Electroconvulsive Therapy

Electroconvulsive therapy is a psychiatric intervention where seizures are purposefully induced in a patient through shocks delivered by electrodes placed on the temples. It's used for refractory depression as well as other psychiatric illnesses like bipolar disease. The therapy is charged with controversy; no one knows how it works, shocking the brain to cause seizures sounds barbaric, it has a history of use without informed consent, and the patient population may not have rational thinking in deciding whether to pursue this. Nevertheless, it is an amazingly and surprisingly effective treatment for refractory psychiatric illness. I've met patients who say that they've been tried on many, many antidepressants and have had no response or too many side effects, but ever since trying ECT, their lives have completely turned around. I don't know all that much about the psychiatry behind it, but I wanted to talk about the anesthesia.

When we are on pre-operative clinic, we provide anesthesia for ECT in the morning (since clinic doesn't start all that early). It's really fascinating. Usually 4-6 patients show up a day, and many are repeat customers; ECT is sometimes given up to 3 times a week. This allowed me to develop relationships with a few of the patients. The therapy itself is short so I have to set everything up beforehand in order to keep things moving.

I get there early, draw up a ton of medications. While the therapy is short, the anesthesia is complex. We occasionally give caffeine to potentiate seizures. We give patients toradol for post-treatment pain and ondansetron for nausea. Then we give remifentanil as a rapidly acting opiate, induce general anesthesia with etomidate (which promotes seizure activity), and paralyze the patient with succinylcholine (in order to minimize post-seizure pain and injury). After general anesthesia is induced, we hyperventilate the patient with a mask, and the psychiatrists deliver their shock. They monitor the patient's motor activity (through a limb with a tourniquet so it does not get the succinylcholine and will display seizure activity) and electroencephalography. If all goes well, we're done. But I'm prepared to break the seizure with benzodiazepines. I can treat blood pressure with esmolol, nitroglycerin, phenylephrine, or ephedrine. All of this requires the preparation of a cocktail of drugs. I remember drawing up close to 40 syringes one morning.

What's amazing is that it works. After inducing a seizure in a patient, we wake them up, and they have no pain or recollection of the treatment. Most of the patients are completely satisfied with things and go home within half an hour, ready to come back for their next treatment later that week. This experience shows me the diversity of anesthestic techniques and introduces me to interventions I'd not seen before.

Image shown under Fair Use, from psych.med.umich.edu.