The recently published paper by Tecoult and Nathan  reviewed 75 patients during 612 electroconvulsive therapies (ECTs) and described complications in 68% of the patients. The authors concluded that ECT, contrary to the prevailing opinion, is not a low-risk procedure. Our department has a long experience with ECT, and we have never encountered as many complications as reported by Tecoult and Nathan. Furthermore, the published data on complications, e.g. in the American Psychiatric Association's recent Task Force Report , differ substantially.
The reason for the high complication rate becomes evident by reading the methods. Only five of 75 patients received the muscle relaxant succinylcholine! Patients had to be restrained by nursing staff during the convulsion. This explains the high number of traumatic complications. Most likely it is also related to the high number of confused and agitated patients since muscle contractions during ECT raise the serum lactate concentration, which has been shown to be related to post-ECT agitation . In addition, insufficient muscle relaxation will increase the intragastric pressure, explaining the high number of respiratory complications due to aspiration. The authors also admit that at least two patients did not have an empty stomach, which is not a problem specific to ECT but due to insufficient patient information and surveillance. One patient even suffered laryngospasm due to chewing gum that was not discovered and removed before anaesthesia.
The authors seem to have taken great care to analyse the complications and side-effects and concluded that - contrary to recent publications - ECT is not a low-risk procedure. We disagree with the generality of this conclusion. To perform ECT without sufficient muscle relaxation is an outdated, obsolete procedure . The paper may serve to emphasize these medical and ethical issues. However, the presented results must not be compared with recent publications on complications rates during ECT with muscle relaxation since 1970 and should not be used to discredit ECT, which is still the most efficient treatment for severe depression.
G. W. Eschweiler
Department of Psychiatry; Tübingen University; Tübingen, Germany
1. Tecoult E, Nathan N. Morbidity in electroconvulsive therapy. Eur J Anaesthesiol
2. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training and Privileging: A Task Force Report of the American Psychiatric Association,
2nd edn. Washington, DC, USA: American Psychiatric Association, 2001.
3. Auriacombe M, Reneric JP, Usandizaga D, et al.
Post-ECT agitation and plasma lactate concentrations. J ECT