Ictal electroencephalography and heart rate as treatment criteria in electroconvulsive therapy: a systematic review of the literature

Isaak Dilopoulos; Thomas Nickl-Jockschat; Michael Grözinger

doi:10.1007/s00406-026-02298-8

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Ictal electroencephalography and heart rate as treatment criteria in electroconvulsive therapy: a systematic review of the literature

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Ictal electroencephalography and heart rate as treatment criteria in electroconvulsive therapy: a systematic review of the literature

Isaak Dilopoulos, Thomas Nickl-Jockschat and Michael Grözinger

European archives of psychiatry and clinical neuroscience

06/30/2026

DOI: 10.1007/s00406-026-02298-8

PMID: 42377484

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Abstract

Decades before the emergence of precision medicine, psychiatrists raised the question of whether specific seizure characteristics could help optimize electroconvulsive therapy (ECT), as relationships between some of these characteristics and better outcomes were found. From 1990 onward, researchers focused on electroencephalography (EEG) and cardiovascular markers, which were broadly adopted by guidelines worldwide. However, the prognostic value of these markers is still controversial. Here, we provide a systematic summary of the studies on this topic. We conducted a literature review on the use of ictal EEG and heart rate as outcome predictors in ECT using the PubMed, EMBASE, Cochrane and PsycINFO databases. Thirty-seven studies addressing more than 100 quality markers fulfilled our inclusion criteria. Single EEG markers were assigned to five categories (postictal inhibition, amplitude, coherence, regularity, and seizure duration). Heart rate and composite markers were considered separately. In contrast to single EEG markers, heart rate and composite markers could be consistently linked to better outcomes in patients with depression. Only a few studies on schizophrenia could be retrieved. Multiparametric markers outperformed single markers. Furthermore, changes in heart rate during seizures were related to better outcomes. Although clinical assessment remains the cornerstone of treatment guidance decisions, EEG and cardiac monitoring could help prevent insufficient seizures during the period preceding clinical improvement. Evidence on schizophrenia remains limited. More randomized trials are needed to analyze the role of composite markers as prognostic tools.

Electroencephalography

Heart rate

Electroconvulsive

Review

Outcome

Details

Title: Subtitle: Ictal electroencephalography and heart rate as treatment criteria in electroconvulsive therapy: a systematic review of the literature
Creators: Isaak Dilopoulos - RWTH Aachen University
Thomas Nickl-Jockschat - University of Iowa
Michael Grözinger - RWTH Aachen University
Resource Type: Journal article
Publication Details: European archives of psychiatry and clinical neuroscience
DOI: 10.1007/s00406-026-02298-8
PMID: 42377484
NLM abbreviation: Eur Arch Psychiatry Clin Neurosci
ISSN: 1433-8491
eISSN: 1433-8491
Publisher: Springer Nature
Grant note: German Center for Mental Health
Thomas Nickl-Jockschat was supported by the German Center for Mental Health (DZPG) - partner site Halle-Jena-Magdeburg.
Language: English
Electronic publication date: 06/30/2026
Academic Unit: Psychiatry
Record Identifier: 9985178671002771

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