Chapter 38.Electroconvulsive Therapy and Other Brain Stimulation Therapies

Electroconvulsive therapy (ECT) is associated with low morbidity and mortality (Nuttall et al. 2004). Nonetheless, medical comorbidity in ECT patients is common, and the psychiatrist should be aware of a patient’s medical status and familiar with strategies to prevent complications. The essence of the pre-ECT medical evaluation is a history and physical examination. Further testing or specialist consultation can be ordered as needed. Additionally, individual hospitals and clinics may have their own policies governing pre-procedural tests such as blood work or electrocardiograms (ECGs). As a general rule, stabilization of any suboptimally controlled medical conditions before commencing ECT is ideal, but it must be balanced with clinical urgency. For example, waiting a few days to stabilize a medical problem may be acceptable in a behaviorally well-modulated patient, but not in a mute, stuporous, catatonic patient. Good communication among the primary psychiatrist, other specialist consultants, and the anesthesiologist is essential. In many ECT clinics, the anesthesiologist of the day varies from treatment to treatment, so it falls on the psychiatrist to ensure that information obtained from previous treatments is passed on. Also, the patient’s medical status prior to treatments may change during the course of treatments, so ongoing vigilance to assess new-onset medical issues is critical, and this too usually falls on the psychiatrist. Thus, it is unwise for a psychiatrist treating an ECT patient to assume an attitude that it is the anesthesiologist’s or internist’s responsibility to deal with medical problems—good care of these patients begins with the psychiatrist.