A current survey and literature review of seizure induction difficulties during electroconvulsive therapy and how to deal with them

Abstract

We conducted a questionnaire survey of members of the General Hospital Psychiatric Association electroconvulsive therapy (ECT) committee and ECT training centers to investigate the number of “difficult-to-treat with ECT cases” (DEC) in which therapeutic seizures could not be induced by 504 mC stimulation (the maximum dose of Thymatron^®︎ in Japan) of ECT, basic procedure for DEC, seizure augmentation techniques, and opinions on the introduction of a device capable of 1008 mC stimulation (200% device). Of the 42 facilities that responded, 32 had experienced at least one DEC and 11 facilities reported experiencing six or more DEC within the last 3 years. Nearly all centers reported adjustments of benzodiazepine receptor agonists, and around 90% reported the use of thorough hyperventilation and reduced anesthetic dose as basic procedures for DEC. Several strategies of seizure augmentation (e.g. use of remifentanil, switching anesthetic to barbiturate, changing the pulse width, and prolonging anesthetic-ECT interval) were commonly used by the 10 centers that did not experience any DEC. There was disagreement about the introduction of a 200% device. Further knowledge on the effectiveness and risks of the device and other methods of seizure augmentation is needed.