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The influence of anaesthetic medication on safety, tolerability and clinical

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The influence of anaesthetic medication on safety, tolerability and clinical

effectiveness of electroconvulsive therapy
Daniela Eser a; Caroline Nothdurfter a; Cornelius Schüle a; Julia Damm a; Yvonne Steng a; Hans-Jürgen
Möller a; Rainer Rupprecht a; Thomas Baghai a
a
Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany

First published on: 01 June 2009

To cite this Article Eser, Daniela, Nothdurfter, Caroline, Schüle, Cornelius, Damm, Julia, Steng, Yvonne, Möller, Hans-
Jürgen, Rupprecht, Rainer and Baghai, Thomas(2009) 'The influence of anaesthetic medication on safety, tolerability and
clinical effectiveness of electroconvulsive therapy', World Journal of Biological Psychiatry,, First published on: 01 June
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 The World Journal of Biological Psychiatry
2009, 110, iFirst article

ORIGINAL INVESTIGATION

The influence of anaesthetic medication on safety, tolerability

and clinical effectiveness of electroconvulsive therapy

DANIELA ESER, CAROLINE NOTHDURFTER, CORNELIUS SCHÜLE, JULIA DAMM,

YVONNE STENG, HANS-JÜRGEN MÖLLER, RAINER RUPPRECHT &
Downloaded By: [World Federation of Societies of Biological Psychiatry] At: 14:30 23 November 2009

THOMAS BAGHAI

Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany

Abstract
Background: Electroconvulsive therapy (ECT) is still considered the most effective biological treatment strategy in
psychiatric disorders. However, the clinical efficacy of ECT may be affected by stimulus variables and the concomitant use
of psychopharmacological medication. Furthermore, most anaesthetics have anticonvulsant properties and therefore might
additionally influence the efficacy of ECT. Method: In order to explore whether different anaesthetics might alter the
effectiveness or safety of ECT we retrospectively analyzed 5482 ECT treatments in 455 patients. Anaesthetics were chosen
according to clinical reasons and comprised thiopental, methohexital, propofol and etomidate. Results: Seizure duration was
significantly affected by the anaesthetic medication with longest seizure activity during thiopental anaesthesia. In addition,
postictal suppression, a further prospective parameter of ECT effectiveness, was significantly higher during propofol and
thiopental anaesthesia. The clinical effectiveness was significantly better during propofol and thiopental anaesthesia. In
contrast, the overall safety did not differ between the anaesthetic groups. Conclusion: Our study supports the hypothesis that
inducting anaesthetic agents have a different impact on seizure duration, ictal and postictal electrophysiological indices and
clinical efficacy of ECT. Compared to thiopental, which has been established as a standard anaesthetic during ECT, also the
modern anaesthetic propofol is a suitable inducting agent.

Key words: Electroconvulsive therapy, concomitant medication, anaesthetics, clinical effectiveness, safety

Introduction The general efficacy and superiority of ECT in

Since the first placebo-controlled double-blind study
in the early 60s indicating the effectiveness of
electroconvulsive therapy (ECT) (Greenblatt et al.
1964), a variety of reports, which have been sum-
marized in a comprehensive review (ECT Review
Group 2003), described the excellent therapeutic
effectiveness of ECT.
Pharmacotherapy-resistant major depression is still
the most frequent indication for ECT. In addition,
ECT is also an effective treatment strategy in
other psychiatric disorders such as schizophrenia
(Tharyan and Adams 2005), bipolar disorder
(Grunze 2005; Gitlin 2006), obsessive-compulsive
disorder (Dell’Osso et al. 2005) or personality
disorders comorbid with depression (DeBattista and
Mueller 2001; Newton-Howes et al. 2006) in cases of
pharmacotherapy treatment failures.
comparison to antidepressant pharmacotherapy has
been described in several controlled clinical trials
(ECT Review Group 2003). In non-treatment-resis-
tant depression response rates between 80 and 90%
(Prudic et al. 1996, 1990) and even up to 100%
(Sackeim et al. 2000) have been observed, although
in drug-resistant depression lower response rates
have to be expected (Sackeim et al. 2000). Further-
more, the efficacy of ECT not only depends on
treatment history but is especially influenced by
stimulus parameters such as electrode placement
and stimulus intensity. In general bilateral ECT is
considered to be more effective than unilateral ECT
and high-dosage ECT has been suggested to be more
effective than low-dosage ECT (ECT Review Group
2003). Furthermore, several investigations suggested
that concomitant psychopharmacological treatment

Correspondence: Daniela Eser, MD, Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Nussbaumstr. 7,
80336 Munich, Germany. Tel:
49 89 5160 3423. Fax:
49 89 5160 5524. E-mail: Daniela.Eser@med.uni-muenchen.de

(Received 15 January 2009; accepted 18 March 2009)

ISSN 1562-2975 print/ISSN 1814-1412 online # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.1080/15622970902960897
 2 D. Eser et al.
administered during the course of ECT may alter the
efficacy and safety of ECT (Baghai et al. 2006;
Nothdurfter et al. 2006). In a first retrospective
investigation we found that concomitant administra-
tion of mirtazapine and atypical antipsychotics en-
hanced the therapeutic effectiveness of ECT.
Nevertheless, even if ECT is performed as a
monotherapy without any concomitant psychophar-
macological medication the applied general anaes-
thetics might alter the efficacy of ECT.
In general, drugs used for anaesthesia during
ECT should possess a rapid onset and a short
duration of action. Therefore, the barbiturate
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derivate methohexital has been established since
the 60s as the gold standard for anaesthesia during
ECT. Meanwhile, further short-acting anaesthetics
such as the barbiturate thiopental, the imidazole
derivative etomidate and propofol have been estab-
lished for general anaesthesia during ECT.
However, due to their GABA-agonistic properties
methohexital, thiopental and propofol may display
anticonvulsant properties and unfavourably shorten
ECT-induced general seizure activity.
Therefore, in order to explore whether different
anaesthetics would have an impact on the efficacy of
ECT we retrospectively compared the seizure dura-
tions, ictal electrophysiological parameters and clin-
ical outcomes during ECT. Furthermore, we
questioned whether these anaesthetics would influ-
ence the safety of ECT in terms of cognitive and
cardiovascular side effects.
Materials and methods
Patients
We retrospectively analyzed 5482 ECT treatments of
455 patients treated from 1995 up to 2003. During
the observation period 63 patients received more
than one treatment series and therefore a total of 518
treatment series were recorded. Demographic data
including major diagnostic groups and ECT treat-
ment modalities for the whole population have been
published elsewhere (Baghai et al. 2006).
In order to exclude confounding effects of psy-
chotropic medication only treatments done without
concomitant medication were analyzed. However, as
the analysis of electrophysiological and clinical
parameters between the group of no concomitant
medication (813 treatments) and the group of
concomitant non-benzodiazepine hypnotics (997
treatments) revealed no statistical significant differ-
ences (Baghai et al. 2006), no relevant confounding
effects were expected and data from all 997 treat-
ments entered the further analysis.
In these 997 treatments the two major diagnostic
groups were treatment-resistant unipolar or bipolar
major depression (752 treatments; 75.4%) and
paranoid hallucinatory schizophrenia or schizoaffec-
tive disorder (198 treatments; 19.9%). Only 47
treatments (4.7%) were done in rare diagnoses such
as Gilles-de-la-Tourette syndrome or personality
disorder with concomitant depressive syndrome.
Before starting the ECT series patients gave their
written informed consent for ECT procedures and
anaesthesia separately.
ECT treatments (Weiner et al. 1988)
ECT treatment modalities have been described in
detail elsewhere (Baghai et al. 2006). During 1995
up to June 2000 the Thymatron DGxTM device and
from July 2000 the Thymatron System-IVTM was
used to perform ECT. Both devices provide stimulus
delivery in form of constant current (900 mA) bi-
directional pulse wave. The voltage was up to 450 V,
impulse width was 0.51 ms (mean9SD: 0.559
0.13 ms), the frequency was 2070 Hz (52.9916.8
Hz) and the length of a stimulus train was 0.58 s
(5.292.0 s).
In the case of unilateral stimulation, stimulus
intensity was chosen according to the modified age
method and according to the half-age method in
case of bilateral stimulation (Abrams 2002).
Unilateral treatment electrodes were placed ac-
cording to the d?Elia method (d’Elia 1970; d’Elia
and Raotma 1975). In cases of therapy resistance or
if former unilateral ECT treatments were inefficient,
bitemporal electrode placement was recommended.
Since electrode placement was not recorded during
clinical routine treatments up to 1999 these data are
lacking in 28.8% of analyzed treatments. Since 2000
this information is available and 44.2% of analyzed
treatments were performed unilateral, 27.0% bilat-
eral. 89% (887) of treatments were performed as
acute ECTs, while 11% (110) of treatments were
performed as continuation ECT.
The maximal charge was 504 mC during 1995 to
2001 and 1008 mC since January 2002. The mean
postictal suppression index was 85.3914.1%, the
mean stimulation energy was 57.7926.8%.
Up to June 2002, seizure monitoring included one-
lead EEG and EMG monitoring. From July 2002
onwards, two-lead EEG, EMG and ECG monitoring
was available. The two-lead EEG electrodes were
positioned left and right frontopolar (FP1A1 and
FP2A2) and over the ipsilateral mastoid. EMG
conduction was placed in 510 cm distances over
the flexor carpi ulnaris muscle. The mean seizure
duration was 31.3915.7 s (EEG) and 18.3911.2 s
(EMG), which is a little bit shorter than in our

previous investigations (Baghai et al. 2006;
Nothdurfter et al. 2006), and this may be due to
the fact that only treatments done without any
concomitant psychotropic medication were analyzed.
Anaesthesia
Anaesthetic agents were chosen according to clinical
reasons in order to achieve adequate seizures and
with regard to individual clinical conditions. The
most frequent administered anaesthetic was thio-
pental, which was used in 51.7% of treatments
(mean dosage9SD: 368.9997.6 mg; dose per kg
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body weight9 SD: 5.090.1 mg/kg). Propofol was
administered in 18.9% (172.1946.3 mg; dose per
kg body weight9 SD: 2.490.6 mg/kg), methohex-
ital in 8.2% (138.4926.4 mg, dose per kg body
weight9 SD: 1.990.1 mg/kg) and etomidate in
4.4% of treatments (32.2396.5 mg; dose per kg
body weight9 SD: 0.490.02 mg/kg). In 16.9% of
treatments information about anaesthetic agents was
not recorded. For muscle relaxation succinylcholine
or pyridostigmine, together with atracurium for
precurarisation, were used.
Electrophysiological measures
Regular monitoring of EEG and EMG quality and
all treatment procedures was performed by senior
psychiatrists. In addition to the duration of general-
ized convulsions measured with EEG and EMG
further electrophysiological parameters of ECT
effectiveness entered the analysis.
The postictal suppression index (PSI) shows how
fast and complete the EEG amplitude flattens
directly after the convulsions. The PSI is calculated
from the quotient of the mean EEG amplitude
during a 3-s derivation 0.5 s after the end of
convulsions and the mean amplitude of a 3-s passage
during the convulsions. Its unit ‘‘% suppression’’ is
highly positively correlated to the probability of
therapeutic efficacy (Suppes et al. 1996). Restimula-
tion is recommended if the PSI is lower 80% (Weiner
et al. 1991; Nobler et al. 1993). The convulsion
energy index (CEI) is a measure of the intensity of the
ictal response after electrical stimulation (mV ×s)
(Weiner et al. 1991). It is calculated from the product
of the mean EEG amplitude and the duration of
convulsions. The convulsion concordance index
(CCI) is a measure for the intracerebral general-
ization of the convulsions (Swartz and Larson 1986).
It is calculated as: (1(EEGEMG)/(EEG

EMG)) 100 (EEG and EMG represent the dura-
tion of the convulsions). According to the Thyma-
tron manufacturer Somatics restimulation should be
considered, if the CCI is below 51%.
Electroconvulsive therapy and anaesthetic medication 3
Clinical assessments
Clinical data and ECT treatment data recorded in
the patient records and data from ECT device
printouts were recorded together in a relational
database (Microsoft Access 2000, 2003). Diagnoses
were assessed according to ICD-10 (World Health
Organization 1992) and the severity of disease
according to the clinical global impression scale
(CGI, Item 1) (National Institute of Mental Health
1976). CGI scores were assessed after each electro-
convulsive treatment and additionally every week. In
addition therapeutic response and adverse effects
such as cognitive impairment and cardiovascular
side effects were recorded systematically after each
ECT treatment (CGI, Item 3.1 and Item 3.2
respectively). Serious adverse events, if applicable,
were recorded in free form in the patient’s record.
Clinical, technical and electrophysiological ECT
parameters, such as length of convulsions measured
with EEG and EMG, PSI, CEI and CCI were
registered after each treatment.
Statistical analyses
SPSS for Windows (Release 15, SPSS Inc., Chicago,
IL, USA) was used for statistical analyses. Mean
differences in demographic and clinical variables
between the treatment groups were compared using
independent samples. Student’s t-tests and x2-tests
and a one-way analysis of variance (ANOVA proce-
dure) were performed to detect significant differ-
ences in electrophysiological variables and clinical
mean scores between the divergent treatment
groups. In the case of significant effects, Bonferroni
correction was used to control for multiple testing.
Correlations between PSI and CGI or dose of the
given anaesthetic were calculated with Pearson
correlation coefficient. The level of significance was
set at 0.05.
Results
Demographic data and ECT treatment modalities
according to the different anaesthetic groups are
shown in Table I. After exclusion of those ECT
treatments where no record of anaesthetic medica-
tion was available (194 treatments) a total of 62.5%
of treatments were done with thiopental as inducting
agent, followed by propofol (22.4%), methohexital
(10.1%) and etomidate (5%).
Due to the lack of randomization significant
differences in demographic data could be observed.
In the group of etomidate anaesthesia patients were
significantly older (F(3,802) 33.4; P B0.001) and
the proportion of males was significantly higher in
this group.
 4 D. Eser et al.
Table I. Demographic data and ECT treatment parameters according to the anaesthetic subgroups.

Anaesthetics

P (x2-test,
Thiopental Propofol Methohexital Etomidate ANOVA)

n (%) 502 (62.5%) 180 (22.4%) 81 (10.1%) 40 (5%)

Sex (M/F) 34.3/65.7% 28.9/71.1% 50.6/49.4% 60.0/40.0% B0.001
Age (mean9SD) 51.75913.7 47.5913.8 48.7914.2 70.796.8 B0.001
Range 2284 2480 2871 6277
Diagnoses (ICD-10)
F2 14.3% 8.3% 58.0% 0%
F3 78.5% 88.9% 42.0% 100%
Others 7.2% 2.8% 0% 0%
ECT treatment modalitis
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Unilateral/bilateral (%) 44.2/14.5% 43.3/24.4% 48.1/51.9% 40.0/25.0% B0.001

Charge (mean9SD, mC) 260.29113 246.39108.3 388.69164.3 400.79146.6 B0.001
Duration (mean9SD, days) 34.8925.4 63.9994.8 84.99107.4 28.197.9 B0.001

F2, schizophrenia and schizoaffective disorder (ICD-10); F3, unipolar and bipolar major depression (ICD-10); Others, rare diagnoses such
as Tourette syndrome or personality disorders with depressive syndromes.

ECT treatment modalities differed significantly
between the four treatment groups. In contrast to
thiopental, propofol or etomidate the overall treat-
ment duration was significantly longer with metho-
hexital (ANOVA F(3,802) 23.9; P B0.001) and
Bonferroni corrected post-hoc tests showed a sig-
nificant longer course of ECT in the methohexital
compared to the thiopental and etomidate group.
In addition, we detected also significant differences
in applied stimulation energies (ANOVA F(3,802) 
43.2; P B0.001). Bonferroni corrected post-hoc test
showed a significantly higher applied charge during
etomidate anaesthesia (mean9SD: 400.79146.6
mC) compared to methohexital (mean9SD: 388.6
9164.3 mC), thiopental (mean9SD: 260.2.7 9113
mC) or propofol (mean9SD: 246.3 9108.3 mC).
Figure 1. Mean duration of generalized convulsions in EEG- and
EMG-derivations. EEG: significantly longer convulsions in thio-
pental treated patients compared to propofol, methohexital and
etomidate. EMG: no statistical significant differences between
treatment groups.
Concerning the duration of generalized convul-
sions measured with EEG and EMG ANOVA
revealed significant differences in the duration
of convulsions between the four treatment
groups (Figure 1: EEG: F(3,750)8.81, PB
0.001; EMG: F(3,583)2.9, P 0.036). Bonfer-
roni corrected post-hoc tests revealed a significant
longer EEG-derived duration of convulsions in
patients treated with thiopental compared to propo-
fol (P 0.044), methohexital (P B0.001) and eto-
midate (P 0.027). In contrast, no significant
differences in EMG-derived duration of convulsions
were observed after post-hoc correction.
Regarding further electrophysiological parameters
of ECT effectiveness only the PSI differed signifi-
cantly between the four anaesthetic treatment
groups (Figure 2: F(3,586) 4.33, P 0.005). Bon-
ferroni corrected post-hoc test revealed a signifi-
cantly lower PSI after ECT treatments with
etomidate compared to propofol and thiopental.
However, PSI did not correlate with the dose of
the given anaesthetics. In contrast, CEI and CCI did
not differ significantly between the treatment groups
(Figure 2).
Furthermore, we questioned whether the anaes-
thetic medication affected the clinical efficacy and
tolerability of ECT. During the course of ECT
treatments the clinical effectiveness was significantly
influenced by the concomitant anaesthetic medication
(F(3,500)2.97; P0.032) (Figure 3). Bonferroni
corrected post-hoc tests showed a significant lower
severity of disease (CGI Item 1) in the propofol group
compared to methohexital (P0.031). In addition,
improvements after single ECT treatments (CGI Item
3.1) differed significantly between the groups
(F(3,541)29.99; PB0.001). Bonferroni corrected
 Electroconvulsive therapy and anaesthetic medication 5
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Figure 2. Quality of convulsions in terms of postictal suppression index (PSI), convulsion energy index (CEI) and convulsion concordance
index (CCI). PSI: significantly higher indices in propofol and thiopental treated patients. CEI and CCI: no statistical significant differences
between the treatment groups.

post-hoc tests showed the best clinical improvements
in propofol treated patients compared to thiopental
(PB0.019), methohexital (P B0.001) and etomidate
(PB0.001). Furthermore treatments done with thio-
pental were more effective then treatments with
methohexital (PB0.001) or etomidate (PB0.001)
(Figure 3). As to be expected PSI, as an electrophy-
siological parameters of ECTeffectiveness, correlated
negatively with CGI Item 1 (r0.12; P0.03) and
therefore positively with lower severity of disease.
In contrast, the overall safety, in terms of cognitive
impairment and cardiovascular side effects measured
with CGI Item 3.2 did not differ between the
treatment groups (F(3,213) 1.27; P 0.28) (Fig-
ure 4). However, considering transient cognitive
impairment alone, a significant difference could be
observed (F(3,690) 6.8; P B0.001). Bonferroni
corrected post-hoc tests revealed less impairment
with thiopental and propofol compared to metho-
hexital (P B0.001 and P 0.009 respectively).
 6 D. Eser et al.
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Figure 3. Clinical efficacy: Significantly lower severity of disease in patients receiving propofol (CGI Item 1) compared to methohexital.
Significantly better improvement after single treatments done with etomidate and thiopental (CGI Item 3.1). CGI Item 1: severity of
disease (lower score indicates lower severity of disease); CGI Item 3.1: efficacy (higher score indicates better efficacy).

Transient cardiovascular adverse events were only
rarely recorded during ECT treatments (11.5% of
treatments) and were predominantly bigemini (4.4%
of treatments), short periods of asystolia (1.5% of
treatments), ventricular extrasystoles (1.2% of treat-
ments) and sinus tachycardia (1.1% of treatments)
with usually no necessity for treatment. Concerning
the rate of cardiovascular side effects x2-test showed
no significant discrepancies between the different
anaesthetic groups (x2 (3,802) 1.82; P 0.61).
Discussion
Due to their GABAergic properties many anaes-
thetics have antiepileptic activity and therefore might
alter the ECT induced seizure duration. Therefore,
in order to investigate the impact of different general
anaesthetics on effectiveness and safety of ECT we
retrospectively analyzed ECT treatments performed
during clinical routine. In order to exclude putative
confounding effects of psychopharmacological med-
ication only treatments performed without any
concomitant medication entered the analysis.
During the observation period the general anaes-
thetics thiopental, methohexital, propofol and eto-
midate, which were applied according to individually
clinical conditions, had a significant impact on
seizure duration, postictal suppression index, clinical
efficacy and side effects of ECT.
Regarding the durations of convulsions measured
with EMG derivations we found no significant
differences between the anaesthetic groups. How-
ever, as the cuff-method was not used to detect
EMG-derived convulsions the EMG deduction is
probably less an indicator for the duration of general
convulsions but reflects the degree of comparable
sufficient muscle relaxation in clinical routine.
In contrast, with regard to EEG derived seizure
durations we found significant differences between
the anaesthetic groups. The duration of general
convulsions were longest in ECT treatments per-
formed under thiopental anaesthesia. Although both
barbiturate derivatives methohexital and thiopental
have been suggested to be comparable applicable for

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Figure 4. Overall safety (CGI Item 3.2): overall safety did not differ between the treatment groups. Transient cognitive impairment alone
was significantly more often observed with methohexital compared to thiopental or propofol. CGI Item 3.2: adverse effects (lower score
indicates better tolerability of the treatment).
general anaesthesia during ECT (Stromgren et al.
1980; Dew et al. 2005) we found significant shorter
EEG-derived seizure durations during methohexital
anaesthesia. Furthermore and in contrast to the
former observation that propofol decreases seizure
durations (Dwyer et al. 1988; Malsch et al. 1994;
Martensson et al. 1994; Geretsegger et al. 1998) we
found comparable seizure durations between propo-
fol and methohexital anaesthesia.
One possible explanation for the differences in
EEG seizure duration between thiopental and meth-
ohexital might be the different applied stimulation
energies. The stimulus intensity was chosen accord-
ing to the modified age method and therefore was
significantly higher during etomidate and methohex-
ital anaesthesia due to the older age of patients in
these groups. The seizure threshold is increasing
with increasing age and may therefore cause shorter
seizures with higher age. Furthermore, also higher
stimulation energy in older patients might shorten
the convulsions (Frey et al. 2001), and therefore the
significant higher applied charge in the methohexital
group might have shortened EEG seizure duration.
However, while applied charges were also signifi-
Electroconvulsive therapy and anaesthetic medication 7
cantly higher in the thiopental compared to the
propofol group, EEG derived seizure durations were
significantly shorter in the latter group. Therefore,
the more potent anticonvulsant properties might
have shortened the seizure duration during propofol
compared to thiopental anaesthesia.
Nevertheless, several studies indicated that no
absolute correlation exists between seizure duration
and efficacy of ECT. Therefore, other electrophy-
siological indices have been established to evaluate
the effectiveness of ECT. In terms of these indices
we found no significant differences in CEI and CCI.
In contrast, the PSI, which correlates positively with
the clinical effectiveness of ECT (Suppes et al.
1996), was significantly affected by the anaesthetic
medication. The PSI was significantly lower during
etomidate anaesthesia, while it did not differ be-
tween thiopental, methohexital or propofol anaes-
thesia.
This is of particular interest as the use of propofol
during ECT has been evaluated controversially.
Propofol exerts more potent anticonvulsant effects
than other anaesthetics (Avramov et al. 1995) and in
line with our data has been reported to shorten ECT-
 8 D. Eser et al.
derived seizure durations (Avramov et al. 1995;
Matters et al. 1995; Geretsegger et al. 1998; Gazdag
et al. 2004; Grati et al. 2005). Therefore, it has been
suggested that propofol is less applicable for general
anaesthesia during ECT (Martin et al. 1998).
In contrast, further studies indicated that the
potent anticonvulsant effects of propofol do not
diminish the clinical efficacy of ECT (Fear et al.
1994; Malsch et al. 1994; Geretsegger et al. 2007).
In line with these results and in line with the finding
of comparable PSIs during propofol, methohexital
(Geretsegger et al. 1998; Gazdag et al. 2004) and
thiopental anaesthesia (Geretsegger et al. 2007) also
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our results indicated that the PSI may not be altered
during propofol anaesthesia.
With regard to clinical efficacy of ECT we found
significant differences, although the severity of disease
did not differ at the beginning of ECT treatments.
In terms of severity of disease (CGI item 1)
patients which underwent propofol anaesthesia had
a significant better outcome compared to patients
with methohexital anaesthesia. Furthermore, during
the course of ECT the mean amelioration of
symptoms indicated by the CGI Item 3.1 was
significantly more pronounced in patients treated
with propofol and thiopental compared to etomidate
or methohexital.
Therefore, these clinical results parallel the ob-
servation of effective seizures during propofol anaes-
thesia and suggest that the PSI in contrast to EEG-
derived seizure duration may be a more reliable
parameter to estimate the clinical effectiveness of
ECT. This assumption was underlined by the
finding that PSI correlated negatively with CGI.
Nevertheless, it has to be considered that we studied
only ECT treatments done without any concomitant
psychotropic medication. Therefore, in cases of
combination therapies other parameters may be
more suitable to predict clinical effectiveness of
ECT (Baghai et al. 2006).
In contrast to clinical effectiveness the overall
safety in terms of cognitive impairment and cardio-
vascular side effects measured with CGI Item 3.2
did not differ between the anaesthetic groups.
However, regarding transient cognitive disturbances
alone we found a significantly lower impairment in
patients treated with propofol and thiopental com-
pared to methohexital. Therefore, the favourable
effects of propofol on the clinical effectiveness of
ECT were paired with good tolerability and a
favorable side effect profile compared to methohex-
ital. Nevertheless, due to the retrospective nature of
our study we cannot fully exclude that the incidence
of minor cardiovascular events differed between the
different anaesthetic groups. Several studies sug-
gested that minor cardiovascular side effects such as
short-term asystoles or cardiac arrhythmias are
much more frequent during ECT, when quantified
by echocardiography, especially in the patients at
cardiac risk (Mokriski 1992; Agelink 1998; Sartorius
2007). However, in line with our study results severe
cardiac side effects have been reported only rarely
and therefore ECT has been suggested as safe
treatment option even in patients with preexisting
cardiac risk factors (Zielinski 1993; Rice 1994;
Agelink 1998).
As limitations of our study it has to be considered
that the number of patients differed between the
anaesthetic groups and that the retrospective ana-
lyses were treatment session oriented and not patient
oriented. This includes the putative disadvantages
that we cannot fully exclude that differences in group
populations affected our study results and that
single-treatment series in treatment-resistant pa-
tients, which may have received more treatments
than other patients, might have influenced our
results in a certain way. However, the fact that we
analyzed only ECT treatments done without any
concomitant psychotropic medication diminishes
the probability that treatment-resistant patients
were over-represented in our study population.
In conclusion, our results show an excellent
tolerability of ECT monotherapy irrespective of
anaesthetic agent used. Furthermore, the present
data underline that not only the barbiturate derivates
methohexital and thiopental, which have been es-
tablished over decades as standard anaesthetics
during ECT (Martin et al. 1998; Ding and White
2002), but also propofol, are suitable inducting
agents during ECT. Also other modern anaesthetics
such as ketamine might be suitable and even
favourable for the induction during ECT. Of course,
this cannot be proven in our study due to the
naturalistic and retrospective design and due to the
lack of ketamine anaesthesia. However, our analysis
provides data encouraging further controlled studies
to answer whether further anaesthetics would en-
hance the effectiveness of ECT.
Acknowledgements
The authors would like to thank Mrs M. Ertl, Mrs S.
Rauch and Mr K. Neuner for patient nursing, ECT
organization and database management. Parts of this
study were done in the framework of the doctoral
thesis of Mrs Yvonne Steng which has been sub-
mitted to the Faculty of Medicine, University of
Munich.

Conflict of interest
Each author certifies that he or she has no commer-
cial associations that might pose a conflict of interest
in connection with the submitted article.
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