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ELECTROCONVULSIVE THERPAPY (ECT)
1) EXPLAIN WHY PROCEDURE IS BEING PERFORMED
Mechanism = unclear by appears to have positive effect on inducing brain neurotransmitters
 High dose right unilateral therapy over right temporal region and near vertex most common
 Bilateral approach = elderly or need rapid response - SE: more memory problems/confusion
Indications = need a RAPID response, other Rx more risky, HISTORY of good response, PREFERENCE
 Major depression = refractory, psychotic, postnatal, melancholic, high suicide risk
o Substantial improvement in 80% patients with severe depression
 Mania = not responding to drug therapy - 80% improvement
 Schizophrenia = refractory to other Mx, past effective
 Schizoaffective/Bipolar
 Catatonia = extreme under or over activity of motor system
 Medical conditions = Neuroleptic malignant Syndrome/Parkinson’s
2) EXPLANATION OF PROCEDURE – check prior experience
ECT is a treatment where electrical currents are applied to the brain. Your brain has electrical activity
and ECT can change this activity by causing a controlled seizure. This acts as a reset to your brain
waves. We don’t know exactly how this works but we know it helps a lot of people. You need at least
6 treatments in one course, and this usually involves 3 per week.
BEFORE = FAST + REVIEW
 Fast overnight = 6-8 hours + NO SMOKING for 2 hours prior
 Review medications
o BZD/Anti convulsants reduce quality
o Stop Lithium unless strong reason to continue- bipolar may get post ECT mania
o Antidepressants = not much point keeping on refractory drug, start near end
o Diabetic medications = monitor – may need to reduce to prevent hypos
 Physical exam and check + MMSE
o HTN
o MSK injuries/Osteoporosis
o Fundoscopy
o If raised ICP = CTB
 FBE + UEC + CXR + ECG
 Mask with oxygen
 Anaesthetics will give you a muscle relaxant and some medication to put you asleep
 Put in a mouthguard
DURING = asleep for a few minutes. You won’t know what is happening
 30 second seizure
 No pain or discomfort
High dose more effective, but causes more cognitive impairment
Missed = wait 20-40s to allow for delayed
Inadequate = <15-25sec or on EEG morphology - wait 60-90s for refractory period
Prolonged seizures - > 120s – terminate (midazolam)
AFTER = wake up in recovery
 May feel drowsy or have a headache – can have Panadol
 If outpatient get someone to drive you home
COURSE = until optimum outcome but usually 3 times /week with total 6-12
3) BENEFITS = QUICK + EFFECTIVE
4) RISKS =– IS VERY SAFE (No deaths in 25 years in NSW with 200,000 treatments)
 Anaesthetic risk as with any procedure
 Headache, nausea and myalgia = common – can have Panadol
 Injury during = if not enough relaxant – but anaesthetists make sure yo udont
 Confusion/disorientation = ACUTE POST ECT DELIRIUM - orientate + reduce frequency
 Memory problems – conditions treated also have cognitive impairment
 Short term antegrade memory loss
 Long term retrograde memory loss – RARE
 May not work right away – important to finish course
 Medical conditions – this is why we check you out
CONTRAINDICATIONS – NO ABSOLUTE – case by case risk benefit analysis
 Raised ICP
 Recent AMI
 Severe HTN a/o Aneurysm = BP T-C
 Bradyarrhythmia = HR during shocks
 Pacemakers low risk of electrical damage
 Osteoporosis risk of # in TC phase
 MAOI or TCA use within the last 14days
 Cochlear implant = destroys
Pregnancy = Evidence it is safe in 2nd and 3rd Trimester - less for 1st
RISKS OF NOT = not improving – risk to self or others
5) ALTERNATIVES
 Medications – have AE, take time to work, may not work at all
 Psychotherapy – not as good for serious conditions
 Transcranial Magnetic Stimulation – still experimental
 Deep Brain Stimulation – requires invasive techniques
6) CHECK UNDERSTANDING – repeat back
7) CONSENT = verbal or written – have right to second opinion
 Patient gives consent to treatment
(Patient can be compulsory)
 Statement of Rights Given and explained to person – WRITTEN BOOKLET
 Family notified and educated
 Can withdraw consent at ANY time
Authorised MHT Consent = For patients who are unable to give INFORMED consent
 Must be assessed by Consultant Psychiatrist = Good rationale & documentation must be
provided, outlining reason for ECT being deemed best possible treatment for this person
 TRIBUNAL HEARING = Patient (if they wish), mental health practitioners, Dr’s present case
 Family, nominated person notified and educated
 Statement of Rights MUST be given and explained to patient
 Advance Statement (if present) must be considered
8) DOCUMENT IN NOTES