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In a patient under intravenous sedation or general anesthesia, electroconvulsive therapy (ECT) uses an electric current to create a generalized cerebral seizure. Although it is primarily utilized to treat patients with severe depression, patients with schizophrenia, schizoaffective disorder, catatonia, neuroleptic malignant syndrome, and bipolar disorder may also benefit. This activity describes the indications, contraindications, and complications of ECT and highlights the role of the interprofessional team in the management of patients with mental health disorders. Objectives: Determine the effects of electroconvulsive therapy. Identify the potential uses of electroconvulsive therapy. Assess misinformation associated with electroconvulsive therapy. Communicate electroconvulsive therapy, and review the role of the interprofessional team in managing patients who undergo ECT. Access free multiple choice questions on this topic.

In a patient under intravenous sedation or general anesthesia, electroconvulsive therapy (ECT) uses an electric current to create a generalized cerebral seizure. Although it is primarily utilized to treat patients with severe depression, patients with schizophrenia, schizoaffective disorder, catatonia, neuroleptic malignant syndrome, and bipolar disorder may also benefit. However, the practice has a stigma attached to it due to misinformation regarding procedural methodology.

Bilateral or bitemporal ECT causes more cognitive impairment than unilateral ECT, although this effect is transient. A meta-analysis of 1415 depressed patients treated with ECT revealed that global cognition, verbal memory, and autobiographical memory were worse with bilateral treatment 3 days after treatment.[29] According to the American Psychiatric Association, patients receiving ECT are at higher risk if they show evidence of unstable or severe cardiovascular disease, a space-occupying intracranial lesion with evidence of elevated intracranial pressure, a history of an acute cerebral hemorrhage or stroke, an unstable vascular aneurysm, severe pulmonary disease, or qualify as American Society of Anesthesiologists (ASA) Class 4 or 5. Physiologically, during the tonic phase of the seizure, a 15- to 20-second parasympathetic discharge occurs, which can lead to bradyarrhythmias, including premature atrial and ventricular contractions, atrioventricular block, and asystole. Patients with subconvulsive seizures are at higher risk for asystole.[30] Paradoxically, patients with heart block or underlying arrhythmias are less likely to develop asystole. The clonic phase of the seizure correlates with a catecholamine surge that causes tachycardia and hypertension, which lasts temporally with seizure duration.[31] Hypertension and tachycardia resolve within 10 to 20 minutes of the seizure, although some patients exhibit persistent hypertension that requires medical intervention.

Physiologically, during the tonic phase of the seizure, a 15- to 20-second parasympathetic discharge occurs, which can lead to bradyarrhythmias, including premature atrial and ventricular contractions, atrioventricular block, and asystole. Patients with subconvulsive seizures are at higher risk for asystole.[30] Paradoxically, patients with heart block or underlying arrhythmias are less likely to develop asystole. The clonic phase of the seizure correlates with a catecholamine surge that causes tachycardia and hypertension, which lasts temporally with seizure duration.[31] Hypertension and tachycardia resolve within 10 to 20 minutes of the seizure, although some patients exhibit persistent hypertension that requires medical intervention. Although patients with cardiac disease at baseline are at higher risk following treatment, ejection fraction can also decrease following ECT in healthy patients.[32] In a study of 53 adults undergoing ECT, 7 developed new global left ventricular (LV) systolic dysfunction, and 8 developed regional wall motion abnormalities.[33] Of these patients, no adverse outcomes were in patients with LV dysfunction. In a prospective cohort study of 100 subjects undergoing ECT, increased cardiac troponin levels were present in 8 patients, with only 2 having other evidence of myocardial ischemia or infarction.[34] Cerebral blood flow and intracranial pressure both increase with ECT therapy. Clinically, patients may exhibit confusion, delirium, disorientation, and memory loss. ECT is classified as a low-risk procedure by the AHA-ACC guidelines because it is well tolerated and demonstrates only transient hemodynamic lability and a low mortality rate.[35][36][37]

ECT is now frequently used to treat a variety of mental health disorders besides depression. The procedure is relatively safe and does work. However, the delivery of ECT requires an interprofessional team that includes a nurse, an anesthesiologist, and a psychiatrist. The benefits of ECT are seen after several sessions, and the results are durable. The key is to educate the patient and family about ECT because the procedure has been associated with many false and illogical beliefs. The antidepressant effect is seen relatively quickly and may last up to a few years. Overall, the mortality rate is very low with ECT administered in a controlled setting, but it continues to cause mild memory loss in the long term. ECT is commonly utilized in pregnant and older patients due to the avoidance of psychotropic medication side effects. Although its mechanism of action is multifactorial, ECT causes changes in cerebral blood flow and regional metabolism. Most patients who undergo ECT have a beneficial response without any adverse sequelae.[38]