title: The safety and efficacy of benzodiazepine-modified treatments as a special form of unmodified ECT.
abstract: BACKGROUND
  Muscle relaxants reduce musculoskeletal morbidity with electroconvulsive therapy (ECT) but need to be administered under general anesthesia. The administration of anesthesia is not always possible for patients prescribed ECT. Consequently, unmodified ECT is still widely practiced, especially in developing countries.
  
  
  METHODS
  We prospectively assessed musculoskeletal morbidity in consecutive patients who received unmodified bitemporal ECT during a part or the whole of their ECT course. All patients were pretreated with an intravenous benzodiazepine (usually diazepam, 10 mg) to effect sedation, anxiolysis, and limited skeletal muscle relaxation. Anteroposterior and lateral digital x-rays of the thoracolumbar spine were obtained after the last unmodified treatment.
  
  
  RESULTS
  Fifty-six patients aged 11 to 49 years and with a mean body mass index of 23.0 received a total of 162 (mean, 2.9) unmodified ECTs. There was significant attenuation of psychopathology ratings. Against our expectations, no patient developed clinical or radiological evidence of orthopedic morbidity; however, in 2 patients, the x-rays revealed old spinal fractures. Twelve patients had spots of oral bleeding after ECT. Whereas 5 patients experienced mild, transient, self-limiting postictal confusion, only one had confusion which required medical termination. Five patients complained of body ache and one of memory impairment. There were no other adverse events.
  
  
  CONCLUSIONS
  The complete absence of orthopedic morbidity with benzodiazepine-modified ECT contrasts with historical descriptions of a 20% to 40% risk with unmodified ECT. We speculate that the limited muscle relaxant action of the pre-ECT parenteral benzodiazepine may have had protective effects. If so, if ECT is urgently indicated but anesthesia and hence conventional muscle relaxants cannot be administered, benzodiazepine-modified ECT may be a safer alternative to unmodified ECT. This suggestion merits wide attention because of its public health importance in countries with poor medical infrastructure, where unmodified ECT is still widely practiced.
authors.affiliation: Department of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Bombay, India.
authors.forename: Nilesh
authors.initials: N
authors.lastname: Shah
authors.forename: Sarika
authors.initials: S
authors.lastname: Mahadeshwar
authors.forename: Savita
authors.initials: S
authors.lastname: Bhakta
authors.forename: Mahesh
authors.initials: M
authors.lastname: Bhirud
authors.forename: Praveen
authors.initials: P
authors.lastname: Fernandes
authors.forename: Chittaranjan
authors.initials: C
authors.lastname: Andrade
mesh_terms: D000293:Adolescent; D000328:Adult; D001569:Benzodiazepines / Q000009:adverse effects* / Q000627:therapeutic use*; D002648:Child; D003866:Depressive Disorder / Q000523:psychology / Q000628:therapy; D003975:Diazepam / Q000627:therapeutic use; D004565:Electroconvulsive Therapy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D009125:Muscle Relaxants, Central / Q000009:adverse effects* / Q000627:therapeutic use*; D009141:Musculoskeletal System / Q000293:injuries; D011292:Premedication / Q000009:adverse effects / Q000379:methods*; D011446:Prospective Studies; D011569:Psychiatric Status Rating Scales; D011859:Radiography; D012559:Schizophrenia / Q000628:therapy; D012565:Schizophrenic Psychology; D013124:Spinal Injuries / Q000000981:diagnostic imaging / Q000209:etiology; D013131:Spine / Q000000981:diagnostic imaging; D014947:Wounds and Injuries / Q000000981:diagnostic imaging / Q000209:etiology / Q000517:prevention & control*; D055815:Young Adult
chemical_list: D009125:Muscle Relaxants, Central; D001569:Benzodiazepines; D003975:Diazepam