Psych · Psychopharmacology — ECT and neurostimulation
ECT and neurostimulation
Also known as Electroconvulsive therapy · ECT · rTMS · iTBS · theta burst stimulation · tDCS · vagus nerve stimulation · VNS · deep brain stimulation depression · neurostimulation psychiatry · continuation ECT · maintenance ECT
Exam-exhaustive fellowship reference on ECT and neurostimulation — indications (depression, mania, catatonia, clozapine-resistant schizophrenia), consent and capacity, electrode placement and stimulus dosing, anaesthesia essentials for psychiatrists, cognitive adverse effects, continuation and maintenance, plus evidence-tiered rTMS/iTBS, tDCS, VNS and DBS. FRANZCP-primary, globally tagged.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
FRANZCPMRCPsychABPNMD-DNBNEET-SS
Red flags
- Malignant catatonia, food–fluid refusal, or high-intent suicidality with severe depression — do not delay ECT for endless medication trials
- Prolonged seizure or status epilepticus peri-ECT — abort stimulation, manage airway, follow anaesthetic emergency protocols
- New focal neurology or unexpected prolonged post-ictal coma — investigate medical/neurological complication, not 'just ECT recovery'
- Capacity lost for treatment decisions — use jurisdiction-specific mental health law; never invent section numbers
- Leaving successful index ECT without a relapse-prevention plan (pharmacotherapy and/or continuation ECT) — high early relapse risk
- Suspected NMS vs catatonia vs serotonin toxicity — wrong pathway kills; examine and treat the syndrome you have
Meet the patient
A 71-year-old man with psychotic depression has not eaten for six days. He believes his bowel has rotted away and that food would be wasted on him. Three adequate antidepressant trials behind him, an augmenting antipsychotic on board, urea and creatinine climbing.[1][4][6]
The team is discussing a fourth drug. The examiner will ask a different question: how many more weeks does this man have? That is the question ECT answers, and speed of response is exactly why it exists.[3][5][6]
References30ShowHide
- [1]UK ECT Review Group Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis Lancet, 2003.PMID 12642045
- [2]Kellner CH, Knapp RG, Petrides G, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE) Arch Gen Psychiatry, 2006.PMID 17146008
- [3]Husain MM, Rush AJ, Fink M, et al. Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for Research in ECT (CORE) report J Clin Psychiatry, 2004.PMID 15119910
- [4]Prudic J, Haskett RF, Mulsant B, et al. Resistance to antidepressant medications and short-term clinical response to ECT Am J Psychiatry, 1996.PMID 8678194
- [5]Lisanby SH Electroconvulsive therapy for depression N Engl J Med, 2007.PMID 17989386
- [6]Espinoza RT, Kellner CH Electroconvulsive Therapy N Engl J Med, 2022.PMID 35172057
- [7]Sackeim HA, Prudic J, Nobler MS, et al. Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy Brain Stimul, 2008.PMID 19756236
- [8]Sackeim HA, Prudic J, Fuller R, et al. The cognitive effects of electroconvulsive therapy in community settings Neuropsychopharmacology, 2007.PMID 16936712
- [9]Semkovska M, Keane D, Babalola O, et al. Unilateral brief-pulse electroconvulsive therapy and cognition: effects of electrode placement, stimulus dosage and time J Psychiatr Res, 2011.PMID 21109254
- [10]Semkovska M, Landau S, Dunne R, et al. Bitemporal Versus High-Dose Unilateral Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A Pragmatic, Randomized, Non-Inferiority Trial Am J Psychiatry, 2016.PMID 26892939
- [11]Kellner CH, Husain MM, Knapp RG, et al. Right Unilateral Ultrabrief Pulse ECT in Geriatric Depression: Phase 1 of the PRIDE Study Am J Psychiatry, 2016.PMID 27418379
- [12]Petrides G, Malur C, Braga RJ, et al. Electroconvulsive therapy augmentation in clozapine-resistant schizophrenia: a prospective, randomized study Am J Psychiatry, 2015.PMID 25157964
- [13]Tharyan P, Adams CE Electroconvulsive therapy for schizophrenia Cochrane Database Syst Rev, 2005.PMID 15846598
- [14]Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination Acta Psychiatr Scand, 1996.PMID 8686483
- [15]Weiss A, Hussain S, Ng B, et al. Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of electroconvulsive therapy Aust N Z J Psychiatry, 2019.PMID 30966782
- [16]O'Reardon JP, Solvason HB, Janicak PG, et al. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial Biol Psychiatry, 2007.PMID 17573044
- [17]George MS, Lisanby SH, Avery D, et al. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial Arch Gen Psychiatry, 2010.PMID 20439832
- [18]Lefaucheur JP, Aleman A, Baeken C, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014-2018) Clin Neurophysiol, 2020.PMID 31901449
- [19]Berlim MT, van den Eynde F, Tovar-Perdomo S, et al. Response, remission and drop-out rates following high-frequency repetitive transcranial magnetic stimulation (rTMS) for treating major depression: a systematic review and meta-analysis of randomized, double-blind and sham-controlled trials Psychol Med, 2014.PMID 23507264
- [20]Brunoni AR, Moffa AH, Sampaio-Junior B, et al. Trial of Electrical Direct-Current Therapy versus Escitalopram for Depression N Engl J Med, 2017.PMID 28657871
- [21]Milev RV, Giacobbe P, Kennedy SH, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 4. Neurostimulation Treatments Can J Psychiatry, 2016.PMID 27486154
- [22]Rush AJ, Marangell LB, Sackeim HA, et al. Effects of 12 months of vagus nerve stimulation in treatment-resistant depression: a naturalistic study Biol Psychiatry, 2005.PMID 16139581
- [23]Aaronson ST, Sears P, Ruvuna F, et al. A 5-Year Observational Study of Patients With Treatment-Resistant Depression Treated With Vagus Nerve Stimulation or Treatment as Usual: Comparison of Response, Remission, and Suicidality Am J Psychiatry, 2017.PMID 28359201
- [24]Mayberg HS, Lozano AM, Voon V, et al. Deep brain stimulation for treatment-resistant depression Neuron, 2005.PMID 15748841
- [25]Holtzheimer PE, Husain MM, Lisanby SH, et al. Subcallosal cingulate deep brain stimulation for treatment-resistant depression: a multisite, randomised, sham-controlled trial Lancet Psychiatry, 2017.PMID 28988904
- [26]Blumberger DM, Vila-Rodriguez F, Thorpe KE, et al. Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial Lancet, 2018.PMID 29726344
- [27]Daly JJ, Prudic J, Devanand DP, et al. ECT in bipolar and unipolar depression: differences in speed of response Bipolar Disord, 2001.PMID 11333069
- [28]Prudic J, Haskett RF, McCall WV, et al. Pharmacological strategies in the prevention of relapse after electroconvulsive therapy J ECT, 2013.PMID 23303417
- [29]Lefaucheur JP, André-Obadia N, Antal A, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS) Clin Neurophysiol, 2014.PMID 25034472
- [30]McCall WV, Lisanby SH, Rosenquist PB, et al. Effects of continuation electroconvulsive therapy on quality of life in elderly depressed patients: A randomized clinical trial J Psychiatr Res, 2018.PMID 29195125