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Download electroconvulsive therapy - Association for Academic Psychiatry
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ELECTROCONVULSIVE THERAPY ELECTROCONVULSIVE THERAPY Jon Lehrmann MD Assistant Professor of Psychiatry Medical College of WI VAMC Milwaukee, WI Mental Health Care Pre-1930’s History of ECT • Von Meduna (1934)- Autopsies of patients w/ Seizure disorders and of patients w/ Schizophrenia. • Difference in Glial cell proliferation Chemically induced seizures(camphor, pentylenetetrazol) Insulin Shock Therapy • In the 1930’s , Dr Sakel developed Insulin Shock Therapy Cerletti and Bini (1934): Electricity Initially done without muscle blocker or anesthetic Early ECT • • • • Assylums Few effective medications Many often severe side effects 1950’s- ether, and curare extract developed (Abram Bennett- a psychiatrist helped develop a method for extracting curare). • In 1950’s antidepressant and antipsychotic meds introduced- significantly decreased utilization of ECT Electrophysiological Principles • Ohm’s Law: I=E/R (I=current, E=voltage, and R=resistance) • Dose of electricity in ECT= 100-500 milliCoulombs • Brain has low impedance (resistance), skull has very high impedance. Only 20% of applied charge actually enters the brain. • Seizure involves propagation of action potentials in a large percentage of neurons. Mechanism of Action • Neurotransmitter levels all increased in CSF after seizure. Results in down regulation of Beta adrenergic receptors. • During seizure- PET studies show an increase in BBB permeability and in cerebral blood flow and metabolism. • After seizure, blood flow and metabolism is decreased especially in the frontal lobes. Research shows this correlated w/ response. Indications • Major Depression w/ or w/o psychotic features • Bipolar disorder - manic or depressed phase • Acute or Catatonic Schizophrenia • Some studies have shown efficacy in treating OCD, Delirium, NMS, Chronic pain syndromes, and intractable seizure disorders Major Depression • Efficacy vs antidepressants • When is it a first line treatment consideration? • Length of Antidepressant effect • Maintenance ECT Bipolar Mania • Efficacy vs Lithium • Indications for First Line Treatment: • -Recent Myocardial Infarction w/ Acute Mania • -Pregnancy w/ Acute mania Pre ECT Workup • • • • • • Physical Exam Head CT CXR CBC, Basic Chem EKG ? Spinal Films Contraindications? • No Absolute Contraindications • Relative Contraindications: Recent MI, Berry Aneurysm, Brain Mass, Increased Intracranial Pressure Treatments • Premedicate w/ Glycopyrrolate, consider short acting Beta blocker • Patient not intubated • Bite block • Cuff leg to monitor sz • EEG and EMG • Length of sz- 20 sec to 1 min. Number and Spacing of ECT • 2-3x/wk- efficacy vs less memory impairment • 5-12 sessions/ treatment (although up to 20 is possible) • Point of maximum improvement- no more improvement after 2 further treatments. Adverse Effects • Mortality rate: .002% per treatment session, .01% per patient. • Sore Muscles • Head ache • Short term confusion/ delirium • Memory Transcranial Magnetic Stimulation (TMS) • Rt Frontal lobe- TMS pulses suppress activity and causes happiness and increased energy • Left Frontal lobe- TMS pulses suppress activity and leads to sadness • 4/250 had seizure • 10Hz stimulation 20x/day, 11/17 patients w/ Major Depression showed significant improvement. TMS continued • So far positive effects have not lasted as long as positive effects from ECT • Handful of case reports show efficacy w/ anxiety disorders.
