Review and Update of Anesthetic Management for Electroconvulsive Therapy: A Narrative Review

Electroconvulsive therapy (ECT) is a well-established treatment for severe psychiatric disorders, and its role in modern-day psychiatry continues to expand with rising rates of complex mental illnesses. ECT has proven to be an effective treatment for conditions such as treatment-resistant depression, catatonia, bipolar disorder, schizophrenia, and other serious mental health disorders. Individuals who are resistant to or have contraindications against conventional pharmacologic therapies can particularly benefit from ECT. The procedure involves inducing a brief and controlled generalized seizure by passing an electrical stimulus through a patient's cerebral cortex. The safety of ECT was historically an area of concern due to injuries from the involuntary convulsions during the induced seizure. The use of general anesthesia and adjunct muscle-relaxing agents has made ECT considerably safer in the modern day. The goal of anesthesia in ECT is to induce a quick sedation with adequate depth, to prevent pain and injury from convulsions, and to provide a targeted amnesia. However, many anesthetic agents also function as anticonvulsants and consequently can affect the seizure threshold. The benefits of ECT are inextricably linked to the quality and duration of the induced seizure, therefore, careful consideration must be given to the choice of anesthetic. Alongside its effects on seizure threshold, anesthesia can also affect hemodynamic stability, cardiovascular response, and even the recovery course following ECT. Furthermore, special populations such as elderly patients, pregnant individuals, or those with significant comorbidities require an individual-based approach to anesthetic management. Ultimately, the choice of anesthetic plays an integral role in the therapeutic benefit of ECT. Therefore, strategic management of the anesthetic component of the procedure is critical in improving patient outcomes. This narrative review intends to analyze the dynamic role of anesthesia in ECT by synthesizing current clinical evidence on physiologic changes, pharmacodynamics, procedure optimization, and management of comorbidities and complications.