Clinical Practice Guidelines for the Use of Electroconvulsive Therapy

Abstract

INTRODUCTION Electroconvulsive therapy (ECT) is a clinical procedure where a small dose of electric current is passed through the brain for a brief period to induce seizures for therapeutic purposes in psychiatric (and certain neurological) conditions. Modified ECT is the modern form of ECT where the electrical stimulus is given under general anesthesia and muscle relaxation. This is one of the most effective treatments for many psychiatric conditions. Modern modified ECT is a safe treatment when practiced with adequate knowledge, skills, and expertise. Following the basic standards of ECT practice is necessary for better clinical outcomes including minimal cognitive adversities. This guideline document is aimed at enabling consistent, safe, and effective practice of ECT in patients in applicable psychiatric disorders. METHODS These guidelines are developed as part of the initiative of Clinical Practice Guidelines (CPG) subcommittee of Indian Psychiatric Society. The initial draft guideline was developed by the authors. The information was sourced from key research articles, national/international guidelines on psychiatric care, and ECT. No formal systematic literature search was conducted. The current guideline was prepared to suit the existing Indian mental health care system and legislations. The draft was further presented and discussed in the in-person workshop of CPG-2022. The draft was revised following the discussion in the workshop based on the consensus-based recommendation method. This guideline is not a directive or mandatory instruction but a guidance document for professional practitioners administering ECT. This is not a full and complete review of ECT procedure. But it is intended to improve patient outcomes by facilitating best practice standards by maximizing benefits and minimizing adversities. USE OF ELECTROCONVULSIVE THERAPY Indications Table 1 shows the indications for ECT. Evidence exists for the efficacy of ECT in depressive episodes, manic episodes, and acute exacerbations of psychosis in schizophrenia. Treatment-resistant depression, mania, and schizophrenia, including clozapine-resistant schizophrenia, are well-recognized indications,[1-6] with evidence from comparative trials (comparison across types of ECT or with waitlisted patients). ECT should not be withheld until the failure of several medication/psychotherapy trials in severe depression. Health economics suggest that it is beneficial to consider ECT as a second or third line agent in severe depression. ECT is considered as first-line (primary) treatment for emergency psychiatric conditions across diagnoses. These include high suicidality, catatonia, excitement, aggression, poor oral intake, acute psychotic symptom exacerbations, and severe physical debilitation secondary to psychiatric disorders.[7-13] The rigor of the evidence base is limited for such indications due to ethical and pragmatic considerations in conducting sham-controlled trials in these emergency life-threatening transdiagnostic situations. It may be noted that almost all international standard guidelines suggest ECT as a first-line treatment option for these indications.[8-13]Table 1: Indications of ECTPredictors of response In general, older age, psychotic symptoms, and shorter episode duration are predictors of response to ECT. Melancholic features and greater baseline depressive symptom severity are also associated with better ECT response. Past good response to ECT is considered a good predictor of response for the current episode. Continuation/Maintenance (C/M) ECT should be considered for patients with a history of severe, recurrent episodes who have failed to remain well on medications.[14] ECT is a first-line treatment when rapid and/or definitive response to avert harm to self/others is needed. Acute suicidal risk, agitation, catatonia, and deteriorating physical status secondary to psychiatric conditions are some of such situations. After an acute course of ECT, C/M treatment with pharmacotherapy and/or psychotherapy is needed. All the indications mentioned above have to be individualized and should be based on the clinical needs, patient’s preferences, and putative risk of adverse effects. ECT staffing ECT without anesthesia and muscle relaxation is now prohibited under the Mental Health Care Act, 2017. Hence, the staffing shown in Table 2 is advisable for administering modified ECT.Table 2: Staffing for ECTTreatment site and equipment The treatment suite ideally involves three distinct areas, but which are nearby or closely connected:[9,10] a. Waiting/preparation room: should have the following facilities: i. Waiting area for patients and caregivers ii. Space for assessment: for interviewing, examining, verifying the records, and to ensure adequate preparation iii. Sphygmomanometer and stethoscope b. ECT administration room i. ECT apparatus including bite block, electroencephalogram (EEG) monitor, and ECG monitor ii. Anesthetic agents (e.g., thiopentone, propofol, etomidate, ketamine, isoflurane, sevoflurane, etc.) and muscle relaxants (along with succinylcholine, at least one nondepolarizing agent like atracurium or rocuronium should be available) iii. Emergency medication tray to manage uncontrolled hypertension, hypotension, cardiac arrhythmia, cardiopulmonary arrest, anaphylactic shock, prolonged seizure, and status epilepticus. This should include intravenous fluids, epinephrine, dopamine, atropine or glycopyrrolate, cholinesterase inhibitors (neostigmine, physostigmine), anticonvulsants (lorazepam, diazepam, phenytoin), steroids, beta blockers (esmolol, labetalol), alpha-blockers (prazosin, clonidine), vasodilators (nitroglycerin, hydralazine), antiarrhythmics (lidocaine), analgesics (paracetamol), antiemetics (domperidone, metoclopramide), antihistamines (chlorpheniramine, cetirizine), bronchodilators (aminophylline) among others) iv. Vitals monitoring: sphygmomanometer, reflex hammer, oxygen saturation, ECG v. Intubation set: oral and naso-pharyngeal airways vi. Oxygen delivery system with intermittent positive pressure ventilation capabilities through a mask as well as endotracheal tubes vii. Suction apparatus, iv infusion set, syringes with needles, cotton and gauze pads, hand gloves. viii. Defibrillator ix. Portable cots/beds, disposable containers c. Recovery room: should have all items iii to ix listed above Informed consent (Supplements 1–4) Written informed consent has to be taken before initiating ECT based on principles of shared decision-making. Consent should be taken following due procedures in accordance with the highest ethical standards and applicable laws/regulations. Written information material may be provided to the patient and caregivers, and adequate time should be provided for reverting with any clarifications. Information should be provided regarding the anticipated benefits and possible short-term and long-term adverse effects of modified ECT, including possible risks with both anesthesia and ECT, in the given individual. Discussion on the type of ECT, modification procedure, electrode placement, and expected outcomes should be included in this process. Unless the patient disagrees, it is recommended to make caregivers a part of the consenting process. If a patient does not have the capacity to consent, the same needs to be documented. The advance directives, if any, have to be examined and, in accordance with that, consent may be obtained from the nominated representative. In the case of minors, oral/verbal assent (as per the age) should be obtained along with written informed consent from parents/nominated representative; the decision about initiating ECT has to be taken only after concurrence by two independent psychiatrists or a psychiatrist + a physician, and due permission from the mental health review board as per the law. As and when a patient regains the capacity to consent or attains 18 years of age, his/her consent has to be obtained for continuing ECT sessions then onwards.[15,16] Consent has to be obtained again before initiating C/M ECT, as the clinical condition, purpose (consolidation/relapse prevention), and character of treatment (frequency of ECT sessions and end-point) would have changed. Pre-ECT evaluation (Supplement 5): This should be performed as close to the ECT course as possible. Psychiatric and physical evaluation Psychiatric evaluation is needed to ascertain indications. Rating scales can be used to determine these indications systematically and measure the changes during the ECT course. If the patient has received ECT in the past, details of the electrode placement and electrical parameters in earlier ECTs, level of achieved response, and associated cognitive deficits would guide the current course of ECT. It is important to evaluate the psychotropic medications that can potentially interfere with anesthesia and ECT. For instance, anticonvulsants increase seizure threshold; antipsychotics like chlorpromazine and clozapine are known to be pro-convulsants; lithium can increase the risk of postictal delirium; tricyclic antidepressants are known to increase the risk of cardiac adverse events during ECT/anesthesia. Physical examination is needed to identify any relative contra-indications and prevent complications [Table 3]. It should mandatorily involve fundoscopic examination along with other systemic examinations. Dental evaluation for loose or missing teeth, cardiovascular examination for arrhythmias, assessment for neurological comorbidities, and pulmonary clinical evaluation are mandatory.Table 3: Clinical conditions requiring caution while administering ECTPreanesthetic evaluation is recommended to plan for an anesthetic agent and a muscle relaxant. Also, suitable investigations or interventions can be planned in the presence of medical conditions associated with a substantial risk for general anesthesia-related complications. Liaison with other specialist if is necessary by the cognitive of cognitive adverse effects would be necessary for patients ECT. of cognitive is in the changes in cognitive with ECT. Mental and Mental are for but are not to cognitive changes associated with ECT. cognitive assessment and brief ECT cognitive are assessment used for is a in the Indian and is recommended to be used during the and course of For general and would the of medical but are not and other would be based on physical evaluation and associated medical ECT is mandatorily used as a modified procedure, as per the in The modification involves muscle relaxants to the and anesthetic agents to induce and for the procedure muscle relaxation and electrical a. before anesthesia Table and procedure may be patients while initiating the procedure including while iv and the mask for anesthetic agent for ECT would be and from effects of has a good and during ECT, and would not have any effects on seizure and information in anesthetic of and can be used to seizure duration and effects. or have effects and can be but evidence of in ECT. The effects of anesthetic agents are on and this needs to be considered while the anesthetic relaxation is an important of modified ECT. muscle relaxants should have the to without seizure and rapid without is a muscle due to rapid and muscle relaxants may be considered in certain conditions. These include severe, severe or (e.g., history of in the patient or his/her In a patient with history of a and to ECT, a high of should be are of prolonged after of may consider the assessment of level when in or may of nondepolarizing agents in such level can be in patients with high (e.g., patients to an earlier history of prolonged of level is not of and blockers for cardiovascular is not the for such an agent should be b. ECT The of ECT and on the should be based on needs of a given The of needed response, and cognitive adverse effects of the should guide the any of it is important to have of in the and of can be based on clinical i. brief or is recommended and should be with a current ECT and are not recommended in the modern practice of ECT due to is considered as a measure and of But this is and the of electric current and duration of along with electrode placement of sessions and duration of should be considered in a current has used in the practice of ECT. with a current of The current is known to with cognitive as well as seizure but is and not modified during dose has as part of individualized seizure clinical is to be ECT is as brief and is to have a on cognitive adverse effects with associated with cognitive effects. of has shown to have a cognitive brief with placement in depressive disorders. But the efficacy may be with of brief may be considered to a rapid clinical But when cognitive effects are of a stimulus with may be The of second is the electrical that is of the It is an important electrical that from to per with are a seizure can be at a with with when all other parameters are ECT in the involve an increase in ECT should be of this while a of stimulus to the of high seizure This is the most modified to the the duration is limited by the have a of but certain with the highest of to No has on the highest increase in is achieved by duration the of the is The of It is a of duration and also be by The of may suggest a with But as of is in seizure, the of by may not be a good for electrical The ECT is are trials of current at one site and at the But the evidence is limited to suggest the clinical of of are provided to in The evidence is for with which is by most be recommended for clinical ii. placement The are in method. electrode is in the above the line the and on above on an line to the line two Clinical trials have shown that is if not effective placement, but with cognitive effects in patients with mania, as well as schizophrenia. placement of with the on the and on is Evidence from systematic is for this electrode is on the and electrode 1 to of of two one two and other This is shown to have cognitive but the dose when provided as an for that of as on the This is to be to the This placement can be when and is needed It is also considered in the brain The evidence for the efficacy of ECT is only for depression. The evidence of ECT is for other indications or iii. of ECT ECT is discussed in of is associated with better efficacy and cognitive adverse effects. But as discussed the is not a measure but a of electrical parameters 3]. Table for ECT of of anesthesia agents in for and of anesthetic agents used during 1: of 2: ECT electrode 3: The dose for efficacy through ECT sessions is considered with to the seizure threshold; efficacy is also on and electrode seizure is recommended in ECT with brief ECT of 1 or evidence a of a seizure when a of is used with ECT. is evidence that a seizure is with ECT, with the evidence for ECT, in depression. For ECT with brief electrical is to be considered the seizure at is to be effective and may not be advisable with the existing the dose has to for a current and Hence, the dose should also be a of But most of the standard have a of duration at in and increase to increase the have used these and this guideline should be with are needed to ascertain this This be the recommended in The can be in the dose needed for seizure can be used as guidance for the dose of may be with in and with may be in sessions can be provided at as discussed on the and of the are is a to be in the as medications and anesthetic agents may the seizure The stimulus should have the same and electrode from which the was high This a high the for all the The of a high should be only for patients with medical conditions in which of is a from high dose be at the The and would be In the are to at the dose a This be a better to the high it is c. and and i. ECT procedure of ECT is recommended for seizures by the in the from muscle a measure of seizure and is recommended from at least two and to the is only a is a is can have due to muscle and other Hence, should be used to seizure seizure should be given any good seizure, of shorter has to be in of of seizure and of seizure to adequate seizure is to be of clinical or seizure involves is a seizure during after the the This be by which the with the of and The should be in the presence of of and of the in the case of electrode is in modified ECTs, as it of from the of ECT stimulus the of the in any part of the in the be considered for seizure seizure involves the of seizure in seizure have 1: with 2: high at to 3: with for to the a line is The of this the of The is from to to of is better in patients in of If is or seizure after of of electrical then may be by the stimulus seizure should be If the seizure is of or the seizure is to one of the or to the at may be after may be the patient of relaxant. to can be If of or can be from the It may be noted that the of If the seizures are brief (e.g., and if the patient is the expected clinical response, then with a dose not be on the same after adequate seizure, the ECT is not in of ECT, would not be necessary on the of This be considered only conditions like or In the case of a prolonged seizure can be if a seizure and should be closely the complete of seizure may be or the anesthetic agent used for If the patient is on or or may be to anesthetic agents may also be and in the ECT suite should under the care of an is the patient can be to the ii. in the room of the should be and oxygen ECG should be in patients of cardiac should be for arrhythmia, seizure, and should be until the patient regains full during the procedure should be and should be for to baseline or baseline before the patient from the iii. the course of ECT The of should not be but should be based on the needs of in of clinical and cognitive and other adverse effects should be at least a during the course of ECT. ECT may be at any time if complete clinical is If clinical is not a of ECT sessions should be provided in acute before the failure of response to ECT. course may be needed in some and this decision to sessions should be taken after a In general, the response to ECT is after sessions in in and from to and/or to brief ECT can be considered after a if clinical is not noted after to clinical symptom may be used for assessment clinical assessment is a after ECT, following the ECT but before the adverse cognitive assessment can be brief ECT cognitive and for may be used during the course of It should be noted that be an in some cognitive with in clinical is one of the most adverse which is to measure cognitive assessment of should be given due assessment and should be a part of cognitive cognitive would be to and standard cognitive assessment This to a of cognitive The of the cognitive in the given may be the severity of cognitive is be a part of the course of would be to the cognitive after symptom of with ECT. deficits be associated with a with and ECT ECT can be used as a treatment to of for of effects and treatment of as in depressive and schizophrenia. Acute if can be from a to and The and of should be to the clinical The course should not be It should be planned during the course and based on clinical After of based on clinical needs, ECT may be It is given at a from one and interventions should be considered for while of adverse effects seizures or prolonged is advisable in such patients for should be for seizure history and of brain in the past, and or type of anesthetic agent should be revised based on expected effects on and may be in of or In case of the stimulus may be modified to and/or The of sessions may be If the patient is ECTs, to ECT may be as the seizure is with the In case of recurrent prolonged dose But it is to that seizure duration would be highest the Hence, in certain duration noted during dose the dose in sessions may be effective in the seizure may of an ECT This for other of may be of to be patients after an adequate If and poor response to with or without after this period or if are severe during this should be should be in a safe and and should be line should be from should be and physical may be used if necessary to prevent the patient from or anesthetic agents may be used if is or antipsychotics (e.g., with dose when may be used if the are Physical conditions like or should be in of recurrent postictal prolonged status or seizures should be considered as diagnoses. dose of anesthetic agent or may be considered in of recurrent postictal adverse effects or of the following may be considered to The decision should be taken with the possible in with these of ECT to ECT. to of stimulus or of medications like lithium that are known to of the dose of anesthesia if given in of ECT if the risks as muscle and It is If severe, analgesics like or may be be to a it is after the and would not be with with to muscle of dose or to muscle can be due to of the and may with modified ECT due to of during the stimulus would the for and in such situations. These are associated with and to If severe, and may be may also be used as ECT may be or may be based on clinical and ECT and should be given the to and Information and should be the consent can be a to sessions of patients and caregivers, including who have received ECTs, would and about ECT during a course of ECT may be due to of the of muscle relaxants under In such the dose of the anesthetic agent should be modified to ensure muscle relaxants should be after that the patient is and regarding ECT in this is is evidence for efficacy or in this The Mental Health Care of of from the mental health review board to ECT under in this two regarding the for and of ECT would be ECT is only after other have seizures are in this and it is best to anesthetic agents like and ECT is safe and effective in and is a given risk of to many The risk evaluation should be a of the and should be considered in applicable in second and third should be while should be used if any of are or should be provided to should be but should be with should be considered to the risk of of should be it would the risk of and after ECT, or should be used for along with the of the as per After of ECT should be in with the of of and should be to any risk of ECT is safe and effective in Evidence a response of the adverse effects would be of greater when ECT is for of high seizure medical comorbidities, and postictal are in general regarding ECT in older may be as an anesthetic agent and anticonvulsants may be should initial dose and can be or ECT would be to ECT. of brief or may also be lithium should be due to a risk of postictal medical should be and close would be necessary with high of the to medical and care to be taken while administering ECT for patients with medical In all should be a of the and a to complications. risks should be to the while care during ECT in patients with medical ECT is an procedure. to the of may be taken as per risk assessment by [Table during and of are of

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