Electroconvulsive Therapy (ECT)
Comprehensive Study Guide for Nursing Students
Electroconvulsive therapy (ECT) is a procedure in which a brief electrical current is passed through the brain to induce a controlled seizure while the patient is under general anesthesia. Despite historical stigma, modern ECT is a safe and effective treatment for certain psychiatric conditions when performed under appropriate medical supervision.
Historical Context
Mechanism of Action
The exact mechanism of ECT’s therapeutic effect remains incompletely understood, but several theories have substantial evidence:
- Neurotransmitter Changes: Enhances monoaminergic neurotransmission (serotonin, norepinephrine, dopamine)
- Neuroendocrine Effects: Normalizes hypothalamic-pituitary-adrenal (HPA) axis function
- Neuroplasticity: Increases brain-derived neurotrophic factor (BDNF) and promotes neurogenesis
- Seizure Threshold (ST) Elevation: Repeated seizures increase ST, improving mood stability by enhancing GABAergic activity
- Functional Connectivity: Alters connectivity between brain regions involved in mood regulation
Mnemonic: “BRAIN” – ECT Mechanism of Action
B – BDNF production increases
R – Reuptake of monoamines decreases
A – Anticonvulsant effect develops with repeated treatments
I – Inhibitory neurotransmission (GABA) increases
N – Neurogenesis and neuroplasticity are enhanced
Indications
Primary indications for ECT:
- Major Depressive Disorder (MDD) – especially when:
- Treatment-resistant to medications
- Psychotic features are present
- High suicide risk exists
- Rapid response is needed (e.g., catatonia, severe nutritional compromise)
- Bipolar Disorder – for both:
- Depressive episodes (80% response rate)
- Manic episodes (80-100% response rate)
- Mixed episodes (80% response rate)
- Schizophrenia – particularly with:
- Catatonic features
- Treatment-resistant psychosis
- Affective symptoms predominant
- Other conditions:
- Catatonia (regardless of underlying cause)
- Severe or malignant Neuroleptic Malignant Syndrome
- Parkinson’s disease with severe depression
- Medication-resistant Parkinson’s disease for motor symptoms
Mnemonic: “CARES” – When to Consider ECT
C – Catatonia unresponsive to benzodiazepines
A – Antidepressant failure (treatment-resistant)
R – Rapid response needed (suicidality, food refusal)
E – Extreme symptoms (psychotic depression, severe mania)
S – Safety concerns with medications (elderly, pregnant)
Contraindications
According to most authorities, including the American Psychiatric Association (APA), there are no absolute contraindications to ECT. However, certain conditions require special consideration and risk assessment:
High-Risk Conditions (Relative Contraindications):
- Cardiovascular Conditions:
- Recent myocardial infarction (MI)
- Unstable angina or congestive heart failure
- Severe cardiac arrhythmias
- Neurological Conditions:
- Space-occupying lesions with mass effect
- Elevated intracranial pressure
- Recent cerebrovascular accident (stroke)
- Cerebral aneurysm or AVM at risk of rupture
- Other Conditions:
- Pheochromocytoma (risk of hypertensive crisis)
- High anesthetic risk
- Severe pulmonary disease limiting oxygenation
Conditions Requiring Special Precautions:
- Pregnancy (ECT is generally considered safe but requires specialized monitoring)
- Osteoporosis (increased risk of fractures)
- Glaucoma (risk of increased intraocular pressure)
- Dental/oral conditions that may complicate airway management
- Known hypersensitivity to anesthetic agents
Types of ECT
Figure 1: Electrode Placement in ECT – (A) Bilateral (Bitemporal) and (B) Right Unilateral
| Parameter | Bilateral ECT | Right Unilateral ECT |
|---|---|---|
| Electrode Placement | Both temples (bitemporal) or both frontal lobes (bifrontal) | Right temple and top of head (vertex) |
| Efficacy | Higher (70-90% response rate) | Slightly lower unless higher stimulus dose used |
| Speed of Response | Faster response | May require more treatments for full response |
| Cognitive Side Effects | More pronounced memory impairment | Less memory impairment, fewer cognitive effects |
| Clinical Indication | When rapid improvement needed (e.g., severe suicidality) | When cognitive preservation is prioritized |
| Seizure Threshold | Higher seizure threshold | Lower seizure threshold |
Clinical Pearl: Many practitioners start with right unilateral ECT at higher stimulus doses to minimize cognitive side effects. If inadequate response occurs after 3-4 treatments, they may switch to bilateral ECT. Conversely, in cases where seizure duration becomes inadequate with bilateral ECT, switching to unilateral placement may help elicit adequate seizures.
ECT Procedure
Figure 2: Modern ECT Equipment
ECT Procedure Flowchart
Pre-Procedure (6-12 hours before)
- NPO status (no food for 6-8 hours, clear liquids up to 2 hours before)
- Baseline vital signs and physical assessment
- Lab tests and ECG as ordered
- Medication management (hold or continue as directed)
- Remove dentures, jewelry, contact lenses
- Void bladder
- Emotional support and education
Immediate Pre-Procedure (Treatment Room)
- Establish IV access
- Place electrocardiogram (ECG) leads
- Apply blood pressure cuff
- Connect pulse oximeter
- Attach EEG monitoring leads
- Insert bite block/oral airway
Treatment Administration
- Anesthesia administration (typically propofol or methohexital)
- Muscle relaxant administration (typically succinylcholine)
- Pre-oxygenation and ventilation assistance
- Electrode placement (bilateral or unilateral)
- Electrical stimulus delivered
- Seizure monitoring (motor and EEG)
- Airway management throughout
Immediate Post-Procedure (Recovery Room)
- Continuous monitoring of vital signs
- Airway management until fully awake
- Oxygen administration as needed
- Assessment for complications
- Management of post-ictal confusion
Post-Procedure Care
- Orientation and reassurance
- Vital signs monitoring until stable
- Assessment for side effects
- Management of headache, nausea, muscle pain
- Post-procedure assessment and documentation
- Gradual resumption of activities and diet
Nursing Care in ECT
Pre-Procedure Nursing Care
Assessment:
- Confirm informed consent has been obtained and documented
- Complete physical assessment including vital signs, neurological status
- Verify NPO status (6-8 hours for food, 2 hours for clear liquids)
- Review laboratory results and ECG
- Assess for contraindications or risk factors
- Document baseline cognitive status
- Confirm medication management (held or taken as ordered)
Interventions:
- Provide patient education about procedure, expected sensations, and recovery
- Address patient and family concerns and questions
- Remove dentures, contact lenses, jewelry, hairpins
- Ensure patient has voided
- Administer pre-procedure medications if ordered
- Establish IV access
- Document allergies prominently
- Transport patient to treatment area
Intra-Procedure Nursing Care
Assessment:
- Assist with monitoring vital signs
- Observe seizure duration and quality
- Monitor for adequate oxygenation
- Assist with documentation of procedure parameters
Interventions:
- Assist with placement of monitoring equipment
- Support airway management
- Assist with electrode placement
- Maintain patient safety during seizure
- Provide positioning support
- Assist with medication administration
- Document procedure details including seizure duration
Figure 3: EEG Monitoring During ECT-Induced Seizure
Post-Procedure Nursing Care
Assessment:
- Monitor vital signs (every 15 minutes until stable)
- Assess respiratory status and oxygenation
- Evaluate level of consciousness and orientation
- Assess for confusion, agitation, or discomfort
- Monitor for post-procedure complications
- Assess gag reflex before offering fluids
Interventions:
- Maintain patient safety during post-ictal state
- Position patient on side until fully awake to prevent aspiration
- Provide frequent orientation and reassurance
- Manage common side effects (headache, nausea, muscle aches)
- Administer ordered medications for side effects
- Assist with gradual resumption of activities
- Provide oral care
- Document response to treatment and recovery
- Provide discharge instructions when applicable
Mnemonic: “RECOVERY” – Post-ECT Nursing Care
R – Respiratory status monitoring
E – Ensure safety and prevent falls
C – Cardiovascular monitoring (vital signs)
O – Orientation provided frequently
V – Verify gag reflex before offering fluids
E – Evaluate and manage side effects
R – Reassurance and emotional support
Y – Yield thorough documentation
Side Effects and Management
| Side Effect Category | Specific Effects | Nursing Management |
|---|---|---|
| Cognitive |
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| Physical |
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| Cardiovascular |
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| Rare Complications |
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Important Note on Memory Effects:
The most persistent adverse effect is retrograde amnesia. Shortly after ECT, most patients have gaps in their memory for events that occurred close in time to the treatment course, but amnesia may extend back several months in some cases. Memory for personal information is more affected than memory for public events. Modern ECT techniques have significantly reduced memory impairment compared to older methods.
Clinical Pearl: Memory function typically improves over weeks to months after ECT completion. Patients should be educated that while some memory gaps may persist, new learning ability usually returns to baseline. Right unilateral ECT and ultrabrief pulse width stimulus reduce cognitive side effects significantly.
Efficacy and Treatment Course
Response Rates by Condition
- Major Depression: 70-90% response rate (higher than most antidepressants)
- Bipolar Depression: 80% response rate (often with faster response than unipolar depression)
- Bipolar Mania: 80-100% response rate
- Catatonia: 80-100% response rate, often with dramatic improvement
- Schizophrenia: 40-70% response rate (higher with prominent affective symptoms)
Typical Treatment Course
- Acute Phase: 6-12 treatments, typically given 2-3 times per week
- Response typically begins after 3-4 treatments
- Continuation Phase: May include maintenance ECT (weekly, biweekly, or monthly)
- Maintenance Schedule Examples:
- Weekly for 1 month
- Biweekly for 2 months
- Monthly thereafter (individualized)
Clinical Pearl: Maintenance ECT significantly reduces relapse rates in patients who respond to acute treatment. Combination with pharmacotherapy is common and increases effectiveness.
Patient Teaching Points
- Explain the procedure, including the use of anesthesia and muscle relaxants
- Address common misconceptions about ECT (e.g., it’s not like portrayed in old movies)
- Discuss expected benefits and potential side effects
- Explain NPO requirements (no food for 6-8 hours, clear liquids up to 2 hours before)
- Advise to remove jewelry, dentures, contact lenses before treatment
- Explain that someone will need to drive the patient home after treatment
- Discuss temporary activity restrictions (no driving 24 hours after treatment)
- Inform about expected confusion and how it typically resolves within hours
- Provide strategies for managing memory difficulties
- Discuss symptom management for headache and muscle soreness
- Explain the importance of continued medication compliance if prescribed
- Emphasize the need for follow-up appointments
- Provide written instructions for home care
- Educate about signs and symptoms that should prompt medical attention
- Discuss the potential need for maintenance treatment
Important Safety Teaching Points:
- Avoid driving or operating heavy machinery for 24 hours after treatment
- Avoid making important decisions on treatment days
- Have a responsible adult present for the first 24 hours after each treatment
- Use memory aids such as calendars, lists, and alarms for appointments
- Report any unusual or severe symptoms immediately
Key Takeaways
- ECT is a safe and effective treatment for severe psychiatric conditions, especially treatment-resistant depression, bipolar disorder, and catatonia.
- Modern ECT uses anesthesia, muscle relaxants, and oxygenation, making it much safer than historical versions.
- Bilateral ECT offers faster response but more cognitive side effects; right unilateral ECT has fewer cognitive effects but may require more treatments.
- The most common side effects are confusion, headache, nausea, and memory issues, most of which are temporary.
- Nursing care focuses on patient safety, monitoring, side effect management, and thorough patient education.
- Response rates are high (70-90% for depression), often exceeding medication response rates.
- Maintenance ECT may be necessary to prevent relapse in responding patients.
- Patient and family education is crucial to address misconceptions and ensure informed consent.
References
1. American Psychiatric Association. (2001). The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging.
2. Kellner, C. H., & Patel, P. (2018). Neuromodulation in Psychiatry. Cambridge University Press.
3. Weiner, R. D., & Reti, I. M. (2017). Key updates in the clinical application of electroconvulsive therapy. International Review of Psychiatry, 29(2), 54-62.
4. McCall, W. V., Andrade, C., & Sienaert, P. (2019). Searching for the mechanism(s) of ECT’s therapeutic effect. The Journal of ECT, 35(3), 153-156.
5. Sackeim, H. A. (2017). Modern electroconvulsive therapy: Vastly improved yet greatly underused. JAMA Psychiatry, 74(8), 779-780.
6. Andrade, C., & Arumugham, S. S. (2021). Cognitive and memory impairment after electroconvulsive therapy. Journal of Clinical Psychiatry, 82(2).
7. Tess, A. V., & Smetana, G. W. (2009). Medical evaluation of patients undergoing electroconvulsive therapy. New England Journal of Medicine, 360(14), 1437-1444.
8. Narang, P., Iancu, D., Best, T., & Lippmann, S. (2017). Efficacy of electroconvulsive therapy in the treatment of bipolar depression. Annals of Clinical Psychiatry, 29(2), 149-152.
Electroconvulsive Therapy (ECT) Nursing Notes © 2025
Created BY Soumya Ranjan Parida for educational purposes for nursing students.