Electroconvulsive Therapy

Aka: Electroconvulsive Therapy

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II. History

  1. First ECT performed in 1938 by Cerletti and Bini

III. Indications

  1. Medication resistant Major Depression
  2. Severe Major Depression with Suicidal Ideation
  3. Delusional Depression
  4. Acute Mania
  5. Catatonia
  6. Severe psychiatric illness with food and fluid refusal
  7. Severe adverse medication affects
    1. Neuroleptic Malignant Syndrome
  8. Comorbid Condition
    1. Parkinson's Disease
  9. Pregnancy with severe refractory depression
    1. See Psychiatric Medications in Pregnancy

IV. Contraindications

  1. Brain Tumor or other space occupying lesion
  2. Cerebrovascular Accident within the last month
  3. Age <13 years old (approved in U.S. for age >=13 years old)

V. Indications: Symptoms most responsive to ECT

  1. Guilt
  2. Loss of interest
  3. Agitation
  4. Anxiety
  5. Dysphoria
  6. Helplessness
  7. Worthlessness
  8. Delusions
    1. Nihilism
    2. Impoverishment
    3. Sin or guilt

VI. Examination: Pre-procedure evaluation

  1. Consider cardiology clearance in known cardiovascular disease
  2. Complete History and Physical Examination
  3. Focused areas of attention
    1. Cardiopulmonary examination
    2. Neurologic Examination
    3. Musculoskeletal Examination

VII. Labs: Pre-procedure evaluation

  1. Hemoglobin
  2. Hematocrit
  3. Serum Electrolytes

VIII. Diagnostics: Pre-procedure evaluation

  1. Electrocardiogram

IX. Technique

  1. Monitoring
    1. Blood Pressure
    2. Oxygen Saturation
    3. Telemetry monitoring of Heart Rate and rhythm
    4. Electroencephalogram
  2. Respiratory support
    1. Airway management
    2. Bag Valve Mask Ventilation
  3. Anesthesia
    1. Sedative-Hypnotic agent: Methohexital (Brevital)
    2. Paralytic Agent: Succinylcholine
  4. Electrical Stimulus
    1. Brief unilateral or bilateral stimulus
    2. Results in 50 second Generalized Seizure
  5. Course
    1. ECT administered 2 to 3 times per week for 3 to 6 weeks
    2. Total course may last 6-12 treatments

X. Cost

  1. Each treatment: $1500
  2. Total Course (6-12 treatments): $9,000 to $18,000

XI. Adverse Effects

  1. Headache
  2. Fatigue
  3. Cognitive Impairment (mild, and resolve within 2 to 4 weeks)
  4. Jaw pain
  5. Hypertension
  6. Cardiac Arrhythmia (rare)
  7. Post-ECT Confusion
  8. Memory Loss
    1. Memory Loss is short-term and reversible

XII. Safety

  1. Pregnancy
    1. Considered safe without increased risk of congenital abnormalities or childhood neurocognitive deficits

XIII. Efficacy

  1. High response rate (80%) and remission rate (60%) in refractory Major Depression
  2. Decreases Suicide rates and psychiatric hospitalization rates
  3. Relapse rate after ECT: 50% within one year

XIV. Management following ECT (relapse prevention)

  1. Example protocol: Nortriptyline and Lithium

XV. References

  1. Banazak (1996) Am Fam Physician 53(1):273-8 [PubMed]
  2. Espinoza (2022) N Engl J Med 386(7): 667-72 [PubMed]
  3. Gaddey (2024) Am Fam Physician 109(5): 410-6 [PubMed]
  4. Sackeim (2001) JAMA 285:1299-307 [PubMed]

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