From the Guidelines
Risk assessment before electroconvulsive therapy (ECT) should include a comprehensive medical evaluation to identify potential complications, focusing on cardiovascular, neurological, and pulmonary systems, as well as anesthesia risks and medication review, to minimize complications and maximize treatment efficacy, as supported by the practice parameter for use of electroconvulsive therapy with adolescents 1.
Key Components of Risk Assessment
- Complete history and physical examination to identify potential complications
- Baseline laboratory tests, including complete blood count, comprehensive metabolic panel, and electrocardiogram
- Specific attention to patients with cardiovascular disease, as ECT causes a transient increase in heart rate and blood pressure
- Cardiology consultation for patients with recent myocardial infarction, unstable angina, decompensated heart failure, or severe valvular disease
- Neurology consultation for patients with intracranial masses or recent stroke
- Anesthesia risks evaluation, particularly regarding airway management
- Medication review, including adjustment of anticonvulsants and holding lithium 24-48 hours before ECT
- Documentation of dental status to assess aspiration risks
- Informed consent discussion of benefits, risks, and alternatives
Consideration of Adverse Effects
- Impairment of memory and new learning
- Tardive seizures, which are rare but potentially serious
- Prolonged seizures, which can be effectively terminated with additional medication
- Risks associated with general anesthesia, including fatality rate and anesthesia-related mortality rate
- Other minor side effects, such as headache, nausea, vomiting, muscle aches, confusion, and agitation, which can be managed conservatively
Importance of Comprehensive Evaluation
A thorough risk assessment is crucial to minimize complications and maximize treatment efficacy, as ECT remains one of the most effective treatments for severe depression, particularly when medication resistance is present, as noted in the practice parameter for use of electroconvulsive therapy with adolescents 1.
From the Research
Risk Assessment Prior to ECT
- The risk assessment prior to Electroconvulsive Therapy (ECT) is crucial to prevent cardiac complications and provide timely care to treatment-resistant populations who are at risk for excessive morbidity and suicide 2.
- A comprehensive multidisciplinary team approach can help manage and minimize cardiovascular complications associated with ECT 2.
- Providing proper cardiac clearance can prevent cardiac complications, and it is essential to evaluate patients with preexisting heart disease before undergoing ECT 2.
- The incidence of serious potentially life-threatening adverse events (pLTAEs) during ECT is low, and ECT can be considered a rather safe treatment when performed in a controlled setting 3.
- A thorough risk assessment should be conducted to identify patients who may be at high risk for ECT, and safety protocols should be implemented to mitigate these risks 4.
Factors to Consider in Risk Assessment
- Patients with underlying cardiovascular disease are at a higher risk for cardiac complications during ECT 2.
- The risk of ECT is independent of sex, age, and diagnosis of patients, and anesthesia medication 3.
- Minor adverse events occur more often with higher stimulus doses and an increasing number of treatments 3.
- Certain medical conditions, such as recent myocardial infarction, deep vein thrombosis, intracranial aneurysm and tumors, pheochromocytoma, sepsis, and pregnancy, may indicate a high risk for ECT 4.
Safety Protocols and Precautions
- Safety protocols, adequate stakeholder communication, collaboration with anesthetists and specialists, consultation-liaison services, and ECT education can help mitigate the risks associated with ECT 4.
- Educating referring clinicians, patients, and their families about the factors involved in the safe delivery of ECT is essential 5.
- A careful analysis of the risks of outpatient ECT and the implementation of measures to ensure patient safety are necessary when providing ECT on an outpatient basis 5.