Electroconvulsive therapy in the medically ill

This chapter focuses on prevention of electroconvulsive therapy (ECT-) related morbidity and mortality. There are three general steps in the management of medically ill patients receiving ECT. The first is careful pretreatment assessment and stabilization of medical problems. In addition to the obligatory medical history and physical examination, laboratory studies, electrocardiogram, chest x-ray, echocardiogram, and exercise stress test should be selectively considered. ECT may need to be delayed until decompensated medical concerns (e.g., angina pectoris, severe hypertension, asthma, poorly controlled diabetes mellitus) are stabilized. The ECT clinician should have access to specialist consultants, such as from internal medicine or cardiology, to advise on the pre-ECT evaluation. The second step is planned management of medical concerns during ECT sessions. In addition to customary ECT anesthesia (see Chapter 26), additional medications, such as anticholinergics, beta blockers, or antiarrhythmics, can be selected for individual patient needs. The third step is regularly repeated reevaluation during the ECT course to check for emerging medical complications. For example, a patient with congestive heart failure (CHF) may be stable enough to commence ECT but then decompensate after several treatments, so that further treatment must be postponed. Regular reevaluation can be made routine on the mornings of ECT. Ordinarily, recommendations for evaluation and management of medically ill patients are based on systematic clinical trials. However, studies specific to ECT patients are lacking. Individual and series case reports are too numerous to compile here.