Electroconvulsive Therapy Technique
Decision to Administer ECT
As already noted, the decision to refer a patient to ECT is based on an assessment of applicable risks and benefits. Once a referral is made, informed consent is provided by the patient or, if the patient is incapable of informed consent, by an individual so designated under state law (usually a family member). All aspects of the consent procedure should follow applicable state regulations, which vary considerably among states. It is also important to recognize that consent is an ongoing process and can be revoked at any time.
The following generic information should be included in the consent form and/or in a “patient information sheet”: a description of ECT procedures; a statement of why ECT is being recommended; a consideration of treatment alternatives; a discussion of the considerations regarding treatment electrode placement; a statement as to the typical range of the number of treatments administered; a statement that therapeutic response may be absent or transient and that continuation therapy might be needed; a description of the risks (including death and also the possibility of persistent amnesia) and benefits; a statement that necessary procedures will be carried out if an emergency arises; a list of restrictions on behavior that are likely to be necessary before, during, or after ECT; and a statement that consent can be revoked at any time (American Psychiatric Association Committee on ECT 2000). This information should be read by the consentor as part of the informed consent procedure and should be kept by him or her after the formal consent document is signed. This generic information should be supplemented by any significant additional case-specific information that is applicable and the provision of this information documented. Although a consent form covers an entire series of ECT treatments (except in certain states), it is now recommended that reconsent be obtained if an index ECT series is unusually prolonged (American Psychiatric Association Committee on ECT 2000). Because continuation ECT differs in a number of ways from an index course of treatments, it is useful to have a separate consent form for such purposes.
Lay information on ECT, in the form of both written materials and videotapes, can be obtained from the American Psychiatric Association (ask for the “Fact Sheet” on ECT) and from ECT device manufacturers. In addition, several books oriented to the general public have been published on the topic (Endler 1990; Fink 1999). Practitioners should take care to point out to the consentor any major discrepancies between local regulations and information presented in such materials that they use.
Pre-ECT Psychiatric and Medical Workup
The American Psychiatric Association Committee on ECT (2000) recommendations state that an individual privileged to administer ECT at the facility should evaluate the patient before initiating the treatments. The history and examination should 1) delineate the indication for ECT; 2) address the effects of prior treatments, including ECT; 3) assess risk factors based on a medical and dental history and examination and address how the risks might be minimized; and 4) make recommendations for any further pre-ECT consultations or laboratory studies (many practitioners routinely screen patients with a complete blood count, serum potassium and sodium levels, and electrocardiogram) or any changes in the patient’s management that are indicated before or during ECT, including alterations in psychotropic and medical pharmacological agents. In addition to the psychiatric evaluation, a preoperative anesthetic assessment should be carried out to further clarify the risk component of the risk-benefit equation and to determine whether and how such risks can be minimized, particularly in terms of modifications of the anesthetic procedure.
Management of Medications Before and During ECT Course
The preparation of a patient for ECT includes devising a plan for management of the patient’s medication regimen (both psychotropics and other agents), including which medications should be discontinued and which should be taken before or held until after treatment on ECT days. Medications that are medically needed or that have a beneficial effect (e.g., most cardiac agents and antireflux preparations) should be administered before ECT on treatment days, making sure that the amount of fluid taken with any oral preparations is kept to a minimum. In general, agents that have a potentially deleterious effect—in terms of either diminishing efficacy or increasing risks—should be discontinued or substituted with another agent whenever possible; at the least, dosages should be decreased to the minimum necessary (agents with withdrawal risk need to be gradually tapered). Examples include theophylline, lithium, benzodiazepines, and anticonvulsants (American Psychiatric Association Committee on ECT 2000). Although it is disputed whether the combination of lithium and ECT is associated with an increased risk of cerebral toxicity (American Psychiatric Association Committee on ECT 2000; Mukherjee 1993; Small and Milstein 1990), lowering the level of lithium administered before each ECT treatment may decrease the risk. When benzodiazepines cannot be withdrawn or held, the benzodiazepine antagonist flumazenil may be used to reverse their anticonvulsant effect during the treatment (Krystal et al. 1998). In such cases, a parenteral benzodiazepine (e.g., intravenous midazolam) should be readministered immediately after the treatment to avoid withdrawal symptoms. Antipsychotic medication should be continued during ECT in patients with psychosis, particularly those with schizophrenia or schizoaffective disorder, although doses should be in the low to moderate range, particularly with clozapine. There has recently been renewed interest in antidepressant medication augmentation of ECT. While only preliminary data presently exist regarding this practice (Lauritzen et al. 1996), its use is presently widespread, particularly given pressures from third-party carriers to rapidly institute definitive treatment (American Psychiatric Association Committee on ECT 2000).
ECT in Patients With General Medical Illness
It is common for patients receiving ECT—particularly elderly patients—to have underlying medical disorders. Many of these conditions raise special concerns with respect to the use of ECT or require modification of technique. The situation with respect to high-risk patients has already been briefly discussed, as has the use of ECT to treat certain medical disorders. Several additional disorders also bear attention (see Weiner et al. 2000 for more comprehensive coverage of this topic).
Patients with hypertensive disease should have their blood pressure stabilized before receiving ECT and should also receive a dose of their routine antihypertensive medication before each treatment. Although agents with short half-lives, such as labetalol, can be used to diminish the transient blood pressure rise at the time of ECT, it is also important to avoid iatrogenically induced hypotension during the postictal and recovery periods. Patients with coronary artery disease should receive their antianginal agents before ECT, and consideration should also be given to the use of acute sympatholytics at the time of the treatment. Cardiac pacemakers actually reduce the risk with ECT, because the likelihood of pathological arrhythmias is decreased. A similar situation exists with implanted cardiac defibrillators, although a cardiologist with electrophysiology expertise should be consulted before administering ECT in such cases to ascertain whether the defibrillator portion of the device should be inhibited at the time of the procedure.
With diabetes mellitus, the dosing of antidiabetic agents should be adjusted to take into account the fact that patients must avoid food or fluid intake for at least 5 hours prior to each treatment. An intravenous drip containing glucose should be considered in patients who have brittle diabetes mellitus or when a prolonged wait will be necessary before the treatment. In addition, a fingerstick glucose level should be obtained within 30-60 minutes before each treatment to ensure that the patient is not hypoglycemic at the time of seizure induction. Practitioners should also keep in mind that increased appetite often accompanies clinical improvement with ECT and that increases in insulin dose may therefore be necessary for those receiving this agent.
Patients with asthma who are receiving theophylline should have doses kept to a minimum or, preferably, switched to an alternative agent, to diminish the epileptogenic effects of this medication. Close monitoring of blood levels early in the ECT course is helpful in this regard. Persons with epilepsy who are receiving anticonvulsant agents should be managed in a similar fashion: in this case, to allow the seizure threshold-elevating effects of these drugs to be ameliorated.
Unlike most psychotropic agents, neither ECT nor the drugs routinely used in conjunction with the treatments have teratogenic effects or otherwise have an adverse impact on pregnancy, at least during the first two trimesters (Miller 1994; Wisner and Perel 1988). Closer to term, the resulting mass effect is associated with a greater risk of aspiration. All pregnant women should receive an obstetrical consultation before undergoing ECT, and noninvasive fetal monitoring should be considered in situations in which fetal heart rate is detectable.
Revision date: July 4, 2011
Last revised: by Jorge P. Ribeiro, MD