Electroconvulsive Therapy (ECT) Treatment Considerations

ECT remains one of the most effective treatment modalities for patients with treatment resistant depression and other treatment resistant mental health disorders. Studies support the efficacy and safety of this treatment (Salani et al., 2023, Joung et al. 2022). According to the American Psychiatric Association (APA), ECT has a response rate of 80-90% for patients receiving it as a first line treatment and between 50-60% for patients who have had multiple trials of medications and treatment without effect (APA, 2001, p.10).

Historically, psychiatric-mental health nurses (PMH) have provided individualized care for patients receiving ECT and the roles of PMH nurses in this area are developing and expanding. PMH advanced practice nurses, properly trained and credentialed, are administering ECT and directly managing related care and PMH nurses have long been involved in the care of patients receiving this treatment and the operations of ECT services. In addition, PMH nurses serve as patient advocates, dispelling stigma associated with ECT, are involved in education of individuals and the public about ECT, assuring accurate information is disseminated, and in the development of public policies involving ECT (APNA, 2021, Poole & D’Alessandro, 2020).

Electroconvulsive Therapy (ECT) Considerations Checklist

This checklist provides considerations for caring for patients receiving ECT and is not intended to be all inclusive.

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State Scope of Practice

The function of physically performing ECT may be completed by many providers of various backgrounds as credentialed by their facility in congruence with state laws and scope. The recommendation for ECT for the purpose of treating a mental illness and related follow up should be performed by an appropriate credentialed psychiatric provider including PMHNP-BC APRNs. (Livingston et al., 2018)

• Review applicable state nursing, medical, drug and facility statutes and regulations to identify existing and anticipated practice barriers.
• Verify whether the state board of nursing or other relevant board has issued a related opinion applicable to RNs and/or psych APRNs.
• If in doubt consult the Scope of Nursing Practice Decision-Making Framework.

Patients with treatment-resistant mental illnesses including, but not limited to, depression, bipolar disorder, catatonia, agitated mania, schizophrenia, schizoaffective disorder, agitated dementia. (Salani, et al., 2023; Thirthalli et al., 2023, Mankad, 2019, APA 2001)

• Patients at risk for severe harm due to acute suicidality, self-injurious behavior, or decompensating medical status due to psychiatric illness.
• Other complicated psychiatric and/or medical disorders may respond to ECT.

Considerations for Candidate Eligibility

Currently, there are no absolute contraindications for ECT (Salani et al., 2023, Mankad, 2019, APA, 2001); medically stable patients can safely be treated in ECT facilities. Some patients with complicated medical, neurologic or other comorbidities, or implanted medical devices may require a medical hospital setting for ECT. The decision of treatment location is made by the clinical team, taking into account the risk/benefit analysis and conversation with the patient and their loved ones (Mankad, 2019, APA, 2001).

Medical Considerations for ECT Treatment

(may require further evaluation by specialist and/or diagnostic testing)
(Salani, et al. 2023; Thirthalli et al., 2023, Mankad, 2019, Quazizada, 2016, Reasoner & Rondeau, 2023, APA, 2001):

• Related to ECT anticipated effects:
  • Acute or recent Cardiovascular events (e.g., MI, stroke, etc.)
  • Space occupying brain lesions/aneurysms
  • Anticoagulation
  • Implantable devices including pacemakers, implantable defibrillators, deep brain stimulation devices, vagus nerve stimulators
  • Metal or other implanted devices in scalp/brain (e.g., metal plates, shrapnel, DBS)
    Other implanted devices (e.g., VNS, pacemaker, defibrillator, etc.)
  • Cochlear implants in one or both ears
  • Conditions making increased intracranial pressure of concern (consider head imaging)
• Related to anesthesia (Joung et al., 2022):
  • Acute respiratory events (pneumonia, PE, etc.)
  • Uncontrolled blood sugars
  • Moderate to severe gastric reflux (may preclude treatment in a free-standing psych facility)
  • Delayed gastric emptying (primary or medication-induced)
  • Pseudocholinesterase deficiency*
  • History or family history of Malignant Hyperthermia*
  • Potential anesthesia issues including airway concerns, ASA 3 or 4, cracked/loose teeth, mouth piercings and allergies to common anesthesia medications
• History and physical:
  • General medical clearance (Joung et al., 2022)
  • Specialty medical clearance (e.g., cardiac, neurological) as necessary based on history
  • Pre-procedure labs (e.g., CBC with diff, CMP, TSH, HCG, as appropriate and required by anesthesia)
  • EKG
  • Other diagnostics if indicated (e.g., CT/MRI/Echocardiogram/stress test/Barium Swallow)
• Outreach to PCP and Primary Psych Providers in community

NOTE: Patients can still be safely treated with ECT if they have pseudocholinesterase deficiency or history of Malignant Hyperthermia (MH) by using a non-depolarizing medication (i.e. atracurium, rocuronium).

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Financial Considerations Treatment

(Reti et al., 2012)

• Individual should verify insurance coverage (e.g., private, Medicare, Medicaid)
  • ECT is covered by most private and public insurers
  • Preauthorization often required (DeMarzo, 2020)
  • Private pay options may be available

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Clinic Location and Equipment

(Salani et al., 2023, Thirthalli et al., 2023, Reasoner & Rondeau, 2023, APA, 2001)

• Medical Facility, often in Post-anesthesia Care Units (PACU) or freestanding Psychiatric Facility
• Accessibility for patients who need to be driven to/from appointments
• Waiting Room
• Pre-treatment area
• Treatment room/private area
• Recovery area
• Required equipment:
  • ECT machine (FDA-approved device)
  • Anesthesia equipment
  • IV access equipment
  • Monitoring equipment
  • Emergency equipment readily available
    • Crash cart including AED/Defibrillator
    • Emergency airway management
    • Emergency/rescue medications
  • Other supplies (i.e., comfort tools for clients, linens/warm blankets, depends/adult diapers, wheelchairs, nourishment like juice, snacks, etc.)

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Documentation

(Mankad, 2019, APA, 2001)

• Informed Consent (Livingston, et al., 2018)
• Legal documents as indicated (i.e, guardianship, court order, conservatorship, Release of Information form, etc.)
• Electronic or paper record
• Procedure-specific forms
• Self-assessment tools (e.g., PHQ9, QIDs, GAD7, etc.) (Spitzer et al., 1999, Folstein et.al., 1975, Rush et al., 2003, Kroenke et al., 2001)
• Clinician-administered tools (e.g., MoCA, HAM-D, MADRS, SLUMS, MMSE, etc.) (Thirthalli et al., 2023, Martin et al., 2020, Tariq et al., 2006, Hamilton, 1960, Ridha, 2005, Quilty et al., 2013, Nasraddin et al.,2005)
• Columbia Suicide Severity Rating Scale (C-SSRS)

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Manage Treatment Expectations

(Salani, et al., 2023, Thirthalli et al., 2023, Reti et al., 2012, APA, 2001)

• Pretreatment education (nursing review of what to expect) (Thirthalli et al., 2023)
  • Efficacy – highly effective; (in general, 50-90% efficacy rates) (APA, 2001)
  • Potential need for taper/maintenance treatments
  • Side effect profile (e.g., headache/jaw pain, muscle aches, nausea, potential memory and cognitive issues, anesthesia-related issues)
  • Review education video or facility created educational packet (Salani, et al., 2023)
  • Tour of the unit if feasible
  • Logistics/restrictions (i.e., need ride home, scheduling issues, NPO timeframe based on anesthesia requirements)
  • Safety precautions (i.e., judgement issues, self-care, etc.)
• Review/verify Consent for ECT/Anesthesia (Salani, et al., 2023)
• Review safety plans

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Day of Treatment/Pre-Treatment Nursing Assessment:

• Medical changes since last treatment (i.e., trips to ER, major medical events, etc.)
• Medication review/reconciliation
  • Include:
    • Medications administered/held by patient, as appropriate, to mitigate adverse events (for example – hold benzos, lithium, anticonvulsants; give cardiac meds and GERD meds; may necessitate consultation with anesthesia team) (Thirthalli et al., 2023)
• Blood glucose check pretreatment (for diabetes – BS should be <200 prior to treatment)
• Pre-treatment dosing of headache, nausea meds, etc. (preferably 2 hours prior to scheduled treatment with less than 30 ml of water)
• If outpatient, confirm transportation/discharge need
• Psych assessment at each treatment (include SI/Safety) (Salani, et al., 2023, NIMH, 2023, Posner et al., 2011)
• Date of last H&P (needed every 30 days)
• Date of ECT/Anesthesia consent (need for re-consent)
• Need for pre-treatment huddle of treatment team
• Removal of contact lenses/dentures, etc. (Thirthalli et al., 2023)
• Identification of devices (e.g., VNS, DBS, pacemaker, implantable defibrillator: evaluate need to be monitored and/or powered off during procedure)

NOTE: unusual medical/medication/safety assessment should be reviewed with treatment team prior to procedure.

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ECT Administration

• Treatment Room Time Out (for example, assure right patient, right treatment, right medications before anesthesia/treatment administered)
• Treatment Team (BLS and/or ACLS certification) (Salani, et al., 2023, Reasoner & Rondeau, 2023):
  • Fully licensed/competent/credentialed by institution ECT Provider (MD, DO, APRN) (Livingston et al., 2018)
  • Anesthesiologist and/or CRNA

• • APP (APRN, PA)
  • RNs (pre-treatment/intra-treatment/PACU roles)
  • Tech/PCA/MHS
  • Administrative Support (for pre-authorizations/insurance/scheduling)
• H&P review every 30 days
• Acute course – Standard course of treatment is usually three times per week for 3-5 weeks (average 8-12 treatments) with taper to reduce risk of relapse (Mankad, 2019, APA, 2001)
• Maintenance ECT every 1-12 weeks is common and safe (Thirthalli et al., 2023, Mankad, 2019, APA, 2001)
• Types of treatment (Salani et al., 2023):
  • unilateral/bilateral/bifrontal electrode placement (additional placements not common but currently being researched, such as left anterior right temporal or LART)
  • ultrabrief/brief stimulus
• Seizure threshold determination (determines needed power or percent energy) (Mankad, 2019, APA, 2001)
  • Determined at first treatment
  • Bilateral/bifrontal treatments = 2.5 times seizure threshold
  • Unilateral treatments = 5-7 times seizure threshold
• Intra-treatment considerations/monitoring (APA, 2001)
  • IV access
  • Bite Blocks
  • VS monitoring (i.e., BP, P, O2 sat/CO2)
  • Cardiac monitoring (3 lead)
  • EEG monitoring for seizure quality/duration (Mankad, 2019)
  • Ventilation (may/may not be needed)
  • Suctioning
• Medications – anesthesia/other (Salani et al., 2023, Joung et al. 2022, APA, 2001)
  • Anesthetics (i.e., methohexital, etomidate, ketamine, propofol, etc.).
  • Paralytics (i.e., succinylcholine, rocuronium, etc.)
  • Reversal agents (i.e., neostigmine, flumazenil, sugammadex, etc.)
  • Other medications (i.e., anti-hypertensive, ondansetron, ketorolac, versed, glycopyrrolate, toradol, acetaminophen, po pain meds)
  • Emergency medications should be readily available (including dantrolene)
  • Calming agents (e.g., propofol, precedex, midazolam, lorazepam, haldol, etc.)
• Other considerations: (APA, 2001)
  • Use of blood pressure cuff on leg (for ease of identifying seizures) (Mankad, 2019)
  • Fluid replacement (for dehydration)
  • Inhalers/nebulizers (pre/post as needed)

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Post-ECT Care Considerations

• Immediate Level One Recovery Room (Salani et al., et al., 2023, Mankad, 2019, APA, 2001)
  • Monitor
    • Airway issues
    • Cardiac Issues
    • Post-ECT agitation
    • Disorientation/confusion
    • Nausea
    • Headache/worsening of TMJ
    • Muscle aches
• Discharge criteria for discharge from PACU (Aldrete Score)
• Consider Level 2 Recovery for patients (until VS and cognition/orientation return to baseline – outpatients may be monitored for longer timeframe)
• Handoff of inpatient care to unit
  • Inpatients must be monitored routinely on unit after treatment.
  • Outpatients
    • Must be driven home after treatment/responsible adult for rest of day
    • Written discharge instructions are reviewed with patient and support person (driver) including number to call if issues arise post discharge
    • Discharge assessment including risk/safety assessment for SI/HI or other safety issues
• Protocols for emergency measures (may depend if stand-alone psychiatric facility versus medical setting)

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Group Programming

• Support groups held in person or virtually
  • Provide education, encouragement and forum for support
  • Help to reduce stigma (Poole & D’Alessandro, 2020)
  • Persons with lived experience provide context for living before/after/during ECT
• Cognitive retraining groups held in person or virtually (Copersino et al., 2023)
• Educational groups for non-ECT providers considering referral

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References

American Psychiatric Association (APA) (2001). The Practice of Electroconvulsive Therapy, Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association, Second Edition. American Psychiatric Association Publishing.

American Psychiatric Nurses Association (APNA) (2021, July). Position Paper: Electroconvulsive Therapy. American Psychiatric Nurses Association (APNA.org) https://www.apna.org/news/electroconvulsive-therapy/

Copersino, M.L., DeTore, N.R., Piltch, C., Bolton, P., Henderson, T., Davis, V., Eberlin, E.S., Kadden, L., McGurk, S.R., Seiner, S.J., Mueser, K.T. (2023). A pilot study of adjunctive group therapy to enhance coping with cognitive challenges and support cognitive health after electroconvulsive therapy. The Journal of ECT, 39(4), 248-254. https://doi.org/10.1097/YCT.0000000000000943

DeMarzo, A. (2020). What is prior authorization? Accreditation Council for Medical Affairs (ACMA). https://www.priorauthtraining.org/prior-authorization/

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. https://doi.org/10.1016/0022-3956(75)90026-6

Gligorovic, P. & Wake Forest Baptist Health. (2024). An overview of electroconvulsive treatment [Video]. International Society of Electroconvulsive Therapy (ECT) and Neuromodulation (ISEN). https://www.isen-ect.org/videos-of-ect-procedures

Hamilton M. (1960). A rating scale for depression. Journal of Neurology and Neurosurgical Psychiatry, 1960(23), 56–62. https://doi.org/10.1136/jnnp.23.1.56

Joung K.W., Park, D.H., Jeong, C.Y., Yang, H.S. (2022) Anesthetic care for electroconvulsive therapy. Anesthesia Pain Med, 17(2), 145-156. https://doi.org/10.17085/apm.22145

Kroenke, K., Spitzer, R.L., Williams, J.B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-13. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Livingston, R., Wu, C., Mu, K., Coffey, M.J. (2018). Regulation of ECT: A systematic review of US state laws. Journal of ECT 34(1), 60-68. https://doi.org/10.1097/YCT.0000000000000460

Lonergan, A., Timmins, F., Donohue, G. (2021). Mental Health Nurse experiences of delivering care to severely depressed adults receiving electroconvulsive therapy. Journal of Psychiatric Mental Health Nursing, 28(3), 309-316. https://doi.org/10.1111/jpm.12692.

Mankad, M. (2019, September 24). Electroconvulsive therapy: Overview, Preparation, Technique. Medscape. https://emedicine.medscape.com/article/1525957-overview#a2

Martin, D.M., McClintock, S.M., Loo, C.K. (2020). Brief cognitive screening instruments for electroconvulsive therapy: Which one should I use? Australian & New Zealand Journal of Psychiatry, 54(9), 867-873. https://doi.org/10.1177/0004867420924093

Nasreddine, Z.S., Phillip, N.A., Bédirian. V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J.L. & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695-699. https://doi.org/10.1111/j.1532-5415.2005.53221.x

National Institute of Mental Health (NIH). (2023). Ask suicide-screening questions (ASQ) toolkit. National Institute of Mental Health (NIH). https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials

Poole, J. & D’Alessandro, T.M. (2020, October 3). ECT: Dispelling the myths and focusing on facts. American Nurse. https://www.myamericannurse.com/ect-dispelling-the-myths-and-focusing-on-facts/

Posner, K., Brown, G.K., Stanley, B., Brent, D.A., Yershova, K.V., Oquendo, M.A., Currier, G.W., Melvin, G.A., Greenhill, L., Shen, S., Mann, J.J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266-77. https://doi.org/10.1176/appi.ajp.2011.10111704

Quazizada, A. (2016). The importance of medical consultation before electroconvulsive therapy. Consultant 360, 56(7). https://www.consultant360.com/articles/importance-medical-consultation-electroconvulsive-therapy

Quilty, L.C., Robinson, J.J., Rolland, J.P., Fruyt, F.D., Rouillon, F., Bagby, R.M. (2013). The structure of the Montgomery-Åsberg depression rating scale over the course of treatment for depression. International Journal of Methods in Psychiatric Research, 22(3), 175-84. https://doi.org/10.1002/mpr.1388

Reasoner, J. & Rondeau, B. (2023, January 3). Anesthetic considerations in electroconvulsive therapy. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK576431/

Reti, I., Walker, M., Pulia, K., Gallegos, J., Jayaran, G. & Vaidya, P. (2012) Safety considerations for outpatient electroconvulsive therapy. Journal of Psychiatric Practice, 18(2), 130-136. https://doi.org/10.1097/01.pra.0000413280.95843.d3

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Salini, D., Goldin, D., Valdes, B. & DeSantis, J. (2023). Electroconvulsive therapy for treatment-resistant depression: dispelling the stigma. Journal of Psychosocial Nursing and Mental Health Services, 61(6), 11-17. https://doi.org/10.3928/02793695-20230222-02

Spitzer, R.L., Kroenke, K. & Williams, J.B.W. (1999). Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA, 282(18), 1737–44. https://doi.org/10.1001/jama.282.18.1737

Tariq, S.H., Tumosa, N., Chibnall, J.T., Perry III, H.M., & Morley, J.E. (2006). The Saint Louis University Mental Status (SLUMS) Examination for detecting mild cognitive impairment and dementia is more sensitive than the MiniMental Status Examination (MMSE) – A pilot study. American Journal of Geriatric Psychiatry, 14(11), 900-10. https://doi.org/10.1097/01.JGP.0000221510.33817.86

Thirthalli, J., Sinha, P. & Sreeraj, V. (2023) Clinical practice guidelines for the use of electroconvulsive therapy. Indian Journal of Psychiatry, 65(2), 258-269. https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry_491_22