The difficult-to-treat electroconvulsive therapy patient — Strategies for augmenting outcomes

BackgroundSeveral treatment strategies for augmenting outcomes with ECT (concurrent antidepressant treatment, frequency of ECT treatments, hyperventilation and use of remifentanil) are discussed in the context of a difficult clinical case, accompanied by a review of the relevant existing literature.MethodsLiterature on the above aspects of ECT technique was identified via a PubMed search and was critically reviewed.ResultsThere is preliminary evidence that concurrent administration of some antidepressant medications may be useful in the highly treatment resistant patient, though due attention should be given to potential risks in combining these with ECT; reduction of the treatment frequency to twice a week; hyperventilation prior to each treatment; and the use of remifentanil to minimise the dosage of induction anaesthetics with anticonvulsant properties, may be useful strategies to enhance seizure production in cases where a high or rapidly rising seizure threshold is a major impediment to ECT treatment.LimitationsIt should be noted that empirical evidence for the effectiveness of each of the above strategies in producing better outcomes with ECT is not definitive, pointing to the need for further research in these areas.ConclusionsThe above strategies may be useful in clinical ECT practice, particularly in patients who are apparently treatment resistant, but the practitioner should be aware that the level of evidence underpinning these approaches is at present, preliminary.