1. Background
Electroconvulsive therapy (ECT) remains one of the most effective treatments for severe psychiatric disorders, particularly in cases resistant to pharmacotherapy or where a rapid clinical response is critical. This method is effective, safe, and practical, with several advantages compared to other treatment options. It is a simple and brief procedure with transient side effects; however, some cases are high risk and require necessary precautions to prevent complications (1, 2). The ECT was first used eighty years ago for the treatment of schizophrenia cases. However, it still remains stigmatized (3). In this clinical procedure, an electric current is passed through the brain to induce a brief seizure. The modern form of ECT is called modified ECT, in which the procedure is performed under general anesthesia with muscle relaxation (4). During the process, following sympathetic and parasympathetic nervous system activation, severe hemodynamic fluctuations occur (5, 6). Therefore, it is crucial to pay enough attention to patients’ comorbidities. Obviously, for the safe management of ECT patients, proper communication between psychiatrists and anesthesiologists is essential. The growing prevalence of psychiatric disorders comorbid with medical conditions underscores the need for meticulous preoperative assessment and tailored anesthetic management during ECT. The anesthesia drugs can cause hemodynamic instability (7). As a result, it is recommended that before performing ECT, all necessary preparations and consultations be made similar to surgery patients (8). Hemodynamic changes in ECT patients are sometimes so severe that they can cause life-threatening cardiovascular and cerebral complications, which are especially noticeable in the elderly (5, 9). Also, in diseases such as diabetes, as these patients have autonomic disorders, they are more sensitive to sympathetic and parasympathetic changes and require more attention (6, 10). In patients with hypertriglyceridemia, it is frequently recommended to use alternative sedatives (10, 11), and in patients with high blood pressure, acute sympathetic and parasympathetic fluctuations are expected during ECT (12, 13). The most common causes of death during ECT are cardiac arrhythmias and acute coronary syndrome. The most common complication associated with ECT is craniofacial trauma, especially dental and tongue injuries. In addition, complications may occur in the respiratory system (prolonged apnea, aspiration pneumonia, bronchospasm), the nervous system (subarachnoid hemorrhage, subdural hematoma), or the cardiovascular system (Takotsubo cardiomyopathy) (14). In some cases, psychiatric patients, despite not being in ideal physical condition, are scheduled for emergency ECT, which sometimes results in death. Based on recent authoritative studies, the importance and necessity of optimal preparation of ECT patients before receiving the procedure have been emphasized more than ever, and it has been clearly reminded that necessary consultations should be carried out with regard to comorbidities (15). In fact, performing ECT in emergency conditions can lead to irreparable complications for the patient and legal conflicts for the treatment team.
2. Objectives
The present study aimed to determine the frequency of co-morbidities and outcomes in ECT patients at Shafa Educational and Medical Center, Guilan, Iran.
3. Methods
This descriptive cross-sectional study was conducted at Shafa Hospital, an academic and referral center affiliated with Guilan University of Medical Sciences (GUMS), from June 2023 to May 2024.
3.1. Inclusion Criteria
Psychiatric patients who were candidates for ECT, aged over 18 years, based on the American Society of Anesthesiologists (ASA) physical status classifications I-III.
3.2. Exclusion Criteria
Unwillingness to participate in the study. In cases of eligibility, informed consent was obtained from the patient or, if necessary, from a legal guardian. A checklist containing demographic data, comorbidities, and high-risk conditions, including pregnancy, obesity, and old age, was completed. The Body Mass Index (BMI) is calculated by dividing an adult’s weight in kilograms by their height in meters squared. Values between 18.5 and 24.9 kg/m2 are described as the 'healthy range', between 25 and 29.9 kg/m2 as overweight, and between 30 and 39.9 kg/m2 as obesity. In this study, values equal to or higher than 25 kg/m2 were considered high BMI (16). Elderly was defined as a person 65 years old or older (17).
3.3. Anesthesia Management
All ECT patients underwent a standard preoperative visit based on a prepared checklist for this purpose (18) and were fasted for 6 - 8 hours before the procedure. Atropine sulfate (0.01 mg/kg IM) was administered 30 minutes before the procedure to restrict airway secretions. Immediately after admission, standard monitoring, including pulse oximetry (POM), electrocardiography (ECG), and non-invasive blood pressure (NIBP), was performed, and a peripheral intravenous access was secured, and hydration with crystalloids was started. Anesthesia was induced by propofol (1 mg/kg IV) followed by 0.5 mg/kg succinylcholine (500 mg/10 mL, Caspian Tamin Co, Iran). When the patient was completely unconscious, active hyperventilation at a rate of 40 - 50 breaths per minute was performed via a properly sized face mask, and a mouth guard was placed. After placing bitemporal electrodes, a grand-mal seizure was induced with the following characteristics: 70 - 120 V, 800 mA of direct current with a duration of 100 ms to 6 s, and active ventilation was started at the end of the seizure movements until the patient’s spontaneous breathing resumed. When the patients were fully conscious with stable hemodynamic status, they were transferred to the recovery ward and underwent close monitoring to meet Aldrete scoring criteria. The patients were monitored for detecting complications both during the ECT procedure and the first 24 hours after ECT. Furthermore, the patients were followed for suicide during the first year after ECT.
3.4. Statistical Analysis
The gathered data were analyzed using SPSS version 21 (IBM Corporation, Inc., Chicago, IL, USA) and presented using descriptive statistics, frequency, mean, standard deviation, or median. The chi-square test was applied to analyze categorical variables. A P-value of less than 0.05 indicated statistical significance.
4. Results
A total of 156 psychiatric patients who underwent ECT, with a mean age of 46.62 ± 14.14 years and a mean BMI of 26.73 ± 2.71, participated in this study. Of these, 83 (53.2%) were male and 73 (46.8%) were female. The majority of the patients were in ASA class II (Table 1). In terms of psychiatric diagnosis, bipolar disorder type 1 (36.5%) and schizophrenia (30.8%) were the most common medical diagnoses. Our results demonstrated that a significant proportion of ECT recipients (87.8%) had at least one underlying medical condition, with hyperlipidemia (28.8%) and diabetes (26.3%) being the most prevalent (Table 2). The results showed a statistically significant association between diabetes (P = 0.034), hypertension (P = 0.001), heart disease (P = 0.016), high BMI (P = 0.023), and individuals’ gender (Table 3). A statistically significant association was also seen between diabetes (P = 0.003), hypertension (P = 0.026), high BMI (P = 0.066), and patients’ age (Table 4). During the follow-up period, no patient was affected by adverse events, and no case of suicide was reported.
| Variables | Values |
|---|---|
| Gender | |
| Male | 83 (53.2) |
| Female | 73 (46.8) |
| Age (y) | |
| ≤ 40 | 58 (37.2) |
| 41 - 65 | 83 (53.2) |
| > 65 | 15 (9.6) |
| Age (y) | 46.62 ± 14.14 (14 - 79) |
| BMI ( Kg/m2 ) | 26.73 ± 2.71 (21.5 - 34.1) |
| ASA | |
| I | 115 (73.7) |
| II | 41 (26.3) |
Abbreviations: BMI, Body Mass Index; ASA, American Society of Anesthesiologists.
a Values are expressed as No. (%) or mean ± SD (range).
| Risk Factors | No. (%) |
|---|---|
| Diabetes | 41 (26.3) |
| Hypertension | 20 (12.8) |
| Cardiac disease | 19 (12.2) |
| Hyperlipidemia | 45 (28.8) |
| History of allergies | 5 (3.2) |
| Seizures | 13 (8.3) |
| Respiratory diseases | 2 (1.3) |
| Thyroid diseases | 8 (5.1) |
| Liver diseases | 3 (1.9) |
| Renal diseases | 1 (0.6) |
| Other co-morbidities | 9 (5.8) |
| Pregnancy | 2 (2.7) |
| Age above 65 | 15 (9.6) |
| High BMI | 13 (8.3) |
| One underlying diseases | 112 (71.8) |
| Two underlying diseases | 21 (13.5) |
| Three or more underlying diseases | 4 (2.6) |
Abbreviation: BMI, Body Mass Index.
| Risk Factors | Male | Female | P-Value |
|---|---|---|---|
| Diabetes | 16 (19.3) | 25 (34.2) | 0.034 |
| Hypertension | 4 (4.8) | 16 (21.9) | 0.001 |
| Cardiac disease | 15 (18.1) | 4 (5.5) | 0.016 |
| Hyperlipidemia | 27 (32.5) | 18 (24.7) | 0.279 |
| History of allergies | 4 (4.8) | 1 (1.4) | 0.372 |
| Seizures | 8 (9.6) | 5 (6.8) | 0.529 |
| Respiratory diseases | 2 (2.4) | 0 (0) | 0.499 |
| Thyroid diseases | 3 (3.6) | 5 (6.8) | 0.475 |
| Liver diseases | 3 (3.6) | 0 (0) | 0.248 |
| Renal diseases | 0 (0) | 1 (1.4) | 0.468 |
| Other co-morbidities | 3 (3.6) | 6 (8.2) | 0.306 |
| Age above 65 | 5 (6) | 10 (13.7) | 0.105 |
| High BMI | 3 (3.6) | 10 (13.7) | 0.023 |
| No underlying diseases | 5 (6) | 14 (19.2) | 0.0001 |
| One underlying diseases | 72 (86.7) | 40 (54.8) | 0.0001 |
| Two underlying diseases | 5 (6) | 16 (21.9) | 0.0001 |
| Three or more underlying diseases | 1 (1.2) | 3 (4.1) | 0.0001 |
Abbreviation: BMI, Body Mass Index.
a Values are expressed as No. (%).
| Risk Factors and Status | Age ≤ 40 | Age 41 - 65 | Age > 65 | P-Value |
|---|---|---|---|---|
| Diabetes | 0.003 | |||
| Yes | 7 (11.2) | 31 (37.3) | 3 (20) | |
| No | 51 (87.9) | 52 (62.7) | 12 (80) | |
| Hypertension | 0.026 | |||
| Yes | 2 (4.3) | 15 (18.1) | 3 (20) | |
| No | 56 (96.6) | 68 (81.9) | 12 (80) | |
| Cardiacdisease | 0.107 | |||
| Yes | 5 (6.8) | 14 (16.9) | 0 (0) | |
| No | 53 (91.4) | 69 (83.1) | 15 (100) | |
| Hyperlipidemia | 0.075 | |||
| Yes | 21 (36.2) | 23 (27.7) | 1 (7) | |
| No | 37 (63.8) | 60 (72.3) | 14 (93) | |
| History of allergy | 0.496 | |||
| Yes | 2 (4.3) | 2 (2.4) | 1 (7) | |
| No | 56 (96.6) | 81 (97.6) | 14 (93) | |
| Seizure | 0.129 | |||
| Yes | 8 (13.8) | 5 (6.0) | 0 (0) | |
| No | 50 (86.2) | 78 (94.0) | 15 (100) | |
| Respiratory disease | 0.184 | |||
| Yes | 0 (0) | 1 (1.2) | 1 (7) | |
| No | 58 (100) | 82 (98.8) | 14 (93) | |
| Thyroid disease | 0.086 | |||
| Yes | 6 (10.3) | 2 (2.4) | 0 (0) | |
| No | 52 (89.7) | 81 (97.6) | 15 (100) | |
| Liver disease | 0.539 | |||
| Yes | 2 (4.3) | 1 (1.2) | 0 (0) | |
| No | 56 (96.6) | 82 (98.8) | 15 (100) | |
| Renal disease | 0.682 | |||
| Yes | 0 (0) | 0 (0) | 1 (7) | |
| No | 58 (100) | 83 (100) | 14 (93) | |
| Other comorbidities | 0.966 | |||
| Yes | 3 (5.2) | 5 (6.0) | 1 (7) | |
| No | 55 (94.8) | 78 (94.0) | 14 (93) | |
| High BMI | 0.066 | |||
| Yes | 9 (15.5) | 4 (4.8) | 0 (0) | |
| No | 49 (84.5) | 79 (95.2) | 15 (100) |
Abbreviation: BMI, Body Mass Index.
a Values are expressed as No. (%).
5. Discussion
While previous studies have explored the safety and efficacy of ECT, there remains a gap in comprehensive data regarding the frequency of comorbidities and their impact on outcomes in diverse populations. According to the results of this study, a total of 156 eligible psychiatric patients who underwent ECT were enrolled. In total, 12.2% of patients had no comorbidities, and 2.6% had three concurrent diseases. Notably, our study revealed significant associations between specific comorbidities and demographic factors. For instance, diabetes and hypertension were more prevalent in older patients (P = 0.003 and P = 0.026, respectively), while high BMI was more common in younger individuals (P = 0.066). These findings are consistent with global trends in metabolic disorders among psychiatric populations.
2.6% of patients were in the elderly age group, which can present significant challenges for anesthesiologists. Due to comorbidities and cardiovascular problems, they require complete assessment before anesthesia. Choosing the right anesthetic drug for the elderly requires special attention because they are at risk of hemodynamic instability, and on the other hand, there are interactions of anesthetic drugs with seizure quality (14). Elderly patients who suffer from serious mood disorders are at risk of poor nutritional status and improper control of underlying diseases such as blood pressure and diabetes (19-21). No cases of mortality or serious complications were reported in this age group. This result aligns with the study by Rhee et al., which showed that the suicide rate in the elderly who underwent ECT treatment was lower than in those who underwent drug treatment. They also did not report any serious complications in their study (22).
In terms of diagnosis, the most common cases of hospitalization were for bipolar disorder. According to existing research, this mood disorder has often been one of the common disorders in psychiatry (23). A total of 26.3% of patients had diabetes, but no complications occurred. Diabetic patients are more susceptible to hemodynamic instability due to disorders in the autonomic system (24). Also, kidney involvement, cardiac, and neurological problems should be considered (21). In line with previous studies (25), the frequency of diabetes was higher among people with mood disorders (26). A total of 12.8% of the patients were hypertensive and also completed the ECT sessions without any complications. Hypertensive patients present challenges for the anesthesiologist and should be evaluated before anesthesia (27).
Another concern in ECT patients is post-electroshock suicides, which indicate treatment failure, but no report was received in this study. This result was found in this study, but it should be noted that many studies have mentioned suicide after the end of the ECT course as a challenge. The absence of post-ECT suicides in our study contrasts with some literature suggesting an increased short-term suicide risk following ECT (28). However, this discrepancy may reflect differences in follow-up duration or patient selection. Notably, our cohort included a higher proportion of bipolar disorder (36.5%) compared to severe unipolar depression, which has been linked to higher post-ECT suicide risk (28-30). On the other hand, it cannot be definitively judged that the treatment response rate was higher in this center. Unlike many other studies, patients’ initial attitude towards suicide or their attempts in this regard were not questioned, and they were generally studied. Additionally, post-ECT suicide appears to be more common among certain conditions such as major depression, which was not considered in this study (28). Non-response to ECT treatment has different causes, one of which is ineffective seizures in the context of anesthetic drug interactions on seizure quality. Therefore, the uncomplicated and complete course of ECT consecutive sessions indicates successful teamwork, including psychiatrists, anesthesiologists, and ECT staff. Comparing these findings with previous studies shows promising results, which can be due to the numerous studies conducted in different areas in this hospital, which explored some essential interventions to maintain patient safety (31, 32). Indeed, despite these comorbidities, no major adverse events were reported during or after ECT, underscoring the safety of the procedure when proper protocols are followed. A study was conducted in which a checklist was developed to prepare ECT patients. The purpose of this checklist was to ensure that patients undergo the procedure in optimal conditions after adequate evaluations (18). Also, the acceptable results in this study indicate appropriate coordination between the psychiatrist and the anesthesiologist.
5.1. Conclusions
This study emphasizes the importance of physicians being aware of the details of the medical center where they work, which was clearly revealed by this study. The results showed that, despite the high prevalence of comorbidities, no significant complications were observed during the procedure and follow-up time, indicating the importance of involved psychiatrists and anesthesiologists always following standard protocols for these patients. Special attention should be paid to their medical conditions, which may be overlooked due to their mental status.
5.2. Limitations
This study provided valuable information. However, a few limitations should be considered. It was a single-center study with a small sample size. Furthermore, a number of patients’ families refused to answer our follow-up phone calls, so these patients were excluded from the survey. It can be assumed that patients’ families who were affected by adverse outcomes such as death may be among this group who left the survey. Another limitation of this study is that other variables such as patients’ marital status, occupation, and more high-risk conditions were not recorded.
