Pain Practice - 2023 - Yoon

DOI: 10.1111/papr.
13268
REVIEW
Chronic pain outcomes of patients receiving electroconvulsive

therapy: A systematic review and case series
Isabel A. Yoon MD1,2 | David Galarneau MD1,3
1
Ochsner Clinical School, University of Abstract
Queensland, New Orleans, Louisiana, USA
2
Introduction: The potential benefits of electroconvulsive therapy (ECT) in chronic
Department of Psychiatry and Psychology,
Mayo Clinic, Rochester, Minnesota, USA
pain and several theories for its mechanism have been reported in the past, but
3
Department of Psychiatry, Ochsner Clinic
mixed findings have also been reported. In the current systematic review and case
Foundation, New Orleans, Louisiana, USA series, our primary aim was to assess whether pain and functional outcomes are
improved after ECT in patients with chronic pain. Secondary objectives included
Correspondence
David Galarneau, Department of
examining whether psychiatric improvement, specific pain diagnoses, and
Psychiatry, Ochsner Clinic Foundation, demographic or medical characteristics were associated with differences in pain
1401 Jefferson Hwy, Jefferson, LA 70121, treatment response.
USA.
Email: dgalarneau@ochsner.org
Methods: We performed a retrospective chart review to identify patients with
chronic pain diagnoses for more than 3 months prior to the initiation of ECT and
a systematic literature search on electronic databases for studies on chronic pain
outcomes after ECT.
Results: Eleven patients with various chronic pain diagnoses and comorbid
psychiatric conditions were identified in the case series. Six patients reported
improvement in pain while 10 patients reported improvement in mood following
ECT. Systematic review identified 22 articles reporting a total of 109 cases. Eighty-
five (78%) of cases reported reduction in pain while 96.3% of the patients with a
comorbid psychiatric diagnosis reported improvement in mood symptoms post-
ECT. While there was an association between improvement in mood and pain in
studies with numeric ratings in both outcomes (r = 0.61; p < 0.001), some patients
reported pain improvement without improvement in mood in both the case series
and the pooled analysis of cases in the review. Certain pain diagnoses such as
CRPS, phantom limb pain, neuropathic pain, and low back pain have consistently
reported benefits and should be further studied in future studies with matched case
controls.
Conclusion: ECT may be offered to patients with certain pain conditions who have
not responded sufficiently to conventional therapies, particularly when comorbid
mood symptoms are present. Improved documentation practices on the outcomes
in chronic pain patients receiving ECT will help generate more studies that are
needed on this topic.
K EY WOR DS
chronic pain, depression, ECT, functional outcomes, systematic review
I N T RODUC T ION depressive disorder (MDD),2,3 less well-k nown is its po-
tential beneficial effects on various pain states. Studies
Electroconvulsive therapy (ECT) has been utilized dating back as early as 1946 have reported resolution of
worldwide as a neuropsychiatric procedure since 1938.1 several pain syndromes including phantom limb pain
While the evidence is strong for its effectiveness in psy- after electroshock therapy.4–9 While it is expected that
chiatric conditions such as treatment- resistant major physical symptoms from primary psychiatric conditions
Pain Practice. 2023;00:1–14. wileyonlinelibrary.com/journal/papr |
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2 CHRONIC PAIN OUTCOMES OF PATIENTS RECEIVING ECT
(eg, somatic symptom disorder) would improve with ef- neurobiological substrates between depression and chronic
fective psychiatric treatment with ECT,10–13 conditions pain conditions are shown to exist.40 Neuroimaging data
that are not deemed secondary to a psychiatric condi- also indicate that brain regions such as the prefrontal cor-
tion have shown improvement as well. Several reports tex, anterior cingulate gyrus, insula, and amygdala are im-
have supported the clinical effectiveness of ECT for portant areas for modulating both pain and mood.19,41 ECT
neuropathic pain14 and fibromyalgia.15–17 For example, a has been shown to increase blood flow in broad cortical and
patient with chronic intractable neuropathic pain of the subcortical areas in patients with either major depression or
right upper extremity and shoulder for 10 years achieved chronic pain, while patients with major depression gener-
remission of pain for 2 months after ECT, despite no sig- ally demonstrate abnormal blood flow in these areas.42 A
nificant pain relief previously with multiple pain med- theorized model explains that in limbically augmented pain
ications and various interventional pain procedures.14 syndromes, disrupted affective processing of pain leads to
A 3-month prospective trial of ECT in 15 patients with sensory pain inputs that enhance the receptive field and in-
fibromyalgia without MDD showed significantly lower tensity of pain perception—similar to the process of central
pain as measured by the visual analog scale (VAS) and sensitization at the spinal level.43 In this model, prior expe-
evaluation of tender points, which were sustained at 3- riences of pain, even if unrelated to the current pain, can
month follow-ups.15 Case studies have also shown posi- serve as a substrate for current pain to be amplified in pa-
tive findings in complex regional pain syndrome (CRPS) tients with affective disorders.43 Similarly, it has been sug-
(previously known as reflex sympathetic dystrophy)18,19 gested that the effect of ECT on memory may contribute to
and phantom limb pain.20 Even acute intractable pelvic a reduction in pain levels by inhibiting the long-term poten-
pain from a motor vehicle trauma has been reported to tiation involved in synaptic plasticity and pain memory.44,45
respond to ECT in one case report.21 Patients with MDD The thalamus, a central component of the limbic system,
without a comorbid chronic pain diagnosis also showed has been shown to have reduced regional blood flow on
increased pain threshold and tolerance post-ECT.22,23 single-photon emission tomography in CRPS46 and neuro-
A large clinical trial of ECT has also shown improve- pathic pain conditions,47 which normalized after ECT with
ment in the bodily pains immediately after ECT in associated pain relief.42,48
patients with major depression as assessed by standard- While previous case studies have reported potential
ized health-related quality-of-life measures such as the improvements in pain conditions following ECT, mixed
Medical Outcomes Study Short Form-36 (SF-36).24 findings have also been described in other reports with-
The exact mechanisms are yet to be known, but there out a systematic review on this topic to date. The cur-
have been several theories suggested to underlie the effec- rent systematic review and case series, therefore, aim to
tiveness of ECT in reducing pain. First, ECT is thought to contribute to the existing body of evidence with updated
enhance the responsiveness of serotonergic, noradrener- and comprehensive information on the effects of ECT
gic, and dopaminergic neurotransmission systems in the on chronic pain. The primary objective of this article
brain, which are critical to processing pain throughout the will be to examine whether pain severity and functional
central nervous system.15,25 ECT is also thought to modu- outcomes (ie, degree of limitation in daily activities due
late endogenous opiate systems.19 For example, increases to a chronic pain condition) are improved in patients
in CNS enkephalin levels (eg, beta-endorphins)26–29 and with chronic pain after ECT. Secondary objectives in-
enkephalin receptors (eg, mu-opioid receptors)18,30,31 have clude: (1) to examine whether changes in pain severity
been identified during ECT via animal studies26,30,32,33 and functional outcomes are associated with significant
and plasma levels in patients pre-and post-ECT,27,28,34 treatment response from ECT regarding their psychiat-
though levels may return to baseline over time (eg, 4 weeks ric condition; (2) to assess differences in pain outcomes
post-ECT).34 Focal changes in concentration and binding by subgroups of specific pain diagnoses; (3) to examine
of other neuropeptide transmitters such as neuropeptide whether demographic characteristics such as age, sex,
Y,35,36 somatostatin,37 as well as an increase in central ben- and medical characteristics such as duration of diagno-
zodiazepine receptors31 have also been reported in vivo ses are associated with differences in treatment response.
studies after induced seizures. As these neurotransmitters
and receptors are associated with the modulation or medi-
ation of pain, ECT is thought to enhance the activity of the M ET HOD S
descending inhibitory pain pathways of the brain.15 ECT
has also been hypothesized to block a pathologic focal Case series
corticothalamic reverberatory loop implicated in main-
taining chronic neuropathic pain.38 A retrospective chart review was conducted using the data
The effect of ECT on pain may also be modulated by the available in the current electronic medical record system
reduction in a patient's emotional response to pain, as sug- at Ochsner Medical Center in New Orleans, Louisiana.
gested in previous studies.9,39 There is convincing evidence Eligibility criteria included adults over age 18 who re-
that pain and affect are processed in many of the same ceived ECT at Ochsner Medical Center and had any of
brain areas, and thus are intimately linked. Overlapping the following chronic pain diagnoses (based on ICD-10
YOON and GALARNEAU |
3
codes) for more than 3 months prior to the initiation of Search strategy and study selection
ECT: neuropathic pain, nerve pain, neuralgia (eg, oc-
cipital neuralgia, trigeminal neuralgia), fibromyalgia, A systematic literature search was performed on elec-
chronic pain syndrome, myofascial pain, orofacial pain, tronic databases (EMBASE, MEDLINE, PsycINFO,
neck pain, thoracolumbar pain, back pain, headache, PubMed, Web of Science) using the search terms de-
migraines, pelvic pain, abdominal pain, abdominal mi- tailed in Appendix S1 (last search, February 2023).
graine, CRPS, centralized pain, interstitial cystitis, and Duplicates were removed, and records were first
phantom limb pain. Based on the inclusion criteria pro- screened based on title and abstract. Full texts of arti-
vided, a biomedical research informatics specialist pro- cles were assessed for the inclusion and exclusion crite-
vided a list of potential cases by querying the institution's ria. Articles needed to report original data on chronic
Research Electronic Data Capture (REDCap) system. pain outcomes with appropriate diagnoses in patients
Data queries were periodically run from October 2021 who received ECT. Only articles written in English
through February 2023, which captured all data in the were included and nonhuman studies were excluded.
system proceeding that date. A detailed chart review by Reference lists of included articles were examined for
the authors identified eligible cases that had appropriate additional identification of eligible reports (Figure 1).
chronic pain diagnoses within the required period (eg,
3 months prior to initiating ECT and not resolved before
the start of ECT sessions) and had sufficient data on their Extraction of data
pain level and functional status before and after the ECT
sessions. Patient demographics (ie, age, sex, race), medi- The first author (I.A.Y.) and the second extractor inde-
cal and psychiatric diagnoses, medications, relevant out- pendently screened the search results. Any discrepancies
come data (eg, pain level, functional status, psychiatric or questions were resolved via discussion between the two
outcome), and ECT details (eg, number of sessions, pro- individuals. The following information was extracted from
cedure details) were collected. Medical and psychiatric each article: authors and publication year, age and sex of
diagnoses were also verified in the progress notes charted patient(s), chronic pain diagnosis, pain diagnosis duration,
by treatment providers. Descriptive statistics on age and psychiatric diagnosis, medical history, ECT procedural
duration of treatment were performed. Qualitative analy- details, medications, outcome measure(s), and effects.
sis was performed to summarize findings from the data.
The Ochsner Clinic Foundation Institutional Review
Board approved the study, and all data were collected and Data synthesis and analysis
stored in accordance with the required standards.
Quality appraisal of included cases was performed to look
for adequacy in the description of the extracted variables
Procedure mentioned earlier. Pooled data from the included studies
were summarized using descriptive statistics for continu-
All treatments were performed with MECTA spectrum ous variables and frequencies and percentages for dichot-
5000Q device (MECTA Corp) with bitemporal elec- omous variables. Pearson's correlation coefficients were
trode placement. General anesthesia was performed calculated for improvement in pain ratings and mood (de-
using a combination of succinylcholine and methohexi- pression) ratings post-ECT for studies that reported both
tal. Labetalol and toradol were given during the proce- outcomes numerically. The improvement was calculated
dure to prevent hypertension and myalgias, respectively. as a percentage of the change in levels in relation to pre-
Ondansetron was sometimes given before or after the ECT scores, in order to accommodate depression scores
procedure for associated nausea. While there were some that are not based on a 0–10 scale (eg, Beck Depression
variations in the stimulus settings in the first 3–8 ses- Inventory, Hamilton Depression Rating Scale). The find-
sions, patients were generally given the following uni- ings of the studies were also summarized qualitatively.
form setting once a stable setting was reached: current
of 800 mA, pulse width of 1 ms, charge of 576 mC, fre-
quency of 60 Hz, and stimulation duration of 6 s. R E SU LT S
Case series
Systematic review
Patient characteristics
The Preferred Reporting Items for Systematic re-
views and Meta-A nalyses (PRISMA) statement were The initial data query resulted in 83 potential cases for
followed,49 and the protocol was registered on OSF inclusion in the dataset. After a detailed chart review
Registries prior to data extraction (DOI: 10.17605/OSF. of these cases, a total of 11 cases were identified to
IO/XV85P).50 fully meet the inclusion and exclusion criteria. Most
|
Identification of studies via databases and registers Identification of studies via other methods
Records identified from:

Identification
EMBASE (n = 221) Records removed before

Records identified from:
MEDLINE (n = 109) screening:
Citation searching (n = 11)
PsycINFO (n = 82) Duplicate records removed
PubMed (n = 134) (n = 338)
Web of Science (n = 117)
Records excluded based on title,

Records screened abstract
(n = 325)
(n = 294)
Reports sought for retrieval Reports not retrieved Reports sought for retrieval Reports not retrieved
(n = 31) (Unavailable foreign articles) (n = 11) (n = 0)
Screening
(n = 3)
Reports excluded:
Reports assessed for eligibility Abstract only (n = 1) Reports assessed for eligibility
(n = 28) Confounding intervention (n = 1) (n = 11) Reports excluded:
No chronic pain diagnoses (n = 2) Insufficient ECT details
No chronic pain outcomes (n = 4) (n = 6)
No ECT intervention (n = 1) Published before 1950 (n = 1)
Opinion article (n = 1)
Included
Studies included in review

(n = 22)
F I G U R E 1 PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers, and other sources.
From: Page et al.49 For more information, visit: http://www.prisma-statement.org/.
exclusions were due to insufficient records of pre-or were most commonly MDD (n = 8), anxiety disorders
post-ECT chronic pain levels or outcomes. Cased (n = 6), bipolar disorder (n = 4), and substance use disor-
included nine women and two men and the mean age of ders (n = 2). Seven patients had more than 2 comorbid
patients was 58.3 (SD 14.08; range 44–86). ECT sessions psychiatric diagnoses. The mean duration between pre-
were conducted during dates ranging from July 2013 to and post-ECT treatment measures was 29.6 months (SD
May 2022. Only one patient was identified as African 21.6; range 2.9–73.7) with an average of 26.6 sessions per-
American, and the rest of the patients were Caucasian. formed (SD 20.81; range 12–82).
Most patients had multiple comorbid chronic medical
diagnoses such as hypertension (n = 10), hypothyroidism
(n = 6), hyperlipidemia (n = 5), vitamin D deficiency Treatment outcomes
(n = 5), iron-
deficiency anemia (n = 5), and obstructive
sleep apnea (n = 4). Less common comorbid medical In terms of absolute reduction in average pain levels on
diagnoses included psoriasis (n = 3), cirrhosis (n = 1), the VAS or based on general comments on their follow-
ulcerative colitis (n = 1), chronic pancreatitis (n = 1), and up notes, 6/11 (54.5%) patients showed improvement in
sensorineural hearing loss (n = 1). Three patients had a pain. Of these patients, 3 had 3 points or greater reduc-
personal history of cancer (ie, breast, prostate, thyroid) tion on the VAS, and two patients only had a general
and two patients had bariatric surgery. comment on the reduction without a specific pain rating
A range of different chronic pain diagnoses were pres- recorded post-ECT treatment. Two patients reported no
ent, including chronic pain syndrome (n = 3), headache/ change in their pain rating, and three patients reported
migraine (n = 3), fibromyalgia (n = 2), trigeminal neural- an increase in their pain levels post-ECT. In terms of
gia (n = 2), polymyalgia (n = 1), low back pain, neck pain functional outcomes, three patients had no data avail-
(n = 1), phantom limb pain (n = 1) (Table 1). All except two able, but five patients reported some improvement
patients had more than one chronic pain diagnoses, with in activity level or the physical disability index (PDI).
five patients with up to three concurrent pain diagno- While most patients were on multiple medications for
ses. The primary pain condition was identified from the their pain and psychiatric diagnoses, opioid medica-
clinical notes by the treatment provider and was the con- tions were discontinued prior to the initiation of ECT
dition on which the pain ratings were based. The mean (Table 1).
duration of chronic pain diagnosis was 9.5 years (median Of the 11 patients, 10 (90.9%) reported some im-
6; SD 11.3; range 1–40). Comorbid psychiatric diagnoses provement in mood symptoms post-ECT. One patient
T A B L E 1 Patient characteristics and treatment data.
Pain No. Treatment

duration ECT durations Pre-ECT Post-ECT Functional and
Pt no. Age, sex Chronic pain diagnosis (years) Psychiatric diagnosis sessions (months) pain (VAS) pain psychiatric outcome Pain medsa Psych meds
1 65, F Trigeminal neuralgia 8 AMS with catatonia 19 9 6 5 Unchanged (PDI 30); Pregabalin, Mirtazapine,
psychiatrically tetrabenazine, olanzapine,
stable methocarbamol escitalopram,
YOON and GALARNEAU
risperidone,
venlafaxine
2 73, F Polymyalgia 3 MDD without 13 49 6 ↓b Not reported; MDD Hydrocodone/ Paroxetine
psychosis resolved acetaminophen
3 86, M Low back pain, 2 MDD, recurrent 14 12 9 6 Improved (PDI 46 Nerve blocks Duloxetine,
radiculopathy to 24); MDD not nortriptyline
improved
4 44, F Fibromyalgia, 19 GAD; bipolar disorder; 18 25 6 7 Mildly improved (PDI Tramadol, oxycodone Quetiapine,
abdominal pain, SUD in remission 59 to 57); some trazodone
interstitial cystitis symptoms but
improved
5 74, F Headaches, 9 MDD, recurrent; 38 53 5 7 Not reported; MDD Baclofen, topiramate, Sinemet, donepezil,
polymyositis, Parkinson improved naratriptan, fluoxetine
cervical myositis naproxen,
acetaminophen
6 56, F Occipital neuralgia, 6 MDD, recurrent; 12 14 6 6 Mildly improved (PDI Roxicodone Bupropion,
trigeminal PTSD; GAD 57 to 55); mood escitalopram,
neuralgia, chronic improved trazodone
pain syndrome
7 44, F Neck pain, cervical 8 MDD 30 34 8 8 “Increasing daily Amitriptyline, Buspirone,
dystonia activity slowly”; cyclobenzaprine, desvenlafaxine
some limited oxycodone,
improvement oxycarbazepine
8 48, M Fibromyalgia, psoriatic 2 Bipolar I, depression, 17 21 7 ↓b Improved (DAS28 5.47 DMARDs (MTX), Duloxetine,
arthritis anxiety to 2.5); improved celecoxib clonazepam
9 53, F Phantom limb 1 MDD, recurrent; 12 3 7 3 Complicated by other Gabapentin, Venlafaxine,
pain, chronic GAD; SUD pain (eg, arthritis); oxycodone, clonazepam,
neuropathic pain, mood improving trazodone, quetiapine,
chronic pain pregabalin trazodone,
syndrome vortioxetine
10 48, F Chronic migraine, 40 Bipolar I, borderline 38 32 2 8 Not reported; ongoing Acetaminophen, Mirtazapine,
chronic pain personality symptoms with Botox injections quetiapine,
syndrome, meralgia disorder, anxiety, maintenance ECT (discontinued) trazodone
paresthetica MDD
11 51, F Piriformis syndrome, 6 Bipolar I, MDD, 82 74 5 2 “Good functional Hydrocodone/ Aripiprazole,
lumbar facet anxiety capacity (≥4 acetaminophen, bupropion,
arthropathy, METs)” to PDI 32; meloxicam, escitalopram,
migraine mood improved rizatriptan haloperidol,
quetiapine
Abbreviations: AMS, altered mental status; DAS28, Disease Activity Score (28 joints; rheumatoid arthritis disease severity); DMARD, disease-modifying antirheumatic drugs; GAD, generalized anxiety disorder; MDD,
major depressive disorder; METs, metabolic; MTX, methotrexate equivalents; PDI, physical disability index; PTSD, posttraumatic stress disorder; SUD, substance use disorder; VAS, visual analog scale.
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a
Opioid medications were discontinued prior to start of ECT.
5
b
No numeric rating provided.
|
reported no improvement in mood, despite improve- Quality appraisal

ment in his low back pain post-ECT. In terms of treat-
ment response in specific chronic pain diagnoses, a The overall quality of the included case reports and
patient with polymyalgia reported improvement after case series ranged from good (all parameters of the
13 sessions over 49 months. A patient with low back data extraction adequately described) to moderate
pain and radiculopathy reported 33.3% improvement (few parameters missing or insufficiently described).
in pain after 14 sessions in 12 months. Similarly, a pa- Twelve studies reporting 45 (41.3%) cases had adequate
tient with piriformis syndrome, lumbar facet arthrop- reporting of all parameters, whereas the most commonly
athy, and migraine showed 60% reduction in pain after missing parameter was information on comorbidities
82 sessions in 74 months. A patient with phantom limb (psychiatric or medical), which was in four studies
pain with concurrent chronic pain syndrome and neu- reporting 33 (30.3%) cases. One study reporting 21 (19.3%)
ropathic pain showed a 57% reduction in pain after 12 cases lacked detail about the amount of change in pain
sessions in 3 months. level when the pain was not completely resolved. Other
In terms of side effects from the treatment, short-term missing parameters included the total number of ECT
memory deficits were noted in 9 of the 11 patients. Four sessions (two studies; five cases), chronic pain duration
patients reported baseline memory issues prior to the (three studies; three cases), and laterality of ECT (two
initiation of treatment, and other patients noted that the studies; two cases).
memory deficits were temporary and stabilized in be-
tween multiple treatments. One patient noted increased
intention tremors, which were improved at follow-up in Results of pooled analysis
3 months.
A total of 109 patients (60 women, 49 men) with a mean
age of 55.2 (range: 22–82) were included in the pooled
Systematic review analysis. Chronic pain duration ranged from 2 months to
30 years. Chronic pain diagnoses included fibromyalgia
Publication characteristics (n = 31; 28.4%), abdominal pain (n = 13; 11.9%), head/
neck pain (n = 13; 11.9%), CRPS (n = 12; 11.0%), low back
A total of 663 records were identified from the data- pain (n = 12; 11.0%), undifferentiated spine/limb pain
base searches, with 325 records remaining after re- (n = 12; 11.0%), poststroke thalamic pain (n = 8; 7.3%),
moving duplicates. After removing off-topic articles urogenital pain (n = 5; 4.6%), chronic facial pain (n = 4;
based on title and abstract, 31 articles were sought 3.7%), headache/migraine (n = 3; 2.8%), chest pain (n = 3;
for retrieval. Excluding 3 foreign articles that were 2.8%), neuropathic pain (n = 2; 1.8%), phantom limb
not available in full-t ext, 28 articles were screened for pain (n = 2; 1.8%), TMJ arthritis (n = 2; 1.8%), trigeminal
eligibility. The main reasons for exclusion were hav- neuralgia (n = 1; 1.0%), central pain syndrome (n = 1;
ing no chronic pain diagnosis or outcome reported in 1.0%), burning mouth syndrome (n = 1; 1.0%), and
the studies (Figure 1). Of the 11 articles additionally postherpetic neuralgia (n = 1; 1.0%). For patients with
identified through citation searching, 7 studies were any comorbid pain conditions, the pain outcomes were
excluded mainly due to insufficient details on the ECT based on the primary pain condition as identified by
procedure. While there was not a predetermined pub- each study author. Among the 80 patients with any
lication date cutoff due to the limited literature on identified psychiatric comorbidity (73.4%), the most
this topic, studies published in the 1950s were mainly common psychiatric diagnosis was MDD (n = 51; 63.8%).
excluded due to insufficient ECT details. One study Others included anxiety disorders (n = 3; 3.8%), bipolar
published before 1950 was excluded due to likely dis- disorder (n = 3; 3.8%), substance use disorder (n = 4; 5%),
crepancies from current ECT practices. Along with and adjustment disorder (n = 1; 1.3%). Eighteen (22.5%)
16 articles from the database search, a final set of 22 patients had various other psychiatric diagnoses (eg,
studies reporting a total of 109 cases were included personality disorders, dysthymia, and dementia). The
in this review.14–18,20,39,42,45,48,51– 62 Eleven of the stud- number of ECT sessions ranged from 5 to 55 or indefinite
ies were individual case reports,14,17,39,42,52–54,59– 62 and monthly maintenance treatments. Among the patients
the other half were case series.15,16,18,20,45,48,51,55–58 Four that had details available (n = 82), 45 (54.9%) patients
of the case series included more than 10 cases (range received unilateral ECT (usually right or nondominant
13–25)15,16,45,51 and 1 case series had case- m atched hemisphere), and 37 (45.1%) patients received bilateral
controls for comparative analysis.45 Publication years ECT.
ranged from 1975 to 2018, and countries included Improvement in pain outcomes was noted in 85 (78%)
U.S.A.,14,18,20,39,51–59,62 Japan,15,42,48,60,61 Puerto Rico,17 patients. The level of pain reduction ranged from 1 point
and Finland.16 Characteristics of the included studies on the VAS or 0.11% decrease to 9.5 points on VAS or
are detailed in Table 2. 100% reduction. Table 3 and Figure 2 demonstrate the
T A B L E 2 Characteristics of included studies.
Chronic pain Pain diagnosis

Authors and year Age and sex diagnosis duration Psychiatric diagnosis Medical history ECT details Medicationsa Outcome measure and effect
Abdi et al. 32, M Neuropathic 10 years MDD HTN, seizure disorder Right UL Methadone 100 mg, Pain VAS scale 9–10/10 to 3/10 (8-week
(2004)14 pain 5 sessions, avg. seizure hydromorphone 2 mg period); MDD improved
syndrome duration: 62 s PRN, gabapentin
of arm, 1200 mg TID,
YOON and GALARNEAU
shoulder clonidine 0.1 g,

(idiopathic clonazepam 1 mg
brachial QID, ibuprofen
neuritis) 800 mg TID
Bloomstein et al. 56–82 Head/neck (8), 2 months to MDD (19), chemical DM (5), CAD (3), 2–3 sessions per week, Opioid pain medications 19/21 improvement in pain syndromes;
(1996)63 (mean: chest (1), 10+ years dependence (4), arthritis (2), total 5–14; median: discontinued for 20/21 improvement in depression,
69), 10 abdomen (8), (median: somatoform heart disease (3), 7, UL (19), BL (2); ECT anxiety
men, 11 urogenital 1–2 years) pain disorder carcinoma (2), low switched from UL to
women (5), spine/ (2), dysthymia back pain (2) BL due to inadequate
limb (11) (2), personality response (4); machine:
disorder (1), Mecta (5), Thymatron
dementia (1), (16)
organic mental
disorder (1),
acute delirium
(1)
Borisovskaya 55, F Abdominal pain 5 months MDD, anxiety Cholecystectomy, Right UL Pantoprazole, Pain resolved in 5 sessions; mood
and 11 years ago, prior 3 sessions per week, antiemetics, improved in 3 sessions
Augsburger Helicobacter pylori total 7; avg. seizure fluoxetine 40 mg
(2017)52 infection (gastric duration: 30–60 s;
ulcer) charge: 504 mC;
machine: Thymatron
Cooper (2016)53 70, F Recurrent RUQ 4 years Depressive Prior cholecystectomy Right UL Mirtazapine, Pain, mood improved in 3 sessions,
pain symptoms 1st session: 20 mC; 2nd cyclobenzaprine, complete resolution in following
secondary to session: 0.25 ms pulse tramadol sessions (pain free at 7 months);
pain width, 100 mC, 30 Hz; MoCA improved 18–26, functional
machine: Thymatron level returned to highest in 3 years
Maintenance: Right UL
Every 2 weeks; 0.25 ms, 150
mC, 50 Hz
Fukui et al. (1) 33–58 CRPS 3–6 years N/A N/A BL 2 sessions per week; Prior to ECT: 50% treatment responsive (defined as
(2002)48 (mean: machine: Thymatron anticonvulsants, ≥60% VAS reduction)
47.2), 4 IV lidocaine, Pain VAS 4–8 to 0–1; effect persisted at
men PO mexiletine, 6 months
IV ketamine,
antidepressants
Fukui et al. (2) 50, F Neuropathic 5 years N/A N/A BL 2 sessions per week Buprenorphine 16 mg Pain VAS 4–9 to 1–2; stopped pain
(2002)42 pain for 4 weeks; machine: medications; functional return to
postliver Thymatron baseline
resection
(Continues)
| 7
| 8
T A B L E 2 (Continued)

Hampf et al. 60, F Chronic facial 7 years MDD Not reported UL 7 sessions; total 94 s Amitriptyline 150 mg, No subjective decrease in pain but
(1992)39 pain clonazepam 2 mg, reported feeling “greater control
methadone 5–10 mg of pain”; mood improved; in good
(resumed after control at 9 months follow-up
discharge)
Huuhka et al. 36–61 Fibromyalgia 6.1 years (SD: 5.7, Refractory HTN (3), DM (2), UL 8 sessions (3 or 7 in Mirtazapine (3), Nonstatistically significant changes:
(2004)16 (mean: range: 1–14) depression (≥2 asthma (1) two patients that venlafaxine (2), self-report pain (0–5) 3.13 ± 0.49
49), 4 failed trials on did not require more reboxetine (2), to 3.00 ± 1.24, FIQ –pain (0–10)
men, 9 different types of treatment); stimulus fluoxetine (1), 8.92 ± 1.06 to 8.25 ± 2.01, tender points
women antidepressants) dosage: 5 times amitriptyline (1), (0–18): 15.83 ± 2.33 to 15.08 ± 2.79;
patient's age; machine: paroxetine (1), mood improved (p < 0.05)
Thymatron combination of
venlafaxine and
sertraline (1), small
dose anxiolytics
(4), hypnotics
(3), NSAIDs (5),
tramadol (2)
King and Nuss 32, F RSD (CRPS) 1 year MDD (secondary to HTN BL 8 sessions Antidepressant Pain remission after 1st session (returned
(1993)54 pain diagnosis) in 12 h); complete resolution of
pain, skin color, temperature after
7 sessions; remission at 6 months;
depression initially resolved but
required ongoing treatment
Mandel (1975)55 47, M Head 5 years, 20 years Clinical depression, N/A UL (nondominant TCA (200–250 mg Pain resolution, no recurrence at
55, F Head (2 years acute), personality hemispheric); 3 imipramine), 6 months/1 year (4); no significant
64, F Chest 10 months, diagnoses sessions per week, narcotic analgesics improvement (2); mood improvement
52, F Back, face, head, 6 months, total 6–10 (Percodan) (4), in all but less decrease in Hamilton
73, F chest 20 years ergotamine tartrate Score in nonresponders
68, F Face (2 years acute), and caffeine (1),
Face, head 30 years amphetamine (1)
(2 years acute)
McCance et al. 42, M Poststroke 4 years, 1 year MDD (1) Not reported except BL 6 sessions Prior: antidepressants, No significant pain/symptom/mood
(1996)56 45, M thalamic 3 months, stroke history anticonvulsants, change; pain VAS: 9.4–8.2; 2.9–6.2;
73, M pain 1 year unconventional 2.8–4.7
4 months analgesics PSE –total symptom score: 20 (no
change); 7–8; 3–2
McDaniel 53, F CRPS (3), 5 years Depression Hypothyroid BL 12 sessions; dose: Amitriptyline 200 mg, Immobile hand moveable by 5th session,
(2003)18 28, F fibromyalgia 1 year Bipolar disorder “just above seizure methylphenidate pain/mood symptoms resolved by
46, M (1) 6 months Depression with threshold” Divalproex 1500 mg, 10th, no recurrence at 6-month
psychotic UL 8 sessions; dose: fluoxetine 60 mg Complete CRPS remission, fibromyalgia
features twice above seizure Bupropion 150 mg, not resolved; depression recurrences
threshold paroxetine 30 mg, Complete CRPS remission, partial
BL 16 sessions; 200% quetiapine 600 mg remission of psychotic depression
CHRONIC PAIN OUTCOMES OF PATIENTS RECEIVING ECT
suprathreshold
Machine: Mecta
Rajan and Sun 36, F TMJ arthritis, Not reported Bipolar disorder N/A Right UL Nefazodone TMJ symptom improvement 18% global
(2016)57 44, F migraines Bipolar, anxiety 11 sessions; pulse width: Prior to ECT: scale; HAM-D 76% reduced (46 to 11)
YOON and GALARNEAU
TMJ arthritis, 0.25 ms; machine: clonazepam, lithium TMJ symptom global scale decline 1%;
trigeminal Mecta HAM-D 64% reduced (47 to 17)
neuralgia
Rasmussen and 48, M Phantom limb “Long-standing,” Insomnia HTN, peptic ulcer BL 11 sessions and 6- Trazodone, sodium Pain 9/10–1/10; 1–2/10 at 2 year follow-up
Rummans 81, M pain, other 11 years Adjustment disorder disease, IBS, month maintenance; divalproex, since maintenance
(2000)20 limb pain, with depressed obesity, benign 45% max charge omeprazole, Pain 10/10 to 4–5/10; loss to follow-up
fibromyalgia mood (past) thyroid nodule BL 14 sessions; 45% max zolpidem, melatonin
Phantom limb MI charge for 1st, 80% For chronic overuse
pain for rest pain of joints:
Machine: Thymatron prn tramadol,
hydrocodone
Nitrate, aspirin, prn
trazodone, fluoxetine
Salmon et al. 56, F Thalamic pain 2 years MDD (1) Not reported except UL 6 sessions TCAs, anticonvulsant McGuill Pain Rating Index: 56–58; 55–
(1988)58 68, F (post-CVA) 9 years CVA history 41; 47–54; 42–37; pain VAS: 6–4; 7–6;
49, M 4 years 5 (unchanged); 9–5
69, M 4 years MDD (1) unchanged
Strand et al. 47, F Central pain Not reported Symptoms Huntington disease 3 sequential sessions, 2nd Duloxetine, TCAs, Dramatic decrease in pain from 3
(2018)59 syndrome secondary to course of session after pregabalin sessions, significant increase in
Huntington 3 months, 1 session/ physical functioning; remission
disease month maintenance after 2nd course with maintenance
sessions
Suda et al. 66, F Burning mouth 2 years N/A T2DM, pancreatic BL 12 sessions NSAIDs, antiepileptics, VAS 10 to 0–1, <1 h, few times/week;
(2008)60 syndrome cystadenoma benzodiazepine, stable over 24-week follow-up
amitriptyline
Suzuki et al. 48, F CRPS 4 years MDD Herniated lumbar BL; first course 12 Codeine 240 mg, Pain 50% reduction after 3rd course
(2009)61 intervertebral disc sessions, 2nd diclofenac (VAS 100/100–50/100); depression
20 sessions, 11 suppository 200 mg, improved after recurrences (HAM-D
continuation sessions, mexiletine 100 mg, 33 to 5)
3rd 12 sessions paroxetine 40 mg,
milnacipran 75 mg
Usui et al. 22–76 Fibromyalgia Mean 4.6 years N/A N/A BL; 6 sessions (12), 4 Antidepressants Pain VAS 7.53 ± 0.56 to 3.27 ± 0.64 (3 days;
(2006)15 (mean: (SD: 1.2) sessions (3) due to (milnacipran, p = 0.0006), 3.93 ± 0.65 (3 months;
42.1, SD: sufficient response; paroxetine, p = 0.0013); tender points (0–18):
13.1); 7 110 V for 5 s amitriptyline), 16.47 ± 0.59 to 6.73 ± 1.04 (p = 0.0006)
men 8 Machine: SAKAI CS-1 neurotropine (14),
women low-dose steroid (2)
(Continues)
| 9
|

10
Vázquez- 57, F Fibromyalgia 8 years Depression, anxiety IBS, irritable bladder 11 sessions over 4 months Pregabalin, tramadol; Tender points 18/18 to 0/18; persisting
Sanabria and trialed on NSAIDs, depression, anxiety controlled with
Vilá (2016)17 SSRIs, TCA, duloxetine
nefazodone,
aripiprazole,
quetiapine fumarate,
gabapentin,
cyclobenzaprine,
zolpidem,
clonazepam
Wasan et al. 58.1 (mean), Low back (12), ≥2 years MDD Not reported UL/BL; avg. 10 sessions Antidepressants ± mood Avg. pain 8.1 ± 1.4 to 3.4 ± 3.2; p < 0.05 (%
(2004)45 14 abdominal/ (3–20); 3/week; pulse stabilizers decrease: 59.8 ± 38.8)
men, 11 pelvic (3), width 1 ms, duration p < 0.0001
women neck (2), 2 s, 0.8 amps, 40–90 Hz compared to case-m atched controls
headache (age dependent); Nonsignificant difference in depression
(2), total machine: Mecta scores with controls
body (1), (spectrum 5000Q)
poststroke
(1),
postherpetic
neuralgia (1),
CRPS (1)
Wolanin et al. 42, F CRPS 4 years MDD IBS, gastroparesis, BL 12 sessions NSAIDs, SSRI, Pain 8/10–1/10 (dynamic and statis)
(2007)62 osteopenia benzodiazepines, or 3/10 (deep compression/arm
topiramate, movement); depression resolved; full
gabapentin, physical and social recovery
oxycodone,
cyclobenzaprine,
lamotrigine,
metoclopramide,
bupropion, lithium,
quetiapine
Abbreviations: avg., average; BL, bilateral; CAD, coronary artery disease; CRPS, complex regional pain syndrome; CVA, cerebrovascular accident; DM, diabetes mellitus (T2DM = type 2); F, female; FIQ, Fibromyalgia
Impact Questionnaire; HAM-D, Hamilton Depression Rating Scale; HTN, hypertension; IBS, irritable bowel syndrome; M, male; MDD, major depressive disorder; MI, myocardial infarction; MoCA, Montreal Cognitive
Assessment; N/A, not applicable; NSAID, nonsteroidal anti-i nflammatory drug; PSE, present state examination; RSD, reflex sympathetic dystrophy (older term for CRPS); SD, standard deviation; SSRI, selective
serotonin reuptake inhibitor; TCA, tricyclic antidepressants; TMJ, temporomandibular joint; UL, unilateral; VAS, visual analog scale.
a
Once daily dosing if otherwise unspecified.
CHRONIC PAIN OUTCOMES OF PATIENTS RECEIVING ECT
11
T A B L E 3 Changes in pain levels after electroconvulsive therapy

by pain type. previous articles included in the systematic review.
While it is difficult to assess based on a limited number
Sample of cases, patients with diagnoses of low back pain or
Diagnosis Pre Post size phantom limb pain reported a reduction in their pain
Low back pain 8.2 3.6 13 levels post-ECT, whereas two patients with fibromyal-
CRPS 7.2 3.0 6 gia reported mixed findings. These findings are consist-
Phantom limb pain 8.7 2.8 3
ent with prior literature. The patient with fibromyalgia
who improved had psoriatic arthritis—the symptoms
Neuropathic pain 7.8 2.3 2
of which was improving based on disease- specific
Fibromyalgia 8.2 5.4 30
measure. The other fibromyalgia patient had comorbid
Poststroke thalamic pain 6.0 5.4 7 chronic abdominal pain (secondary to chronic pancrea-
titis) and interstitial cystitis, which may be complicating
the picture. In line with limited prior cases indepen-
10.0 dently reporting outcomes in headaches or migraines,
9.0 our cases did not report improvement with these diag-
8.0 noses. It is important to note that many of our patients
7.0 had multiple chronic pain diagnoses, which compli-
6.0
cated the interpretation of limited improvement after
5.0
ECT. In general, patients with significant comorbid
4.0
3.0
chronic medical conditions (eg, chronic pancreatitis,
2.0 ulcerative colitis) tended to report less improvement
1.0 post-ECT, as expected. MDD was the most common
0.0 psychiatric diagnosis in our cases, which is also con-
Pre Post
sistent with previous cases in the literature. In general,
Low back pain CRPS
patients with shorter chronic pain duration tended to
Phantom limb pain Neuropathic pain
Fibromyalgia Post-stroke thalamic pain
report improvement in pain levels or functioning post-
ECT compared to those with longer duration of chronic
F I G U R E 2 Changes in pain levels after electroconvulsive pain duration (ie, >8 years). This finding makes intuitive
therapy by pain type. sense since chronic pain with a longer duration is more
likely to be treatment resistant compared to others who
may still be early on in their natural trajectory toward
changes in pain ratings after ECT by pain types with improvement. It is also important to note that only 6 of
more than one sample with numerical data. Of 80 pa- 11 (54.5%) patients reported any reduction in pain and
tients that had a current psychiatric diagnosis, 77 5 reported improvements in activity level or the PDI.
(96.3%) patients reported at least an initial improvement While such rates do not support an impressive effect of
in mood post-ECT. Based on 62 patients with numeri- ECT on chronic pain, future studies focusing on certain
cal outcome measures, improvement in pain and mood chronic pain diagnoses that have consistently reported
showed a correlation coefficient of 0.61 (p < 0.001). Four more improvement would be better able to delineate
(5.2%) patients reported recurrence of their depression the validity of pursuing ECT to improve chronic pain
despite the resolution of chronic pain. Moreover, in the symptoms in such conditions. The fact that most of the
case-matched controlled study, 25 patients reported sta- patients (90.9%) reported some improvement in symp-
tistically significant greater improvement in pain com- toms while one patient without improvement in mood
pared to the control group despite a lack of statistically reported improvement in pain highlights that some of
significant difference in the level of improvement in de- the beneficial effects of ECT on pain may only be par-
pression between the two groups. tially explained by its effect on mood. There is likely
a separate analgesic effect for certain chronic pain eti-
ologies, as mentioned in the literature. It must be noted
DI SC US SION that while there were 83 potential cases from the initial
data query, detailed documentation on pain levels and
In this article, we aimed to present the most up-to-d ate functional outcomes was lacking in most of these cases.
review of published cases on chronic pain outcomes in Therefore, future investigations would be more fruitful
ECT patients as well as the 11 new cases in our case if such documentation becomes more common practice
series. Patients in our case series were predominantly and part of standard of care.
middle or older age women, which is consistent with the The pooled results of cases in the systemic review re-
group with a higher prevalence of chronic pain in the ported a higher rate of chronic pain response to ECT
literature. Patients also had a range of different chronic (78.0%) and a high rate of psychiatric response to treat-
pain diagnoses, all of which have been reported in the ment (96.3%), though the interpretation of findings must
|
be taken with caution as it is largely based on case re- still reported improvement. Therefore, even though uni-
ports and case series without control groups. An anal- lateral electrode placements have been historically uti-
ysis based on a subsample of 62 patients with pre-and lized to minimize the cognitive adverse effects of ECT,
posttreatment scores in pain and depression showed a bilateral (ie, bitemporal) electrode placements should be
statistically significant correlation of moderate strength given a stronger recommendation for patients who wish
(0.61; p < 0.001), suggesting that improvements in both to benefit in their chronic pain.
areas are often concurrent among patients presenting It is worth noting that transcranial magnetic stimula-
with both symptoms. However, the fact that some pa- tion (TMS), which is considered less invasive than ECT,
tients reported greater responses in chronic pain com- has also been explored for its potential benefits in chronic
pared to their mood symptoms and that patients without pain. While the evidence from systematic reviews and
a comorbid psychiatric diagnosis also reported improve- meta-analyses has been inconclusive due to the limited
ment in pain further supports the notion that ECT may number of existing studies,63,64 further research is war-
have a distinct analgesic effect in certain chronic pain ranted particularly for patients with comorbid MDD.65
conditions aside from relief due to psychiatric improve- A major limitation of the current review is that all cases
ment. Furthermore, findings support that chronic pain except one study were case reports and case series without
improvement is generally achieved fairly quickly (eg, controls, which are subject to publication bias and prevent
within 3 sessions) with the initiation of ECT, but many comparative quantitative analysis to provide stronger evi-
patients require multiple rounds of ECTs or ongoing dence for the effect of ECT on chronic pain. This limitation
maintenance for sustained effect, which is comparable is expected given the limited number of ECT conducted
to its use in the management of psychiatric conditions. for chronic patients overall, let alone any experimental
Chronic pain diagnoses that seemed to show consis- trials with ECT. It is promising, however, that the study
tent response to ECT included CRPS (ie, all six studies incorporating case-matched controls showed a significant
on CRPS reporting a total of nine cases showed positive effect in the ECT group. More studies employing such
improvement with an average of 4.2 points decrease on control groups need to be conducted, and measurement
the VAS and 6 of which had follow-up data showing sus- and analysis of confounding variables in such studies will
tained remission at 6 months), phantom limb pain, dif- better characterize the true effect of ECT on chronic pain
ferent subtypes of neuropathic pain, low back pain (ie, conditions. In addition, the administration of a uniform
all three studies with 15 cases of patients with low back assessment tool for pain outcomes using measures such
pain showed positive outcomes, with one patient with as the PROMIS Pain Interference Short Form would fa-
follow-up information with sustained benefit at 6 months cilitate a more systematic and comprehensive assessment
and at 1 year; average 4.6 points decrease on the VAS) of pain outcomes in ECT patients.66 While some studies
and other musculoskeletal type pain. Fibromyalgia had included follow-up outcomes at 6-month or longer follow-
mixed findings in the overall pooled analysis (ie, only 3 ups even up to several years posttreatment, most of the
out of 5 studies reporting on three cases of fibromyal- cases did not provide standardized follow-up time frames.
gia reported benefit, whereas two other studies report- Therefore, more future studies with outcomes at standard
ing on 14 cases reported no improvement). Postthalamic follow-up time points will be better able to support sus-
stroke was one diagnosis that consistently showed a lack tained long-term effects of ECT on pain. Finally, while
of treatment response to ECT, with an average of only four countries were included in the systematic review, the
0.6 point decrease on the VAS ratings. Because the ma- majority of cases were reported from the U.S. and Japan.
jority of cases had MDD as their comorbid psychiatric Future studies in different regions will be beneficial for
diagnosis, there were no differences evident in pain out- improved generalizability of findings.
comes in association with certain psychiatric diagnoses.
Moreover, the review of the pooled cases did not suggest
a clear association with certain demographic character- CONC LUSION S
istics such as age and sex as well as comorbid medical
diagnoses or duration of chronic pain diagnoses with Despite initial reports of the beneficial effect of ECT
differences in the effect of ECT on chronic pain out- in chronic pain and the hypothesized theories for its
comes. While patients were on multiple medications for mechanism dating back many decades, more recent
their pain and psychiatric diagnoses, opioid pain medi- studies must be performed to provide stronger evidence,
cations were generally discontinued before the initiation particularly with control groups such as a case-matched
of ECT treatment, and other treatments were reported control. This article aims to bring back the scientific
to be providing no substantial benefit prior to ECT. community's attention on this topic and to stimulate
Therefore, other medications are less likely to be con- additional future studies. Certain pain diagnoses such
founding the effects of ECT in the chronic pain outcomes as CRPS, phantom limb pain, neuropathic pain, and
of reported cases. Based on the combined cases, bilat- low back pain have consistently reported benefits from
eral electrode placement tended to be more effective than ECT and should be preferentially studied in future
unilateral placement, even though many unilateral cases studies with case-matched controls. With the current
13
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DOI: 10.1111/papr.

Chronic pain outcomes of patients receiving electroconvulsive

Isabel A. Yoon MD1,2 | David Galarneau MD1,3

Records identified from:

EMBASE (n = 221) Records removed before

Records excluded based on title,

Studies included in review

Pain No. Treatment

reported no improvement in mood, despite improve- Quality appraisal

Chronic pain Pain diagnosis

shoulder clonidine 0.1 g,

Chronic pain Pain diagnosis

Chronic pain Pain diagnosis

T A B L E 3 Changes in pain levels after electroconvulsive therapy

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