ECT: balancing risks and benefits

Position statement and guidelines on unmodified electroconvulsive therapy

BACKGROUND

In modern day psychiatric practice, it is assumed as a matter of fact that when electroconvulsive therapy (ECT) is administered, it will be administered under anesthesia and with succinylcholine (or its equivalent) modification. Yet, as surveys indicate, there is considerable practice of unmodified ECT in developing countries and, to a small extent, in the developed world, as well.

MATERIALS AND METHODS

This document examines historical and recent literature on the geographical practice, physiology, efficacy, and adverse effects of unmodified ECT. Particular attention is paid to musculoskeletal risks.

RESULTS

Although almost all the research is of poor methodological quality, there is a good reason to accept that unmodified ECT is associated with a wide range of adverse consequences, important among which are musculoskeletal complications, pre-ECT anxiety, and post-ECT confusion. However, it appears from recent data that these risks are not as large as historically portrayed. Possibly explanations are suggested, with seizure modification using parenteral benzodiazepines as a special possibility.

CONCLUSIONS

Under exceptional circumstances, if ECT is strongly indicated and seizure modification with succinylcholine is not feasible, unmodified ECT, especially benzodiazepine-modified ECT, may be a viable option. A detailed set of recommendations for such use of unmodified ECT is proposed along with necessary checks and balances. This document has been approved by the Indian Psychatric Society, the Indian Association of Biological Psychiatry, and the Indian Association of Private Psychiatry (which commissioned the preparation of the document).

The safety and efficacy of benzodiazepine-modified treatments as a special form of unmodified ECT

BACKGROUND

Muscle relaxants reduce musculoskeletal morbidity with electroconvulsive therapy (ECT) but need to be administered under general anesthesia. The administration of anesthesia is not always possible for patients prescribed ECT. Consequently, unmodified ECT is still widely practiced, especially in developing countries.

METHODS

We prospectively assessed musculoskeletal morbidity in consecutive patients who received unmodified bitemporal ECT during a part or the whole of their ECT course. All patients were pretreated with an intravenous benzodiazepine (usually diazepam, 10 mg) to effect sedation, anxiolysis, and limited skeletal muscle relaxation. Anteroposterior and lateral digital x-rays of the thoracolumbar spine were obtained after the last unmodified treatment.

RESULTS

Fifty-six patients aged 11 to 49 years and with a mean body mass index of 23.0 received a total of 162 (mean, 2.9) unmodified ECTs. There was significant attenuation of psychopathology ratings. Against our expectations, no patient developed clinical or radiological evidence of orthopedic morbidity; however, in 2 patients, the x-rays revealed old spinal fractures. Twelve patients had spots of oral bleeding after ECT. Whereas 5 patients experienced mild, transient, self-limiting postictal confusion, only one had confusion which required medical termination. Five patients complained of body ache and one of memory impairment. There were no other adverse events.

CONCLUSIONS

The complete absence of orthopedic morbidity with benzodiazepine-modified ECT contrasts with historical descriptions of a 20% to 40% risk with unmodified ECT. We speculate that the limited muscle relaxant action of the pre-ECT parenteral benzodiazepine may have had protective effects. If so, if ECT is urgently indicated but anesthesia and hence conventional muscle relaxants cannot be administered, benzodiazepine-modified ECT may be a safer alternative to unmodified ECT. This suggestion merits wide attention because of its public health importance in countries with poor medical infrastructure, where unmodified ECT is still widely practiced.