Neuromodulation Service – UPENN Psychiatry MAC 2023-2024

UNIVERSITY OF PENNSYLVANIA ELECTROCONVULSIVE THERAPY

SERVICE DESCRIPTION AND PROTOCOL

Electroconvulsive Therapy (ECT) is a noninvasive brain stimulation technology. The ECT device delivers
electrical pulses to the brain resulting in a controlled generalized seizure that exert biological effects that
translate into clinical benefit (antidepressant).

Indications:
The most common indications for ECT in our service are catatonia and treatment resistant unipolar or
bipolar depression in patients with treatment resistance or who required a rapid response due to the
severity of symptoms. Other indications include mania and treatment refractory psychotic disorders. Our
service provide care to adults only (18 and older) due to hospital licensing limitations.

As of 2018 the FDA cleared indications for ECT are limited to Catatonia and Depression (unipolar and
bipolar) in >13 y old patients with treatment resistance or who required a rapid response due to the
severity of symptoms. Other clinical indications are considered “off-label” (i.e, Schizophrenia, Bipolar
mania or mixed states, Schizoaffective disorder, Schizophreniform disorder)

Effectiveness:
ECT’s beneficial role for the treatment of depression is supported by meta-analytic studies in which ECT
was significantly superior to sham stimulation (5 times more likely to respond). Remission rates of 80-90%
are expected in pure non treatment resistant depression. The remission rates decrease to 50-75% with
treatment resistance and comorbid conditions.

Safety:
The practice of ECT has evolved over the last decade and is considered relatively safe with a mortality
rate of 1 per 10,000 patients and 1 per 80,000 ECT sessions. Advancements on the technique have
improved significantly the tolerability of ECT. Headache, nausea, muscle aches, and cognitive impairment
(confusion, memory) are the most commonly reported side effects. A number of interventions can be used
to minimize the risk of these side effects.

When cognitive impairment occurs it tends to improve / resolve as ECT is delivered less frequently.
Retrograde amnesia can be experienced and it resolves over several weeks to 6 months. Anterograde
memory impairment is also expected and resolves faster. Some patients will report more protracted
memory loss, especially for autobiographical events and events that took placed around the acute course.
Unilateral stimulation, less frequent stimulation, and PW control are some of the strategies used to
minimize the risk of ECT induced cognitive impairment. As part of the ECT device reclassification from
class III into class II (special controls), the cognitive status (e.g., orientation, attention, memory, executive
function) of the patient needs to be monitored pre AND during the ECT course. At Penn we use items
from the MINI Mental State Examination – MMSE, focusing on orientation, registration, attention, and
recall) at baseline and when transitioning from acute to continuation / MNT and when changing electrode
placement. Another assessment will be done once the patient is on a one per month (or further) schedule
and at any other time the clinician considers it needed.

Although there are not absolute contraindications to the use of ECT, the risk is relative high in the
presence of space occupying brain lesions, increased intracranial pressure, recent MI (6 weeks), recent
brain hemorrhage, unstable vascular aneurysm or malformation, pheochromocytoma, and ASA level 4-5.

Especial considerations should be made in the following situations:

− Recent severe fracture

− Cardiac arrhythmias (e.g., Afib)– needs to be anti-coagulated or have echo to rule-out clot
− History of brain surgery (including burr holes)
− Baseline irreversible cognitive impairment (not secondary to mood disorder)

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− Prior problems with anesthesia (pseudocholinesterase deficiency)

− Prolonged motor retardation or immobility e.g., ICU / chronic illness myopathy
− Delirium (ECT-induced or related to other causes)
− Borderline personality disorder
− Substance abuse

Patient selection:
Individual and clinical characteristics such old age (psychomotor agitation / retardation, psychosis),
absence of comorbid anxiety and personality disorders are associated with greater chance to respond to
ECT. Individuals with chronic episodes, higher degree of treatment resistance, severe clinical features
(severe neurovegetative symptoms, severe dysfunction, and suicidality), and comorbid disorders may
require a more aggressive and fast paced approach

Workup:
Inpatients should have a medicine consult to obtain a preprocedure evaluation for ECT (i.e., general
anesthesia and electroconvulsive therapy). Outpatients need a documented a preprocedure medical
evaluation by their PCP for ECT (i.e., general anesthesia and electroconvulsive therapy). The
preprocedure evaluation should include a complete history and physical. All patients require an ECG prior
to ECT. Necessary labs include a CBC and a basic metabolic panel (including electrolytes and
creatinine). Chest X-ray may be necessary for patients with history of pulmonary disease (smoker,
COPD). Spine and neuroimaging are not necessary unless specifically indicated (including significant
cervical arthritis or suspicion of brain lesions, mass, or abnormalities). Further evaluations /clearance
needs to be obtained as needed (e.g., clearance by cardiology if there is a significant cardiovascular
disease, clearance by OBGYN in pregnant patients)

The history and physical (H&P) needs to be renewed every 30 days during ECT treatment. This can be
done the day of treatment by the ECT attending however an updated H&P by patient’s PCP needs to be
obtained every 3 months. A copy of the most recent H&P, as well as a copy of the pre ECT psychiatric
evaluation, and clearance labs / EKG should to be maintained in the patient’s file.

Concomitant medications:
Medications that raise the seizure threshold (e.g., benzodiazepines, other anticonvulsants) should be
avoided as it will decrease effectiveness and increase the risk of complications. If absolutely necessary,
shorter-acting benzos (e.g., alprazolam, lorazepam) will be used at the lowest possible dose and holding
it ~12 hrs before ECT. Trazodone is preferred in patients who need hypnotics. If a patient has a seizure
disorder, cut dose of anticonvulsant(s) to at least half prior to initiating ECT (which has anticonvulsant
effects). Lithium use during ECT can lead to post ictal agitation. If continuation of Lithium is required it
should be held ~12 hrs prior to ECT to decrease risk of agitation.

During the acute course, psychiatric medications should be kept as fixed as clinically feasible to allow for
adequate determination of ECT efficacy and tolerability.

Other considerations include discontinuation of Theophylline (it increases the risk of prolonged seizures
and status epilepticus) and reduction by half of Parkinson’s medications (it increases risk of delirium).

Once a clear response to ECT is seen and the patient is nearing transition to continuation and
maintenance ECT, the antidepressant regimen should be optimized (changed if needed) for it to provide
protection against relapse during ECT taper and after ECT discontinuation.

Informed consent:
All patients must provide informed consent. If unable to provide, court order for ECT should be obtained.
Initial consent is obtained by the inpatient attending psychiatrist (for all inpatients) or by the ECT attending
prior to the fist ECT session. Initial consent is obtained for 12 sessions / 4 weeks. Consent is renewed
every 3 months (for 12 sessions / 12 weeks) by the ECT attending and a copy of the most recent consent
should to be maintained in the patient’s file.

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ECT day:
Patients should be NPO after midnight with the exception of necessary medications taken with a small sip
of water (just water and just a sip). Avoid/hold use of hypnotics, anticonvulsants, and lithium on nights
prior to ECT.

Outpatients arrive to the spruce building’s short procedure unit (SPU) registration area (1st floor). Once
registration is complete they are send to the SPU pre procedure holding area (2 nd floor Spruce building).
Inpatients arrive to the SPU directly from the units by patient escort / transport.

Patients will be seen by SPU’s RN (vital signs, HCG, finger stick, medication and history reconciliation, as
well as screen for abuse and documentation completeness), anesthesiologist (for a brief pre procedure
evaluation and anesthesia consent), and ECT attending.

The anesthesia team will obtain peripheral access while in the holding area (or in the procedure room if
preferred).

The patient will be transferred to the procedure room (SPU OR 6) where ECT takes place. Once the
effects of the anesthesia wear off and vitals become stable, the patient is transferred to the recovery area.
Once patient is fully awake and tolerating PO and he/she will be transferred back to the holding area for
discharge to the relative or friend.

Outpatients, with no exception, should have an appropriate companion for the procedure day (patients
cannot drive due to potential confusion after ECT and anesthesia). Inpatients will be transported directly
from the recovery area to the unit by patient escort.

Pre-procedure documentation:
Surgical pre-procedure orders (i.e., vitals, urine HCG, and finger stick glucose if appropriate) need to be
entered for all outpatients. Access the pre procedure tab through the surgical navigator and complete the
Surgical Preoperative Order Set located under “Order sets”.

A brief interval psychiatric history including progress, safety assessment, psychosis, tolerability, and
update on cognitive status (alertness, orientation 5/5, Registration 3/3, attention 5/5, and recall 3/3)
should be obtained and documented in EPIC under “DOS H&P Update” before each procedure to
ensure safety and to guide treatment modifications. Access the pre procedure tab through the surgical
navigator and complete the DOS H&P Update using the “MD DAY OF PROCEDURE H&P UPDATE”
smart text. The DOS H&P note needs to be linked to the last H&P note (it has to be within 30 days). You
can do that by finding the last H&P note in the “DOS H&P Update” section, and click “+ add interval”. If
you don’t see an H&P there it is likely that the patient needs one as it only shows notes form the last 30
days. Some new patients will have an external (not in EPIC) paper H&P. You can reference those (with
the date it was done - within 30 days) in your DOS H&P Update.

Consents and H&P are reviewed and renewed if needed. Document new H&P under “H&P note”.
Access the pre procedure tab through the surgical navigator and complete the H&P note using the
“”PREPROCEDURE HISTORY & PHYSICAL” smart text.

A patient identification note should also be entered into EPIC under “Surg ID Certification”. Access the
post procedure discharge tab through the surgical navigator and complete the Surg ID Certification set.

Procedure documentation:
Stimulation parameters, medications used, and outcome are manually documented in the ECT log. The
ECT log provides a rapidly accessible treatment reference and longitudinal documentation of the
parameters used.

A formal procedure note is entered under “Final Op note”. Access the post procedure discharge tab
through the surgical navigator and complete the Final Op note using the smart text “MD PSYCH ECT”.

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This note contains all the details of the procedure including anesthesia staff, complications, and
recommendations.

Post-procedure documentation:
Discharge or transfer orders need to be entered at the end of the procedure so the patient can be
discharged home or sent back to the unit.

For outpatients, access the post procedure discharge tab through the surgical navigator and complete the
Discharge Ord/Rec sets and complete the Ambulatory Surgical Postoperative Order Set.

For inpatients, access the “Transfer” tab in the left side (or top) main menu. Select “Transfer Orders”.
Reconcile meds (these are the unit meds and usually are marked unreconciled and continue). Complete
the Ambulatory Surgical Postoperative Order Set and enter “inpatient transfer” into the additional
transfer order search. Use Med-Surg as level of service and psychiatry as the service (medicine if there).
Enter “resume pre procedure orders” in the comments space.

Patient instructions are entered for the outpatients only. This document includes post anesthesia
instructions, date of next ECT, and any other information you want to remind the patient about. Access
the post procedure discharge tab through the surgical navigator and complete the “Patient Instructions”
using the smart text “OR PAH POST-ANESTHESIA DISCHARGE INSTRUCTIONS”. To include the date
of next ECT and ECT website address you can use .MACECT

Administration of ECT:
We use a SigmaStim device to deliver ultra-brief pulse and standard brief pulse stimulation through 2
hand-held electrodes. The device also has an EEG monitor and paper output.

Turn device ON. The device will perform an internal test. Once the internal test is completed touch the
CLEAR button on the screen. Check if device has enough paper to record the EEG (a red mark will
indicate need for changing the paper roll).

Determine electrode placement and set appropriate stimulation parameters based on ECT log and patient
clinical progress.

Patient preparation:

1. Wipe patient’s forehead, temporal areas, and mastoid processes with a 4x4 soaked in an
isopropyl alcohol solution to clean the scalp of oil and dirt. This is a very important step as it
reduces impedance for optimal EEG and ECT.
2. Place blue electrode leads (5 total): 2 leads in forehead vertically above the pupil in the midline of
the forehead over the bilateral (BL) frontal poles, 2 leads in mastoid prominences, and 1 lead in
chest/shoulder area.
3. Connect/snap to EEG electrodes from ECT device: Attach opposite color (brown and gray) EEG
lead to opposite sides of head. Attach same color EEG lead to ipsilateral mastoid prominences.
Attach EEG ground lead (green) to the chest/ shoulder area.
4. Check EEG screen on ECT machine for good signal.
5. Attach an inflatable BP cuff around right ankle to prevent flow of muscle relaxant to foot and allow
for monitoring of the peripheral motor seizure duration. The right lower extremity is the preferred
location but it can be modified if need (e.g., DVT or skin lesions).
6. Connect the peripheral nerve stimulator: 2 blue electrode leads to the left posterior tibial nerve to
assess degree of muscle relaxation after administration of muscle relaxant. Do not turn on until
after patient is anesthetized. The left posterior tibial nerve is the preferred location but it can be
modified if need (e., peripheral edema)

Anesthesia:

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We use a rapid induction of general anesthesia with intravenous agents. Anesthesia monitoring involves,
IV access, vital signs monitoring, ECG monitoring, sedation, muscle relaxation, ventilation, placement of
bite blocks, and post-ECT recovery

Prior to stimulation patient are ventilated to an oxygen saturation of 100% by pulse oximetry to ensure
stable cardiovascular function during administration of ECT and to provide oxygenation during a seizure
that increases metabolic oxygen demand while patients are apneic. Patients receiving ECT do not
require intubation (exceptions include 3rd trimester pregnancy) but some may require a laryngeal mask
airway (LMA), particularly obese patients.

Anesthetic agents:
Most hospitals use propofol (Diprivan) as anesthesia but the preferred agent at PAH is methohexital
(Brevital). Use the lowest dose of anesthetic possible, since some anesthetic (e.g., methohexital,
propofol) have mild anticonvulsant properties and may interfere with induction of a seizures leading to
short or inadequate seizures. Generally patients are given methohexital and later switched to etomidate
(Amidate) as their seizure threshold increases with each treatment. This is done because etomidate
lowers the seizure threshold. A reduction of the methohexital dose and addition of remifentanil (Ultiva) is
another strategy to optimize seizure induction and duration (by virtue of using less methohexital). Propofol
is particularly useful in patients with recurrent significant post ictal agitation.

Muscle relaxant:
Once the patient is unconscious (e.g., no eyelash reflex), inflate the tourniquet cuff around the right ankle
above systolic blood pressure (at least 200 mm Hg). The anesthesiologist then will administer
succinylcholine. Use of a muscle relaxant allows for prevention of musculoskeletal trauma and facilitates
the airway management. Turn on the nerve stimulator and assess for degree of muscle relaxation prior to
administering ECT. Fasciculations should be observed throughout the body with succinylcholine
(Anectine) due to its partial agonist properties. Full muscle relaxation is achieved when the nerve
stimulator fails to elicit a toe twitch and fasciculations disappear. Some patients may not tolerate
succinylcholine (allergic, pseudocholinesterase deficiency, CU or chronic illness myopathy) and a non-
depolarizing agent such as rocuronium (Zemuron) will need to be used. That will require reversal with
Sugammadex (Bridion) to avoid longer recovery times and need for intubation.

Other medications:
Glycopyrrolate (Robinul) is an anticholinergic medication routinely administered at the first ECT treatment
to minimize secretions and bradycardia if multiple stimuli are required during titration. This medication is
usually unnecessary after the first ECT session and should be avoided in patients with a history of
arrhythmias or tachycardia.

Symphatholytics agents may be administered pre or post procedure to minimize transient tachycardia /
hypertension. Agents include esmolol, labetalol, nifedipine, and nitroglycerine.

Ondansetron (Zofran) is also used to prevent nausea induced by ECT or by anesthetic agents (more
commonly seen when using remifentanil)

Ketorolac (Toradol) is used to prevent head ache and muscle aches. It needs to be avoid in patients with
renal impairment, NSAIDs allergies, or those taking lithium.

Index ECT Course:

In general, all patients should start with right unilateral (RUL) electrode placement and ultra-brief pulse
stimulation. Ultra-brief pulse refers to a pulse width (PW) between 0.3-0.37 miliseconds (ms). We
maintain ultra-brief pulse width at 0.3 ms to minimize chances of cognitive side effects. Exceptions to this
include; mania, catatonia, prior response to bilateral ECT, status epilepticus, very urgent need for
response. In those cases the initial electrode placement is bilateral bifrontal with brief pulse stimulation.
Brief pulse refers to a PW between 0.5-1 ms. We maintain brief pulse width at 0.5 ms to minimize
chances of cognitive side effects. Brief PW ECT should be used for all bilateral cases (i.e., bifrontal and
bitemporal) cases since is proven to be more effective (~ 2 fold) than ultra-brief bilateral ECT. If cognitive

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impairment is a concern, one may consider using BL ultra-brief ECT or decreasing sessions frequency to
2 per week.

Electrode placement:
Bite blocks should always be in place before handheld electrodes are positioned. Despite the use of
muscle relaxants, direct stimulation of the temporalis muscle will cause mandibular contraction that can
lead to dental damage or tongue biting / lacerations if not adequately protected by bite blocks.

Unilateral electrode placement is based on the d’Elia technique where electrodes are placed at positions
1 and 2. - figure 1 - The center of the 2-inch electrode should be positioned 1 inch above the mid-point
between the right outer canthus and tragus (position 1). This location corresponds to the right temporal
pole of the brain. For position 2, the center of the 2-inch electrode should be placed 1 inch lateral to the
the vertex. This location corresponds to the right motor cortex— the most easily excitable area of the
brain.

Position 3 is where electrodes are placed bilaterally during bifrontal (BF) stimulation. For this, the centers
of the 2 inch electrodes are placed 2 inches above (in the parasagittal plane) each outer canthi. This
corresponds to stimulation of the frontal lobes.

Bitemporal (BT) ECT is administered by placing the electrodes bilaterally at position 1. With this electrode
placement both temporal lobes are stimulated leading to more chances of cognitive impairment.

Electrode placement is associated with increasing therapeutic efficacy and increased cognitive side
effects in the following order:

Unilateral (RUL) → Bifrontal (BF) → Bitemporal (BT)

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First ECT and Dose Titration:

The first ECT session is used to determine the seizure threshold and is usually referred to as initial dose
titration. We use standardized titration tables (Tables 1 and 2) to start and escalate the stimulation dose
during this session. The majority of patients have a seizure with 5 Joules (28.8 mC charge) but a higher
or lower seizure threshold can be seen in patients with recent use of benzodiazepines and/or
anticonvulsants or current use of antipsychotics and/or stimulants.

Typically on the first stimulation, a higher than usual dose of anesthesia is used based on the patient’s
body weight and to ensure adequate anesthesia if multiple ECT stimulations are required to induce a
seizure. No more than 4 attempts should be made during a single session because the anesthesia time is
limited and multiple stimulations even subthreshold can lead to significant bradycardia.

The intensity of the stimulation (the dose) depends on four parameters that can be manually adjusted by
turning the dials on the front of the device as illustrated in Figure 2:

− Pulse width (ultra-brief 0.3-0.37 ms or brief pulse 0.5-1 ms)

− Frequency (ultra-brief 20-120 Hz or brief pulse 20-60 Hz)
− Duration (ultra brief 0.5-8 s or brief pulse 0.5-6 s)
− Current (always kept constant at 800 mA)

As a general rule to minimize potential for cognitive side effects, attempt to keep the PW as narrow as
possible and first increase the frequency and duration.

Figure 2. SigmaStim device screen and control panel illustrating parameters adjusted when administering ECT and
output settings. This screen displays ECT stimulus parameters including charge (mC) and energy (J) delivered with each
setting in addition to two channel EEG.

Second ECT session:

It is important to increase the energy delivered on the 2nd session because for therapeutic purposes the
stimulation should always be delivered well above seizure threshold. In order to ensure this, the energy /
charge should be increased as follows:

4-6 times (400 - 600%) for ultra-brief RUL ECT

1.5 times (50%) for brief pulse BL ECT

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The seizure threshold (in terms of charge mC) can be determined by setting the ECT device to the
parameters in which a seizure was induced during the initial titration (first session). Then increase that
value accordingly.

So, for UB RUL, the threshold charge is multiplied by 5 to obtain the target charge (mC) and the
parameters are then adjusted by increasing frequency and duration to provide that charge (mC) during
the 2nd ECT session. For brief pulse BL ECT the threshold charge is multiplied by 1.5 to obtain the target
charge (mC).

Refer to Tables 1 and 2 for a list of ultra-brief pulse RUL and brief pulse BL ECT parameters and
associated energy / charge delivered.

Subsequent ECT sessions:

As patients receive subsequent ECT treatments, their seizure thresholds will rise thus necessitating an
increase in ECT stimulation energy to keep the stimulation suprathreshold and therapeutic. This is
particularly true during the index course. Optimization of the dose may not be necessity if the central
seizure lasts well over 25 sec, is of adequate quality (amplitude, symmetry, duration, and suppression)
and a clinical response is evident. When a seizure last less than 30 sec, the dose should be optimized at
the next treatment. If the stimulation is already being delivered at maximum settings (100 J for UBP RUL
and 101 J for BP BL) and with hyperventilation, adjustment to the anesthetic agents and electrode
placement should be pursued.

RUL ultra-brief pulse initial dose titration parameters

Pulse width Frequency Duration Current Charge
Stimulation Energy (J)
(ms) (Hz) (s) (mA) (mC)
1 0.30 30 1 800 14.4 2.5
2 0.30 30 2 800 28.8 5.1
3 0.30 40 3 800 57.6 10.1
4 0.30 50 4 800 96.0 16.9
5 0.30 50 5 800 120.0 21.1
6 0.30 50 6 800 144.0 25.3
7 0.30 60 6 800 172.0 30.4
8 0.30 60 7 800 201.0 35.5
9 0.30 70 7 800 235.2 41.4
10 0.30 80 8 800 307.2 54.1
11 0.30 90 8 800 345.6 60.8
12 0.30 100 8 800 384.0 67.6
13 0.30 110 8 800 422.4 74.3
14 0.30 120 8 800 460.8 81.1
15 0.33 120 8 800 506.9 89.2
16 0.37 120 8 800 568.3 100.0

Table 1. Stimulation parameters for initial RUL ultra-brief ECT and determination of seizure threshold. Most
patients have a seizure with 5 J of energy. If a patient does not have a seizure, increase energy of stimulus by
approximately 5 J increments until patient has a seizure. The 2nd RUL ECT delivered on the next treatment day
should be increased 4-6 times (4-6x) the energy (in mC) of the 1st ECT stimulation.

BL brief pulse ECT initial dose titration parameters

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Pulse Frequency Current Charge

Stimulation Duration (s) Energy (J)
width (ms) (Hz) (mA) (mC)
1 0.5 20 1.0 800 16.0 2.8
2 0.5 20 2.0 800 32.0 5.6
3 0.5 30 2.5 800 60.0 10.6
4 0.5 40 3.0 800 96.0 16.9
5 0.5 40 4.0 800 128.0 22.5
6 0.5 40 5.0 800 160.0 28.2
7 0.5 50 5.0 800 200.0 35.2
8 0.5 50 6.0 800 240.0 42.2
9 0.5 60 6.0 800 288.0 50.7
10 0.6 60 6.0 800 345.6 60.8
11 0.7 60 6.0 800 403.2 71.0
12 0.8 60 6.0 800 460.8 81.1
13 0.9 60 6.0 800 518.4 91.2
14 1.0 60 6.0 800 576.0 101.4

Table 2. Stimulation parameters for initial BL standard brief pulse ECT and determination of seizure threshold.
If a patient does not have a seizure, increase energy of stimulus by approximately 5 J increments until patient has
a seizure. The 2nd BL ECT delivered on the next treatment day should be increased 50% (1.5x) energy (in
mC) delivered of the 1st ECT stimulation. We avoid using PW over 0.5 ms. On a case by case basis we may
use a PW >0.5 ms

Treatment protocol:
We follow this algorithm during an index course of ECT:

RUL ultra-brief pulse ECT

for 6 sessions

Response (>50% Minimal or no

improvement) improvement
responds
(>50%
improvement)
RUL ultra-brief pulse ECT Switch to brief pulse BF
until remission or 12 ECT for 6 more sessions
sessions total

Remission Minimal or no
improvement

Switch to BT electrode
Transition to
continuation/ placement for 6 more
maintenance ECT sessions

Remission Minimal or no
improvement

Stop ECT

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− Symptom improvement is usually seen after 4-6 ECT treatments.

− Response and remission typically occurs after 9-12 treatments. Up to 15 sessions can be done in patient
with partial responses.
− Switching to BL brief pulse ECT is an option but the remission rate is almost half the remission rate with
BL brief pulse (35% vs 65%) so we usually switch directly to brief pulse.
− Assess for cognitive side effects when switching from RUL to BL BF and BT ECT.
− Development and intolerance of side effects may lead to modification (e.g., twice weekly sessions, pulse
with reduction, or modification of electrode placement) or discontinuation of ECT.
− We use BF electrode placement before using BT stimulation to keep the potential for cognitive side
effects as low as possible.

Continuation / Maintenance ECT:

It is recommended that all patients who demonstrate a benefit from an index course of ECT gradually
transition to maintenance ECT as it increases the time to recurrence. Transition to adequate
pharmacotherapy also increases the time to recurrence and the best evidence exists for nortriptyline and
lithium combination. In our service we recommend gradual ECT taper into maintenance and optimization
of medications to minimize the risk of recurrence.

We use the following continuation / maintenance schedule:

1. Weekly ECT for 4 weeks (1 month)

2. Biweekly ECT for 8 weeks (2 months)
3. Monthly ECT for 12 weeks (3 months)
4. If doing well can gradually space out by 2 weeks to every 6-8-10-12 weeks
5. If symptoms are consistently in remission with every 12 week (3 month) ECT it can be stopped

As one reduces the frequency of maintenance ECT, monitor for recurrence of symptoms. If a patient
reports recurrent symptoms, consider increasing the frequency of ECT. The duration of time between
ECT treatment and recurrence of symptoms helps guide clinicians to determine the greatest amount of
time a patient can remain symptom free between ECT sessions.

Adequacy of medications as well as degree of recurrence and treatment resistance will determine the
frequency and duration of maintenance ECT.

Special Considerations:

1. Inability to induce a seizure – In a number of patients, induction of an adequate seizure with ECT is
difficult or impossible. Interventions useful to promote seizure induction include hyperventilation and
changing or reducing anesthesia (e.g., switching from methohexital to etomidate and/or using
remifentanil with lower dose anesthesia).
2. Prolonged seizures – Defined as a central duration of 3 minutes or more. Measures to stop the
seizure should start after ~2 and half minutes of seizure activity and include administering extra
methohexital or Midazolam 2 mg IV in repeated boluses (if needed). Most seizures spontaneously
resolve.
3. Status epilepticus – Paradoxically, ECT can both cause and treat status epilepticus. ECT-induced
status is defined as a central seizure that continues for more than 3 minutes (1-2% incidence). If a
patient has a post-ECT seizure, use of prophylactic lorazepam 2 mg IV post-ECT should prevent
future post-ECT seizures. Patients may also have non-convulsive status epilepticus determined by
examining the EEG. On rare occasions, neurology may request ECT to treat a patient in status
epilepticus. For that it is recommended to stop all anticonvulsants and administer BT ECT at
maximum stimulation settings.
4. Critical illness myopathy – This is likely to be present in patients that have been immobile (ICU
stays or catatonia). This myopathy is characterized by upregulated extrajunctional nicotinic

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acetylcholine receptors. Succinylcholine competes with acetylcholine at those receptors and causes a
transient increase in plasma potassium levels by 0.5–1.0 mEq/L but this hyperkalemic response is
more intense in patients with upregulated extrajunctional nicotinic acetylcholine receptors leading to
high risk for hyperkalemia (potassium ≥ 6.5 mEq/L) and cardiac events. Succinylcholine needs to be
avoided in those cases and a non-depolarizing muscle relaxant is recommended. The effect of a
depolarizing muscle relaxant like Rocuronium needs to be reversed with Sugammadex (Bridion).
5. BZD reversal requirement – Patients with malignant catatonia require high doses of BZD. If failed,
taper of BZD needs to be initiated in preparation for ECT but not to the point that ECT is delayed and
complications from catatonia develop. In this cases Flumazenil can be used to reverse some of the
BZD effect increasing the changes of inducing a therapeutic seizure. This needs to be discussed with
anesthesia and planed ahead of time. Flumazenil (0.2 – 0.4 mg IV) is usually administered 2-3 min
before the anesthetic agent and signs of withdraw needs to be monitored. Once the seizure is
suppressed by the patient, a dose of Midazolam 1-2 mg IV can be administered to decrease chances
of full BZD withdrawal. In some cases where the risk of withdrawal seizures is high, Flumazenil can
be administered after the anesthetic agent and muscle relaxant and 2-3 min before stimulation. That
way a withdrawal seizure will take place with a protected airway and muscle relaxation. Flumazenil
reversal has risk (i.e., acute BZD withdraw, seizures, arrhythmias) so it is reserved for cases where
BZD are needed for severe catatonia (i.e., not for anxiety or agitation where other agents can be
used).
6. ECT-induced delirium or agitation – Post ictal agitation is a common side effect seen in up to 10%
of patients as they recover from the ECT and anesthesia (more common during BL ECT). Most ECT-
induced agitation resolves spontaneously as the patient recovers from the procedure. Prior to
assuming post-ictal agitation, assess for non-convulsive seizures by EEG. ECT-induced delirium
may be avoided by reducing the frequency of ECT and by modifying medications specifically Lithium
(should not be taking the night before ECT or if feasible discontinued). Minimizing sensory
stimulation helps, and use of restraints may be necessary. This can also be prevented by switching
the anesthetic agent to Propofol. Should the patient become agitated, administer midazolam or
lorazepam 2 mg IV.
7. Cardiovascular disease – Cardiovascular complications occur in 7.5% of patients without prior
cardiovascular disease. Benign arrthymias are the most common cardiovascular side effect
associated with ECT and usually resolve spontaneously. Patients with a history of cardiac disease
are at greatest risk of cardiac complications (up to 55% of patients). Cardiovascular side effects are
usually benign and transient. ECT typically results in initial parasympathetic nervous system
activation with bradycardia (sometimes with transient asystole) followed by a reflex tachycardia as a
result of secondary increased sympathetic catecholamine output. Patients are most vulnerable to
developing cardiovascular complications in the period immediately following ECT stimulation. Beta-
blockers may minimize hemodynamic changes but should be avoided in those prone to developing
asystole, bradycardia, and asthma. Furthermore, beta-blockers may interfere with the ability to
induce a seizure. Maintenance of stable blood pressure, heart rhythm, and ventilation prior to and
during ECT reduces the risk of cardiovascular complications.
8. Pregnancy – ECT is sometimes used as a treatment during pregnancy when medications are
ineffective or when symptoms are severe (e.g., catatonia). Prior to performing ECT in a pregnant
patient, obtain clearance from obstetrics. The most common side effect of ECT during pregnancy is
transient fetal arrhythmias. ECT procedures are the same as in non-pregnant patients with the
exception that fetal heart tones are recorded before and after every ECT procedure (when pregnant
>14 weeks). An in-house labor and delivery nurse assess fetal heart tones. When women are
greater than 20 weeks pregnant, ECT is administered with a wedge under the right hip to displace
uterus to left and prevent aortocaval compression. Patients who are pregnant and undergoing ECT
do not need to be intubated but may be at slightly higher risk of aspiration during the procedure.
9. Implanted pacemakers/VNS/devices – Patients with implanted electronic devices sometimes need
to inactivate these devices while receiving ECT. ECT does not interfere with pacemaker or implanted
defibrillator function, but this may need to be verified by the device manufacturer. VNS is an
anticonvulsant and needs to be turned off or deactivated prior to ECT. Orthopedic devices are safe in
ECT, and several case reports show that ECT can be safely used in patients with DBS for
Parkinson’s disease and depression.

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10. Difficult airways – Patients do not need intubation for ECT, but anesthesia will recommend
intubation in some patients with difficult airways. Some patients, particularly patients with significant
upper airway and abdominal obesity, will need a laryngeal mask airway (LMA) to provide adequate
ventilation during the procedure.
11. Treatment-emergent mania – Similar to antidepressants, some patients will develop manic
symptoms during the index course of ECT. When this occurs, continue with ECT to treat the manic
symptoms and recommend addition of a non-anticonvulsant mood stabilizer.
12. Pain – Headaches and musculoskeletal pain are a common side effect from ECT. Approximately half
of patients will experience headache. Prophylactic use of ketorolac 30 mg IV (15 mg in elderly) will
prevent headache and myalgias that are a result of succinylcholine. Acetaminophen 650 mg PRN
can be administered in the recovery unit. Infrequently, a dose of Percocet can be used in patient with
consistent treatment associated pain.
13. Death – ECT has a mortality rate similar to minor surgery or childbirth. The APA estimates a
mortality rate of 1 per 10,000 patients or 1 per 80,000 treatments. Most deaths are due to
cardiovascular collapse that can be prevented by cardiac screening and monitoring.

Referral of patients:
Our patient population includes both inpatients and outpatients. Outpatients can be referred for an ECT
evaluation with one of the ECT attendings. Patients can schedule an appointment by calling the PBH
Contact Center at 215 746 6701

Inpatients are referred for ECT by the inpatient psychiatry units and consult services and approved by the
ECT attendings.

Both inpatient and outpatient ECT patients are put on the OR schedule by the ECT attending by
contacting Patty Seeley at (pat.seeley@uphs.upenn.edu or 215-829-6351). Pat Seeley ensures
outpatients have insurance coverage for ECT at PAH. If a prior authorization is required, the referring
physicians are responsible for calling insurance companies and provide Pat Seeley with the authorization
number and dates. Once receiving treatment, ECT attendings obtain ongoing authorization for
continuation of treatment as needed.

ECT Schedule:
We perform ECT on Monday, Wednesday,Thursday, and Friday mornings (7:30am to 11:30am)
The first case is expected to start at 7:30am
IV access and anesthesia consent should be ready by 7:30am.

We have a 6-7 case/day capacity and the circulating RNs and attending will distribute patients
accordingly to keep a balanced schedule.

The circulating nurse generates the schedule for the next ECT day (e.g., the Wednesday schedule is
generated on Monday after all ECT cases are completed). Patient can be added to the schedule only by
the ECT attendings.

Patient contact:
Patients are contacted by the admission staff the day before their procedure to confirm the visit. This call
is to be expected between the hours of 4pm to 7pm. Patients can call PAH Admissions between 4pm and
7pm to find their appointment time if needed.

Patients can contact the ECT attending (office number only) or the ECT coordinators with questions or to
request changes in the schedule. See ECT patient coordination protocols.

Patients can also access the service website

http://www.med.upenn.edu/ect/

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ECT attendings: Mario A. Cristancho, MD

marioc@pennmedicine.upenn.edu
Office: (215) 746 - 7181
Cellphone: (267) 804-4868

Jenny Rodriguez, MD
jennypaola.rodriguezalzate@pennmedicine.upenn.edu
Office: (215) 573-9566
Cellphone: (305) 815-3270

Golkoo Hosseini, MD
golkoo.hosseini@pennmedicine.upenn.edu
Office: (215)
Cellphone: (610) 322-5113

ECT Coordinators: Dominique Spence

dominique.spence@uphs.upenn.edu
Office: (215) 746-3452
Cell: (267) 242-6199

Urooj Iqbal
Urooj.Iqbal@pennmedicine.upenn.edu
Office: (215) 746-3452
Cell: (732) 890-4880

ECT Insurance eligibility / schedule: Patty Seeley

pat.seeley@uphs.upenn.edu
Office: (215) 829-6351

PAH admissions: 215-829-6338

PBH Contact Center: 1-866-301-4724

Recommended Reading:
1. American Psychiatric Association: Recommendations for Treatment, Training, and Privileging, 2nd
ed. Washington DC, American Psychiatric Press, 2001.
2. Handbook of ECT. A guide to ECT for practitioners. Kellner C, Cambridge, 2019
3. Sackeim HA, et al JAMA, 2001
4. UK ECT Review Group. Lancet. 2003
5. Keller et al Arch Gen Psychiatry 2006
6. Kellner et al. Br J psychiatry 2010

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2024

7. Kellner et al. Am J Psychiatry 2016

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