What are the contraindications for Electroconvulsive Therapy (ECT) in patients with various medical conditions, including increased intracranial pressure, space-occupying brain lesions, severe cardiovascular disease, pregnancy, and osteoporosis?

Contraindications to Electroconvulsive Therapy

There are no absolute contraindications to ECT in clinical practice, though elevated intracranial pressure from space-occupying lesions represents the highest-risk scenario requiring careful case-by-case assessment. 1

Understanding the Absence of Absolute Contraindications

The modern evidence base has fundamentally shifted away from viewing any condition as an absolute barrier to ECT. The American Academy of Child and Adolescent Psychiatry explicitly states that no absolute contraindications exist for ECT in adults or adolescents 1. This represents a critical departure from older teaching that listed multiple "absolute" contraindications.

Even the historically cited absolute contraindication of raised intracranial pressure is now considered relative rather than absolute 2. While elevated intracranial pressure remains the highest-risk neurological scenario, successful ECT has been documented even in these challenging cases 1.

Relative Contraindications Requiring Risk Assessment

Neurological Conditions

• Central nervous system tumors with elevated intracranial pressure represent the highest-risk scenario and warrant the most careful consideration 1
• Space-occupying brain lesions require prospective risk assessment before proceeding, but ECT has been successfully administered in 40 patients with intracranial tumors, with only 15% having prior knowledge of the neoplasm 3
• History of craniotomy for intracranial tumor does not preclude ECT use, with multiple successful cases reported 3, 1
• Intracranial aneurysms (treated or untreated) are not contraindications, though blood pressure must be carefully monitored and antihypertensive agents considered 4
• Idiopathic intracranial hypertension (pseudotumor cerebri) can be managed with appropriate clinical observation, brain imaging, and lumbar puncture before treatment 5

Cardiovascular Disease

• Preexisting cardiovascular conditions are not contraindications to ECT in patients with disabling psychiatric disease, despite ECT causing transient increases in blood pressure, heart rate, and cardiac workload 6, 7
• Cardiac complications occur most frequently in patients with underlying cardiovascular disease, but with appropriate pre-ECT cardiac evaluation and multidisciplinary team involvement, these complications can be well managed and minimized 7
• Recent myocardial infarction is no longer considered an absolute contraindication 1

Active Infections

• Active chest infection should be treated before proceeding with ECT, though this represents a temporary rather than permanent contraindication 1

Pregnancy

• Pregnancy is not a contraindication to ECT, though fetal deaths have been reported in rare cases with confounding factors 1
• ECT may be indicated when chemotherapy is contraindicated because of pregnancy 2

Conditions That Are NOT Contraindications

Seizure Disorders

• Seizure disorders do not contraindicate ECT use and may even benefit from treatment 3, 1
• ECT does not have long-term effects on seizure threshold and may reduce seizure frequency in patients refractory to anticonvulsive treatment 3, 1

Psychiatric Comorbidity

• Personality disorders, conduct disorder, oppositional defiant disorder, PTSD, ADHD, and eating disorders should not be considered contraindications 3, 1
• The presence of personality disorder may affect treatment response but does not preclude ECT use 3

Cognitive Impairment

• Mental retardation is not a contraindication, with successful ECT reported in patients with mild to profound intellectual disability 3

Other Neurological Conditions

• Meningomyelocele, hydrocephalus, and ventriculoperitoneal shunts do not contraindicate ECT 3, 4
• Cerebral venous shunts and history of craniotomy have been successfully managed 3

Risk Mitigation Protocol

When proceeding with ECT in higher-risk patients:

• Obtain comprehensive medical consultation from cardiology, neurology, and anesthesiology before proceeding 1
• Complete prospective risk assessment documenting potential neurological or cardiovascular complications 1
• Implement enhanced monitoring protocols during and after treatment, with close observation of vital signs, seizure duration, and adverse effects 1
• Consider blood pressure management with antihypertensive agents and/or anesthetics with blood-pressure-lowering qualities in patients with vascular malformations 4
• Perform brain imaging and lumbar puncture before ECT in patients with suspected elevated intracranial pressure 5

Critical Pitfalls to Avoid

• Do not assume old contraindications still apply: Conditions like cerebral tumor, active chest infection, and recent MI are no longer absolute contraindications 1
• Do not overlook medication effects: Benzodiazepines, theophylline, lithium, and carbamazepine affect seizure threshold and require discontinuation or special attention 1, 8
• Do not deny ECT based on cardiovascular disease alone: With proper cardiac clearance and monitoring, even patients with significant heart disease can safely receive ECT 7
• Do not delay ECT for minor medical optimization when psychiatric severity is life-threatening, as the risk of untreated severe depression (including suicide) often exceeds procedural risks 8