Review Article

Electroconvulsive Therapy: A Review of History, Patient Selection, Technique, and Medication Management

Authors: Stephen Taylor, MD

Abstract

Electroconvulsive therapy (ECT) is a safe and effective treatment for severe and persistent depression, bipolar disorder and schizophrenia. Though ECT is now over 60 years old, it remains an underutilized treatment today. History, patient selection, safety, and characteristics of the treatment stimulus, technique, and medications used in ECT are reviewed. Dosing strategies, as pertaining to seizure threshold, will be considered. Mechanisms of action, especially with regard to serotonin, norepinephrine, and dopamine receptor expression will be discussed.


Key Points


* Electroconvulsive therapy (ECT) has been shown to be a highly effective, safe, and even life-saving treatment for persistent and severe depression, bipolar disorder and schizophrenia.


* ECT is safe for patients with comorbid medical conditions, as modern anesthesia techniques and medications have greatly reduced the morbidity and mortality of ECT.


* Experience and emerging research have made it clear that ECT should be offered to patients as a viable treatment option at all stages of their illness process.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Beyer JL, Weiner RD, Glenn MD. Electroconvulsive Therapy: A Programmed Text. 2nd edition. Washington, DC, American Psychiatric Press, Inc, 2001.
 
2. Abrams R. Electroconvulsive Therapy. 4th edition. Oxford, Oxford University Press, 2002.
 
3. Glass RM. Electroconvulsive therapy: time to bring it out of the shadows. JAMA 2001;285:1346–1348.
 
4. Sackeim HA, Haskett RF, Mulsant BH, et al. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. JAMA 2001;285:1299–1307.
 
5. Weiner RD, Coffey CE, Fochtmann LJ, et al. The Practice of Electroconvulsive Therapy Recommendations for Treatment, Training, and Privileging. 2nd edition. Washington, DC, American Psychiatric Association, 2001.
 
6. Tharyan P, Adams CE. Electroconvulsive Therapy for Schizophrenia. Cochrane Database of Systemic Reviews. (2):CD000076, March 2005.
 
7. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th edition. New York, Lippincott Williams & Wilkins, 2003.
 
8. Gur E, Dremencov E, Garcia F, et al. Functional effects of chronic electroconvulsive shock on serotonergic 5-HT(1A) and 5-HT(1B) receptor activity in rat hippocampus and hypothalamus. Brain Res 2002;952: 52–60.
 
9. Benkelfat C. Biochemical effects of electroconvulsive therapy. Encephale 1988;14:273–281.
 
10. Dam H, Pakkenberg H, Bolwig TG. Electric stimulation (ECT) in Parkinson disease. Ugesk Laeger 1992;154:183–187.
 
11. Li B, Suemaru K, Cui R, et al. Repeated electroconvulsive stimuli increase brain derived neurotrophic factor in ACTH-treated rats. Eur J Pharmacol 2006;529:114–121.
 
12. Palmio J, Huuhka M, Saransaari P, et al. Changes in plasma amino acids after electroconvulsive therapy of depressed patients. Psychiatry Res 2005;137:183–190.
 
13. Devanand DP, Dwork AJ Hutchinson ER, et al. Does ECT alter brain structure? Am J Psychiatry 1994;151:957–970.
 
14. Moscrip TD, Terrace HS, Sackeim HA, et al. A primate model of anterograde and retrograde amnesia produced by convulsive treatment. JECT 2004;20:26–36.
 
15. O’Connor M, Brenninkmeyer C, Morgan A, et al. Relative effects of repetitive transcranial magnetic stimulation and electroconvulsive therapy on mood and memory: a neurocognitive risk-benefit analysis.Cogn Behav Neurol 2003;16:118–127.
 
16. Reid WH Electroconvulsive therapy. Tex Med 1993;89:58–62.
 
17. Werawatganon T, Kyokong O, Charuluxananan S, et al. Muscular injury after succinylcholine and electroconvulsive therapy. Anesth Analg 2004;98:1676–1679.
 
18. Datto C, Rai AK, Ilivicky HJ, et al. Augmentation of seizure induction in electroconvulsive therapy: a clinical reappraisal. JECT 2002;18:118–125.
 
19. Krystal AD, Dean MD, Weiner RD, et al. ECT Stimulus intensity: are present ECT devices too limited? Am J Psychiatry 2000;157:963–967
 
20. McCall WV, Reboussin DM, Weiner RD, et al. Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy: acute antidepressant and cognitive effects. Arch Gen Psychiatry 2000;57:438–444.
 
21. 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;57:425–434.
 
22. Heikman P, Tuunainen A, Kuoppasalmi K. Value of the initial stimulus dose in right unilateral and bifrontal electroconvulsive therapy. Psychol Med 1999;29:1417–1423.
 
23. Mokriski BK, Nagle SE, Papuchis GC, et al. Electroconvulsive therapy-induced cardiac arrhythmias during anesthesia with methohexital, thiamylal, or thiopental sodium. J Clin Anesth 1992;4:208–212.
 
24. Ding Z, White PF. Anestheisa for electroconvulsive therapy. Anesth Analg 2002;94:1351–1364.
 
25. Tang WK, Ungvari GS. Asystole during electroconvulsive therapy: a case report. Aust N Z J Psychiatry 2001;35:382–385.
 
26. Coffey CE, Lucke J, Weiner RD, et al. Seizure threshold in electroconvulsive therapy, II: the anticonvulsant effect of ECT. Biol Psychiatry 1995;37:777–788.
 
27. Sackeim HA, Decina P, Prohovnik I, et al. Anticonvulsant and antidepressant properties of electroconvulsive therapy: a proposed mechanism of Action. Biol Psychiatry 1983;18:1301–1310.
 
28. El-Mallakh RS. Complications of concurrent lithium and electroconvulsive therapy: a review of clinical material and theoretical considerations. Biol Psychiatry 1988;23:595–601.
 
29. Fink M, Sackeim HA. Theophylline and the risk of status epilepticus in ECT. JECT 1998;14:286–290.
 
30. Krystal AD, Coffey CE. Neuropsychiatric considerations in the use of electroconvulsive therapy. J Neuropsychiatry Clin Neurosci 1997;9:283–292.
 
31. Kellner CH, Ramas L. Dexamethasone pretreatment for ECT in an elderly patient with meningioma. Clin Gerontol 1990;10:67–72.
 
32. Takada JY, Solimene MC, da Luz PL, et al. Assessment of the cardiovascular effects of electroconvulsive therapy in individuals older than 50 years. Braz J Med Biol Res 2005;38:1349–1357.
 
33. Giltay EJ, Kho KH, Keijzer LT, et al. Electroconvulsive therapy (ECT) in a patient with a dual-chamber sensing, VDDR pacemaker. JECT 2005;21:35–38.
 
34. Dolenc TJ, Barnes RD, Hayes DL, et al. Electroconvulsive therapy in patients with cardiac pacemakers and implantable cardioverter defibrillators. Pacing Clin Electrophysiol 2004;27:1257–1263.