What are the contraindications to Electroconvulsive Therapy (ECT)?

Contraindications to Electroconvulsive Therapy (ECT)

There are no absolute contraindications to ECT in adult patients, and the same principle applies to adolescents, though certain conditions require careful risk assessment and may be considered relative contraindications. 1

Absolute Contraindications

None exist. The American Academy of Child and Adolescent Psychiatry explicitly states that there are no absolute contraindications to ECT in adult patients, and while data for adolescents are more limited, the available evidence supports the same conclusion. 1

Relative Contraindications

These conditions increase procedural risk but do not preclude ECT use when the risk-benefit ratio favors treatment:

Neurological Conditions

• Central nervous system tumors with elevated intracranial pressure or cerebrospinal fluid levels represent the highest-risk neurological scenario and warrant careful consideration. 1, 2
• Recent cerebral hemorrhage or stroke increases risk but has been successfully managed with appropriate precautions. 2
• Intracranial aneurysm poses elevated risk due to hemodynamic changes during ECT. 3, 2
• Vascular aneurysm requires careful assessment before proceeding. 2
• Retinal detachment may be exacerbated by the procedure. 2

Important caveat: Despite these concerns, ECT has been successfully administered in patients with cerebral lesions, tumors, venous shunts, and history of craniotomy after prospective risk assessment. 1 One review identified 40 adult patients with intracranial tumors who received ECT safely, with only 15% having prior knowledge of the neoplasm. 1

Cardiovascular Conditions

• Recent myocardial infarction is traditionally considered high-risk, with conventional recommendations to wait at least 3 months post-MI. 1, 4 However, ECT has been successfully administered as early as 10 days post-MI with appropriate multidisciplinary cardiac management. 4
• Unstable cardiac arrhythmias require stabilization and monitoring. 5
• Pheochromocytoma poses significant risk due to catecholamine surges during ECT. 3, 2

Critical point: Preexisting cardiovascular conditions are not contraindications per se in patients with disabling psychiatric disease, as significant hemodynamic changes can occur even in patients without preexisting conditions. 5

Pulmonary Conditions

• Active chest infection should be treated before proceeding with ECT. 1

Other Medical Conditions

• Deep vein thrombosis has been associated with rare fatalities, though causation is unclear. 3
• Sepsis represents a high-risk scenario. 3
• Increased intracranial pressure from any cause is considered high-risk. 2

Conditions That Are NOT Contraindications

Explicitly Safe Conditions

• Pregnancy is not a contraindication to ECT, though fetal deaths have been reported in rare cases with confounding factors. 1, 3
• Seizure disorders are not contraindications; ECT may even reduce seizure frequency in refractory cases and does not have long-term effects on seizure threshold. 1
• Psychiatric comorbidity (personality disorders, conduct disorder, PTSD, ADHD, eating disorders) should not be considered contraindications. 1
• History of craniotomy for intracranial tumor does not preclude ECT use. 1
• Neurological compromise (meningomyelocele, hydrocephalus) has been successfully managed. 1

Risk Mitigation Strategies

When relative contraindications are present:

• Obtain comprehensive medical consultation from appropriate specialists (cardiology, neurology, anesthesiology) before proceeding. 1, 6
• Complete prospective risk assessment documenting potential neurological or cardiovascular complications. 1
• Ensure multidisciplinary team involvement including psychiatrists, internists, specialists, and experienced anesthesiologists. 6, 4
• Implement enhanced monitoring protocols during and after treatment, with close observation of vital signs, seizure duration, and adverse effects. 7
• Document the risk-benefit analysis clearly when proceeding despite relative contraindications. 3

Common Pitfalls to Avoid

• Assuming old contraindications still apply: Conditions like cerebral tumor, active chest infection, and recent MI are no longer absolute contraindications. 1
• Overlooking medication effects: Benzodiazepines, theophylline, and carbamazepine affect seizure threshold and require special attention. 6
• Inadequate pre-procedure workup: Failing to identify relative contraindications through comprehensive physical evaluation and appropriate laboratory investigations. 6
• Premature treatment discontinuation: Manageable complications should not lead to unnecessary ECT cessation. 5