ELECTROCONVULSIVE THERAPY
(ECT)
Dr. Altaf Qadir Khan
Professor of Psychiatry
PGMI/ LGH, Lahore
Electro Convulsive Therapy
Electro Convulsive Therapy (ECT) is a treatment for severe
mental illness in which a brief application of electrical stimulus
is used to produce a generalized seizure
History of convulsive therapy
It was introduced in the late 1930s on the basis of the
mistaken idea that epilepsy and schizophrenia do not occur
together, it seemed to follow that induced fits should lead to
improvement in schizophrenia
.
When the treatment was tried it became apparent that the
most striking changes occurred not in schizophrenia but in
severe depressive disorder and brought substantial reduction
in chronicity and mortality
Chemically induced seizures-
(camphor, pentylenetetrazol)
Insulin Therapy
Depressed patients were given an overdose of insulin to
cause a convulsion
Difficulties in determining the proper dosage of insulin
led to a decline in use of this therapy
Was replaced by Electroconvulsive Therapy (ECT)
History of Convulsive Therapies
1938 – Lucio Cerletti and Ugo Bini induced seizures in Rome
using electrical stimuli in catatonic patients and produced
successful results .
1940 – Renato Almansi and David Impasto administered ECT at
Columbus Hospital in NYC. Lothar Kalinowsky started giving
ECT at Psychiatric Institute
Cerletti and Bini (1934): Electricity
Initially done without
muscle blocker or
anesthetic
.
1958-First controlled study in unilateral ECT
1960-Randomised clinical trials of the efficacy of ECT versus
medication in the treatment of depression yielded response
rates that were significantly higher with ECT
Early ECT
Asylums
Few effective medications
Many often severe side effects
In 1950’s antidepressant and antipsychotic medications
significantly decreased utilization of ECT
Introduction
Excellent safety profile
Superior Efficacy
Economic benefits
Stigmatization
Introduction to ECT
ECT has changed substantially during the past decades. The
use of general anesthesia has promoted the interest in ECT
ECT become more complex , more precise and safer procedure
(mortality rate 1/1000 early to 3-4/100,000 now)
Introduction to ECT
Generalized seizures can be induced by adjusting waveform,
frequency, duration of electrical stimuli.
Seizure should last at least 30 -60 seconds in duration
Good therapeutic effect is generally not achieved until 400-
700 seizure seconds
.
ECT is usually given twice a week , even thrice a week but has
little therapeutic effect over a twice weekly regimen
Length of course depends on clinical experience
Course of ECT is usually 6 to a maximum of 12 treatments
.
Progress should be reviewed after each treatment
If response is rapid fewer treatments may be given
If there is no response after six to eight treatments course
should be abandoned
Memory should be assessed after each treatment
.
75 – 90% of patients exhibit a dramatic and sustained
improvement
Transient neurological dysfunction does occur but permanent
neuronal injury is questionable
Indications
Major Depressive Disorder
Catatonic Schizophrenia
Post-partum psychosis
Some studies have shown efficacy in treating
OCD
Delirium
NMS
Chronic pain syndromes
Intractable seizure disorders
Major Depressive Disorder
Major depressive disorder; when associated with:
Suicide
Stupor
Life threatening dehydration
Marked psychomotor retardation
Depressive delusions and hallucinations
ECT may be considered 2nd or 3rd line treatment if not
responsive to antidepressants
.
Non response to one or more adequate trials of
antidepressants or intolerance of therapeutic dosages
Prophylaxis or attenuation of recurrent major depression
Prevention of relapse of major depression
.
Depressed phase of bipolar disorder
Atypical depression (patients with atypical depression were
2.6 times more likely to have remission with ECT treatment
than those with other types of depression )
.
ECT may be considered for the treatment of mania associated
with :-
Life threatening physical exhaustion
Mania that has not responded appropriate drug treatment
.
ECT may be considered for the treatment of acute
schizophrenia as a 4th line option for treatment resistant
schizophrenia after treatment with two antipsychotic drugs
and then Clozapine has proved ineffective
Patients with catatonia where treatment with benzodiazepine
(Lorazepam) has proved ineffective
.
First episode psychosis (after non response to one or more
adequate drug trial )
Parkinson’s disease
NMS
Status Epilepticus
Tardive dyskinesia
Refractory OCD
.
Post partum psychosis, second line of treatment after non-
response to antidepressants and / or antipsychotics
Safe in all trimesters but need:
Obstetrical consultation
Fetal monitoring and precaution of increase of GERD
General Comments
Consider ECT early in the treatment algorithm
In the presence of very serious illness
May be first line treatment for very severe depression or
mania
No specific risks, benefits or contraindications attributable to
age
Informed Consent
Fully explain the risks and benefits of procedure and answer
questions from patients or their relatives
Information sheets
Reduce patient’s anxiety and help establish good patient-
doctor relationship
Pre ECT Workup
Nursing implication
Physical examination
Head CT
CXR
CBC
EKG
Nursing implication
Patient must be kept NPO (especially for solid foods )
approximately 8 hours before treatment
Continuous observation to be required
Dentures must be removed before treatment
Observe and monitor vitals until patient is recovered, oriented
and alert before discharge
.
Should be advised not to operate motor vehicle or potentially
dangerous equipment and tools until the day after each
treatment
Outpatients should be escorted home after treatment
Limit the use of sedatives and hypnotics the night before and
the morning of treatment
.
IV line should be established
Bite block is inserted in the mouth before the treatment to
protect teeth and tongue during seizure
100 percent oxygen is administered at the rate of 5 litter a
minute during the procedure until spontaneous respiration
returns
Contraindications
No Absolute Contraindications
Relative Contraindications:
Recent MI, fever, Brain Mass, Increased Intracranial Pressure,
significant arrhythmias, extreme hypertension, recent stroke,
retinal detachment, unstable angina, severe pulmonary disease
Technique
Two types:
Direct ECT –administered in the absence of muscular
relaxation and general anesthesia, now a days very
infrequently used
Modified ECT –by drug induced muscular relaxation and
general anesthesia administered by anesthetist
.
Succinylcholine 1mg/kg
Atropine (0.6mg )is given IV before Tx to decrease oral
secretions and to prevent vagal stimulation during ECT which
can cause cardiac arrest
Propofol (0.75-2.5 mg /kg ) or
Thiopentone (2.5 mg /kg )
.
Electrodes are moistened with saline or 25 percent
bicarbonate solution and are applied to head according to the
position of electrodes
Types of ECT :-
Bilateral ECT --- most commonly used
Unilateral ECT – placed on one side non- dominant side
(Fink M. Electroshock revisited. American Scientist. March-April 2000.)
Electrode Placement
Bilateral (BL) - most common, most effective, most
cognitive dysfunction
Right unilateral (RUL) - less cognitive effect, may be less
clinically effective
Bifrontal (BF) – may be as effective as BL with less cognitive
effect
Bilateral RUL Bifrontal
Response rate BL vs UL
Response rates:
Low-dose RUL - 17%
High-dose RUL - 43%
Low-dose BL - 65%
High-dose BL - 63%
Risks/Side Effects
Muscle contractions: can result in fractures and
dislocations; prevented by small doses of muscle relaxants
Injury to teeth, tongue or lips: stimulus causes intense
contraction of the masseter muscles and forceful
movement of the jaw; use a bite block
Electrical injury to the staff or patient
Risks/Side effects
Postictal Headache (45%) and muscle ache
Short-term memory loss and cognitive deficits
Difficult relationship with patients: frightened; withdrawn;
suspicious; uncooperative
Anaesthesia related problem: i.e. air way issue (more
patient with OSA); aspiration
Risks/Side effects
Common: transient confusion, headache, nausea, myalgia,
retrograde and anterograde amnesia
Uncommon: cardiac arrest, unstable arrhythmias,
ischemia, severe hypertension or hypotension, stroke,
prolonged apnoea, aspiration, laryngospasm, prolonged
seizures (status), fractures, malignant hyperthermia
Death: 1:80,000 Txs (1:10,000 patients)
.
.
.
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