ONE-DAY HANDS-ON & OBSERVATIONAL WORKSHOP
Electroconvulsive Therapy (ECT)
From Theory to Practice
Indications · Types · Stimulus Dosing · Anaesthesia · Procedure · Post-ECT Care
Sunday, 27 September 2026
10:00 AM – 1:00 PM
Bharosa Neuro Psychiatry Hospitals
LB Nagar, Hyderabad
Your Partner in Change
Psychiatry · Neurology · Rehab · De-addiction
WORKSHOP OVERVIEW
Programme Schedule
1
Introduction to ECT
What ECT is, history, modern modified ECT, evidence, myths
10:00 – 10:15
2
Indications & Clinical Applications
Depression, bipolar, catatonia, schizophrenia, special groups
10:15 – 10:35
3
Contraindications & Pre-ECT Assessment
Risk assessment, workup, medication review, consent (MHCA)
10:35 – 10:50
4
Types of ECT & Electrical Parameters
Electrode placement, waveforms, stimulus parameters, dosing
10:50 – 11:15
5
Mechanism of Action
Neurotransmitters, neuroplasticity, how the seizure works
11:15 – 11:30
6
Anaesthesia & Muscle Relaxation
Physiology, why anaesthesia, agents & doses, relaxants
11:30 – 11:55
7
ECT Procedure & Monitoring
ECT suite, step-by-step, seizure monitoring, course planning
11:55 – 12:15
8
Complications & Post-ECT Care
Recovery, side effects, cognitive effects, complications
12:15 – 12:35
9
Live Demonstration & Observation
What to observe, observer guidelines
12:35 – 12:50
10
Case Discussion & Q&A
Clinical cases, key takeaways, open questions
12:50 – 1:00
Programme: 10:00 AM – 1:00 PM · 3 hours · Session timings follow the published schedule
ECT Workshop 2026 · Bharosa Neuro Psychiatry Hospitals, LB Nagar, Hyderabad
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WORKSHOP OVERVIEW
Learning Objectives
By the end of this workshop, participants will be able to:
01
Explain how ECT works and summarise the evidence for its efficacy and safety
02
Identify indications, relative contraindications and high-risk situations
03
Choose electrode placement, pulse width and stimulus dose for an individual patient
04
Understand anaesthetic choices and how each drug influences the seizure
05
Complete a structured pre-ECT workup and obtain valid consent under MHCA 2017
06
Monitor seizure adequacy and manage post-ECT effects and complications
ECT Workshop 2026 · Bharosa Neuro Psychiatry Hospitals, LB Nagar, Hyderabad
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SESSION
01
Introduction to ECT
What ECT is · History · Modern modified ECT · Evidence · Myths vs facts
10:00 – 10:15 AM · 15 min
SESSION 01 · INTRODUCTION TO ECT
What is Electroconvulsive Therapy?
ECT is a medical treatment in which a brief, controlled electrical stimulus is applied to the scalp – under general anaesthesia and muscle relaxation – to induce a generalised seizure of adequate duration and quality.
The seizure is the treatment
A stimulus that fails to produce an adequate seizure has little or no therapeutic effect.
Always “modified” ECT
Anaesthesia, muscle relaxant, 100% oxygen and full monitoring – no pain, no violent convulsion.
A short procedure
Stimulus lasts up to 8 seconds; the treatment takes about 10 minutes, recovery 30–60 minutes.
Given as a course
Usually 6–12 sessions, 2–3 times per week, adjusted to clinical response.
ECT Workshop 2026 · Bharosa Neuro Psychiatry Hospitals, LB Nagar, Hyderabad
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SESSION 01 · INTRODUCTION TO ECT
The Evolution of ECT
1934
Ladislas Meduna induces therapeutic seizures chemically – camphor, then pentylenetetrazol.
1938
Ugo Cerletti and Lucio Bini give the first electrically induced seizure treatment in Rome.
1940s
ECT spreads worldwide and becomes a mainstay of psychiatric treatment.
1951
Succinylcholine is introduced – muscle relaxation makes “modified ECT” possible.
1958
Right unilateral electrode placement introduced to reduce memory side effects.
1970s–80s
Brief-pulse, constant-current devices with EEG monitoring replace sine-wave machines.
2000s
Ultrabrief pulse, dose titration and evidence-based guidelines (APA 2001, NICE 2003).
2017
India’s Mental Healthcare Act permits ECT only with anaesthesia and muscle relaxants.
ECT Workshop 2026 · Bharosa Neuro Psychiatry Hospitals, LB Nagar, Hyderabad
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SESSION 01 · INTRODUCTION TO ECT
Modified vs Unmodified ECT
Unmodified (Direct) ECT
PROHIBITED IN INDIA – MHCA 2017, Section 95
vs
Modified ECT
GLOBAL STANDARD OF CARE
At Bharosa, every ECT is performed as modified ECT with an anaesthetist present.
ECT Workshop 2026 · Bharosa Neuro Psychiatry Hospitals, LB Nagar, Hyderabad
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SESSION 01 · INTRODUCTION TO ECT
Why ECT Still Matters: The Evidence
60–80%
response rate in severe major depression – higher than any antidepressant medication
80–90%
response rate in catatonia, including many patients who fail benzodiazepines
~50%
of clozapine-resistant schizophrenia patients respond to ECT augmentation
~2
deaths per 100,000 treatments – comparable to minor procedures under general anaesthesia
Rapid onset
Meaningful improvement is often seen within the first 1–2 weeks (3–6 sessions) – critical when life is at risk from suicide, starvation or catatonia.
Superior to medication
Meta-analyses show real ECT is more effective than both simulated ECT and pharmacotherapy for depression.
Sources: UK ECT Review Group, Lancet 2003; Petrides et al., Am J Psychiatry 2015; Tørring et al., Acta Psychiatr Scand 2017; APA Task Force Report 2001.
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SESSION 01 · INTRODUCTION TO ECT
ECT: Myths vs Facts
MYTH
FACT
ECT is painful and frightening, like in the movies.
Patients are asleep under general anaesthesia with muscles relaxed – there is no pain and no violent convulsion.
ECT damages the brain.
Imaging and neuropathology studies show no structural brain damage; MRI studies show increases in hippocampal volume.
ECT permanently erases memory.
Memory effects are mostly temporary; new learning recovers within weeks, though patchy gaps around the treatment period may remain.
ECT is outdated – a last resort only.
It is the most effective acute treatment for severe depression and a first-line option in several urgent situations.
ECT changes personality.
ECT does not alter personality; as illness remits, patients often feel more like themselves again.
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SESSION
02
Indications &
Clinical Applications
Major depression · Bipolar disorder · Catatonia · Schizophrenia · Special populations
10:15 – 10:35 AM · 20 min
SESSION 02 · INDICATIONS & CLINICAL APPLICATIONS
Indications for ECT
Major Depressive Disorder
The most common and best-established indication
Bipolar Disorder
Schizophrenia Spectrum
Catatonia
Other Indications
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SESSION 02 · INDICATIONS & CLINICAL APPLICATIONS
When Is ECT First-Line?
Primary (first-line) use
Secondary use
Framework adapted from the APA Task Force on ECT – the decision always rests on individual risk–benefit assessment.
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SESSION 02 · INDICATIONS & CLINICAL APPLICATIONS
Special Populations & Precautions
Pregnancy
Elderly
Children & Adolescents
Devices & Medical Illness
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SESSION
03
Contraindications &
Pre-ECT Assessment
Medical risk assessment · Investigations · Medication review · Consent & MHCA 2017
10:35 – 10:50 AM · 15 min
SESSION 03 · CONTRAINDICATIONS & PRE-ECT ASSESSMENT
Contraindications: Assessing Risk
There are no absolute contraindications to ECT – only conditions that carry substantially higher risk.
Raised intracranial pressure
Space-occupying lesions – ECT transiently raises ICP; risk of herniation. Highest-risk condition.
Unstable cardiac disease
Recent myocardial infarction, unstable angina, decompensated heart failure, severe valvular disease.
Recent stroke or haemorrhage
Recent cerebral infarction or intracerebral bleed – BP surge risks extension or re-bleeding.
Aneurysm / vascular malformation
Lesions liable to rupture with the acute rise in blood pressure during the seizure.
Severe pulmonary disease
Severe COPD, poorly controlled asthma or pneumonia increase anaesthetic risk.
Very high anaesthetic risk
ASA physical status 4–5; phaeochromocytoma (risk of hypertensive crisis).
When the psychiatric illness is itself life-threatening, ECT may still be justified – after optimisation with cardiology, neurology and anaesthesia input.
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SESSION 03 · CONTRAINDICATIONS & PRE-ECT ASSESSMENT
Pre-ECT Evaluation & Workup
Clinical assessment
Investigations
Baseline measures
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SESSION 03 · CONTRAINDICATIONS & PRE-ECT ASSESSMENT
Medication Review Before ECT
Drug / class | Concern with ECT | Recommended action |
Lithium | Post-ECT delirium, prolonged seizures | Reduce or withhold before sessions; keep levels low-therapeutic |
Benzodiazepines | Raise seizure threshold, shorten seizures | Taper or withhold evening/morning doses; flumazenil at induction if needed |
Anticonvulsants | Raise seizure threshold | Mood-stabiliser use: taper or hold. Epilepsy: continue, omit morning dose |
Theophylline | Prolonged seizures, status epilepticus | Avoid, or keep levels at the low end of the therapeutic range |
Clozapine / bupropion | Lower seizure threshold – prolonged or late seizures | Usually continue; consider holding the morning dose |
Antihypertensives, cardiac drugs | Help control the haemodynamic surge | Continue with a sip of water on the morning of ECT |
Insulin / oral hypoglycaemics | Hypoglycaemia while fasting | Withhold morning dose; schedule ECT early; monitor glucose |
TCAs / MAOIs | Arrhythmias (TCAs); hypertensive reactions (MAOIs) | Can generally be continued with close monitoring |
Always individualise with the treating psychiatrist and anaesthetist; never stop medications abruptly without a plan.
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SESSION 03 · CONTRAINDICATIONS & PRE-ECT ASSESSMENT
Informed Consent & the Legal Framework
Elements of valid informed consent
Nature and purpose of ECT, and the number of sessions expected
Expected benefits and likelihood of response
Risks and side effects – especially memory effects
Alternatives, including no treatment
Right to refuse or withdraw consent at any time
Written, in a language the patient understands, and witnessed
Capacity assessed and documented; consent reviewed during the course
Mental Healthcare Act, 2017
Refer to the Act and State Mental Health Authority rules for full procedural requirements.
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SESSION
04
Types of ECT &
Electrical Parameters
Electrode placement · Brief vs ultrabrief pulse · Stimulus parameters · Seizure threshold & dosing
10:50 – 11:15 AM · 25 min
SESSION 04 · TYPES OF ECT & ELECTRICAL PARAMETERS
Types of ECT at a Glance
By Anaesthesia
Modified ECT
Anaesthesia + muscle relaxant – the standard of care
Unmodified (direct)
Obsolete – prohibited in India (MHCA 2017)
By Electrode Placement
Bitemporal (BT)
Both frontotemporal regions
Bifrontal (BF)
Both frontal regions
Right Unilateral (RUL)
Right temporal + right vertex
By Stimulus Waveform
Sine wave
Obsolete – more cognitive effects
Brief pulse
0.5–2.0 ms – the current standard
Ultrabrief pulse
< 0.5 ms – cognition-sparing
By Course / Phase
Acute (index) course
To achieve remission
Continuation ECT
Up to 6 months after remission
Maintenance ECT
Beyond 6 months, to prevent recurrence
ECT Workshop 2026 · Bharosa Neuro Psychiatry Hospitals, LB Nagar, Hyderabad
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SESSION 04 · TYPES OF ECT & ELECTRICAL PARAMETERS
Electrode Placement (Top View of the Head)
Bitemporal (BT)
Both sides: ~2.5 cm above the midpoint of a line joining the tragus and the lateral canthus.
Dose: 1.5–2.5 × seizure threshold
Bifrontal (BF)
Both sides: ~5 cm above the lateral angle of each orbit (outer canthus), on the forehead.
Dose: ~1.5 × seizure threshold
Right Unilateral (RUL)
d’Elia position: right frontotemporal (as BT) + just right of the vertex, over the non-dominant hemisphere.
Dose: ~6 × seizure threshold
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SESSION 04 · TYPES OF ECT & ELECTRICAL PARAMETERS
Choosing a Placement: BT vs BF vs RUL
| Bitemporal (BT) | Bifrontal (BF) | Right Unilateral (RUL) |
Dose above threshold | 1.5–2.5 × | ~1.5 × | ~6 × (range 5–8 ×) |
Speed of response | Fastest | Fast | Moderate – may need more sessions |
Efficacy | High | High – comparable to BT | High, only at adequate suprathreshold dose |
Cognitive side effects | Most | Intermediate (evidence mixed) | Least |
Best suited for | Urgent / life-threatening illness, catatonia, mania, RUL non-response | When bilateral efficacy is needed with cognitive concern | Elderly, cognitively vulnerable, outpatients, continuation & maintenance ECT |
Practical rule: Start with RUL at 6 × threshold for most non-urgent cases; switch to bitemporal if there is no meaningful improvement after about 4–6 sessions. Choose BT from the outset when speed is essential.
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SESSION 04 · TYPES OF ECT & ELECTRICAL PARAMETERS
Stimulus Waveform: Sine, Brief & Ultrabrief Pulse
Sine Wave
Continuous alternating current
OBSOLETE
Brief Pulse
Pulse width 0.5–2.0 ms (usually 1.0 ms)
CURRENT STANDARD
Ultrabrief Pulse
Pulse width < 0.5 ms (usually 0.25–0.3 ms)
COGNITION-SPARING
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SESSION 04 · TYPES OF ECT & ELECTRICAL PARAMETERS
Stimulus Parameters: The Electrical Prescription
Current (amplitude)
800–900 mA, constant
Sets electric-field strength and the volume of brain stimulated; fixed on most devices
Pulse width
0.25–2.0 ms
Duration of each pulse – shorter pulses are more efficient
Frequency
20–120 Hz
Number of pulse pairs delivered per second
Train duration
0.5–8 s
How long the pulse train is delivered
Charge (dose)
millicoulombs (mC)
Total stimulus dose – device maximum usually 504 mC (1008 mC on extended-range models)
CALCULATING THE DOSE
Charge (mC) = Current (A) × Pulse width (ms) × 2 × Frequency (Hz) × Duration (s)
Worked example
0.8 A × 1.0 ms × 2 × 60 Hz × 4 s
= 384 mC
Impedance check: constant-current devices adjust voltage to impedance (V = I × R). Check static impedance before every stimulus – high = poor contact; very low = current shunting through gel or sweat.
ECT Workshop 2026 · Bharosa Neuro Psychiatry Hospitals, LB Nagar, Hyderabad
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SESSION 04 · TYPES OF ECT & ELECTRICAL PARAMETERS
Stimulus Dosing Strategies
Empirical dose titration
RECOMMENDED
Session 1: start at a low charge and step up until an adequate seizure occurs – this is the seizure threshold (ST). Then treat at: BT 1.5–2.5 × ST · BF ~1.5 × ST · RUL ~6 × ST.
Age-based formula
PRACTICAL
% of device output ≈ age ÷ 2 for bilateral (“half-age” method), ≈ age for RUL. Quick, but may over- or under-dose because thresholds vary widely.
Fixed dose
LEAST PRECISE
The same (often high) dose for every patient. Simple, but ignores individual thresholds – risk of excess cognitive effects or inadequate seizures.
Seizure thresholds can vary up to 40-fold between patients – titration is the most precise way to dose.
What changes the seizure threshold?
Raises threshold
Lowers threshold
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SESSION
05
Mechanism of Action
Neurotransmitters · Neuroplasticity & brain networks · How the therapeutic seizure works
11:15 – 11:30 AM · 15 min
SESSION 05 · MECHANISM OF ACTION
Mechanism of Action: How Does ECT Work?
Neurotransmitter
Enhances serotonergic, noradrenergic and dopaminergic transmission; increases GABA activity; down-regulates β-adrenergic receptors.
Neuroendocrine
Seizure releases hypothalamic–pituitary hormones (prolactin, ACTH, cortisol, oxytocin, vasopressin); may normalise HPA-axis dysregulation.
Anticonvulsant
Seizure threshold rises across the course (GABA, endogenous opioids). Stronger post-ictal suppression is linked with better response.
Neuroplasticity
Increases BDNF and promotes hippocampal neurogenesis (animal studies); MRI shows increased hippocampal and amygdala volume.
Network “reset”
Modulates connectivity in mood-regulating circuits, e.g. reducing frontal hyperconnectivity seen in depression.
No single mechanism explains ECT fully – its effects are likely multi-level, from molecules to brain networks.
ECT Workshop 2026 · Bharosa Neuro Psychiatry Hospitals, LB Nagar, Hyderabad
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SESSION 05 · MECHANISM OF ACTION
How the Therapeutic Seizure Works
STEP 1
The stimulus
Brief electrical pulses depolarise cortical neurons. The dose must be above the patient’s own seizure threshold.
STEP 2
Generalised seizure
Synchronised firing spreads through cortical and deep (thalamic, hypothalamic) circuits, releasing monoamines and neuropeptides.
STEP 3
Active inhibition
GABA, adenosine and endogenous opioids end the seizure; post-ictal EEG suppression follows and the threshold rises.
STEP 4
Cumulative change
Across the course: BDNF release, neurogenesis and synaptic remodelling reset mood-regulating networks.
Why seizure quality matters
The seizure is necessary
Sham ECT – anaesthesia without a seizure – is clearly less effective than real ECT.
…but not sufficient
Low-dose RUL produces seizures yet works poorly; efficacy rises with dose above threshold.
Quality predicts response
Strong post-ictal suppression and a rising threshold across the course are linked to better outcomes.
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SESSION
06
Anaesthesia &
Muscle Relaxation
Why anaesthesia · Agents & doses · Muscle relaxation · Effects on seizure threshold
11:30 – 11:55 AM · 25 min
SESSION 06 · ANAESTHESIA & MUSCLE RELAXATION
Physiological Response to the ECT Stimulus
PHASE 1
Stimulus & early seizure
Parasympathetic (vagal) discharge
PHASE 2
During the seizure
Sympathetic surge (catecholamines)
PHASE 3
Post-ictal
Return towards baseline
Clinical implications
Anticholinergic for bradycardia / asystole
β-blocker for hypertension in cardiac patients
Continuous ECG, SpO₂ and BP monitoring
Oxygenation and airway control throughout
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SESSION 06 · ANAESTHESIA & MUSCLE RELAXATION
Why Anaesthesia? The Five Goals
Unconsciousness & amnesia
The patient must never be aware of paralysis or the stimulus – humane, dignified care.
Muscle relaxation
Prevents fractures, dislocations and dental or tongue injury from convulsive movements.
Oxygenation
100% O₂ and hyperventilation protect brain and heart; hypocapnia also improves seizure quality.
Haemodynamic control
Blunts the vagal and sympathetic surges, protecting vulnerable patients.
Rapid recovery
Ultra-short anaesthesia (5–10 min) allows early return to the ward or same-day discharge.
THE IDEAL ECT ANAESTHETIC
Rapid onset
Short duration, quick recovery
Minimal anticonvulsant effect – does not shorten the seizure
Haemodynamic stability
Low incidence of nausea and emergence agitation
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SESSION 06 · ANAESTHESIA & MUSCLE RELAXATION
Induction Agents & Their Effect on the Seizure
Shortens seizure
Lengthens seizure
Propofol
Thiopentone
Methohexital
Etomidate
Ketamine
Agent | Typical IV dose | Effect on seizure | Key points |
Propofol | 0.75–1.5 mg/kg | Shortens (dose-dependent) | Smooth induction, blunts BP/HR surge, less nausea; widely used |
Thiopentone | 2–3 mg/kg | Shortens | Anticonvulsant; risk of arrhythmias and laryngospasm |
Methohexital | 0.75–1.0 mg/kg | Minimal effect | Historical gold standard; limited availability in India |
Etomidate | 0.15–0.3 mg/kg | Lengthens | For high thresholds / short seizures; myoclonus, nausea, transient adrenal suppression |
Ketamine | 0.5–2 mg/kg | Lengthens | Proconvulsant with rapid antidepressant action; ↑ BP/HR, emergence reactions |
Combination “ketofol” (ketamine + propofol) can balance haemodynamic stability with better seizure quality. Doses are indicative adult ranges – individualise with the anaesthetist.
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SESSION 06 · ANAESTHESIA & MUSCLE RELAXATION
Muscle Relaxants, Anticholinergics & Adjuncts
Muscle relaxants
Anticholinergics
Adjuncts
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SESSION
07
ECT Procedure &
Monitoring
ECT suite · Step-by-step procedure · EEG & motor seizure monitoring · Course planning
11:55 AM – 12:15 PM · 20 min
SESSION 07 · ECT PROCEDURE & MONITORING
The ECT Suite: Team & Equipment
Psychiatrist
Indication, electrode placement, stimulus dosing, seizure assessment
Anaesthetist
Airway, anaesthetic drugs, oxygenation, haemodynamics
ECT nurse
Checklist, patient preparation, monitoring, documentation
Recovery nurse
Post-ictal monitoring, reorientation, discharge criteria
Essential equipment
Brief-pulse, constant-current ECT device with EEG/ECG
Anaesthesia workstation, O₂ supply, bag-valve-mask
Suction, airway kit, intubation equipment
ECG, SpO₂ and NIBP monitoring
Defibrillator and crash cart with emergency drugs
Bite blocks, conductive gel, saline, skin-prep swabs
Recovery beds with O₂, suction and monitoring
Pre-ECT checklist and treatment record
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SESSION 07 · ECT PROCEDURE & MONITORING
Step-by-Step ECT Procedure
1
Pre-procedure check
Consent, fasting ≥ 6 h, vitals, bladder emptied; dentures, jewellery and hairpins removed
2
IV line & monitors
IV access; ECG, SpO₂, NIBP and EEG leads attached
3
Electrode preparation
Clean skin, apply conductive gel, place electrodes; check static impedance
4
Pre-oxygenate
100% O₂ by face mask for about 2–3 minutes
5
Induction
Anticholinergic if indicated; IV induction agent until loss of consciousness
6
Inflate limb cuff
BP cuff on one limb above systolic pressure – isolates it for motor-seizure observation
7
Muscle relaxant
Succinylcholine; wait for fasciculations to settle before stimulus
8
Hyperventilate & bite block
Ventilate with 100% O₂; insert bite block and support the jaw
9
Deliver stimulus
“All clear” call; deliver stimulus; time motor and EEG seizure
10
Recover & record
Ventilate until spontaneous breathing; recovery position; document parameters
For RUL, place the cuff on the right limb (ipsilateral to the stimulus) to confirm the seizure has generalised.
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SESSION 07 · ECT PROCEDURE & MONITORING
Seizure Monitoring & Adequacy
Stimulus
Recruitment: polyspikes
Spike-and-slow-wave (~3 Hz)
End
Post-ictal suppression
Motor seizure
≥ 20 s
Observed in a limb isolated from the relaxant by an inflated BP cuff (“cuff method”).
EEG seizure
≥ 25 s
Recorded on the device’s EEG channels; usually outlasts the motor seizure.
Quality markers
Look for
High amplitude · bilateral symmetry · clear slow-wave phase · abrupt end · marked post-ictal suppression · heart-rate surge
Duration alone does not guarantee efficacy – judge seizure quality, not just length.
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SESSION 07 · ECT PROCEDURE & MONITORING
Managing Seizure Problems
Missed or short seizure
No seizure, or motor < 20 s / EEG < 25 s
Prolonged seizure
EEG or motor seizure > 180 s
Tardive seizure / non-convulsive status
Seizure recurs after the treatment, or confusion is unusually prolonged
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SESSION 07 · ECT PROCEDURE & MONITORING
Planning the Course of ECT
Frequency
2–3 sessions per week (e.g. Mon–Wed–Fri). Thrice-weekly acts faster; twice-weekly has fewer cognitive effects.
Number of sessions
Usually 6–12 (range 4–20) – guided by response, not a fixed number.
Review regularly
Rate severity and cognition every 2–3 sessions; stop at remission or when improvement plateaus over 2 sessions.
Switch if needed
Move RUL → BT if there is little improvement after ~4–6 sessions.
Daily ECT
Only briefly, in emergencies – e.g. malignant catatonia, NMS, severe mania.
Acute (index) course
2–3 per week until remission
Continuation ECT
Up to 6 months after remission – e.g. weekly ×4, fortnightly ×4, then monthly
Maintenance ECT
Beyond 6 months – individualised interval, often every 2–5 weeks
Relapse prevention is essential: without continuation treatment, more than half of patients relapse within 6 months. Start continuation pharmacotherapy or ECT.
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SESSION
08
Complications &
Post-ECT Care
Recovery care · Post-ECT instructions · Side effects · Cognitive effects · Complications
12:15 – 12:35 PM · 20 min
SESSION 08 · COMPLICATIONS & POST-ECT CARE
Immediate Post-ECT Care (Recovery)
Position & airway
Recovery (lateral) position; airway clear; suction ready
Oxygen
Continue O₂ until fully awake and SpO₂ stable on room air
Vital signs
BP, HR, SpO₂, RR every 15 min until stable
Consciousness
Monitor orientation; calm, low-stimulation environment
Agitation / delirium
Reassure and reorient; IV midazolam or propofol if severe
Symptom relief
Treat headache, nausea and myalgia; watch for prolonged apnoea
READY TO LEAVE RECOVERY WHEN…
Vital signs stable, near baseline
Awake and oriented (or back to baseline)
Maintaining airway and SpO₂ on room air
Able to swallow and tolerate sips
Steady on standing with assistance
Modified Aldrete score ≥ 9
30–60 min
typical recovery time
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SESSION 08 · COMPLICATIONS & POST-ECT CARE
Post-ECT Instructions for Patients & Caregivers
Rest
Rest for the rest of the day. A responsible adult should accompany the patient home.
No driving
No driving, cycling or operating machinery for at least 24 hours – ideally throughout the course.
No major decisions
Postpone important legal, financial or life decisions during the course.
Eating
Start with sips of water, then a light meal once fully awake and able to swallow.
Medicines
Resume medicines as advised. Avoid alcohol and any non-prescribed drugs.
Before next session
Nothing by mouth for ≥ 6 h; wash hair (no oil); remove nail polish and jewellery.
Memory support
Keep a diary; family can gently remind about recent events. Memory usually improves within weeks.
Report immediately
Severe confusion, chest pain, breathlessness, severe headache, fever, a fall or injury.
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SESSION 08 · COMPLICATIONS & POST-ECT CARE
Common Short-Term Side Effects
Headache
Common after treatment
Manage: Paracetamol or NSAIDs; pre-treat before the next session if recurrent.
Muscle aches
Linked to succinylcholine fasciculations, mostly after early sessions
Manage: Simple analgesics; optimise relaxant dosing.
Nausea / vomiting
Often anaesthetic-related (e.g. etomidate)
Manage: Ondansetron; review the anaesthetic agent.
Jaw pain / dental injury
Direct stimulation of the masseter – not blocked by the relaxant
Manage: Correctly placed bite block; dental check.
Post-ictal confusion
Minutes to about an hour; more with BT and in the elderly
Manage: Reorient, calm environment; review dose and placement.
Fatigue / drowsiness
Usual on treatment days
Manage: Rest; reassure – resolves the same day.
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SESSION 08 · COMPLICATIONS & POST-ECT CARE
Cognitive Effects: What to Expect
Acute confusion
Post-ictal disorientation
Minutes to hours after each session – resolves.
Anterograde amnesia
Difficulty retaining new information
During the course – usually resolves within about 2–4 weeks after the last session.
Retrograde amnesia
Gaps for past events, esp. autobiographical
Mostly recovers over weeks to months; some patchy gaps around the treatment period may persist.
Risk factors
How to minimise
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SESSION 08 · COMPLICATIONS & POST-ECT CARE
Serious Complications & Their Management
Complication | Management |
Cardiovascular: arrhythmia, bradycardia/asystole, hypertension, ischaemia | Anticholinergic; β-blocker; continuous ECG; cardiology input for high-risk patients |
Prolonged seizure (> 180 s) | IV benzodiazepine or propofol/thiopentone; oxygenate; review dose and drugs |
Tardive seizure / non-convulsive status | EEG, benzodiazepines, antiepileptics; neurology opinion |
Prolonged apnoea | Continue ventilation and sedation until recovery; test pseudocholinesterase (dibucaine number) |
Post-ictal delirium / severe agitation | Calm environment, reorientation; IV midazolam or propofol; prophylaxis next session |
Aspiration | Strict fasting, suction, lateral position, airway protection |
Fracture, dislocation, dental injury | Adequate relaxation, bite block, dental check – rare with modified ECT |
Treatment-emergent (hypo)mania | Evaluate; continue ECT or add a mood stabiliser as appropriate |
~2
deaths per 100,000 treatments
Comparable to minor procedures under general anaesthesia; most deaths are cardiovascular, in patients with significant medical illness.
Tørring et al., 2017
ECT Workshop 2026 · Bharosa Neuro Psychiatry Hospitals, LB Nagar, Hyderabad
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SESSION
09
Live Demonstration &
Observation
What to observe · Observer guidelines
12:35 – 12:50 PM · 15 min
SESSION 09 · LIVE DEMONSTRATION & OBSERVATION
Live Demonstration: What to Observe
PHASE 1
Preparation
PHASE 2
The stimulus
PHASE 3
The seizure
PHASE 4
Recovery
Note for the Q&A: stimulus dose (mC) · motor and EEG seizure duration · peak heart rate · time to reorientation
ECT Workshop 2026 · Bharosa Neuro Psychiatry Hospitals, LB Nagar, Hyderabad
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SESSION 09 · LIVE DEMONSTRATION & OBSERVATION
Observer Guidelines
Patient consent first
Observation takes place only with the patient’s (or nominated representative’s) consent. Respect their dignity throughout.
Confidentiality
Do not share names, faces or any identifying details – in person or online.
No photos or recordings
Phones on silent and put away. No photography, video or audio recording at any time.
Keep quiet
The team must hear the “all clear” call and the monitor alarms. Talk only between treatments.
Stay in the observation area
Keep to the marked area and follow instructions from the ECT team at all times.
Questions at the end
Note your questions as you watch – we take them in the case discussion and Q&A.
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SESSION
10
Case Discussion & Q&A
Clinical cases · Key takeaways · Questions & answers
12:50 – 1:00 PM · 10 min
SESSION 10 · CASE DISCUSSION & Q&A
Case Discussions
Illustrative teaching cases – choose one for whole-group discussion
CASE 1
Psychotic depression with food refusal
45-year-old woman with severe depression, nihilistic delusions, refusing food and fluids for 5 days, with active suicidal ideation.
Discuss
CASE 2
Catatonia after prolonged immobility
24-year-old man with catatonic stupor for 3 weeks, only partial response to lorazepam; bedbound, with fever and rising CPK.
Discuss
CASE 3
Elderly patient with resistant depression
68-year-old man, recurrent depression unresponsive to two antidepressants; on lithium and clonazepam; hypertensive; mild memory complaints.
Discuss
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KEY TAKEAWAYS
Six things to remember
01
Most effective, fastest-acting
ECT is the most effective acute treatment for severe depression – and safe when done well.
02
The seizure is the treatment
Anaesthesia makes it safe, painless and humane; modified ECT is mandatory in India.
03
No absolute contraindications
Weigh risk against benefit and optimise medical conditions before starting.
04
Dose deliberately
Titrate the dose; RUL ultrabrief to protect cognition, BT when speed matters.
05
Monitor every session
Seizure quality, haemodynamics and cognition – adjust as the course progresses.
06
Plan continuation from day one
Relapse is common without continuation pharmacotherapy or ECT.
RESOURCES
References & Further Reading
For education of healthcare professionals. Doses and protocols are indicative – always follow current guidelines, the ECT device manufacturer’s instructions and institutional protocols.
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Thank You
Questions & Discussion
Science · Safety · Second Chances
Registrations & enquiries
95050 58886 | 95050 58887
Bharosa Neuro Psychiatry Hospitals
LB Nagar, Hyderabad · bharosahospitals.com
Your Partner in Change · Together for a mentally healthier India