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Augmentation Strategies in Electroconvulsive Therapy

Loo, Colleen FRANZCP, MD*†‡; Simpson, Brett FRANZCP; MacPherson, Ross PhD, FANZCA

doi: 10.1097/YCT.0b013e3181e48143
Invited Review

Electroconvulsive therapy (ECT) is a highly effective treatment, but strategies to enhance therapeutic outcomes are occasionally needed. This review examines the evidence for approaches used for enhancing seizure production: hyperventilation, pretreatment with xanthines, and use of remifentanil or ketamine in ECT anesthesia. Hyperventilation may be a useful strategy to enhance seizure production, but its effects on ECT outcomes have not been systematically studied and require further research. Pretreatment with caffeine, theophylline or aminophylline (xanthines) prolongs the duration of ECT seizures but has not been clearly shown in controlled trials to increase efficacy. Caution is also warranted because their use may be associated with significant adverse effects. There are case reports of the usefulness of remifentanil in assisting seizure induction by reducing the dose of barbiturate anesthetic required, but there are no controlled data on whether it independently enhances efficacy outcomes. Preliminary evidence suggests that ketamine and ECT may have synergistic antidepressant effects, although this needs to be further examined in randomized controlled trials.

From the *School of Psychiatry, University of New South Wales, Sydney; †Black Dog Institute, Prince of Wales Hospital, Randwick; ‡St George Hospital, Kogarah; §Older Adult Mental Health Service, St George Hospital, Kogarah; and ∥Department of Anaesthesia and Pain Management, Royal North Shore Hospital, St Leonards, New South Wales, Australia.

Received for publication December 21, 2009; accepted March 12, 2010.

Reprints: Colleen Loo, FRANZCP, MD, Black Dog Institute, Prince of Wales Hospital, Barker St, Randwick, New South Wales 2031, Australia (e-mail:

This work was supported in part by the National Health and Medical Research Council (Australia) project grant no. 568678.

© 2010 Lippincott Williams & Wilkins, Inc.