Elderly patients experience stress to their cardiovascular system during ECT and must be evaluated carefully for their ability to tolerate changes such as bradycardia, tachycardia, hypertension, or arrhythmia (32). The specific indications and relative contraindications are well described in the APA task force report (7).

Patients who reside in nursing homes have higher rates of depression (55,56), upward of 40% in some studies, with high rates of medical comorbidity and disability over long periods of time (49,50). These patients are at high risk for mortality, especially the “old-old,” who are cognitively impaired, are less functional, and are in poorer health (51). Treating depression in the institutionalized, ill, elderly patient may or may not improve survival (51) but likely improves quality of life and outcomes of other comorbid medical conditions (51–53).

Treating depression in elderly patients is challenging on all levels. ECT is a very reasonable choice, particularly for the elderly patient who is medically compromised and is either not tolerating or not responding to medications.

ECT Use During Pregnancy

Treating major mental disorders during pregnancy poses a clinical dilemma, due to potential complications for both the mother and the fetus. The physiological changes of pregnancy, including plasma volume, glomerular filtration rate, intestinal absorption, and protein binding, leave the mother vulnerable to increased medication side effects (57). As well, medications may cause morphologic and behavioural teratogenicity, toxicity, and withdrawal in the fetus (58). These risks, however, must be weighed against the risks of severe untreated mental illness. The consequences (for example, varieties of malnutrition, refusal of prenatal care, inability to follow medical recommendations, attempts at premature self-delivery, substance abuse, suicide, and violence or neonaticide) can be fatal for mother and baby (59).

The APA practice guidelines (60,61) suggest ECT as a primary treatment for major depression and bipolar disorder during pregnancy.

ECT has been reported as a treatment with high efficacy and low risk in the management of these disorders during all 3 trimesters of pregnancy, as well as postpartum (7,62–64).

The morbidity from continued illness and the incompletely understood adverse effects of psychotropic drugs have increased ECT’s attractiveness for pregnant patients with severe depression, especially when they have associated high-risk conditions. Medications that pose some teratogenic risk during the first trimester include benzodiazepines, antipsychotics, lithium and other mood stabilizers (63,65,66), but not tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) (67,68). Later in pregnancy, antipsychotics have been noted to cause neonatal motor abnormalities, and benzodiazepines are associated with neonatal hypotonia, apnea, and temperature dysregulation (65,68). TCA treatment has been reported to cause anticholinergic effects and withdrawal symptoms in neonates (63). Lithium is associated with premature labour, polyhydramnios, neonatal hypothyroidism, or lithium toxicity (63). In terms of teratogenic risk, ECT use in pregnancy is considered relatively safe. Succinylcholine is not transferred to any extent across the placenta, and there is little effect on the fetus (69). The barbiturates used for brief anesthesia have not been fully studied, but the short exposure period is unlikely to cause teratogenicity (70). For the same reasons, neonatal toxicity is relatively low with ECT in the third trimester of pregnancy (71).

According to some reports, depression during pregnancy has come to be seen as a specific indication for the first-line use of ECT (73–75). There are, to date, no prospective controlled studies that compare rates of ECT complications during pregnancy with those of other treatments vs no treatment. In the absence of such studies, the available data are case reports that have been reviewed by Miller (62). This recent review of ECT during pregnancy summarizes 300 case reports drawn from period 1942 to 1991. Of the 300 cases, 28 (9.3%) reported complications associated with ECT during pregnancy (62). In many of these cases, there is a lack of detailed information on the use of psychotropic medication, diagnosis, number of treatments, trimester of pregnancy, and anesthetic procedures.