This week we had to treat a patient with electroconvulsive therapy (ECT). He had a pacemaker. The cardiologist offered to be there during the first treatment to see how things were going with the pacemaker during ECT. Everything went just fine except for the astonishment of the cardiologist. He was flabbergasted about the ECT procedure. He never realized that his ideas and fantasies were far beyond reality. He still had “one flew over the cuckoo’s nest” in his mind. Moreover, he now better understood the challenges faced during ECT. Heart rate and blood pressure can increase for a short while.
This is not our first experience with other doctors from other specialties. Doctors still have the wrong ideas about ECT. In The Netherlands most physicians especially those trained in the sixties, seventies, eighties and nineties of the previous century never saw an ECT treatment. They haven’t got a clue what is actually happening during the procedure. That’s why we always oblige to questions from other specialists but also psychiatrists who never have seen ECT to witness the procedure in our department.
Things have changed. Every medical students now hears and sees ECT at least on video. At least one lecture is given during medical education. All medical students during clerkship in our hospital witness ECT at least once.
During the making of our new guidelines for ECT we had the pleasure of discussing our new guidelines with a focus group with patients who were still undergoing maintenance ECT or who had been treated with ECT in the past. Some of them told us that when they were admitted to a hospital or visiting an outpatient department other than psychiatry and the doctor or nurses learned that they were or had been treated with ECT there faces usually turned pale and they suddenly acted very different from before, mostly with anxiety. That’s not new, other patients with a psychiatric history are sometimes met with fright and disbelief by other health professionals.
Besides these more opinionated views on ECT, doctors also definitely need to know more about the physical consequences of ECT. Luckily two excellent reviews were published on Medical Evaluation of Patients Undergoing Electroconvulsive Therapy and Electroconvulsive therapy: What the internist needs to know. The first in the New England journal of Medicine and the latter in the Cleveland Clinical Journal of Medicine.
The two links above will take you to Scribd were you can read both excellent papers with iPaper. Please read them when in need of information about ECT, risk assessment and patient optimization before ECT or management of preexisting medical conditions.
Usually just an history and physical examination is all the routine evaluation takes. This is to screen patients for conditions that may increase the risk associated with ECT. Laboratory testing can be tailored to the patient’s medical history and medications. ECG are only needed in patients older than 50 years and those patients with a history or signs with physical examination that warrant further analysis.
Conditions that might increase the risk associated with ECT are: cardiovascular disease (ischemic heart disease, heart failure, and arrhythmia), intracranial mass lesions, recent stroke, and pulmonary conditions (chronic obstructive pulmonary disease, asthma, and pneumonia).
Before ECT is performed, patients require a medical evaluation to undergo anesthesia, and some may need special consultation.