Abstract
Electroconvulsive therapy (ECT) remains one of the most effective treatments in psychiatry, but cognitive side effects still pose a clinical concern. Delayed postictal reorientation is linked to worse cognitive outcomes, adversely affecting patient-perceived treatment tolerability and acceptability, while also increasing post-ECT and post-anesthesia care demands. Despite its clear clinical and operational relevance, comparative evidence on anesthetic effects remains scarce. This study therefore investigates the impact of different anesthetic agents (S-ketamine, propofol, etomidate, thiopental, and the combination of S-ketamine and propofol) on reorientation time following ECT. Retrospective data from 5148 ECT sessions were analyzed using a linear mixed-effects model controlling for age, sex, diagnosis, stimulation dose, electrode placement, seizure quality, ECT session number, need for restimulation, ECT duration, and postictal agitation. Compared with S-ketamine, propofol reduced reorientation time by 6.2 min, and the combination of S-ketamine and propofol reduced reorientation time by 1.5 min. Neither thiopental nor etomidate differed significantly from S-ketamine. The differences may be attributed to the distinct pharmacodynamic profiles of the anesthetic agents. The findings demonstrate that anesthetic choice is a significant and independent determinant of reorientation time following ECT, with propofol and the combination of S-ketamine and propofol associated with markedly faster cognitive recovery compared to S-ketamine.