2,279 patients who were given 17,394 ECT treatments during their first series. The median number of treatments received per patient was 7. Twenty-one patients (0.92%) experienced a complication at some time during their first series of ECT treatments. Cardiac complications, mostly arrhythmias, constituted the majority. However, none of the complications caused permanent injury, and none of the patients died during or immediately after ECT. There were 18 deaths within 30 days of the final treatment, none related to ECT. These data are concordant with those of other published large series, and we conclude that ECT is an extremely safe procedure.     

Electroconvulsive Therapy in the Elderly: New Findings in Geriatric Depression

This paper reviews recent research on the use of electroconvulsive therapy (ECT) in elderly depressed patients. The PubMed database was searched for literature published within the past 4 years, using the search terms: “electroconvulsive elderly,” “electroconvulsive geriatric,” “ECT and elderly,” and “ECT elderly cognition.” The studies in this review indicate excellent efficacy for ECT in geriatric patients. Adverse cognitive effects of ECT in this population are usually transient and not typically severe. In addition, continuation/maintenance ECT (C/M-ECT) may be a favorable strategy for relapse prevention in the elderly after a successful acute course of ECT. ECT is an important treatment option for depressed geriatric patients with severe and/or treatment-resistant illness. New data add to the evidence demonstrating that ECT is a highly effective, safe, and well-tolerated antidepressant treatment option for geriatric patients.     

Electroconvulsive therapy and venous angiomas: two case reports and review of the literature

According to the American Psychiatric Association, the risk for complications related to the electroconvulsive therapy (ECT) treatment of patients with cerebrovascular malformations is small. The literature contains a number of case studies presenting the uneventful treatment of patients with cerebral aneurysms with ECT. However, there is a paucity of cases presenting ECT in the context of a cerebral venous angioma. In this article, we present 2 cases of patients treated with ECT who were found to have documented venous angiomas. This is followed with a brief review of the literature.     

Electroconvulsive Therapy Practice Changes in Older Individuals Due to COVID-19: Expert Consensus Statement

The ubiquitous coronavirus 2019 (COVID-19) pandemic has required healthcare providers across all disciplines to rapidly adapt to public health guidelines to reduce risk while maintaining quality of care. Electroconvulsive therapy (ECT), which involves an aerosol-generating procedure from manual ventilation with a bag mask valve while under anesthesia, has undergone drastic practice changes in order to minimize disruption of treatment in the midst of COVID-19. In this paper, we provide a consensus statement on the clinical practice changes in ECT specific to older adults based on expert group discussions of ECT practitioners across the country and a systematic review of the literature. There is a universal consensus that ECT is an essential treatment of severe mental illness. In addition, there is a clear consensus on what modifications are imperative to ensure continued delivery of ECT in a manner that is safe for patients and staff, while maintaining the viability of ECT services. Approaches to modifications in ECT to address infection control, altered ECT procedures, and adjusting ECT operations are almost uniform across the globe. With modified ECT procedures, it is possible to continue to meet the needs of older patients while mitigating risk of transmission to this vulnerable population.     

The use of electroconvulsive therapy in patients with dissociative disorders.

The psychiatric literature generally discourages the use of electroconvulsive therapy (ECT) to treat depression in dissociative disorder patients, but contains little data on outcome. This prospective study of ECT in three dissociative disorder patients demonstrates that ECT is indicated for severe treatment-resistant depression in such patients. Their Hamilton Depression Scale scores fell by 50%, they were remarkably clinically improved, and they maintained their gains for at least 4 months. The ECT proved helpful when depression was felt by most of the active alters rather than just by one depressed personality. Mini-Mental State Examination scores and clinical observation revealed no unusual confusion or side effects from ECT. These patients' dissociated condition was not altered by ECT, which indicates that ECT neither treats nor impairs treatment of dissociation. Electroconvulsive therapy can be helpful in the overall treatment of dissociative disorders by alleviating severe depressions which block utilization of psychotherapy.