Presented By

Mohamed Abdelghani

Electro-convulsive Therapy

Is ECT a method of Brain Washing?

Is it Humane or Not?

Is what we do is True?

Does any psychiatric patient need

ECT?

What about the future of ECT in the

new psychiatric era?

ECT

Historical

Perspective

The use of convulsive

treatments for psychiatric

disorders has at its origin

from the clinical observation

of apparent antagonism

between schizophrenia and

epilepsy.

Meduna 1934

Meduna induced a seizure with an

injection of campor-in-oil in a

patient with catatonic

schizophrenia, and continued this

treatment every 3 days.

After the fifth seizure the patient

was able to talk spontaneously and

began to eat and care for himself for

the first time in 4 years, making a

full recovery with 3 further

treatments.

Ugo Cerletti 1938

Cerletti and Bini introduced the

use of "electric shock" to induce

seizures.

Modified ECTInitially ECT was "unmodified" (i.e.

without anaesthetic or muscle

relaxant), but because of frequent

injury, and advances in brief

anaesthesia, the current procedure

is the more "humane".

ECT

Mode Of Action

Unknown

ECT causes a wide range of effects on

neurotransmitters with net functional

increases in monoamine systems (NA,

5HT, DA), GABA, ACh, endogenous

opioids, and adenosine.

Also, profound effects on the

neuroendocrine system, with release of

hypothalamic, pituitary, and adrenal

hormones.

ECT

NICE Technology Appraisal

(May 2003)

ECT is used only to achieve rapid

and short-term improvement of severe

symptoms after an adequate trial of

other treatment options has proven

ineffective and/or when the condition is

considered to be life-threatening e.g.

severe depressive illness, catatonia,

prolonged or severe manic episode.

Don't allow the general use of ECT

in the management of schizophrenia.

ECT is not recommended as a

maintenance therapy in depressive

illness.

The decision of ECT is based on a

documented assessment of the risks

and benefits to the individual,

including: the risks associated with

the anaesthetic, comorbidities,

anticipated adverse events,

particularly cognitive impairment, and

the risks of not having the treatment.

ECT

Indications

Severe episodes.

Need for rapid antidepressant response

(e.g. due to failure to eat or drink in

depressive stupor; high suicide risk).

Failure of drug treatments.

Patients who are unable to tolerate side-

effects of drug treatment (e.g. puerperal

depressive disorder).

Previous history of good response to ECT.

Patient preference.

i. Depressive episode

ii.Treatment-resistant psychosis and

mania (50:60% effective).

iii.Catatonia.

iv.All of the above disorders during

pregnancy.

v.Neuroleptic malignant syndrome.

vi.Neurological crises (e.g. extreme

Parkinsonian symptoms: on-off

phenomena).

vii.Intractable seizure disorders (raises

seizure threshold).

ECT

Contraindications

ONCE

Indicated

NOT

Contraindicated

1. Cerebral aneurysm.

2. Recent MI.

3. Cardiac arrhythmias.

4. Intracerebral haemorrhage.

5. Acute/impending retinal detachment.

6. Phaeochromocytoma.

7. High anaesthetic risk.

8. Unstable vascular aneurysm or

malformation.

Where possible, ECT should be limited for patients with :

ECT

Problems

Dissipates after a couple of weeks,

hence need for follow-up

medication, or maintenance

treatment, issues of consent to

treatment.

I. Time-limited action:

A. Early:

Some loss of short-term memory:

"retrograde amnesia" usually resolves

completely (64%).

Headache (48% if recurrent, use

simple analgesia).

Temporary confusion (27%).

Nausea/vomiting (9%).

Muscular aches.

II.Side-effects:

C. Mortality:

Not greater than 2:100 000

Usually due to cardiac

complications in patients with

known cardiac disease.

B. Late:

Loss of long-term memory (rare).

ECT

Course

Rarely will a single treatment be effective (but

this does occasionally occur).

ECT is usually given 3 times a week, reduced

to twice a week or once a week once symptoms

begin to respond.

There is no evidence that a greater frequency

enhance treatment response.

Treatment of depression usually consists of

6:12 treatments.

Treatment-resistant psychosis and mania

up to (or sometimes more than) 20 treatments.

Catatonia usually resolves in 3:5 treatments.

Evidence is limited.

Many psychiatrists recommend

maintenance ECT (e.g. once a week, or

every 2 weeks, for 4 months or more)

when a patient has responded well to ECT,

and when drug treatments have been

ineffective prior to ECT.

Maintenance or Continuation ECT

ECT

Work-up & Administration

Ensure full medical history and medication noted on

ECT recording sheet.

Also note any relevant findings from physical

examination.

Ensure recent routine blood results available (FBC,

U&Es, any other relevant investigations).

If indicated, arrange pre-ECT CXR and/or ECG.

Ensure consent form has been signed.

Ensure ECT prescribed correctly.

Inform anaesthetic team of proposed ECT.

Inform ECT service of proposed ECT.

Ensure patient is aware of the usual procedure and

when treatment is scheduled.

ECT work-up:

Check patient's identity.

Check patient is fasted (for 8hrs) and has emptied their

bowels and bladder prior to coming to treatment room.

Check patient is not wearing restrictive clothing and

jewellery/dentures have been removed.

Consult ECT record of previous treatments (including

anaesthetic problems).

Ensure consent form is signed appropriately.

Check no medication that might increase or reduce

seizure threshold has been recently given.

Check ECT machine is functioning correctly.

Ensure dose settings are correct for specific patient.

Pre-ECT checks:

Establish IV access.

Attach monitoring (HR, BP, EEG/EMG).

Ventilate patient with pure oxygen via face mask.

Give muscle relaxant, followed by short-acting

anaesthetic.

Hyperventilation with oxygen is sometimes used

to augment seizure activity.

Insert bite-block between patient's teeth to

protect tongue and teeth from jaw clenching (due

to direct stimulation of masseter muscles).

:Administration of anaesthetic

ECT Placement

Electrode

PlacementBilateral

Unilateral(Non-dominant hemisphere)

When to use Speed of

response a priority.

Speed of

response less

important.

Failure of

unilateral ECT.

Previous good

response to

unilateral ECT.

Previous good

response to bilateral

ECT without

significant memory

problems.

Where

minimising

memory

impairment is

critical (e.g.

evidence of

cognitive

impairment,

outpatient

treatment).

Where

determination of

cerebral dominance

is difficult.

Ensure that there is an adequate airway.

Monitor the patient's pulse and blood

pressure until stable.

Continuous nursing presence and

observation until the patient is fully

orientated.

Maintain IV access until able to leave

recovery.

Recovery:

ECT

Energy Dosing

I. Dose titration: The most accurate method, delivering the minimum

stimulus necessary to produce an adequate seizure, and

is therefore to be preferred.

Treatment begins with a low stimulus, increased

gradually until an adequate seizure is induced.

Once the approximate seizure threshold is known, the

next treatment dose is increased to abut 50:100% (for

bilateral) or 100:200% (for unilateral) above the

threshold.

The dose is only increased further if later treatments are

sub-therapeutic.

Energy Dosing Methods

II.Age dosing:

Selection of a predetermined dose

calculated on the basis of the patient's

age (and the ECT machine used).

The main advantage is that this is a less

complex regime.

However, there is the possibility of

"overdosing" (i.e. inducing excessive

cognitive side-effects) because seizure

threshold is not determined.

ECT

Effective Treatment

The gold standard with a typical ictal EEG

having 4 phases: 1. Build-up of energies. 2. "Spike and wave" activity (mixed high voltage

spike activity with high voltage 3-6Hz slow waves).

3. Trains of lower voltage slow waves.4. An abrupt end to activity followed by

electrical "silence".

This will usually last 35-130s.

A. EEG monitoring

EEG monitoring is not used.

Less reliable measure.

Motor seizure lasting at least 20s

(from end of ECT dose to end of

observable motor activity).

B. Timing of convulsion

Cuff Technique Isolation of a

forearm or leg from the effects of muscle relaxant, by inflation of a blood pressure cuff to above systolic pressure.

As the isolated limb does not become paralysed, the seizure can be more easily observed.

ECT

Specific Problems

Check use of drugs that may raise

seizure threshold.

Consider use of IV caffeine or

theophylline.

1.Persistent ineffective seizures

Administer IV diazepam (5mg)

repeated every 30s until seizure

stops (or midazolam).

Lower energy dosing for next

treatment.

2.Prolonged Seizures (i.e. over 150-180s):

Reassurance.

Nurse in a calm environment.

Ensure safety of patient.

If necessary consider sedation

(e.g. diazepam/midazolam).

If a recurrent problem, use a low

dose of a benzodiazepine

prophylactically during recovery,

immediately after ECT.

3.Post-seizure confusion (10% of treatments):

ECT

&

Psychiatric Drugs

1)Benzodiazepines/barbiturates:

Best avoided during ECT, or reduced

to the lowest dose possible.

2)Anticonvulsants:

Continue during ECT, but higher ECT

stimulus will usually be needed.

Drugs raising seizure threshold

1)Antipsychotics:Continue if clinically indicated.Increased risk of hypotension and post-ECT confusion.Clozapine should be suspended 24hrs before ECT.

2)Antidepressants:Continue if clinically indicated.Increased risk of hypotension and post-ECT confusion

(esp. TCAs).Moclobemide should be suspended 24hrs before ECT.

3)Lithium:Best avoided as may increase cognitive side-effects and increase likelihood of neurotoxic effects of lithium.

Drugs lowering seizure threshold

ECT

Versus

Other Lines Of Treatment

ECT

Versus

Transcranial Magnetic Stimulation

During the past decade, repetitive

transcranial magnetic stimulation

(rTMS) has emerged as a new

antidepressant treatment .

Some randomised trials suggest that

repetitive transcranial magnetic

stimulation (rTMS) might be as

effective as ECT in the treatment of

non-psychotic depression.

However, recent reviews and meta-

analyses show ECT may be more effective

if a higher ECT dosage had been used .

In weighing the benefits and risks of

different treatment methods: ECT has

been shown to induce anterograde

amnesia, retrograde amnesia and

subjective memory complaints .

In contrast, rTMS seems not to have any

substantial cognitive side-effects .

ECTIn

Severely Medically Ill Individuals And Other Special Groups

Depression in liver transplant recipients can be a life-threatening emergency.

ECT is an important consideration when suicide is imminent or the patient has not responded to pharmacotherapy trials.

Adrenal suppression and immunosuppression require special attention.

His immunosuppressed status and the relatively rare rate of fever secondary to ECT need full workup, including blood, cerebrospinal fluid, sputum, and urine cultures.

ECT In Liver Transplant Recipients

Key to the patient’s treatment was: Psychiatric consultation and

management while he was on the transplantation unit.

Followed by intensive transplantation service management while he was on the psychiatric unit.

With close collaboration of psychiatry and transplantation teams, ECT can be administered safely to liver transplant recipients.

ECT

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