Neuromodulation Interventions: ECT and rTMS – Work-Up, Preparation, and Posttreatment Care + Ketamine in Inpatient Psychiatry

  • Lisa A. McMurray
  • Barbara Deren


An inpatient psychiatric unit is often the setting wherein rapid treatment can be safely and efficiently administered for the most intractable and severe psychiatric illnesses. Electroconvulsive therapy (ECT) is an effective intervention for bipolar and major depressive disorders. There are many reasons to consider ECT. For example, aging and medically compromised patients may be unable to tolerate adequate pharmacotherapy for depressive and other disorders, and ECT remains a safe alternative. Suicide rates in geriatric populations are high, particularly in men, and older patients frequently attempt suicide with lethal means (Chap. 8: Suicide). The hospital or partial hospital setting may provide the necessary precautions and treatments for risks of dehydration, inanition, medical comorbidity, functional decline, frailty, and suicidality, in addition to addressing the need for rapid clinical response. There is also evidence emerging to support the use of ECT for the Non-Cognitive Symptoms (NCS) and Neuropsychiatric Symptoms (NPS) of Major Neurocognitive Disorders (MNCD) (Chap. 6: Major neurocognitive disorer MNCD with Behavioral Disturbance).

Newer treatments, such as repetitive transcranial magnetic stimulation (rTMS), are showing promising results and excellent tolerability. rTMS is administered to awake patients, thereby avoiding the associated risks of general anesthesia. Evidence of its efficacy for major depressive episodes is less robust than that for ECT, and it is not yet available and/or covered by insurance in many settings. Also, the place of rTMS on the inpatient unit has yet to be established, as current treatment protocols may require 4–6 weeks to complete.

Intravenous (IV) infusion of ketamine at sub-anesthetic doses is an investigational treatment for depression and suicidal ideation, but has not yet been studied extensively in older adults. More recently, a formulation of esketamine, administered intranasally, has been approved by the FDA for treatment resistant depression (TRD). To date, no studies of this formulation in the geriatric population could be found. If research supports its safety and efficacy in the general adult population, ketamine may eventually be found to have utility in the rapid treatment of suicidal ideation and treatment-resistant depression in the inpatient geriatric psychiatry setting as well.

ECT remains the definitive treatment when there is limited improvement with other modalities, when pharmacotherapy is poorly tolerated, and when psychiatric/behavioral symptoms require a rapid response.


Electroconvulsive therapy ECT Repetitive transcranial magnetic stimulation rTMS Ketamine Late-life depression Inpatient Neuropsychiatric symptoms Behavioral disturbance 


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Lisa A. McMurray
    • 1
  • Barbara Deren
    • 2
  1. 1.University of Ottawa, Royal Ottawa Mental Health CentreOttawaCanada
  2. 2.Resident in PsychiatryUniversity of Ottawa, The Ottawa Hospital (General Campus)OttawaCanada

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