ECT Part I

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Electro-convulsive Therapy

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 ?

ECTHistorical 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 ECT

Initially 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".

ECTMode 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.

ECTNICE 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.

Depressive episode

Treatment-resistant psychosis and mania (50:60% effective).

Catatonia.

All of the above disorders during pregnancy.

Neuroleptic malignant syndrome.

Neurological crises (e.g. extreme Parkinsonian symptoms: on-off phenomena).

Intractable seizure disorders (raises seizure threshold).

ECT Contraindications

ONCE

Indicated

NOT

Contraindicated

Cerebral aneurysm.

Recent MI.

Cardiac arrhythmias.

Intracerebral haemorrhage.

Acute/impending retinal detachment.

Phaeochromocytoma.

High anaesthetic risk.

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.

Time-limited action:

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.

Side-effects:

Mortality:

Not greater than 2:100 000

Usually due to cardiac complications in patients with known cardiac disease.

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 PlacementBilateralUnilateral(Non-dominant hemisphere)When to useSpeed 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

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

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:

Build-up of energies.

"Spike and wave" activity (mixed high voltage spike activity with high voltage 3-6Hz slow waves).

Trains of lower voltage slow waves.

An abrupt end to activity followed by electrical "silence".

This will usually last 35-130s.

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).

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.

Persistent ineffective seizures

Administer IV diazepam (5mg) repeated every 30s until seizure stops (or midazolam).

Lower energy dosing for next t