Current Psychiatry Reports

, Volume 10, Issue 6, pp 474–480 | Cite as

Uncommon but serious complications associated with electroconvulsive therapy: Recognition and management for the clinician

  • Mario A. Cristancho
  • Yesne Alici
  • John G. Augoustides
  • John P. O’Reardon


Electroconvulsive therapy (ECT) is a safe and effective treatment for severe mood disorders. Rarely there can be serious complications, such as postictal agitation, cardiovascular compromise, prolonged seizures, and status epilepticus, all of which are important for the clinician to recognize and treat. Postictal agitation can be severe, requiring emergent intervention and subsequent prophylactic measures to avoid premature ECT discontinuation. Cardiovascular responses to ECT include significant hemodynamic changes that may result in complications, even in patients without preexisting cardiovascular conditions. However, preexisting cardiovascular conditions per se are not contraindications to ECT in patients with disabling psychiatric disease. Recognizing and treating prolonged seizures is essential to prevent progression to status epilepticus. Failure to recognize and treat any of these events may result in increased mortality and morbidity. Understanding such complications and their management strategies avoids unnecessary treatment discontinuation due to manageable ECT complications.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Auriacombe M, Reneric JP, Usandizaga D, et al.: Post-ECT agitation and plasma lactate concentrations. J ECT 2000, 16:263–267.PubMedCrossRefGoogle Scholar
  2. 2.
    Swartz CM: Electroconvulsive therapy emergence agitation and succinylcholine dose. J Nerv Ment Dis 1990, 178:455–457.PubMedCrossRefGoogle Scholar
  3. 3.
    O’Reardon JP, Takieddine N, Datto CJ, Augoustides JG: Propofol for the management of emergence agitation after electroconvulsive therapy: review of a case series. J ECT 2006, 22:247–252.PubMedCrossRefGoogle Scholar
  4. 4.
    Augoustides JG, Greenblatt E, Abbas MA, et al.: Clinical approach to agitation after electroconvulsive therapy: a case report and literature review. J ECT 2002, 18:213–217.PubMedCrossRefGoogle Scholar
  5. 5.
    Trimble MR, Ring HA, Schmitz B: Neuropsychiatric aspects of epilepsy. In Neuropsychiatry. Edited by Fogel BS, Schiffer RB. Baltimore: Williams and Wilkins; 1996:771–803.Google Scholar
  6. 6.
    Gomez J, Dally P: Intravenous tranquilization with ECT. Br J Psychiatry 1975, 127:604–608.PubMedCrossRefGoogle Scholar
  7. 7.
    Logan C, Stewart J: Treatment of post electroconvulsive therapy delirium and agitation with donepezil. J ECT 2007, 23:28–29.PubMedCrossRefGoogle Scholar
  8. 8.
    Vishne T, Amiaz R, Grunhaus L: Promethazine for the treatment of agitation after electroconvulsive therapy. J ECT 2005, 21:118–121.PubMedCrossRefGoogle Scholar
  9. 9.
    Labbate LA, Miller JP: Midazolam for treatment of agitation after ECT. Am J Psychiatry 1995, 152:472–473.PubMedGoogle Scholar
  10. 10.
    Small JG, Milstein V: Lithium interactions: lithium and electroconvulsive therapy. J Clin Psychopharmacol 1990, 10:346–350.PubMedCrossRefGoogle Scholar
  11. 11.
    Sackeim HA, Decina P, Malitz S, et al.: Postictal excitement following bilateral and right-unilateral ECT. Am J Psychiatry 1983, 140:1367–1368.PubMedGoogle Scholar
  12. 12.
    Swartz CM: ECT emergence agitation and methohexitalsuccinylcholine interaction. Gen Hosp Psychiatry 1993, 15:339–341.PubMedCrossRefGoogle Scholar
  13. 13.
    Devanand DP, Sackeim HA: Use of increased anesthetic dose prior to electroconvulsive therapy to prevent postictal excitement. Gen Hosp Psychiatry 1992, 14:345–349.PubMedCrossRefGoogle Scholar
  14. 14.
    Kelly K, Zisselman M: Update on electroconvulsive therapy (ECT) in older adults. J Am Geriatr Soc 2000, 48:560–566.PubMedGoogle Scholar
  15. 15.
    Levin L, Wambold D, Viguera A, et al.: Homodynamic responses to ECT in a patient with critical aortic stenosis. J ECT 2000, 16:52–61.PubMedCrossRefGoogle Scholar
  16. 16.
    Zielinski R, Roose S, Devanand D, et al.: Cardiovascular complications of ECT in depressed patients with cardiac disease. Am J Psychiatry 1993, 150:904–909.PubMedGoogle Scholar
  17. 17.
    Lewis W, Richardson J, Gahagan L: Cardiovascular disturbances and their management in modified electrotherapy for psychiatric illness. N Engl J Med 1955, 252:1016–1020.PubMedCrossRefGoogle Scholar
  18. 18.
    Dec W, Stern T, Welch C: The effects of electroconvulsive therapy on serial electrocardiograms and serum cardiac enzyme values. A prospective study of depressed hospitalized inpatients. JAMA 1985, 253:2525–2529.PubMedCrossRefGoogle Scholar
  19. 19.
    Karliner W: Cardiovascular disease and ECT. Psychosomatics 1978, 19:238–241.PubMedGoogle Scholar
  20. 20.
    O’Reardon J, Cristancho M, Cristancho P, et al.: Electroconvulsive therapy in a 96 year old patient with severe aortic stenosis—a case report and review of the literature. J ECT 2008, 24:96–98.PubMedCrossRefGoogle Scholar
  21. 21.
    O’Reardon J, Lott J, Akthar U, et al.: Acute coronary syndrome (Takutsobo cardiomyopathy) following electroconvulsive therapy in the absence of significant coronary artery disease: case report and review of literature, J ECT 2008 (in press).Google Scholar
  22. 22.
    Prasad A: Apical ballooning syndrome: an important differential diagnosis of acute myocardial infarction. Circulation 2007, 115:e56–e59.PubMedCrossRefGoogle Scholar
  23. 23.
    Ueyama T, Kasamatsu K, Hano T, et al.: Emotional stress induces transient left ventricular hypocontraction in the rat via activation of cardiac adrenoceptors: a possible animal model of ‘tako-tsubo’ cardiomyopathy. Circ J 2002, 66:712–713.PubMedCrossRefGoogle Scholar
  24. 24.
    Messina A, Paranicas MKB, Markowitz J, et al.: Effect of electroconvulsive therapy on the electrocardiogram and echocardiogram. Anesth Analg 1992, 75:511–514.PubMedCrossRefGoogle Scholar
  25. 25.
    Bybee KA, Kara T, Prasad A, et al.: Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004, 141:858–865.PubMedGoogle Scholar
  26. 26.
    Tsuchihashi K, Ueshima K, Uchida T, et al.: Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol 2001, 38:11–18.PubMedCrossRefGoogle Scholar
  27. 27.
    Sienaert P, Koeck A, Bouckaert F, et al.: Prolonged ECT seizure in a patient taking Nimesulide. J ECT 2004, 20:52–53.PubMedGoogle Scholar
  28. 28.
    Abrams R: Electroconvulsive Therapy, edn 4. New York: Oxford University Press; 2002.Google Scholar
  29. 29.
    American Psychiatric Association: The Practice of ECT: Recommendations for Treatment, Training and Privileging. Washington, DC: American Psychiatric Press; 2001.Google Scholar
  30. 30.
    Scott AI, McCreadie RG: Prolonged seizures detectable by electroencephalogram in electroconvulsive therapy. Br J Psychiatry 1999, 175:91–92.PubMedCrossRefGoogle Scholar
  31. 31.
    Guttmacher LB, Cretella H: Electroconvulsive therapy in one child and three adolescents. J Clin Psychiatry 1988, 49:20–23.PubMedGoogle Scholar
  32. 32.
    Solomons K, Holliday S, Illing M: Non-convulsive status epilepticus complicating electroconvulsive therapy. Int J Geriatr Psychiatry 1998, 13:731–734.PubMedCrossRefGoogle Scholar
  33. 33.
    Beyer JL, Glenn MD, Weiner RD: Electroconvulsive Therapy: A Programmed Text, edn 2. Washington, DC: American Psychiatric Press; 1998.Google Scholar
  34. 34.
    Proposal for revised clinical and electroencephalographic classification of epileptic seizures: from the Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 1981, 22:489–501.Google Scholar
  35. 35.
    Mayer SA, Claassen J, Lokin J, et al.: Refractory status epilepticus frequency, risk factors, and impact on outcome. Arch Neurol 2002, 59:205–210.PubMedCrossRefGoogle Scholar
  36. 36.
    Fink M, Kellner CH, Sackeim HA: Intractable seizures, status epilepticus, and ECT. J ECT 1999, 15:282–284.PubMedGoogle Scholar
  37. 37.
    Povlsen UJ, Wildschiodtz G, Hogenhaven H, et al.: Nonconvulsive status epilepticus after electroconvulsive therapy. J ECT 2003, 19:164–169.PubMedCrossRefGoogle Scholar
  38. 38.
    Devinsky O, Duchowny MS: Seizures after convulsive therapy: a retrospective case survey. Neurology 1983, 33:921–925.PubMedGoogle Scholar
  39. 39.
    Balki M, Castro C, Ananthanarayan C: Status epilepticus after electroconvulsive therapy in a pregnant patient. Int J Obstet Anesth 2006, 15:325–328.PubMedCrossRefGoogle Scholar
  40. 40.
    Lowenstein DH, Alldredge BK: Status epilepticus. N Engl J Med 1998, 338:970–976.PubMedCrossRefGoogle Scholar
  41. 41.
    Cline JS, Roos K: Treatment of status epilepticus with electroconvulsive therapy. J ECT 2007, 23:30–32.PubMedCrossRefGoogle Scholar
  42. 42.
    Treiman DM, Meyers PD, Walton NY, et al.: A comparison of four treatments for generalized convulsive status epilepticus. N Engl J Med 1998, 339:792–798.PubMedCrossRefGoogle Scholar
  43. 43.
    Scott AI, Riddle W: Status epilepticus after electroconvulsive therapy. Br J Psychiatry 1989, 155:119–121.PubMedCrossRefGoogle Scholar
  44. 44.
    Smith K, Keepers G: Nonconvulsive status epilepticus after ECT. Am J Psychiatry 2000, 157:1524.PubMedCrossRefGoogle Scholar
  45. 45.
    Pogarell O, Ehrentraut S, Rüther T, et al.: Prolonged confusional state following electroconvulsive therapy—diagnostic clues from serial electroencephalography. Pharmacopsychiatry 2005, 38:316–320.PubMedCrossRefGoogle Scholar
  46. 46.
    Kaplan PW: Assessing the outcomes in patients with nonconvulsive status epilepticus: nonconvulsive status epilepticus is underdiagnosed, potentially overtreated, and confounded by comorbidity. J Clin Neurophysiol 1999, 16:341–352.PubMedCrossRefGoogle Scholar
  47. 47.
    Fink M: Nonconvulsive status epilepticus and electroconvulsive therapy. J ECT 2004, 20:131–132.PubMedCrossRefGoogle Scholar
  48. 48.
    Sackeim HA, Decina P, Prohovnik I, et al.: Anticonvulsant and antidepressant properties of electroconvulsive therapy: a proposed mechanism of action. Biol Psychiatry 1983, 18:1301–1310.PubMedGoogle Scholar
  49. 49.
    Griesemer DA, Kellner CH, Beale MD, et al.: Electroconvulsive therapy for treatment of intractable seizures. Initial findings in two children. Neurology 1997, 49:1389–1392.PubMedGoogle Scholar
  50. 50.
    Lisanby SH, Bazil CW, Resor SR, et al.: ECT in the treatment of status epilepticus. J ECT 2001, 17:210–215.PubMedCrossRefGoogle Scholar

Copyright information

© Current Medicine Group LLC 2008

Authors and Affiliations

  • Mario A. Cristancho
    • 1
  • Yesne Alici
  • John G. Augoustides
  • John P. O’Reardon
  1. 1.Department of PsychiatryUniversity of PennsylvaniaPhiladelphiaUSA

Personalised recommendations