Planning ECT for severe depression and discussing neurostimulation tiers (MEQ)

(i) Indication and work-up. This is severe melancholic–psychotic depression with nutritional risk and high suicide intent after adequate failed trials — classic acute ECT indication. UK Review Group and modern NEJM reviews support ECT's short-term superiority/efficacy in severe depression. Pre-ECT: full history (cardiac/respiratory/neuro/dental/GORD/pregnancy), MSE and suicide risk, capacity, baseline cognition, FBC/U&E/glucose/ECG, medication reconciliation, anaesthetic review, family engagement. Fasting and aspiration risk from GORD flagged to anaesthesia.[1][5][6]

(ii) Capacity and cognition. Capacity is decision- and time-specific. If she can understand, retain, weigh and communicate a choice about ECT, obtain informed consent covering benefits, anaesthesia, course logistics, common effects, rare serious risks, and cognitive risks including variable retrograde autobiographical memory. If capacity is lacking, use jurisdiction-specific mental health law (do not invent section numbers). Address "memory wipe" myth with Sackeim community data honesty: temporary anterograde effects common; autobiographical risk real and variable; mitigation via placement/pulse-width choices. Risk of untreated illness (suicide, starvation) must be stated.[4][5][6]

(iii) Placement and dosing. Given cognitive fear, start with right unilateral ultrabrief at high suprathreshold dose if service-capable, with low threshold to switch to bitemporal if urgency/non-response. Explain that RUL needs adequate suprathreshold dosing; bilateral is stronger at lower multiples but more cognitive cost (Sackeim). Typical index frequency two to three times weekly; individualise number to trajectory (often around 6–12, not a fixed dogma).[3][5]

(iv) Anaesthesia interface and meds. Induction agent + muscle relaxant + oxygen + bite block + monitoring; cuff technique to observe motor seizure as proxy for cerebral seizure. Review diazepam and valproate — both raise seizure threshold and may impair seizure quality; plan supervised reduction/hold with risk management for withdrawal/seizure risk and mood. Coordinate lithium if later used. Psychiatrist confirms legal status and stimulus plan each session.[5][6]

(v) Continuation and tiers. After response, do not discharge without plan: optimised pharmacotherapy (consider lithium-containing strategies where suitable) and/or continuation ECT because CORE shows high relapse without active prevention. rTMS/iTBS suits ambulatory TRD without this urgency (THREE-D: iTBS non-inferior to 10 Hz, shorter sessions). VNS for chronic multi-year TRD after multiple failures (Aaronson long-horizon data). DBS not routine — BROADEN SCC trial failed primary endpoint; specialist/trial only. CANMAT ranks neurostimulation options by evidence tier.[2][7][8][9][10]