Electroconvulsive therapy (ECT) is a procedure in which small electric currents pass through the brain, intentionally triggering a short seizure.1 ECT causes changes in neurons’ electrical and chemical signaling, and it can quickly reverse symptoms of certain mental health conditions.1 This form of therapy has been accompanied by decades of stigma, given its uses in the early 20th century to control “unruly” patients and “treat” homosexuality.2 Additionally, ECT was administered without general anesthesia or muscle relaxants, resulting in memory loss, fractured bones, severe pain and other serious side effects.1 Today, however, ECT is much safer, and is administered in a controlled setting with anesthetic drugs. Anesthesia providers are crucial to making contemporary ECT as pleasant and effective as possible.3
ECT is a non-medication alternative to many psychiatric treatments, and it is used by approximately 100,000 Americans.2 The biology of ECT involves changes to gene expression, the immune system and the brain.4 The neurobiological alterations that accompany ECT include neuron stimulation and depolarization, as well as changes in cerebral blood flow, regional metabolism and the blood-brain barrier.4 ECT is most commonly used to treat severe, treatment-resistant depression, especially when accompanied by anorexia; severe mania; catatonia (e.g., lack of movement or speech); and agitation and aggression in people with dementia.1 Research in ECT has greatly contributed to the literature on depression.3
In order to keep patients safe and reduce pain, today’s modified ECT includes general anesthesia. A recent review by Soehle and Bochem cites the lack of consensus regarding optimal anesthetic drugs for ECT.5 Recent studies have evaluated the effectiveness of dexmedetomidine, remifentanil and ketamine with mixed results.5 Researchers did find that bispectral index (BIS) guided anesthesia (i.e., anesthesia accompanied by monitoring of depth and titration) or a time delay between anesthesia and seizure induction resulted in a better seizure quality.5 While some studies found that ketamine may help with ECT through its additional antidepressant effects,6,7 others did not find a benefit of using ketamine.8,9 Though general anesthesia is vital to making ECT more pleasant3 and may allow for additional performance of non-ECT procedures,10 data on best anesthetic practices are lacking.
As researchers approach the ideal anesthetic drugs for ECT, they must consider the medical issues that may occur during this intense procedure.3 During ECT, heart rate and blood pressure increase, which can lead to serious heart problems.1 Postoperative side effects include confusion that may last from minutes to days, retrograde amnesia, nausea, headache, jaw pain and muscle aches.1 Though ECT-related adverse events appear to be declining in frequency, the anesthesia provider must be prepared for complications.11 Before ECT, anesthesiology practitioners should familiarize themselves with the physiological response to the electrical stimulus, the potential effects of different anesthetic drugs and the patient’s own risk factors.11 According to a review by Rozet et al., advanced age and ischemic heart disease are risk factors for postoperative ECT complications; therefore, the anesthesiologist should select appropriate treatment based on higher risk.3 Anesthesia providers should monitor all patients closely during and after ECT to prevent medical problems. Rozet et al.’s review found that cardiopulmonary complications and falls were the most frequent adverse events associated with ECT,3 while a case study by Acharya et al. reported accidental awareness under general anesthesia (AAGA) during ECT.12 Due to the gravity of ECT, anesthesia providers should be aware of associated side effects and life-threatening complications.
As the stigma surrounding ECT lessens and it becomes more commonplace, anesthesiology practitioners must consider the best practices for ECT. This includes choosing medications that increase the patient’s safety and perhaps enhance the psychiatric effects of ECT. Additionally, anesthesia providers should be wary of potential complications that may arise during the perioperative period. Researchers should aim to remedy the lack of studies on anesthetic drugs for ECT in order to optimize care for future patients.
1. Mayo Clinic. Electroconvulsive therapy (ECT). 2019; https://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/about/pac-20393894.
2. Sadowsky J. Electroconvulsive Therapy: A History of Controversy, but Also of Help. Scientific American. Web: Springer Nature America, Inc.; January 13, 2017.
3. Rozet I, Rozet M, Borisovskaya A. Anesthesia for Electroconvulsive Therapy: an Update. Current Anesthesiology Reports. 2018;8(3):290–297.
4. Singh A, Kar SK. How Electroconvulsive Therapy Works?: Understanding the Neurobiological Mechanisms. Clinical Psychopharmacology and Neuroscience. 2017;15(3):210–221.
5. Soehle M, Bochem J. Anesthesia for electroconvulsive therapy. Current Opinion in Anesthesiology. 2018;31(5):501–505.
6. Anderson IM, Blamire A, Branton T, et al. Ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT): A multicentre, double-blind, randomised, parallel-group, superiority trial. The Lancet Psychiatry. 2017;4(5):365–377.
7. Ostroff R, Gonzales M, Sanacora G. Antidepressant Effect of Ketamine During ECT. American Journal of Psychiatry. 2005;162(7):1385–1386.
8. Zhang M, Rosenheck R, Lin X, et al. A randomized clinical trial of adjunctive ketamine anesthesia in electro-convulsive therapy for depression. Journal of Affective Disorders. 2018;227:372–378.
9. Ray-Griffith SL, Eads LA, Han X, Golden K, Stowe ZN. A Randomized Pilot Study Comparing Ketamine and Methohexital Anesthesia for Electroconvulsive Therapy in Patients With Depression. The Journal of ECT. 2017;33(4):268–271.
10. Li EH, Stork CE, Jim On SC, Bryson EO, Aloysi AS, Kellner CH. Additional Procedures Performed During Electroconvulsive Therapy Anesthesia. The Journal of ECT. 2016;32(3):e7–e8.
11. Bowman-Dalley C, Hilliard JG. Perioperative Challenges During Electro Convulsive Therapy (ECT). In: Brambrink AM, Kirsch JR, eds. Essentials of Neurosurgical Anesthesia & Critical Care: Strategies for Prevention, Early Detection, and Successful Management of Perioperative Complications. Cham, Switzerland: Springer International Publishing; 2020:271–277.
12. Acharya H, Gaur A, Kunigiri G. Anesthetic and psychiatric implications of accidental awareness under general anesthesia during electroconvulsive therapy. Saudi Journal of Anaesthesia. 2018;12(2):335–338.