Download ECT_01 dec 2015

Electroconvulsive
therapy
Dr. Shailendra Mohan Tripathi,
Assistant Professor
DGMH,KGMU, Lucknow
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 Over the years electroconvulsive therapy (ECT)
has established its usefulness as a rapidly acting
treatment for schizophrenia, bipolar disorders
and unipolar depression among others
 Yet its use has remained controversial
 At times, rejected because it is widely perceived
as invasive and coercive
 Lack of understanding of its mechanism of
action
 Use of camphor reported as early as the 16th century and
several accounts of camphor convulsive therapies from the late
1700s to the mid 1800s
 LADISLAUS MEDUNA hypothesized that there might be a
biological antagonism between convulsions and schizophrenia
 In 1934, the first catatonic psychotic patient
successfully
treated using intramuscular injections of camphor in oil
 1938 – UGO CERLETTI and LUCIO BINI induce seizures in Rome
using electrical stimuli
 1940 - A.E. BENNETT uses curare for muscle relaxation with
Metrazol convulsive therapy
 1952 – HOLMBERG uses succinylcholine as a muscle relaxant with ECT
 In 1949, Goldman introduced unilateral ECT
 By late 1950s, efficacy in disorders other than schizophrenia had been
demonstrated
 In the 1980s and 1990s, efforts to ensure uniformly high standards of
practice were under way
Mechanism of action
 The mechanism of action of ECT is not fully known.

ECT affects multiple central nervous system components,
including hormones, neuropeptides, neurotrophic factors,
and neurotransmitters.
 The induction of a bilateral generalized seizure is required
for both the beneficial and adverse effects of ECT. An
increase in gamma-aminobutyric acid (GABA) transmission
and receptor antagonism has been observed, which raises
the seizure threshold during ECT.
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Indications
 Major depressive disorder
- Considered for patients in the acute phase of major
depressive disorder who have a high degree of
symptom severity and functional impairment or who
have psychotic symptoms or catatonia.
- Also be the treatment of choice for patients in whom
treatment response is urgently needed, such as
patients who are suicidal or those who are refusing
food and are nutritionally compromised.
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Bipolar disorder
- Patients with severe or treatment-resistant manic or mixed
episodes of bipolar disorder
- ECT may be efficacious in patients with rapid cycling
bipolar disorder.
In patients with life-threatening inanition, suicidality,or
psychosis, ECT is a reasonable alternative treatment
- For patients who have depression with psychotic or
catatonic features, ECT should be considered.
- Maintenance ECT may be considered for patients whose
acute episode of depression responded to ECT.
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Schizophrenia
- Effective for symptoms of acute schizophrenia but is
not effective for chronic schizophrenia
-In combination with antipsychotics, ECT may be
considered for patients with severe psychosis that has
not responded to treatment with antipsychotic
medications
- Patients with prominent catatonic features that have not
responded to lorazepam
-For patients with comorbid depression, ECT may be
beneficial if depressive symptoms are treatmentresistant or if features such as suicidal ideation and
behaviors or inanition are present
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Cont….
- In the stable phase of schizophrenia, responded well to ECT
but not maintaining well on drug treatment.
- May be especially effective when marked positive and
affective symptoms are present.
Other psychotic disorders
- Effective for psychotic disorders related to schizophrenia,
such as schizophreniform disorder and schizoaffective
disorder.
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Cont….
Comorbid disorders
-Not recommended for the treatment of obsessive-compulsive
disorder (OCD) but may be considered for treating comorbid
disorders such as major depressive disorder, mania, and
schizophrenia in patients with OCD.
Other disorders and indications
-ECT has been effective in the treatment of catatonia,
neuroleptic malignant syndrome,depression associated with
Parkinson disease,pain, particular cases of delirium
-It has also been effective in treating patients with intellectual
disabilities who have treatment-resistant mood or psychotic
disorders.
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contraindications
 ECT has no absolute contraindications
 Many medical conditions place patients at an increased risk
for complications and warrant closer monitoring, however
Electroconvulsive Therapy with
Comorbidity
 Neurological comorbidities
- Caution is advised for patients with space-occupying
intracranial lesions, as these individuals are at increased
risk for edema and brain herniation after ECT.
- Patients with intracerebral lesions that lack a mass effect
can safely undergo ECT
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Cont….
- ECT increases intracranial pressure and blood flow
to the brain.
- Patients who have increased intracerebral pressure
or are at risk for cerebral bleeding, such as those
with cerebrovascular disease and aneurysms, are
at increased risk during ECT. Patients with very
recent strokes are of special concern
- ECT has been safely used after coil embolization of
a cerebral aneurysm.
- ECT has been used in the presence of CharcotMarie-Tooth disease, arachnoid cysts, epilepsy,
myasthenia gravis,and multiple sclerosis.
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Cont….
 Cardiac comorbidities
-Patients with cardiac disease should be evaluated by a
cardiologist who can assist with the patient’s management
during the course of ECT.
- In patients with unstable angina, uncompensated
congestive heart failure, uncontrolled hypertension, highgrade atrioventricular block, and symptomatic ventricular
arrhythmias, ECT raises the risk of symptoms from these
cardiac conditions. Patients with hypertension should be
stabilized with antihypertensive medications before
undergoing ECT.
- Patients with a recent myocardial infarction (MI) are at high
risk of cardiac complications such as MI, although the risk is
greatly decreased 2 weeks after the MI and is further
reduced 3 months after the MI.
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Cont….
- With a proper pre-ECT cardiac and pacemaker/defibrillator
assessment, patients with cardiac pacemakers and
implantable cardioverter defibrillators can safely undergo
ECT.
- ECT has been used in the presence of severe aortic
stenosis, and it has been used after heart transplantation,
though further studies are needed.
 Other comorbidities
-Patients who have medical disorders associated with
autonomic sensitivity (eg, clinically evident hyperthyroidism,
pheochromocytoma), with sensitivity to anesthesia (eg,
amyotrophic lateral sclerosis, porphyria, pseudochE
deficiency), or with cognitive sensitivity (eg, traumatic brain
injury) may require more extensive workup and closer
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monitoring during ECT.
Cont….
- Patients with gastroesophageal reflux disease may
experience worsening symptoms during ECT, due
to stimulation of the vagus nerve.
- Patients with diabetes, metabolic disorders (eg,
hyperkalemia, hypokalemia, hyponatremia), chronic
obstructive pulmonary disease, hypercoagulable
states, glaucoma, and renal disease require close
monitoring during ECT.
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Preparation
 Anesthesia
- Since the late 1950s, however, ECT has been performed
under general anesthesia.The goal is to produce a "light
level" of anesthesia.
- Anesthetic medications used in ECT include the following:
 Methohexital (barbiturate)
 Thiopental (barbiturate)
 Etomidate (nonbarbiturate)
 Ketamine (nonbarbiturate)
 Alfentanil (opioid)
 Propofol (nonbarbiturate)
The cognitive outcome after ECT may be affected by the
choice of the anesthetic medication
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Cont….
Equipment
- The ECT treatment and recovery areas should contain
equipment to monitor vital signs and provide initial
management of medical emergencies.An optimal
treatment site includes separate functional areas for
waiting, treatment, and recovery
- A stethoscope, a blood pressure measurement device,
electrocardiographic and pulse oximetry measurement
devices, and an oxygen delivery system should be
present. Supplies for inducing anesthesia, providing
ventilation, monitoring physiologic functions (including
seizure activity), and performing resuscitation should be
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present
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Positioning
 Common electrode positions in ECT include the
bifrontotemporal, right unilateral, and bifrontal
positions.Further research is needed for the asymmetric
bilateral position.
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Informed Consent
 No patient with a capacity to give voluntary consent should
be treated with ECT without his or her written, informed
consent.
 The use of involuntary ECT is rare. Involuntary ECT should
be reserved for patients who need emergency treatment and
who have a legally appointed guardian who has agreed to
the use of ECT.
 The informed-consent process should be documented in the
patient's medical record and should include a discussion of
the disorder, its natural course, and the option of receiving
no treatment.
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Electroconvulsive Therapy in the
Elderly
 In elderly patients, ECT has been used to treat catatonia,
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bipolar mania, and psychotic disorders.
Generally, geriatric patients with depression have better
outcomes with ECT than do younger patients.
ECT is especially indicated for patients with depression who
are at risk for harm because of psychosis, suicidal ideation,
or severe malnutrition, but it is also helpful for treatmentresistant nonpsychotic major depression.
Seizure threshold may rise with increasing age, and
effective seizures may be hard to induce.
Geriatric patients may be at a higher risk for persistent
confusion and greater memory deficits during and after ECT.
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Frequency of Treatments
 ECT is most commonly performed 3 times per week
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regardless of electrode placement. More frequent regimens
are not justified.
Treatments 2 times per week may result in less memory
impairment than treatments 3 times per week.
Compared with treatments administered 3 times per week,
twice-weekly treatments result in the same degree of final
clinical improvement, although possibly at a slower rate of
response.
Multiple monitored ECT (MMECT) involves treatment in
which more than one adequate seizure is induced in the
same session under continuous anesthesia.
Urgent clinical scenarios such as neuroleptic malignant
syndrome may warrant MMECT, but routine use is not
recommended.
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Number of Treatments
 it varies widely.
 Although the typical number of treatments is 6-12, some
patients may respond after a few treatments, and some
patients may not respond until after 10 treatments.
 The total number should be a function of the patient's
degree and rate of clinical improvement, as well as the
severity of cognitive adverse effects.
 Treatment is stopped when maximal improvement is
reached.
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Cont….
 Cognitive adverse effects
 Major limitations to the use of ECT. The most severe effects
are observed postictally, with a brief period of disorientation
and impairments in attention, praxis, and memory. The
effects reverse over time.
 Anterograde and retrograde amnesia may result from ECT.
After ECT, anterograde amnesia resolves rapidly. With
retrograde amnesia, deficits are greatest for events closest
to the time of treatment.
 Postictal delirium may occur in a minority of patients.
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 In terms of the effect we need to answer the question
as to what is treated by the ECT – psychosis or
depression or a common element to the two
conditions & what explains the effectiveness of the
ECT in delirium
 The undesirable or side effects of the ECT need to be
experimentally documented and their amelioration
through appropriate approaches to be established
 We need answers to questions like
 What is the necessary and/or sufficient therapeutic
component - the generalised seizure or the postictal slowwave state?
 What is the effective seizure - only a generalised/grandmal
or a circumscribed one limited to one set of neurons/region?
The bioethics of ECT - is this a
safe, effective procedure or
should it be banned?
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"ECT has a higher success rate for severe depression than any other form of
treatment.”
-Dr. Dimitris Popolos
Since the 1960s, the methods of ECT have changed
somewhat and it seems to be safer. It is known to
produce some memory loss, but seems to be the most
effective treatment for people with severe depression.
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THANK
YOU
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