Modified ECT Lowers Dental, Skeletal Fracture Risk

Modified electroconvulsive therapy (ECT) can reduce the risk for skeletal and dental fractures, new research shows.

“ECT is associated with a very low risk of skeletal fractures, even in high-risk patients, and is also associated with a low risk of dental fractures,” said study investigator Chittaranjan Andrade, MD, noting that preexisting bone and dental disease increase this risk.

Overall, clinicians who provide ECT “need to be aware of rare adverse effects, as well as the common ones,” Andrade, senior professor of clinical psychopharmacology and neurotoxicology, National Institute of Mental Health and Neurosciences, Bangalore, India, told Medscape Medical News. He added they also “need data to be able to provide reassurance.”

The findings were published online February 6 in the Journal of Clinical Psychiatry.

Avoid Unmodified ECT

Andrade conducted the study because the risk of skeletal and dental fractures associated with ECT is “not commonly discussed.”

Although ECT is perhaps the most effective available treatment for major mental illness, it is associated with several adverse effects, including those associated with delivery of an electrical stimulus to the brain, which results in central and peripheral seizure, he noted.

“The central seizure is essential for the efficacy of ECT,” said Andrade. In contrast, “the motor seizure has no therapeutic value, is cosmetically displeasing, and may rarely be associated with peripheral adverse effects affecting muscles, joints, teeth, and bones,” he added.

The musculoskeletal and dental injuries are caused by stretching, twisting, compression, or direct injury. Particularly during the motor seizure, the “sudden jerk” associated with the tonic contraction of muscles as well as the repeated jerks associated with each clonic contraction can result in injuries, including skeletal and dental fractures.

To address this concern, the motor seizure is “modified” or attenuated through use of an intravenous muscle relaxant administered with other ECT premedication.

“How effectively the musculoskeletal and dental adverse effects are minimized depends on how well the motor seizure is modified,” Andrade said. He emphasized that the “use of unmodified ECT is strongly discouraged.”

Andrade reviewed prior research into the skeletal and dental risks of ECT. The infrequency of cases and ethical difficulties in conducting randomized clinical trials with such patients require reliance on anecdotal reports, he said.

Bite Blocks, Seizure Modifiers

Population-based data showed that the a fracture risk with modified ECT of two events per 100,000 ECTs. However, the risk may be as low as 0.36 events per 100,000 ECTs if calculated only with recent data, Andrade noted.

Population-based studies also suggest that the dental fracture risk with modified ECT is 0.02% per ECT and 0.17% per ECT course.

Although fractures have been reported under “unusual circumstances” among patients receiving modified ECT, many other reports point to the safety of this treatment, even in ultra-high-risk patients.

Such patients include those with severe osteoporosis, metastatic bone disease, osteogenesis imperfecta, Ehlers-Danlos syndrome, Harrington rod implants, recent long bone fractures, multiple bone fractures, surgical repair of hip fracture, vertebroplasty, and maxillofacial repair.

Andrade noted that oral health is “poor” among patients with major mental illness for multiple reasons, including poor nutrition, self-neglect, and decreased salivation caused by the anticholinergic effects of medications.

This places these patients at increased risk for dental eadverse effects during ECT because the muscles of the jaw contract forcefully during the motor seizure, causing sudden impact and, subsequently, sustained pressure on the teeth, Andrade said.

Moreover, because ECT is typically administered through repeated sessions, dental injuries may accumulate over the course of treatment.

ECT-associated skeletal risks arise from the tonic-clonic contractions of the muscles of the trunk and limbs, which need to be addressed via use of succinylcholine or other muscle relaxants included in ECT premedication.

Andrade noted that succinylcholine is effective at modifying the motor seizure at the common dose of 0.5 – 1.0 mg/kg. However, about 5% of patients require a higher dose (>1.5 mg/kg). If the dose is 1 – 2 mg/kg for patients at high risk for orthopedic complications, “muscle relaxation during ECT could be expected to be reasonably complete,” he said.

“Because of wide interpersonal variation, a neurostimulator may need to be used to identify the ideal dose for an individual patient,” he added.

In addition, use of bite blocks and effective jaw immobilization during ECT can reduce the risk. “Careful assessment of preexisting risk and good ECT practice can minimize the risk of skeletal and dental complications during ECT,” Andrade said.

Risks vs Benefits

Commenting for Medscape Medical News, Mark George, MD, distinguished professor of psychiatry, radiology, and neurology and director of the Brain Stimulation Division, Medical University of South Carolina, Charleston, said this was a “well-written review of how frequently patients who are undergoing modern ECT have bone fractures or dental fractures during the procedure.”

George, who was not involved with the research, added that modern medications and management “make ECT a truly safe procedure.”

“It is not without some risk, but these risks are low, especially when compared to the risks of untreated or undertreated depression or catatonia, like suicide,” he said.

Andrade publishes an e-newsletter supported by Sun Pharmaceuticals, with payments made directly to registered charities, but does not benefit financially from the relationship. His travel expenses for delivering lectures and workshops have been supported by the organizers themselves or pharmaceutical companies at the behest of the organizers. He has provided advice to various pharmaceutical companies and has received “nominal compensation.” He has also received payments for developing educational materials for scientific initiatives and programs, such as for the Behavioral and Neurosciences Foundation of India, PsyBase India, Texas Tech University USA, the Nordic Association for Convulsive Therapy, and the American Society of Clinical Psychopharmacology. George reports no relevant financial relationships.

J Clin Psychiatry. Published online February 6, 2023. Full article

Batya Swift Yasgur, MA, LSW is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom(the memoir of two brave Afghan sisters who told her their story).

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