How do medical comorbidities affect electroconvulsive therapy (ECT)?

Updated: Sep 24, 2019
  • Author: Mehul V Mankad, MD; Chief Editor: Dennis M Popeo, MD  more...
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Concurrent medical conditions and their treatments may affect the response to and risks associated with electroconvulsive therapy. [1]

Neurological comorbidities

Caution is advised for patients with space-occupying intracranial lesions, as these individuals are at increased risk for edema and brain herniation after ECT. Patients with intracerebral lesions that lack a mass effect can safely undergo ECT. [56]

ECT increases intracranial pressure and blood flow to the brain. Patients who have increased intracerebral pressure or are at theoretical risk for cerebral bleeding, such as those with cerebrovascular disease and aneurysms, may be at increased risk during ECT. Patients with very recent strokes may be an area of special concern. However, patients with remote history of cerebrovascular accident have not shown adverse effects from ECT when studied. [56]

ECT has been safely used after coil embolization of a cerebral aneurysm. [57] ECT has been used in the presence of Charcot-Marie-Tooth disease, [58] arachnoid cysts, [59, 60] epilepsy, [1, 61] myasthenia gravis, [1] and multiple sclerosis. [1]

Cardiac comorbidities

Patients with cardiac disease can be evaluated by a cardiologist who can provide recommendations for the patient’s management during the course of ECT. [1, 18, 62] In patients with unstable angina, uncompensated congestive heart failure, uncontrolled hypertension, high-grade atrioventricular block, and symptomatic ventricular arrhythmias, ECT raises the risk of symptoms from these cardiac conditions. [1] Patients with hypertension should be stabilized with antihypertensive medications before undergoing ECT. [63] Patients with a recent myocardial infarction (MI) may be at higher risk of cardiac complications such as MI, although the risk decreases as the time interval between the MI and ECT increases.

With a proper pre-ECT cardiac and pacemaker/defibrillator assessment, patients with cardiac pacemakers and implantable cardioverter defibrillators can safely undergo ECT. [64] ECT has been used in the presence of severe aortic stenosis [65] , and it has been used after heart transplantation, though further studies are needed. [66]

Other comorbidities

Patients who have medical disorders associated with autonomic sensitivity (eg, clinically evident hyperthyroidism, pheochromocytoma), with sensitivity to anesthesia (eg, amyotrophic lateral sclerosis, porphyria, pseudocholinesterase deficiency), or with cognitive sensitivity (eg, traumatic brain injury) may require more extensive workup and closer monitoring during ECT. [48]

Patients with gastroesophageal reflux disease may experience worsening symptoms during ECT, due to stimulation of the vagus nerve. [18]

Patients with diabetes, metabolic disorders (eg, hyperkalemia, hypokalemia, hyponatremia), chronic obstructive pulmonary disease, hypercoagulable states, glaucoma, and renal disease require close monitoring during ECT. [1, 67]

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