Download Electroconvulsive Therapy

Electroconvulsive Therapy: Its Safety, Efficacy, and Role in
Mental Health
Tiffany Moore, MSN, APRN, FNP-C; Rhea Ferry, DNP, APRN, FNP
Contributor: Billie Madler, DNP, APRN, FNP-C
INTRODUCTION
ECT SAFETY
BURDEN OF MENTAL HEALTH
• NIH reports 26.2% of U.S. population 18 and older has a
diagnosable mental health disorder
• Mortality is 0.19 per 10,000
• No absolute contraindications
• Relative risk factors
• 20.9 million Americans have a mood disorder (depression,
bipolar disorder and dysthymic disorder)
• Half with a mental health disorder meet diagnostic criteria for
two mental health disorders
• Numerous treatment option
 Psychotherapy
 Medications
 Those with cardiovascular disease have been treated with ECT safely.
However, cardiology consult prior to ECT beneficial.
 Those with cerebrovascular disease may benefit from neurology consult
prior to treatment.
 ECT causes a transient increase in cerebral blood flow to some parts
of the brain and a transient increase in intracranial pressure
 Brain stimulation treatment, such as electroconvulsive therapy
 Transcranial magnetic stimulation or vagal nerve stimulation
ELECTROCONVULSIVE THERAPY
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• Depression ranked fourth in disease burden, expected to rise to
second by 2020
• Many patient are unresponsive or intolerant to pharmacologic
measures
• Bipolar disorder is the 12th most common diagnosis by WHO2.4
million people diagnosed with schizophrenia
INDICATIONS/EFFICACY OF ECT
• Electroconvulsive therapy (ECT) Introduced in 1938 by Ugo
Cerletti, an Italian neurologist
• Depression
 Usually used 2nd line
 Should be consider for 1st line treatment in:
• Electrodes, on one or both sides of the head, sends a measured
charged electrical current through brain
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• Purpose of ECT is to produce a generalized cerebral seizure with
a bilateral tonic-clonic convulsion.
• Controversial despite being safe and effective
• 150,000 ECT treatment per year
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• In use for 75 years
 Crude history
 Unknown cognitive effects
 Uncertain mechanism of action
ECT COMPLICATIONS
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Performed different that in the past
Vitals are monitored
EKG and EEG leads for monitoring
IV access used to administer sedation and subsequent paralytic
 Before neuromuscular blockers were used routinely, nearly 30% of
ECT patient suffered spinal compression fractures
• Mouth guards routine practice
• After patient sedated and paralyzed, electrodes are placed
• Patients are monitored for 30-60 minutes after an ECT and the
majority are able to be discharged home
• Complications
 Confusion and memory problems are the most common
complications
 Headaches and nausea - prophylactic analgesics and antiemetics can
reduce
Dehydrated, severely malnourished patients
Patients with a complicating medical condition
Patients presenting with delusional depression
Those who have been unresponsive to antidepressants
Patients with acute suicidal ideation, catatonia or a major depressive episode with
psychotic features
Patients who request ECT as first line treatment
Can even be considered the first-line treatment in post-stroke depression (PSD), as
this disorder can often be resistant to medications
 Pregnant mothers with severe depression may be candidates
 Those >65 and who are severely ill typically respond better or
faster than patients who are <65
 In patients with major depressive disorder, remission rates with
ECT are high, especially in those who present with psychotic
features
• Controversy sustained for several reasons:
ECT PROCEDURE
Median age 30
Substance abuse and anxiety often comorbidities
Incidence greater in women than men
Occurs across the lifespan, but is the leading cause of disability in
15-44 years olds
• Bipolar/Mania
 ECT with mania is used when patients are intolerant or refractory
to lithium or other anti-manic medications
 Should be considered earlier when potential of self-harm or
harming others, or when symptoms appear life threatening
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Schizophrenia
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ECT not commonly used in the US for schizophrenia, but used in
some countries as 1st line
CONCLUSIONS
• The historical implementation of ECT therapy led to a less favorable
perspective of this treatment strategy. There was a period of
diminished use of ECT, however, over the last 10 years there has been
an increase of ECT use. It may be used as first line therapy in some
scenarios. It has been established that ECT has a role in mental health
treatment, yet further research is needed.