Electroconvulsive therapy pre-treatment with low dose propofol: Comparison with unmodified treatment Adarsh Tripathi a , Nathan C. Winek b , Kapil Goel a , Douglas D’Agati b , Jesus Gallegos b , Geetha Jayaram b , Thai Nguyen c , Punit Vaidya b , Peter Zandi d , Jitendra K. Trivedi a , Irving M. Reti b, * a Department of Psychiatry, The King George’s Medical University, Lucknow, India b Department of Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, MD, USA c Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA d The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA article info Article history: Received 19 September 2013 Received in revised form 8 January 2014 Accepted 6 February 2014 Keywords: Electroconvulsive therapy Propofol Unmodified Modified Anxiety Sedating abstract Background: Whilst electroconvulsive therapy (ECT) is routinely administered under anesthesia in developed nations, in many developing countries, ECT is still administered unmodified. This practice has attracted considerable scrutiny with calls to ban unmodified ECT. However, there are no affordable alternatives for many poor, acutely ill psychiatric patients. We evaluated whether administration of intravenous propofol 0.5 mg/kg for sedation by the ECT psychiatrist just prior to otherwise unmodified treatment improved acceptance of and reduced anxiety surrounding the treatment. Method: We conducted an open label trial at The King George’s Medical University in Lucknow, India. Forty-nine patients received propofol pre-treatment and 50 patients received unmodified treatment as usual. Results: Socio-demographic profiles, diagnoses and clinical responses were comparable. Patients who received propofol experienced less anxiety monitored by the State-Trait Anxiety Inventory just prior to ECT (p < 0.001), and had a more favorable attitude towards treatment assessed by an established questionnaire (Freeman and Kendell, 1980). Propofol patients were less likely to experience post-ictal delirium monitored by the CAM-ICU (p ¼ 0.015) and had fewer cognitive side-effects on the MMSE (p ¼ 0.004). There were no adverse events associated with propofol administration. Conclusion: Whilst unmodified ECT should never be used when modified ECT under anesthesia is available, we have found low dose propofol can be safely administered by the ECT psychiatrist to sedate patients pre-treatment who would otherwise receive completely unmodified treatment. The interven- tion was associated with reduced anxiety and a more positive attitude towards ECT, without compro- mising efficacy. A randomized double blind controlled study is necessary to confirm these benefits. Ó 2014 Elsevier Ltd. All rights reserved. 1. Background Although ECT has been an established treatment for major mental illness since the 1930’s and has been administered under anesthesia since the development of muscle relaxants in the late 1940’s, in many developing countries it is still administered without anesthesia or unmodified (Andrade, 2003; Andrade et al., 2003; Bhave, 2003; Chanpattana and Kramer, 2004; Gallegos et al., 2012). Indeed, unmodified ECT is still sometimes practiced even in more developed nations such as Japan (Chanpattana et al., 2005; Motohashi, 2012), Russia (Nelson, 2005), Spain (Bertolin- Guillen et al., 2006; Leiknes et al., 2012) and China (Leung et al., 2009). Surveys of psychiatrists in Asia and India suggest tens of thousands of patients receive unmodified ECT around the world every year (Andrade et al., 2012; Chanpattana et al., 2010). Un- modified ECT persists in developing countries because many pa- tients with major mental illness are poor. Accordingly, they cannot afford anesthesia and unmodified ECT may be a cheaper and quicker alternative than psychotropic medication. Such patients also lack medical insurance coverage that would pay for anesthesia, * Corresponding author. Psychiatry and Neuroscience, Johns Hopkins University, 600 N. Wolfe St., Meyer 3-181, Baltimore, MD 21205, USA. Tel.: þ1 410 955 1484; fax: þ1 410 955 0152. E-mail address: imreti@jhmi.edu (I.M. Reti). Contents lists available at ScienceDirect Journal of Psychiatric Research journal homepage: www.elsevier.com/locate/psychires http://dx.doi.org/10.1016/j.jpsychires.2014.02.004 0022-3956/Ó 2014 Elsevier Ltd. All rights reserved. Journal of Psychiatric Research 53 (2014) 173e179