What investigations are done before proceeding to Electroconvulsive Therapy (ECT)?

Pre-ECT Investigations Required for Electroconvulsive Therapy

Before proceeding with electroconvulsive therapy (ECT), a comprehensive set of investigations must be completed, including a thorough physical examination, laboratory tests, cognitive assessment, and psychiatric evaluation to ensure patient safety and optimize outcomes. 1

Physical Examination and Laboratory Investigations

• Every patient considered for ECT must receive a comprehensive physical evaluation to identify any relative contraindications 1
• Laboratory investigations are dictated by clinical assessment and must include:
  • Complete blood count with differential white blood cell count 1
  • Thyroid function tests 1
  • Liver function tests 1
  • Urinalysis and toxicology screen 1
  • Electrocardiogram (ECG) 1
  • Serum or urine pregnancy test for all female patients (mandatory) 1
• Neuroimaging studies may be indicated in certain cases:
  • Electroencephalogram (EEG) 1
  • Computed tomography (CT) or magnetic resonance imaging (MRI) of the brain when clinically indicated 1

Psychiatric Evaluation

• A detailed clinical interview documenting target symptoms using reliable rating instruments 1
• Collateral information from parents or other informants 1
• Assessment of illness severity 1
• Review of past treatments including:
  • Documentation of previous pharmacotherapy (medication, dosage, duration, compliance, response, side effects) 1
  • Verification of medication adherence through direct methods (serum or urine drug levels) when appropriate 1
  • Review of psychotherapeutic treatments and psychosocial interventions 1

Cognitive Assessment

• Memory assessment must be performed before treatment 1
• This serves as a baseline for comparison with post-treatment assessments (at treatment termination and 3-6 months post-treatment) 1

Anesthesia Consultation

• Standard procedure requires consultation with an anesthesiologist, preferably one experienced in treating the patient population 1
• Additional specialist consultations should be obtained if there is evidence of concurrent medical pathology 1

Medication Review

• Review and documentation of all current medications 1
• Consideration of discontinuing medications that may interfere with ECT when possible 1
• Special attention to medications that may affect seizure threshold:
  • Benzodiazepines (may increase seizure threshold) 1
  • Theophylline (may prolong seizure duration) 1
  • Carbamazepine (may affect seizure parameters) 1

Second Opinion

• An independent evaluation from a psychiatrist knowledgeable about ECT and not directly responsible for the patient's treatment 1
• This psychiatrist should:
  • Review the diagnosis 1
  • Confirm illness severity and treatment resistance 1
  • Corroborate the advisability of ECT 1
  • Review the adequacy of the pre-ECT workup 1

Informed Consent

• Written informed consent must be obtained 1
• Education regarding the procedure, risks, and benefits must be provided 1
• Familiarity with state and institutional guidelines regarding ECT is necessary 1

Common Pitfalls to Avoid

• Failing to identify relative contraindications such as tumors of the central nervous system with elevated cerebrospinal fluid levels, active chest infections, or recent myocardial infarction 1
• Inadequate documentation of previous treatment failures 1
• Overlooking the need for pregnancy testing in female patients 1
• Insufficient cognitive assessment before treatment 1
• Not obtaining appropriate specialist consultations when concurrent physical illness is present 1
• Inadequate monitoring for patients with lower seizure thresholds, as adolescents may have more prolonged seizures with ECT than adults 1