Electroshock therapy

The use of electroconvulsive therapy (synonyms - electroconvulsive therapy, electroshock therapy) for the treatment of mental disorders has an almost 70-year history. Nevertheless, this method of stress biological influence has not lost its relevance to this day and is a worthy alternative to psychopharmacotherapy. At the same time, a long period of successful clinical use of electroconvulsive therapy has not made the mechanism of action and the causes of side effects and complications clear. This can be explained not only by the complexity of modeling a seizure on animals equivalent to that in mentally ill people, but also by the fact that even a single procedure of electroconvulsive therapy causes one-time changes in almost all neurotransmitter systems of the brain, potentiates multiple electrophysiological, neuroendocrine and neuroimmune reactions, the verification of the significance of which is very difficult.

Over the period of its existence, electroconvulsive therapy has undergone significant changes in clinical, methodological, and theoretical-experimental aspects. The use of general anesthesia and muscle relaxants since the 1950s has led to a decrease in patient mortality and a significant decrease in the risk of traumatic injuries. The use of short-term pulse stimulation, which began in the 1980s, significantly reduced the severity of cognitive side effects and demonstrated for the first time the fact that the type of electric current is the main determinant of side effects. Subsequent studies have shown that the type of electrode application and the parameters of the electric charge determine both the effectiveness of treatment and the severity of side effects. Electroconvulsive therapy techniques have been developed aimed at potentiating a seizure in the prefrontal cortex by modifying the location of electrodes and inducing focal seizures using fast alternating magnetic fields.

Experimental studies were aimed at studying the mechanisms of action of electroshock therapy. Cerletti (1938) linked the positive results of using electricity to potentiate seizures with the secretion of "acroagonins" in the brain in response to shock. It was later established that, like TA, electroshock therapy causes an increase in the "synthesis of noradrenaline, and changes in the serotonin system are less pronounced, the effect on presynaptic receptors is weakly expressed. At the same time, electroshock therapy can lead to the development of hypersensitivity of serotonin receptors. Modern data on the effect on the cholinergic (down-regulation of cholinergic receptors) and dopamine systems are insufficient to explain the antidepressant effect of electroshock therapy. It has been shown that electroconvulsive therapy, like TA, increases the content of γ-aminobutyric acid in the brain, which gives grounds to speak about the possible inclusion of the γ-aminobutyric acid-ergic system in the antidepressant effects of electroconvulsive therapy. It is possible that electroconvulsive therapy increases the activity of the endogenous opioid system.

Indications for the use of electroconvulsive therapy

According to the recommendations of the Russian Ministry of Health, the main indications for prescribing electroshock therapy are the following.

• Depressive disorder (primary episode or recurrent course). Electroconvulsive therapy is indicated in the absence of effect after three courses of intensive therapy with antidepressants of various chemical groups, anti-resistant pharmacological measures (SSRI or MAO inhibitor + lithium carbonate; MAO inhibitor + tryptophan; MAO inhibitor + carbamazepine; mianserin + TA, MAO inhibitor or SSRI), two non-drug anti-resistant measures (complete or partial sleep deprivation, phototherapy, plasmapheresis, normobaric hypoxia, reflexology, laser therapy, fasting-diet therapy). Electroconvulsive therapy is the method of first choice for depressive states with repeated suicide attempts or persistent refusal to eat and drink, when antidepressant therapy can lead to
• Bipolar affective disorder - to interrupt the cyclical course (more than four affective phases per year) in the absence of an effect from normothymic drugs.
• Paranoid form of schizophrenia (primary episode or exacerbation of the disease). Electroconvulsive therapy is used in the absence of an effect from therapy with oral or parenteral psychotropic drugs for 3-4 weeks (three-fold change of neuroleptic: "traditional" neuroleptic, neuroleptic of a different chemical structure, atypical neuroleptic), anti-resistant measures (complete or partial sleep deprivation, plasmapheresis, normobaric hypoxia, reflexology, laser therapy, unloading diet therapy, one-stage cancellation of psychotropic drugs).
• Catatonic schizophrenia. Indications for electroconvulsive therapy are the same as for the paranoid form, with the exception of stupor. In life-threatening conditions, such as inability to eat or drink, electroconvulsive therapy is the first choice.
• Febrile schizophrenia. Electroshock therapy is the first-choice therapy. The effectiveness of electroshock therapy in this pathology correlates with the duration of the febrile period. Prescription of electroshock therapy is most effective in the first 3-5 days of an attack before the development of somatovegetative disorders. Electroshock therapy sessions must be combined with complex intensive infusion therapy, which is aimed at correcting the main indicators of homeostasis.
• The above recommendations summarize domestic experience of clinical application of electroconvulsive therapy and do not take into account some aspects of application of electroconvulsive therapy in other countries. In particular, according to recommendations of the American Psychiatric Association and the British Royal Society of Psychiatrists, electroconvulsive therapy is indicated for the following conditions.
• Major depressive episode or severe recurrent depressive disorder with the following symptoms:
  • suicide attempt;
  • severe suicidal thoughts or intent;
  • life-threatening condition - refusal to eat or drink;
  • stupor;
  • severe psychomotor retardation;
  • depressive delirium, hallucinations.

In these cases, electroconvulsive therapy is used as an emergency first-line therapy, due to its high efficiency and speed of onset of the effect. Electroconvulsive therapy can also be used in cases where there is no response to antidepressant therapy administered for 6 months in effective doses when changing two antidepressants with different mechanisms of action, adding lithium carbonate, lnotyronine, MAO inhibitors, drugs that improve cognitive function, and adding psychotherapy to the therapy. In elderly patients, the duration of antidepressant therapy may exceed 6 months.

Severe mania:

• with a physical condition that threatens the patient's life;
• with symptoms resistant to treatment with mood stabilizers in combination with antipsychotics.

Acute schizophrenia. Electroconvulsive therapy is the fourth-line treatment of choice. It is used when clozapine is ineffective in therapeutic doses.

Catatonia. If treatment with benzodiazepine derivatives (lorazepam) in therapeutic doses is ineffective: intravenously (IV) 2 mg every 2 hours for 4-8 hours.

Preparing for Electroconvulsive Therapy

Before conducting electroshock therapy, it is necessary to collect detailed anamnestic information about the patient's health condition, specifying any somatic diseases suffered. In the presence of acute pathology or exacerbation of chronic diseases, it is necessary to conduct appropriate therapy. It is necessary to conduct laboratory blood and urine tests, electrocardiography (ECG), chest and spine radiography, consultation with a therapist, ophthalmologist and neurologist, and, if necessary, other specialists. The patient must give written consent to conduct electroshock therapy.

Electroconvulsive therapy is performed on an empty stomach. All medications for continuous use, except insulin, must be taken 2 hours before the session of electroconvulsive therapy. It is necessary to evaluate the compatibility of the medications that the patient receives as continuous therapy with the means used in electroconvulsive therapy (anesthetics, muscle relaxants). The patient must remove dentures, jewelry, hearing aids, contact lenses, and empty the bladder. It is necessary to measure blood pressure, pulse, body temperature, body weight, and in patients with diabetes, determine the blood glucose level.

Rationale for Electroconvulsive Therapy

A course of electroconvulsive therapy with bilateral application of electrodes leads to changes in regional glucose metabolism indices in patients suffering from endogenous depression. There is a reliable relationship between clinical improvement and the level of regional cerebral glucose metabolism. The most pronounced changes in glucose metabolism affect the frontal, prefrontal and parietal cortex. The most significant decrease in metabolism occurs bilaterally in the superior frontal lobes, dorsolateral and medial prefrontal cortex, and the left internal temporal lobe. At the same time, regional glucose metabolism indices in the occipital lobe increase significantly. A decrease in regional glucose metabolism leads to the development of side effects and complications of electroconvulsive therapy, therefore, the decrease in regional cerebral glucose metabolism in the left temporal region after electroconvulsive therapy and the reliable relationship between the number of sessions and the percentage of glucose metabolism reduction in the left middle temporal gyrus deserve attention, which can lead to the development of memory disorders and cognitive deficit.

Electroconvulsive therapy stimulates microstructural changes in the hippocampus associated with synaptic plasticity. The mediator of synaptic reorganization is the cerebral neurotrophic factor, the content of which in the hippocampus and dental gyrus increases as a result of long-term use of electroconvulsive therapy or treatment with antidepressants.

Electroconvulsive therapy can promote neurogenesis, the degree of which correlates with the number of treatment sessions. New cells continue to exist for at least 3 months after completion of treatment. Long-term use of electroconvulsive therapy increases synaptic connections in the hippocampal pathways, but depletes long-term potentiation, leading to memory impairment. It is hypothesized that depletion of synaptic potentiation is what causes the cognitive side effects of electroconvulsive therapy.

The results of electrophysiological and neuroimaging studies demonstrated a correlation between the regional effect of electroconvulsive therapy and the clinical response to treatment. These studies once again confirm the great importance of the prefrontal cortex. The magnitude of delta activity in this cortex area on the EEG recorded in the interictal period is reliably associated with a better clinical response to treatment. Moreover, the indicators of glucose metabolism reduction in the anterior frontal area strictly correlate with clinical results and indicators of treatment effectiveness.

Another area of research into electroshock therapy is to clarify the indications and contraindications for its use. Depressive states of various origins are most sensitive to this method. Electroshock therapy is effective in schizophrenic psychoses, especially in the depressive-paranoid form of schizophrenia. In the catatonic form of schizophrenia, improvement is often short-term and unstable. Representatives of the Leningrad psychiatric school have obtained data on the high efficiency of electroshock therapy in patients suffering from involutional melancholy, depressions associated with organic and vascular diseases of the brain, depressions in the structure of which hypochondriacal syndromes, obsessive-compulsive syndromes and depersonalization phenomena occupy a significant place. Research conducted in the Department of Biological Therapy of the Mentally Ill of the V.M. Bekhterev, showed that in the final states of schizophrenia with fragmented thinking and schizophasic disorders, success can be achieved only with the long-term use of electroshock therapy in combination with psychopharmacotherapy. In these cases, negativism decreases and tolerance to neuroleptic drugs increases.

Many countries have developed standards for the treatment of mental disorders that regulate indications for electroconvulsive therapy. Electroconvulsive therapy is considered as an option for emergency care in life-threatening conditions (first-choice therapy), a means of overcoming therapeutic resistance (second- and third-choice therapy), and a maintenance therapy option for patients with bipolar disorders (refractory to treatment, severe manic or depressive episodes, presence of psychotic features or suicidal thoughts).

Goal of treatment

Reduction of psychopathological symptoms and overcoming resistance to psychopharmacological therapy in patients suffering from schizophrenia, depressive and bipolar affective disorders, by inducing generalized paroxysmal activity of the brain with the development of tonic-clonic seizures using electrical stimulation.

Methods of implementation

The procedure involves specially trained personnel: a psychiatrist, anesthesiologist and a nurse. Electroconvulsive therapy requires a special room with an electric convulsor, a couch, an oxygen inhaler, an electric suction machine, a glucometer-stopwatch, a manometer for measuring blood pressure, an ECG machine, an oximeter, a capnograph, a set of instruments and medications for providing emergency care in case of complications (laryngoscope, a set of intubation tubes, mouth dilators, tongue depressors, spatulas, strophanthin-K, lobeline, atropine, caffeine, nikethamide, magnesium sulfate, 0.9% sodium chloride solution, 40% dextrose solution, sodium thiopental, suxamethonium iodide). All electroconvulsive therapy procedures are recorded in a special journal. Currently, electroconvulsive therapy sessions are recommended to be performed using anesthesia and muscle relaxants. However, there are techniques that do not require general anesthesia. Before the procedure, the patient is placed on a couch. To prevent biting the tongue, the patient should clamp a rubber roller with his teeth. A 1% solution of sodium thiopental is used as an anesthetic at a rate of 8-10 mg / kg. After the onset of narcotic sleep, a muscle relaxant solution (suxamethonium iodide) is administered intravenously. The initial dose of 1% suxamethonium iodide solution is 1 ml. During the therapy, the dose of the muscle relaxant may be increased. The drug is administered until fibrillary twitching in the muscles of the distal extremities. Muscle relaxation occurs in 25-30 seconds. After this, electrodes are applied. The selection of the convulsive dose for the development of a seizure is individual. For most patients, the minimum convulsive dose varies within 100-150 V.

The clinical picture of an electroconvulsive seizure is characterized by the sequential development of tonic and clonic seizures. The amplitude of the seizures varies, the duration is 20-30 sec. During the seizure, breathing is switched off. If the breath is held for more than 20-30 sec, it is necessary to press on the lower part of the sternum; if this technique is ineffective, artificial respiration should be started. After the seizure, a short period of psychomotor agitation is possible, after which sleep occurs. After sleep, patients regain consciousness and do not remember the seizure. If the current is insufficient, abortive seizures or absences develop. With an abortive seizure, clonic seizures are absent. Abortive seizures are ineffective, and absences are not effective at all and are often accompanied by complications. After the session, the patient should be under the supervision of personnel for 24 hours in order to prevent or relieve complications. Electroconvulsive therapy should be performed 2-3 times a week. In case of severe psychotic symptoms, it is recommended to use electroshock therapy 3 times a week. The number of electroshock therapy sessions is individual and depends on the patient's condition, usually 5-12 procedures per course of treatment.

Currently, electroconvulsive therapy is used in two modifications that differ in the placement of the electrodes. In bilateral electroconvulsive therapy, the electrodes are placed symmetrically in the temporal regions 4 cm above the point that is in the middle of the line drawn between the outer corner of the eye and the ear canal. In unilateral electroconvulsive therapy, the electrodes are placed in the temporo-parietal region on one side of the head, with the first electrode placed in the same place as in bitemporal electroconvulsive therapy, and the second in the parietal region at a distance of 18 cm from the first. This position of the electrodes is called the dellia position. There is another way to apply electrodes in unilateral electroconvulsive therapy, when one electrode is placed at the junction of the frontal and temporal regions, the other - above the pole of the frontal lobe (12 cm in front of the first electrode). This position is called frontal. Currently, this modification is rarely used due to the frequent development of complications. Both methods have advantages and disadvantages. The choice of the method of electroshock therapy depends on many factors that determine the effectiveness of the therapy and the development of side effects during the treatment.

Recommendations for the preferential choice of bilateral electroconvulsive therapy

The rapid onset of effect and high efficiency suggest the use of this method in severe urgent conditions (intentions or attempts at suicide, refusal to eat, lack of critical attitude towards one’s illness), lack of effect from unipolar electroshock therapy, dominance of the right hemisphere or the impossibility of determining the dominant hemisphere.

Recommendations for the preferential choice of unilateral electroconvulsive therapy

• The patient's current mental state is not urgent and does not threaten the patient's life.
• The patient suffers from organic brain damage, in particular Parkinson's disease.
• The anamnesis contains information about the effectiveness of previously administered unilateral electroconvulsive therapy. 

To conduct sessions of electroshock therapy, special devices are used - electroconvulsators, which provide dosed application of low-frequency, sinusoidal or pulsed electric current. All devices must meet modern requirements: a wide level of current dosing from 60-70 V (up to 500 V and higher, the presence of an EEG recording unit, an ECG recording unit, a monitor of muscle motor activity during a seizure, a computer on-line analysis unit, which allows the doctor to immediately determine the therapeutic quality of the conducted electrical stimulation. The criterion for the effectiveness of a seizure is the appearance of high-frequency wave peaks on the EEG ("polyspike activity"), followed by slower wave complexes, usually three cycles per second. This is followed by a phase of complete suppression of electrical activity. In our country, the electroconvulsator "Elikon-01" meets such parameters. In the USA, "Thymatron System IV", "MECTRA SPECTRUM" are used, in the UK - "Neeta SR 2".

The effectiveness of electroconvulsive therapy

The effectiveness of electroconvulsive therapy in depressive syndromes has been the subject of numerous studies. It has been shown that improvement occurs in 80-90% of patients without drug resistance and in 50-60% of treatment-resistant patients. Patients who have received electroconvulsive therapy usually have more severe symptoms and chronic or treatment-resistant conditions than patients who have received other antidepressant treatment. However, most studies prove better clinical outcomes with the use of electroconvulsive therapy. The number of remissions after electroconvulsive therapy reaches 70-90% and exceeds the effect of any other types of antidepressant therapy.

In patients with delusional symptoms, the effectiveness of electroconvulsive therapy is higher and the effect occurs more quickly than in patients without delusional symptoms, especially when combined with neuroleptics. Elderly patients respond to electroconvulsive therapy better than young patients.

Electroconvulsive therapy is also effective in manic states. The treatment effect is more pronounced than in depressive syndromes. In acute mania, the effectiveness of electroconvulsive therapy is comparable to lithium therapy and is equivalent to that of neuroleptics. Electroconvulsive therapy can be successfully used in patients with mixed states.

Patients with bipolar disorder require fewer sessions of electroconvulsive therapy due to a tendency for the seizure threshold to increase rapidly.

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Factors Affecting Treatment Efficiency

Factors that influence the effectiveness of electroconvulsive therapy can be divided into three groups:

• factors associated with the location of electrodes and the parameters of electric current;
• factors associated with the nature of the mental disorder;
• factors associated with the patient's personality structure and the presence of concomitant pathology.

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Factors related to electrode localization and electric current parameters

The primary determinants of convulsive and post-convulsive manifestations of electroconvulsive therapy are the localization of electrodes and the parameters of the electric current. Depending on the intensity of the stimulus and the position of the electrodes, the frequency of the antidepressant response varies from 20 to 70%. It has been proven that with a bilateral position of the electrodes, the therapeutic effect is more pronounced than with a right-sided unilateral position. However, the number of cognitive impairments in this case is also significantly greater. There is evidence that bifrontal application of electrodes has a therapeutic effect equal in effectiveness to bifrontotemporal with a lower severity of side effects. According to other data, bifrontal stimulation in depression is more effective than unilateral, with an equal frequency of side effects. There is an assumption that better control of the paths of electric current propagation can reduce cognitive side effects and increase the effectiveness of therapy when focusing the effect on the frontal cortex.

Great importance is attached to the parameters of the electrical stimulus - the width of the pulse wave, the frequency and duration of the stimulus. The severity of the positive effect depends on the dose: the effectiveness of the therapy increases with an increase in the pulse power, but the severity of cognitive side effects also increases.

Factors associated with the nature of mental disorder

The effectiveness of electroconvulsive therapy in endogenous depressions has been studied the most. After electroconvulsive therapy, 80-90% of patients without drug resistance and 50-60% of treatment-resistant patients show improvement. The number of patients meeting the remission criteria after electroconvulsive therapy is significantly higher compared not only with placebo (71 and 39%, respectively), but also with TA (52%). The use of electroconvulsive therapy reduces the duration of inpatient treatment of patients. During a course of electroconvulsive therapy, a more rapid improvement is observed in patients with severe depression, primarily in individuals with delusional experiences in the structure of depressive syndrome. In 85-92% of patients with delusional depression, a clear improvement is observed after electroconvulsive therapy. The same indicators when using monotherapy with TA or neuroleptics are 30-50%, and with combination therapy - 45-80%.

In patients with schizophrenia, neuroleptics are the first-choice treatment. However, some controlled studies show that patients with acute schizophrenia with distinct catatonic or affective symptoms respond better to combined treatment with electroconvulsive therapy and neuroleptics than to monotherapy with neuroleptics. There is evidence that electroconvulsive therapy is also effective in other nosological forms, such as psychoorganic syndrome, PD, Parkinson's disease, tardive dyskinesia, and exogenous mania. However, whether this is a nonspecific effect, spontaneous course, or therapeutic effect of electroconvulsive therapy remains unclear.

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Factors related to the patient's personality structure and the presence of concomitant pathology

Comorbidity and addiction disorders in patients receiving electroconvulsive therapy may predict clinical outcomes. More than 25% of patients have comorbid personality disorders and are significantly associated with poor treatment response.

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Contraindications to electroconvulsive therapy

Contraindications to electroconvulsive therapy in Russian and foreign recommendations are different. According to the recommendations of the Ministry of Health of the Russian Federation ("Methodological recommendations: the use of electroconvulsive therapy in psychiatric practice", 1989), all contraindications to electroconvulsive therapy should be divided into absolute, relative and temporary. Temporary contraindications include febrile infectious and purulent inflammatory processes (pneumonia, cholecystitis, pyelonephritis, cystitis, purulent inflammation of the pharynx, etc.). In these conditions, electroconvulsive therapy is temporarily postponed, and the treatment started is interrupted. Absolute contraindications include uncontrolled heart failure, a history of cardiac surgery, the presence of an artificial pacemaker, deep vein thrombosis, myocardial infarction within the last 3 months, severe uncontrolled arrhythmia, decompensated heart defects, cardiac or aortic aneurysm, stage III hypertension with uncontrolled increases in blood pressure, open pulmonary tuberculosis, exudative pleurisy, exacerbation of bronchial asthma, brain tumors, subdural hematoma, glaucoma, internal bleeding. Relative contraindications include hypertension stage I and II, mild forms of coronary insufficiency, severe heart rhythm and conduction disorders, bronchiectasis, bronchial asthma in remission, chronic liver and kidney diseases in remission, malignant neoplasms, gastric ulcer and duodenal ulcer.

According to the recommendations of the British Royal Society of Psychiatrists, there are no absolute contraindications to electroconvulsive therapy. However, in high-risk situations, it is necessary to weigh the risk-benefit ratio of the treatment for the patient's health. There are conditions in which electroconvulsive therapy may have a high risk of complications. In these situations, when a doctor decides to conduct electroconvulsive therapy, the patient must be carefully examined and consulted by an appropriate specialist. The anesthesiologist must be informed of the high-risk condition. He must adjust the doses of muscle relaxants, anesthesia drugs and premedication. The patient and his relatives are also informed of the increased risk when conducting electroconvulsive therapy. Conditions associated with increased risk during electroconvulsive therapy include a history of cardiac surgery, the presence of an artificial pacemaker, deep vein thrombosis, myocardial infarction within the last 3 months, aortic aneurysm, taking antihypertensive and antiarrhythmic drugs, cerebrovascular diseases (cerebral aneurysm, cases of ischemic neurological deficit after electroconvulsive therapy), epilepsy, cerebral tuberculosis, dementia, learning disorders, condition after stroke (without statute of limitations), craniotomy. Conditions associated with increased risk during electroconvulsive therapy also include:

• gastroesophageal reflux (during a session of electroshock therapy, gastric juice may be thrown into the trachea and aspiration pneumonia may develop);
• diabetes mellitus (to reduce the risk of the procedure, it is necessary to monitor the blood glucose level, especially on the day of the electroconvulsive therapy session; if the patient is receiving insulin therapy, he should make an injection before electroconvulsive therapy);
• diseases of bones and muscles (to reduce the risk of complications | it is recommended to increase the doses of muscle relaxants);
• glaucoma (intraocular pressure monitoring is required).

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Complications of electroconvulsive therapy

The nature of the side effects and complications of electroconvulsive therapy is one of the decisive factors in choosing this method of treatment. Fears of severe irreversible side effects of electroconvulsive therapy have become one of the reasons for the sharp reduction in the number of courses. Meanwhile, side effects when using electroconvulsive therapy develop rarely (in 20-23% of cases), as a rule, are weakly expressed and short-lived.

Only 2% of patients develop serious complications. Morbidity and mortality with electroconvulsive therapy are lower than with antidepressant treatment, especially in elderly patients with multiple somatic pathologies. Mortality in patients receiving electroconvulsive therapy for severe depressive disorders is lower than with other methods of treatment, which can be explained by the lower number of suicides. As with other manipulations requiring anesthesia, the risk increases in the presence of somatic disorders.

Modern conditions of electroconvulsive therapy (unilateral application of electrodes, use of muscle relaxants and oxygen, individual titration of seizure threshold) have led to a significant decrease in the frequency of side effects. Dislocations and fractures, which were a frequent complication before the use of muscle relaxants, are now practically unheard of.

The most common complications of electroconvulsive therapy are as follows.

• Short-term anterograde and retrograde amnesia are the most common side effects of electroconvulsive therapy. They are usually short-term and last from several hours to several days, are almost always reversible, and concern events that occurred immediately before or after the electroconvulsive therapy session. In some cases, long-term local memory impairments may occur for events that occurred at a time remote from the time of electroconvulsive therapy. The use of appropriate treatment methods (oxygen, unilateral stimulation, two-day intervals between sessions) can lead to a reduction in memory disorders.
• Spontaneous seizures are rare. They occur in patients with pre-existing organic disorders. Spontaneous epileptic seizures after electroshock therapy occur in 0.2% of patients, no more often than the average in the population. More often, changes occur on the EEG (changes in overall activity, delta and theta waves), which disappear within 3 months after the end of the electroshock therapy course. Histological changes that would indicate irreversible damage to the brain have not been found in either experimental animals or patients.
• Respiratory and cardiovascular disorders: prolonged apnea, aspiration pneumonia (when saliva or stomach contents enter the respiratory tract).
• Transient rhythm disturbances, arterial hypotension or hypertension.
• Injuries to the musculoskeletal system: sprains, vertebral fractures, dislocations.
• Organic psychoses with orientation disorders and irritability develop in 0.5% of patients and are short-term and reversible. The risk of their occurrence is reduced by unilateral application of electrodes and the use of oxygen.

Currently, IT, sleep deprivation, transcranial magnetic stimulation, vagal stimulation, light therapy, transcranial electrotherapeutic stimulation, and atropinocomatose therapy are used.

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