Electroconvulsive Shock Therapy Indications, History, Side Effects and More

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Electroconvulsive therapy (ECT) is a medical treatment performed under anesthesia most commonly used for patients with treatment-resistant depression and catatonia. A generalized tonic-clonic seizure is induced utilizing a small electrical current applied to the head. This seizure lasts from 30-60 seconds. 

ECT is the most rapid and effective treatment available for geriatric patients with psychosis, depression, or bipolar disorder, according to research studies.1

Many believe ECT to be the most effective treatment for depression for all patients. 

This procedure has been a topic of controversy ever since Ken Kesey released “One Flew Over the Cuckoo’s Nest” in 1962. This book was made into a movie in 1975 starring Jack Nicholson and depicted ECT and lobotomies as a method of torture utilized in psychiatric hospitals. This did not sit well with the counterculture movement.

ECT is one of the safest procedures performed under general anesthesia, with only two to four deaths per 100,000 treatments. This is likely because ECT is a short procedure.

History of ECT

The first convulsive therapy was performed in Budapest in 1934 using pentylenetetrazole (Metrazol). Metrazol was used as a circulatory and respiratory stimulant but caused seizures in high doses. It was useful for depression as a convulsant, but side effects and uncontrolled seizures limited its use. 2

Ladislas Meduna gave an IM dose of camphor to a patient who had been in a catatonic stupor for four years in 1934. It is reported that two days after his fifth injection on February 10, 1934, the patient got out of bed, requested breakfast, got dressed, and began to talk. 3

A psychiatry professor, Dr. Ugo Cerletti, induced convulsions by applying electricity directly to the brain at the University of Rome in 1938. Dr. Cerletti achieved success with this method in patients with schizophrenia. 4

In 1938, Cerelli gave the first public presentation on ECT at the Medical Academy of Rome. By 1943, ECT was being used in America. Initially, it was used for schizophrenia, but over time ECT was utilized to treat most psychiatric disorders. After several years, ECT became a common treatment for depression with psychotic features as well as severe mania.

Antidepressants first began to appear in 1958 when an anti-tuberculosis drug, iproniazid (Marsilid), started to be used off-label for depression. This drug was eventually removed from the market due to safety concerns.

 In 1959 imipramine (Tofranil) was approved by the FDA for major depressive disorder (MDD). This was the first tricyclic antidepressant (TCA).

Although the psychiatric community had high hopes following the invention of the TCA’s, these drugs were not 100% effective, and they were associated with side effects. The use of ECT decreased by 46% between 1975-1980, but ECT began to increase in popularity during the 1980s. In the United States in 1980, 2.4% of all hospitalized psychiatric patients received ECT treatment. 5

ECT Safety

As discussed in the introduction, ECT is a safe procedure. Recent studies have suggested depression is associated with a loss of gray and white matter in different parts of the brain. This neurodegeneration is more prevalent in patients with a more extended history of depression, untreated depression, and a larger number of depressive episodes. This suggests rapid treatment of depression as achieved with ECT can reduce the risk of neuropathologic changes. 6

Postmortem studies of ECT patients who had the procedure done with modern techniques do not show brain damage resulting from the ECT itself. 7

ECT for Behavioral and Psychological Symptoms of Dementia (BPSD)

BPSD is a reality for most dementia patients and their families. This is a common reason for hospital admissions. Symptoms of BPSD include agitation, aggression, disinhibition, apathy, depression, sleep and appetite changes. 

There are no medications approved for dementia besides the anticholinesterase inhibitors and memantine. These drugs slow the progression of dementia but usually have little effect on BPSD. We use antipsychotics to treat these behaviors. Antipsychotic agents all have significant side effects associated with them and an FDA boxed warning for increased mortality risk in elderly patients.

A retrospective chart review of sixty elderly dementia patients with BPSD receiving ECT for agitation was published on September 23, 2019. They found ECT to be safe in their population and very effective in reducing agitation and decreasing the psychotropic pill burden as well. There are other hurdles one must consider when utilizing ECT for dementia patients. The largest is that of consent. Most dementia patients are not able to agree with an ECT procedure.


ECT for Catatonia

Catatonia is a condition in which the patient has a significant decrease in their reaction to the environment. Catatonic patients are often mute, appear to be in a stupor, and may demonstrate negativism or motor rigidity. 

The initial treatment for catatonia is benzodiazepines. Many catatonic patients initially respond to IV lorazepam. The conversion to oral lorazepam dosing can sometimes lead to rebound catatonia in which the IV form may need to be reintroduced, or the oral dose increased. 

If the patient does not respond to a benzodiazepine in 2 to 3 days, or if the symptoms are particularly malicious, ECT is the best treatment option. Electroconvulsive therapy works synergistically with benzodiazepines and is beneficial in up to 80% of patients. 8

ECT in Clozapine-Resistant Schizophrenia (CRS)

Clozapine remains the drug of choice for treatment-resistant schizophrenia. Because schizophrenia is a chronic debilitating disease, it is crucial to find effective treatment methods. Clozapine is superior to other antipsychotics with regards to improved social functioning, symptom improvement, and reduction of hospitalization and mortality. Unfortunately, clozapine does not work for every patient. In 2018, Wang et al. evaluated the safety and efficacy of using ECT in addition to clozapine in the treatment of CRS. This meta-analysis showed adding ECT to clozapine was superior to monotherapy. The main adverse effects suffered in these trials were memory impairment (24.2%) and headache (14.5%). These side effects were mostly mild and short-lived. 9

ECT VS. Antidepressant Medications

The FDA performed a systematic review and Meta-Analysis of randomized, controlled trials examining the effectiveness of ECT in 2011. They came to the following conclusions with regard to ECT and antidepressant medication.

  • Immediately to one-month post-ECT, there is conflicting evidence that ECT is more effective than antidepressant medications.
  • One-month post-ECT, conclusive evidence shows ECT to be more effective than antidepressant medication. 


ECT Delirium

There have been cases of delirium reported after ECT treatments. After medical causes are ruled out, delirium may be effectively managed by changing to unilateral ultra-brief pulse ECT with a greater interval between treatment sessions. 10

Lithium is one of our best treatments for bipolar disorder. It is often used for treatment-resistant major depressive disorder (MDD.) There are times when it is beneficial to use Lithium and ECT together as the combination of the two seems to be more effective than either treatment alone. A study published in August of 2019 found that patients treated with lithium and ECT during an inpatient stay had an 11.7 fold higher risk of delirium than those being treated with ECT alone. 11

Lithium should only be used in conjunction with ECT for severe cases or when the risk of suicide is high to prevent delirium.

ECT and Cognitive Function in Major Depression

A paper published in the Journal of Affective Disorders in 2019, discussed a prospective study following twenty-seven depressed patients before, and two years after ECT. The purpose was to measure remission rates as well as any cognitive changes that may be caused by ECT treatment. 

They found improved neurocognitive function two years after ECT regardless of remission status. The remission rate reached 62.9% at two years. The relapse rate was low; 22% relapsed before the six-week follow-up, and 7.4% between six months and two years after ECT. 12

Although the ECT methods were not uniform in this study, and the sample size was small, the results suggest ECT is beneficial in the treatment of depression without negatively affecting cognitive function.

ECT and Age

A study was done to compare various aspects of ECT on three different age groups:

Young (18-45 years)

Middle (46-64 years)

Old (>=65 years)

A total of 402 patients were evaluated the day before ECT and one-week after. 

One week after ECT, the middle and old age groups showed a significant improvement in the Mini-Mental State Examination (MMSE) score when compared to baseline. Rates of response were not statistically different in the three groups. There was also no difference in premature drop-out rates.

This study concluded ECT was a viable treatment for elderly patients with treatment-resistant depression. Rates of response were near 70%, and no life-threatening adverse events occurred. 13

ECT Contraindications


  • Elevated intracranial pressure.
  • Recent myocardial infarction.
  • Heart Failure.
  • Severe Hypertension.
  • Pheochromocytoma.
  • Risk of bleeding.
  • Unruptured aneurysm.
  • Recent stroke.

Side Effects of ECT

  • Memory loss
  • Confusion
  • Nausea
  • Headache
  • Muscle Pain
  • Complications from Anesthesia
Michael Brown pictured with Final Thought written

Electroconvulsive therapy can be a life-changing procedure for many patients. For those who do not experience relief from antidepressant medications, ECT can be their last hope. It is also useful in treatment-resistant catatonia, dementia with BPSD, and clozapine-resistant schizophrenia. 

This procedure has undergone many improvements over the years. No longer do patients have to worry about broken bones caused by seizures. Today, psychiatrists utilize neuromuscular blocking agents which confine seizure activity to the brain. 

The studies support the use of ECT. I have personally viewed several treatments during my Pharmacy Directorship at a private psychiatric hospital in the late 1990s. The procedure is quick, mild, and most adverse reactions are the result of anesthesia. More importantly, ECT is an effective treatment for a vulnerable segment of our population.

As a society, it is our responsibility to take care of our mentally ill population. We should not have these patients living in tents on the side of the road in our major cities. Psychiatric patients are people like us who have a brain disorder. Remember, this can happen to anyone. Electroconvulsive therapy is not a punishment for bad behavior. It is an effective treatment for several debilitating conditions that are resistant to other, less invasive therapies.

If you have any questions or concerns, feel free to contact me. I will answer every message received.

Always strive to live a happy, healthy life.

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

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Feel free to send Michael a message using this link.



Steroid Induced Psychosis

Will taking prednisone make you psychotic?

How about other steroids?

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

What is Psychosis?

Patients with psychosis are not in touch with the real world. They display symptoms of hallucinations and or delusions. They may also speak incoherently or behave in ways that do not fit their current surroundings.

Hallucinations occur when a person senses something that is not there. This can happen with sight, hearing, touch, and smell.

At times, the patient may experience two or more hallucinations simultaneously. For example, a psychotic patient may kneel to pet a dog that doesn’t exist. They can see the dog and feel the dog as they pet it. They may also hear or smell the non-existent animal.

Delusions happen when a person firmly believes something untrue. They may be convinced they are an influential person or someone famous when, in fact, they are not. Delusional patients may think they are younger than their actual age and in better health. They may also suffer from paranoia and swear that people are out to get them.

These patients may only eat packaged food or stop eating entirely due to fear of being poisoned. Delusions are very hard to treat with medication.

Drugs As A Cause Of Psychosis

When a patient presents with new-onset psychosis, it is vital to obtain a thorough history. If a family member has been diagnosed with a psychiatric disorder, there is an increased chance of the illness spreading to other genetic relatives. We also know a patient often responds to the same medications that were effective for family members.

One of the first things I look for as a pharmacist is possible drugs that can cause psychosis. There are several potential agents to consider, but I classify them into two broad groups.




Drugs Of Abuse

These are drugs that are not prescribed by a physician and have a higher incidence of precipitating psychosis. This is true because of the properties of the substance and the erratic dose the patient receives.

Street drugs are not regulated, so drug content is sporadic. The drugs are usually addictive, and individuals take an increasing dose trying to reach the desired effect. Some examples of these agents are:


Prescription Medications

The other group contains medications that are available as prescriptions. It is essential to point out that many of these drugs are also available on the street. Any substance that has the ability to alter mood or perception is a candidate for sale on the black market. Some of these agents are:

Anti-seizure medications
Anticholinergic Drugs (Click to read post on anticholinergics)

Dopamine agonists for Parkinsons Disease

We will concentrate on corticosteroids for this post.

Types Of Steroids

Anabolic Steroids

These include testosterone as well as synthetic substances that are similar in structure to testosterone and have comparable effects. Testosterone is used to treat specific hormone problems in men. The synthetic molecules are often abused by bodybuilders and athletes to build muscle and boost athletic abilities. These are generally not associated with psychosis. Some examples of this type of steroid are:



Corticosteroids are used in modern medicine to remedy a variety of conditions.

They are used in the emergency department to treat asthma attacks, COPD, and croup in children.

They can be used to treat Crohn’s disease, gout, lupus, multiple sclerosis, and other autoimmune disorders. Corticosteroids have an important role in reducing inflammation.

These steroids are also utilized in the treatment of skin conditions such as eczema and rash. They play an essential role in some cancer therapies. Corticosteroids come in a variety of forms including injections, tablets, liquids, creams, ointments, and inhalers. Some examples include:




Corticosteroid Adverse Effects

Unfortunately, although corticosteroids are useful in many of the conditions described above, they can also cause adverse effects. A few common side effects include:

Weight gain
Nausea and vomiting
Mood swings

Steroid Induced Psychosis

Psychosis is a side effect of corticosteroid use and most commonly occurs at prednisone doses above 20mg/day given over a long period. 1 

2 3 

Roughly ten percent of patients remain psychotic after the steroid dose is decreased. 4 

Patients are usually clear after a two-week course of antipsychotic medications.

Although prednisone is often described as the main corticosteroid involved, other members of the steroid family can also cause psychosis.


Dexamethasone is often used in place of prednisone due to its longer duration of action. This glucocorticoid is six times more potent than prednisone.

It is unknown what dose of dexamethasone is most likely to cause psychosis, but it has occurred post-operatively after a single dose.

We should anticipate a psychotic reaction after administering dexamethasone, and for surgery cases, it may be prudent to utilize restraints to prevent self-extubation.

Pre-medicating with haloperidol or olanzapine may prove beneficial in this situation. 5 

Dexamethasone will accumulate in the body more quickly than prednisone due to its longer half-life. For this reason, careful monitoring should occur when giving this agent over a more extended period of time.


An article published in European Psychiatry in March of 2016 describes a case where a thirty-year-old female received three, 80mg daily doses of methylprednisolone following lumbar surgery. This patient had no personal or family history of any psychiatric disorder.

One week after the methylprednisolone was completed, the patient was admitted to the hospital for bizarre delusions, visual and auditory hallucinations, and disorganized thinking.

She was treated with risperidone (up to 6mg/day) and a very short course of diazepam (10mg/day). The patient was discharged several weeks later when the psychosis cleared up. 6 


The first thing to attempt when treating corticosteroid-induced psychosis is to stop the offending agent. Unfortunately, this is not always possible.

There are circumstances when the steroids must be continued. In these cases, our best option is to treat the patient with an antipsychotic medication.

Which agent we choose is based mostly on the characteristics of the patient. I could write an entire chapter on this subject but will list the agents we utilize most commonly for psychosis on our unit. I will also explain reasons to choose one agent over the other.


Haloperidol is still widely used due to its familiarity. Physicians like to use what they are most comfortable with.

Some patients should never receive haloperidol. This medication is contraindicated in Parkinson’s patients. Due to its high dopamine (D2) blocking properties, it makes the movement disorder worse.

Haloperidol is still very effective and is often used for delirium as well as psychosis. It is available in oral, injectable and long-acting injectable forms


Quetiapine is the first choice in a patient who has Parkinson’s disease. This drug is also helpful in patients who are having trouble sleeping as it is one of the most sedating antipsychotics available. Quetiapine is only available in oral dosage forms which limits its usefulness in acute situations.


Olanzapine is one of the most effective medications we have for delirium as well as psychosis. Like haloperidol, it is also available in all dosage forms.

The main problem with this agent is weight gain. This can be a positive attribute in patients that have a poor appetite, but these days patients tend to be overweight. Olanzapine is usually the medication I initially recommend.


Risperidone is also an effective agent for psychosis, but it is not available in a quick acting injectable form. It can also cause movement disorder side effects, especially at higher doses.


Ziprasidone is popular in the emergency department for acute agitation and psychosis due to its availability as a fast-acting injectable. The powder in the vial does take longer to dissolve than olanzapine, and it has cardiac side effects that make it undesirable for elderly patients.

Final Thoughts

There is evidence linking corticosteroid use to psychosis. These medications are used for a variety of ailments. At times, they are needed to treat life-threatening conditions.

Although prednisone is the agent most commonly associated with corticosteroid-induced psychosis, other agents in this class can also lead to psychotic behavior.

It is essential to be aware of the signs of psychosis and seek treatment if you or someone you know is being treated with any of these drugs.

I suggest having someone check on you periodically if you live alone and are taking these medications. Psychotic patients often have no idea they are having a problem until it is discovered by someone else.

If possible, the corticosteroid should be stopped if psychosis develops. If this isn’t prudent, antipsychotic agents can be used based on patient characteristics.

In severe cases, the patient may need to be hospitalized until stable. Most patients will clear after a few days to a couple of weeks.

I hope you have enjoyed this review of corticosteroid-induced psychosis. If you have any questions or comments, please send me an email.

My goal is to make this site as informative and enjoyable as possible for my readers. We can learn the best way to make that happen together.

As always, live a happy, healthy, healing life and remember to HAVE FUN!



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Michael J. Brown, RPh. BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.
Michael – Sunshine Nutraceuticals (sunshinentc.com)