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ORIGINAL RESEARCH

Prevalence and Predictors of Postictal Confusion

After Electroconvulsive Therapy
This article was published in the following Dove Press journal:
Neuropsychiatric Disease and Treatment

Pichai Ittasakul 1 Objective: To investigate the prevalence and predictors of postictal confusion (PIC) in
1 patients who received electroconvulsive therapy (ECT).
Phathamon Jarernrat
Phern-Chern Tor 2 Methods: We conducted chart reviews for 79 patients who were receiving inpatient ECT.
1
Subjects with PIC were identified. PIC was defined by confusion, disorientation, motor
Department of Psychiatry, Faculty of
Medicine, Ramathibodi Hospital, Mahidol restlessness, purposeless movement, and nonresponse to verbal commands following ECT
University, Bangkok, Thailand; within an hour, intravenous benzodiazepine was necessary to manage disturbed behavior.
2
Department of Mood and Anxiety, Multivariable logistic regression analysis was used to examine the association of PIC with
Institute of Mental Health, Singapore
demographic and clinical variables.
Results: Prevalence of PIC was 36.7%. In 912 ECT sessions, the occurrence of PIC was 86
times. Patients with PIC (n = 29) had significant higher body mass index (BMI) (27 ± 6.6 kg/
m2 vs 24.1 ± 5.2 kg/m2, t = −2.22, df = 77, p = 0.029) than patients without PIC (n = 50). PIC
associated with BMI (Pearson correlation = 0.25, p = 0.029). BMI was significant predictor
of PIC after adjusting for other covariates (odds ratio = 0.91, 95% CI= 0.83–0.99, p < 0.035).
Conclusion: PIC was not uncommon in patients receiving ECT. BMI was an independent
predictor of PIC. Psychiatrists should be aware of the risks of PIC in patients with high BMI
receiving ECT.
Keywords: electroconvulsive therapy; ECT, body mass index; BMI, Thai patients, agitation,
postictal confusion; PIC

Introduction
Electroconvulsive therapy (ECT) is commonly used to treat severe mental disorders
including schizophrenia, schizoaffective disorder, bipolar affective disorder and
medication resistant depression. It is a rapid, highly effective treatment.
A common adverse effect is postictal confusion (PIC) following ECT. The pre­
valence of PIC in patients who received ECT treatments was 30–65%.1–4
Symptoms of PIC, including confusion, disorientation, motor restlessness, purpose­
less movement, and nonresponse to verbal commands can last from 1 to 60 minutes
after ECT.3 The severity of PIC can vary from mild to severe. PIC may be leading
to patient falls, and risk to ECT staff.5,6 Thirty-four percent of patients who had
previous history of PIC may be have PIC again after ECT.7 Previous studies
Correspondence: Pichai Ittasakul
Department of Psychiatry, Faculty of demonstrated that risk factors associated with PIC after ECT include old age,8
Medicine, Ramathibodi Hospital, Mahidol catatonia,1 pretreatment anxiety9 electrode placement method,6 using of lithium,10
University, 270 Rama VI Road,
Ratchathewi, Bangkok, 10400, Thailand anesthetic agent and muscle relaxant11,12 and duration of seizure.3
Tel +662-2011478
Fax +662-200-3277
A recent study in Thai psychiatric patients reported the occurrence of PIC after
Email [email protected] ECT at 62.1%.4 To our knowledge, there is limited literature about PIC in Thai

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patients. Therefore, we aimed to investigate the prevalence discontinued at least 48 hours and 15 hours respectively
and predictors of PIC in Thai patients who received ECT before treatment. The ECT procedures were performed at
to guide clinicians in its prevention. the (PACU) by staffs, which included psychiatrists, psychia­
tric residents, anesthetic staff, psychiatric nurses, and anes­
Materials and Methods thetic nurses. Anesthesia consisted of thiopental (2–5 mg/kg
Setting and Study Design IV) or propofol (1–2 mg/kg IV) and succinylcholine
We performed a retrospective chart review on all patients (0.5–1 mg/kg IV). ECT was administered three times per
who received inpatient ECT from December 2014 to week using the brief pulse wave (1.0 millisecond pulse
November 2018 at the Ramathibodi Hospital, Mahidol width) generated by a Mecta Spectrum 5000Q (Mecta
University, Bangkok, Thailand. Psychiatric diagnoses were Corp, USA) or Thymatron System IV (Somatics,
performed by psychiatrists based on the DSM-IV-TR.13 We Northampton, USA).
collected data including age, gender, body mass index The seizure threshold (ST) was determined at the first ECT
(BMI), psychiatric diagnosis, duration of current illness, session using the dose-titration method as shown in Table 1 for
concurrent medication, ECT data (e.g., stimulus intensity, Mecta Spectrum 5000Q and in Table 2 for Thymatron System
seizure duration determined by electroencephalography IV, except that males started at Step 2. The ST was defined as
[EEG], electrode placement method, and number of ECT the dose at which there was definite evidence on the electro­
sessions). In our study, PIC was defined by confusion, dis­ encephalogram of generalized seizure activity for at least 25
orientation, motor restlessness, purposeless movement, non­ s. The method of electrode placement (bilateral [BL] or right
response to verbal command following ECT within an hour unilateral [RUL]) was determined by the symptom severity, as
in post-anesthetic care unit (PACU) and intravenous benzo­ determined by the treating psychiatrist.
diazepine (diazepam 5–20 mg or midazolam 2.5–5 mg) was The stimulus intensity was then increased to 500%
necessary to manage disturbed behavior.14 above ST for RUL electrode placement and 50% above
The study protocol was approved by the Ethics the ST for BL electrode placement.16 Treatment was typi­
Committee on Human Experimentation of the Faculty of cally stopped when maximal improvement (remission or
Medicine, Ramathibodi Hospital, Mahidol University. plateau of effect) was reached as assessed by standardized
Research was conducted in accordance with the psychiatric rating scales or when adverse effects limited
Declaration of Helsinki of the World Medical further treatments. Psychiatric rating scales, including the
Association.15 All patients provided verbal and written Brief Psychiatric Rating Scale (BPRS)17,18 for schizophre­
informed consent before participation. nia, Montgomery Asberg Depression Rating Scale
(MADRS)19,20 for depression, and Young Mania Rating
ECT Treatment Scale (YMRS)21,22 for mania, were used to assess the
Psychiatrists and anesthesiologists assessed all patients severity of symptoms at baseline (24 hours before ECT),
before receiving ECT. Lithium and benzodiazepines were after every 3 sessions of ECT treatment, and after the last

Table 1 Dose Titration Schedule and Parameter Settings for Mecta Spectrum 5000Q
Step Right Unilateral Electrode Placement Bilateral Electrode Placement

Pulse- Frequency Duration Current Charge Pulse Frequency (Hz) Duration Current Charge
Width (ms) (Hz) (Sec) (mA) (mC) width(ms) (Sec) (mA) (mC)

1 0.5 50 0.5 800 20 1 40 0.75 800 48

2 0.5 40 1 800 32 1 40 1.25 800 80
3 0.5 40 1.5 800 48 1 40 2 800 128
4 0.5 40 1.5 800 77 1 60 2 800 192
5 1 40 2 800 128 1 60 3 800 288
6 1 60 2 800 192 1 60 4.5 800 432
7 1 60 3 800 288 1 60 6 800 576
8 1 60 4.5 800 432
9 1 60 6 800 576

Abbreviations: ms, millisecond; Hz, Hertz; mA, milliampere; mC, millicoulomb.

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Table 2 Dose Titration Schedule and Parameter Settings for Thymatron System IV
Step Right Unilateral Electrode Placement Bilateral Electrode Placement

Pulse-Width Frequency Energy Level Charge Pulse Width Frequency Energy Level Charge
(ms) (Hz) (%) (mC) (ms) (Hz) (%) (mC)

1 0.5 40 5 25 0.5 40 10 50
2 0.5 40 10 50 0.5 40 15 76
3 0.5 40 15 76 0.5 40 25 126
4 0.5 40 25 126 0.5 40 35 176
5 0.5 40 35 176 0.5 40 50 252
6 0.5 40 50 252 0.5 60 70 353
7 0.5 60 70 353 1 40 100 504
8 1 40 100 504
Abbreviations: ms, millisecond; Hz, Hertz; mC, millicoulomb.

ECT session. Assessments were performed by staff and Prevalence and Associated Factor of
psychiatric residents who had received appropriate train­
Postictal Confusion
ing. Assessments of inter-rater reliability were performed Of the 79 patients, 29 (36.7%) developed PIC at one or
using the intraclass correlation coefficient (ICC). The ICC
more sessions during the ECT course while 63.3% (50/79)
was 0.9. Remission was defined as follows: BPRS < 31 for
had no PIC. In 912 ECT sessions, the occurrence of PIC
schizophrenia,17 MADRS < 10 for depression,19 and
was 86 times (9.4%, 86/912).
YMRS < 10 for mania.21,22
Table 3 Demographic Data (Total N = 79)
Statistical Analysis Characteristics N (%) or Mean ± SD
Demographic data between patients with and without
Female (%) 48 (60.8%)
PIC were compared with Chi-squared and Fisher’s
Age (years) 45.2 ± 15.9
exact tests for categorical parameters and t-tests for
< 60 years 64 (81%)
continuous parameters. Correlations between PIC and ≥ 60 years 15 (19%)
demographic data, clinical characteristics, and ECT
2
Body mass index (kg/m ) 25.2 ± 5.9
treatment variables were carried out using Pearson cor­
relation. Variables included for analysis were gender, Diagnosis
age, BMI, psychotropic drug (number of concomitant Schizophrenia 23 (29.7%)
Schizoaffective disorder 7 (8.9%)
psychotropic drugs and classes of drugs), anesthetic
Bipolar disorder 16 (20.3%)
agent, electrode placement method, number of ECT ses­ Major depressive disorder 27 (34.2%)
sions, stimulus intensity, and EEG seizure duration. Other diagnosis 6 (7.6%)
Multivariable logistic regression analysis was used to
Duration of illness (years) 11.9 ± 10.5
examine the association of PIC to demographic and clin­
ical variables. The strength of the association was pre­ History of previous ECT 18 (22.8%)

sented by odds ratio with 95% confidence interval (95% Number of psychotropic drug 2.8 ± 1.4
CI). P-value was set at < 0.05. All statistical analysis were
Concurrent medication
performed using SPSS 21.0 for Windows (IBM Corp., Antipsychotic 69 (87.3%)
Armonk, NY, USA). Antidepressant 24 (30.4%)
Anticonvulsant 5 (6.3%)
Anticholinergic drug 8 (10.1%)
Results
Electrode placement
Demographic Characteristics Right unilateral 30 (38%)
Seventy-nine patients were included in the study. The Bilateral 49 (62%)
clinical characteristics of the 79 patients are shown in Abbreviations: SD, standard deviation; ECT, electroconvulsive therapy; RUL, right
Table 3. The total number of ECT was 912 sessions. unilateral; BL, bilateral.

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Table 4 Comparison Between Postictal Confusion and No Postictal Confusion Group

Item Mean ± SD or Number (%) X2 T p-value

No Postictal Confusion (N=50) Postictal Confusion (N=29)

Female 18 (36 %) 13 (44.8 %) 0.6 0.439

Age (years) 46 ± 16.2 43.7 ± 15.6 0.65 0.521

Age ≥ 60 years 7 (17.1%) 16 (21.6%) 0.34 0.559

Body mass index (kg/m2) 24.1 ± 5.2 27 ± 6.6 -2.22 0.029*

Duration of illness (years) 12.3 ± 11.7 11.1 ± 8.1 0.42 0.675

Diagnosis 1.79
Schizophrenia 12 (24%) 11 (37.9%)
Schizoaffective disorder 5 (10%) 2 (6.9%)
Bipolar disorder 11 (22%) 5 (17.2%)
Major depressive disorder 18 (36%) 9 (31%)
Others 4 (8%) 2 (6.9%)

History of previous ECT 9 (18%) 9 (31%) 1.77 0.183

Number of psychotropic drug 2.7 ± 1.4 2.9 ± 1.3 -0.5 0.622

Concurrent medication
Antipsychotic 43 (86%) 26 (89.7%) 0.22 0.738
Antidepressant 15 (30%) 9 (31%) 0.01 0.923
Anticonvulsant 4 (8%) 1 (3.4%) 0.64 0.647
Anticholinergic 7 (14%) 1 (3.4%) 2.25 0.246

Anesthetic agent
Thiopental (2–5 mg/kg) 41 (82%) 27 (93.1%) 1.89 0.312
Propofol (1–2 mg/kg) 9 (18%) 2 (6.9%)

Electrode placement
RUL 21 (42%) 28 (31%) 0.94 0.471
BL 29 (58%) 20 (69%)

Number of ECT sessions 11.4 ± 5.4 11.8 ± 5.7 -0.31 0.761

Charge (mC) 306.9 ± 165.4 315.4 ± 155.5 -0.23 0.823

Seizure duration (seconds) 48.3 ± 13 50.8± 14.3 -0.79 0.431

Note: *p < 0.05.
Abbreviations: SD, standard deviation; ECT, electroconvulsive therapy; RUL, right unilateral; BL, bilateral; mC, millicoulombs.

Among 29 patients who developed PIC 37.9% (11/29) exception that patients with PIC had statistically significant
had only one PIC, 24.1% (7/29) had two PIC, 13.8% (4/29) higher BMI (27 ± 6.6 kg/m2 vs 24.1 ± 5.2 kg/m2, t = −2.22, df
had three PIC, 13.8% (4/29) had four PIC, 3.4% (1/29) had = 77, p = 0.029) than patients without PIC. Occurrence of PIC
seven PIC, 3.4% (1/29) had eight PIC, and 3.4% (1/29) had associated with BMI (Pearson correlation = 0.25, p = 0.029)
eighteen PIC during the ECT course. (Table 4)
Patients with PIC compared to those without PIC were Multivariable logistic regression analysis revealed that
similar with respect to gender, age, duration of illness, psy­ BMI was significant predictor of PIC after adjusting for
chiatric diagnosis, history of previous ECT, concurrent medi­ other covariates (odds ratio = 0.91, 95% CI= 0.83–0.99, p <
cation, anesthetic agent, electrode placement, number of ECT 0.035). The results for multiple logistic regression was demon­
session, stimulus intensity, and EEG seizure duration, with the strated in Table 5.

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Table 5 Multivariable Logistic Regression Analysis for Postictal Confusion

Variables Postictal Confusion p value

Odds Ratio 95% Confidence Interval

Lower Upper

Sex
Female 1.13 0.38 3.33 0.83
Male reference

Age (years) 1 0.96 1.04 0.981

Body mass index (kg/m2) 0.91 0.83 0.99 0.042*

Number of psychotropic drug 0.97 0.63 1.48 0.879

Concurrent medication
Antipsychotic 0.87 0.14 5.52 0.885
Anticholinergic 0.15 0.02 1.42 0.099

Anesthetic agent
Thiopental (2–5 mg/kg) 0.34 0.06 1.96 0.224
Propofol (1–2 mg/kg) reference

Electrode placement
RUL 2.52 0.67 9.41 0.171
BL reference

Number of ECT sessions 1.01 0.9 1.13 0.872

Charge (mC) 1 0.99 1 0.666

EEG seizure duration (seconds) 0.98 0.94 1.03 0.492

Note: *p < 0.05.
Abbreviations: ECT, electroconvulsive therapy; RUL, right unilateral; BL, bilateral; mC, millicoulombs; EEG, electroencephalography.

Discussion demonstrated high prevalence of PIC in patients who

In our study, ECT was commonly used to treat patients receiving ECT.1–4
with major depressive disorders (34.2%) and schizophre­ Furthermore, we found patients who developed PIC after
nia (29.5%), while in other countries, ECT was most ECT had higher BMI compared to those who had no PIC.
commonly used for major depressive disorders followed PIC had a significant positive association with BMI. High
by bipolar depression and, significantly less commonly, BMI increased the likelihood of PIC in psychiatric patients
schizophrenia and schizoaffective disorders, especially in who receiving ECT. These findings may be explained by
the United States.23 patients who had higher BMI may have more frequently
Our study found that PIC was seen in 36.7% of develop oxygen desaturation during ECT24,25 because ven­
patients receiving ECT. This result was lower than the tilation is difficult in high BMI patients, that may lead to
prevalence in a previous study that reported prevalence PIC. It would be interesting to investigate if PIC has an
was 62.1% in Thai psychiatric patients.4 In other stu­ association with the degree of desaturation.
dies, the prevalence of PIC was vary from 7% to In our study, no association was demonstrated between
65%.1–3,7 This may be explained by difference of defini­ PIC and other factors, including sex, age, concurrent anti­
tion of PIC, in our study, we only included patients who psychotic and anticholinergic drug, number of psychotro­
required medication to control symptoms, therefore, the pic drugs, anesthetic agents, and electrode placement,
patients who had mild symptoms of PIC who did not stimulus intensity, EEG seizure duration. This finding
require medication were excluded. Despite this variation was consistent with those of previous studies conducted
in prevalence of PIC, studies have consistently by Devanand et al14 and Kikuchi et al.1

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Ittasakul et al Dovepress

However, regarding electrode placement method and sei­

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