Chapter 5. Adverse Effects - Recommendations - ECT

Written by Juli Lawrence

Recommendations

5. 1. General

a) Physicians administering ECT should be aware of the principal adverse effects which may accompany its use.

b) The type, likelihood, and persistence of adverse effects should be considered on a case-by-case basis in the decision to recommend ECT and in the informed consent process (see Chapter 8).

c) Efforts should be made to minimize adverse effects by optimization of the patient's medical condition prior to treatment, appropriate modifications in ECT technique, and the use of adjunctive medications (see also Section 4.1).

5.1.1. Cardiovascular Complications

a) The electrocardiogram (ECG) and vital signs (blood pressure, pulse, and respiration) should be monitored during each ECT treatment to detect cardiac arrythmias and hypertension (see Section 11.8).

b) The ECT treatment team should be prepared to manage the cardiovascular complications known to be associated with ECT. Personnel, supplies, and equipment necessary to perform such a task should be readily available (see Chapters 9 and 10).

5.1.2. Prolonged Seizures

Each facility should have policies outlining the steps to be taken to terminate prolonged seizures and status epilepticus (see Section 11.9.4).

5.1.3 Prolonged Apnea

Resources for maintaining an airway for an extended period, including intubation, should be available in the treatment room (see Chapters 9 and 10).

Systemic Side Effects

Headache and nausea are the most common systemic side effects of ECT. Systemic side effects should be identified and symptomatic treatment considered.

5.3 Treatment Emergent Mania

Instances in which patients switch from depressive or affectively mixed states into hypomania or mania during a course of ECT should be identified, and a determination to continue or suspend further treatment with ECT.

5.4. Cognitive Dysfunction

a) Orientation and memory function should be assessed prior to ECT and periodically throughout the ECT course to detect and monitor the presence of ECT-related cognitive dysfunction (see Section 12.2.1 for details). This assessment should attend to patient self-reports of memory difficulty.

b) Based on the assessment of the severity of cognitive side effects, the physician administering ECT should take appropriate action. The contributions of medications, ECT technique, and spacing of treatments should be reviewed. Potential treatment modifications include changing from bilateral to right unilateral electrode placement, decreasing the intensity of electrical stimulation, increasing the time interval between treatments, and/or altering the dosage of medications, or, if necessary, terminating the treatment course.

Table 1. Treatment factors that may increase or decrease the severity of adverse cognitive side effects

5.1. Medical Complications

Precise rates of mortality attributable to ECT are difficult to determine due to methodological issues intrinsic to studies of medical mortality, such as uncertainty as to cause of death, time frame for linking death to ECT, and variability in reporting requirements. The mortality attributed to ECT is estimated to be approximately the same as that associated with minor surgery (McCabe 1985 Warner et al. 1993; Brand et al. 1994; Badrinath et al. 1995: Hall et al. 1997). Published estimates from large and diverse patient series over several decades report up to 4 deaths per 100,000 treatments (Heshe and Roeder, 1976; Fink, 1979; Weiner 1979; Babigian and Guttmacher, 1984; Crowe, 1984; Kramer, 1985: Abrams 1997b; Reid et al. 1998). Despite the frequent use of ECT in patients with significant medical complications and in the elderly (Sackeim 1993, 1998; Weiner et al. in press), rates of mortality appear to have decreased in recent years. A reasonable current estimate is that the rate of ECT-related mortality is 1 per 10,000 patients. This rate may be higher in patients with severe medical conditions. The rate of significant morbidity and mortality is believed to be lower with ECT than with treatment with some types of antidepressant medication (e.g., tricyclics) (Sackeim 1998). There is also evidence from longitudinal follow-up studies that mortality rates following hospitalization are lower among depressed patients who received ECT than patients who received alternative forms of treatment or no treatment (Avery and Winokur, 1976; Philibert et al. 1995)