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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