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The Safety and Efficacy of Benzodiazepine-Modified Treatments as a Special Form of Unmodified ECT

Shah, Nilesh DPM, MD, DNB*; Mahadeshwar, Sarika MD†; Bhakta, Savita DPM‡; Bhirud, Mahesh MD§; Fernandes, Praveen MD∥; Andrade, Chittaranjan MD¶

doi: 10.1097/YCT.0b013e3181d2711f
Original Studies

Background: Muscle relaxants reduce musculoskeletal morbidity with electroconvulsive therapy (ECT) but need to be administered under general anesthesia. The administration of anesthesia is not always possible for patients prescribed ECT. Consequently, unmodified ECT is still widely practiced, especially in developing countries.

Methods: We prospectively assessed musculoskeletal morbidity in consecutive patients who received unmodified bitemporal ECT during a part or the whole of their ECT course. All patients were pretreated with an intravenous benzodiazepine (usually diazepam, 10 mg) to effect sedation, anxiolysis, and limited skeletal muscle relaxation. Anteroposterior and lateral digital x-rays of the thoracolumbar spine were obtained after the last unmodified treatment.

Results: Fifty-six patients aged 11 to 49 years and with a mean body mass index of 23.0 received a total of 162 (mean, 2.9) unmodified ECTs. There was significant attenuation of psychopathology ratings. Against our expectations, no patient developed clinical or radiological evidence of orthopedic morbidity; however, in 2 patients, the x-rays revealed old spinal fractures. Twelve patients had spots of oral bleeding after ECT. Whereas 5 patients experienced mild, transient, self-limiting postictal confusion, only one had confusion which required medical termination. Five patients complained of body ache and one of memory impairment. There were no other adverse events.

Conclusions: The complete absence of orthopedic morbidity with benzodiazepine-modified ECT contrasts with historical descriptions of a 20% to 40% risk with unmodified ECT. We speculate that the limited muscle relaxant action of the pre-ECT parenteral benzodiazepine may have had protective effects. If so, if ECT is urgently indicated but anesthesia and hence conventional muscle relaxants cannot be administered, benzodiazepine-modified ECT may be a safer alternative to unmodified ECT. This suggestion merits wide attention because of its public health importance in countries with poor medical infrastructure, where unmodified ECT is still widely practiced.

From the *Department of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Bombay, India; †Department of Psychiatry, D.Y. Patil Medical College, New Bombay, India; ‡Department of Psychiatry, Sucker Hillside Hospital, Glen Oaks, NY; §N.D.M.V.P.S. Medical College, Nasik, India; ∥Department of Psychiatry, Creighton University School of Medicine, Omaha, NE; and ¶Department of Psychopharmacology,National Institute of Mental Health and Neurosciences, Bangalore, India.

Received for publication November 13, 2009; accepted December 4, 2009.

Reprints: Chittaranjan Andrade, MD, Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore 560 029, India (e-mail: andradec@gmail.com; andrade@nimhans.kar.nic.in).

None of the authors of this paper have any conflict of interest, financial or otherwise, with the contents of the paper. The study was unfunded.

© 2010 Lippincott Williams & Wilkins, Inc.