Electroconvulsive therapy

1. Electro-Convulsive Therapy (ECT)
Dr.Asma A Rehman
Consultant Psychiatrist

2. Overview
• Definition
• History
• Machines
• Mechanism of action
• Indications
• Technique
• Unwanted effects
• Summary

3. Definition
• ECT is a procedure in which electric currents are passed
through brain, intentionally triggering a brief seizure.
• Formerly known as “ Electric Shock ”
• Safe for all ages, with debilitating illness, and during
pregnancy.

4. History
• Introduced in late 1930’s
• On basis of mistaken idea :
“ Epilepsy and Schizophrenia do not occur together”
• Induced fits should lead to improvement in Schizophrenia.
• Initially chemically fits were induced by using Camphor or Pentylenetetrazol.
• IV Camphor induced seizure in 1934 by Meduna
As procedure was painful so
Then
started on ECT
• IM pentylenetetrazol
• 1st
ECT in 1938
.

5. • 1940, curare was developed for use as a muscle
relaxant during ECT
• Succinylcholine, a depolarizing muscle relaxant, was
introduced in 1951
• 1975 movie “One Flew Over the Cuckoo’s Nest,” with
Jack Nicholson thrashing about, forced against his will
to endure painful, violent seizures
• In 1985, the National Institutes of Health and National
Institute of Mental Health Consensus Conference on
ECT endorsed a role for the use of ECT

6. ECT machines.
• Four machines currently available are recommended by
the College:
1. the Ectron Series 5A,
2. Ectonus (Electron Ltd, Letchworth),
3. Mecta SR2 and JR2 (Mecta Corp., Lake Oswego, OR)
and
4. Thymatron-DGx (Somatics Inc., Lake Bluff, IL) (
Royal College of Psychiatrists, 1995).

7. ECT machine in LNH (ECTONUS)

9. Mechanism Of Action.
• Neuro-endocrine system
• Neuro-endocrine dysregulation Is prominent in Patients
with Mental disorders for which ECT is effective.
• In severely depressed patients, Adrenal glands produce too
much Cortisol.
• The high blood levels disrupts normal diurnal rhythm of
other glandular discharges and the glands do not respond to
usual feed back mechanism.

10. • The most prominent features of depression are distortion of
functions regulated by Neuro-endocrine gland in self-
adjusting feed back.
• Each Seizure stimulates Hypothalamus to discharge its
hormones, which causes Pituitary gland to discharge its
products which then effects level of Cortisol.
• The first effects of this cascade are Transitory, but repeated
Seizures restore the normal interaction of HPA axis.
• Feeding & sleeping becomes normal, followed by motor
activity, mood , memory & thoughts.

11. • After some course of ECT, the return to normal Endocrine
functions.
• At other times, glands revert their abnormal activities, &
mental disorder becomes evident again.
• In these cases repeated stimulation of Hypothalamus &
Pituitary by continuation of ECT restore & sustain normal
glandular function & support normal mental state.

12. • Neuro-transmitter System.
• Almost all neurotransmitters effected by ECT.
• Down regulation of pot-synaptic beta adrenergic receptor
• Increase post-synaptic receptor & change in pre-synaptic
discharge.

13. Indications.
• 1) Treatment of choice :
• Severe depressive illness when associated with :
oLife threatening illness bec of refusal of food & fluids.
oHigh Suicidal risk.
• 2) Considered for:
• Severe Depressive illness associated with:
oStupor.
oMarked Psychomotor retardation.
oDepressive delusions & hallucinations.

14. • 3) 2nd
& 3rd
line of treatment:
• Depressive illness:
o If not responsive to anti-depressant drugs
• 4) Treatment of Mania:
• associated with:
o Life threatening physical exhaustion.
o Not responded to appropriate drug treatment.
• 5) For treatment of Acute Schizophrenia:
• as 4th
line treatment option.
o After trial of 2 anti-psychotics & Clozapine was ineffective
• 6) Catatonia.
o Where treatment with Benzodiazepine ineffective.

15. • Mortality Rate.
• 3-4/100,000 Treatments.
• Due to General Medical conditions or General Anesthesia
complications.
• Contraindications.
• No absolute contraindications.
• Contraindications are due to anesthesia

16. Technique
• Pre-treatment evaluation:
• Complete physical examination
• Dental examination
• Complete Blood Picture.
• Serum Urea/Creatinine/Electrolytes.
• Urine Tests
• Chest X-ray
• ECG
• CT-Scan.
• MRI.
• ECT Clinic:
• Pleasant safe surroundings
• Waiting area should separate from treatment room
• Emergency equipment should be present
• ETT.
• Suction.
• O2 supply.
• Resuscitation.

17. • Arrival of patient:
• Patient should be at ease.
• Check identity
• Check consent form.
• Check drug sheet.
• Administration of Anesthesia.
• NPO for at least 5 hours.
• I/V access maintained.
• Attach Monitor
• Give Muscle relaxant
• Anesthetic agent
• Hyperventilation with O2
• Bite Block.
• Electrode placement and electical dose.
• Managing complications.
• Shift to recovery room till patient concious and stable.

18. Muscrainic anti-cholinergic:
• Administered before anesthetic agent
• To minimize oral and respiratory secretions.
• Atropine 0.3-0.6 mg IM or SC 30-60 minutes before
anesthetic agent
OR
• 0.4-1.0 mg IV 2 or 3 minutes before anesthetic
• Suxamethonium Chloride 0.5-1mg/kg i/v bolus

19. Anesthetic agent.
• Methohexital (BREVITAL) ( most commonly used)
• 0.75-1mg/kg iv bolus
• Thiopental (PENTOTHAL) 2-3mg/kg iv bolus

20. Other anesthetic agents used.

21. Muscle relaxant.
• After onset of anesthetic effect within a minute.
• To minimize risk of bone fractures and other injuries.
• Succinylcholine 0.5-1 mg/kg iv bolus.

22. Application of electrodes.
• Clear skin
• Moist skin ( dry electrodes can cause skin burns/excessive moisture can cause
shortening & prevent seizure exposure.)
• Position of electrodes
• Unilateral electrode:
• On non-dominant side.
• 3cm above mid-point line between external angle of orbit & external
auditory meatus.
• Bilateral electrode:
• 2nd
electrode.
Either of two points can be used.
• i) At least 10cm away from 1st
one. Vertically above meatus of same side.
or
• ii) Electrodes are placed on opposite sides of head.

24. Electical dose.
• For unilateral fixed ECT:
400 milicoloumbs
• For Bilateral ECT:
100-200 milicoloumbs.
• Seizure threshold increased in men.
• For age <40
• Starting dose: 150 milicoloumbs.
• Dose might be increased if seizure was short or
absent.

26. Signs of seizure.
1st
• Muscle of face begin to twitch & mouth drops open.
Then.
• Upper eyelids, thumbs & big toe jerks rhythmically for
1½ minute.
• Seizure duration: 20-50seconds.

27. Monitoring by EEG
• Many modern ECT machines now include EEG
monitoring, which helps to prevent unwarranted re-
stimulation, as well as to detect prolonged seizures.

29. Concomitant medications.
• Anti-depressant & anti-psychotics decrease seizure threshold.
• Benzodiazepine should be withdrawn because of anti-
convulsant effect.
• Valproate & lamotrigine increase threshold.
• Clozapine and Bupropion should be withdrawn because
associated with late appearing seizures.
• Cognitive impairment when ECT given with Lithium.
• SSRIs prolong seizure duration.
• Lidocaine should not be administred as increase seizure
threshold.
• Theophylline contraindicated as increases seizure duration.
• Reserpine also contraindicated as compromise respiratory and
CVS during ECT

30. Complications.
• Prolonged and tardive seizure.
• Duration > 180 seconds.(APA guidelines)
• > 120 seconds ( Royal College’s revised guidelines)
• Status epilepticus.
• Give i/v diazepam 5-10mg immediately.
• Failed stimulation.
• If no seizure occurred
 Check machine.
 Check electrodes.
 Check contact with skin.
• Charge can be increased by 50% & further stimulus can be given.
• Additional procedure to lower seizure threshold include Hyperventilation
and
• administration of 500-2000 mg iv of Caffeine Sodium Benzoate 5-10
minutes before stimulus.

31. Unwanted effects
• Brief Retrograde Amnesia:
loss of memory up-to 30 minutes after ECT.
• Brief disorientation.
• Headache
• Muscle pain esp. jaws.
• Occasional damage to teeth, tongue or lips.
• Small electical burns (due to poor application of electrodes)
These unwanted effects are rare if good anesthetic technique
used.
Other rare complications occur due to co morbid physical
illness.

32. Memory disorder after ECT
Short-Term effects Long-Term effects
Retrograde
Amnesia
Anterograde
Amnesia
Loss of
memory for
personnel and
impersonal
remote
events.
Dec ability to
learn new
information.

33. Frequency and number of treatments
• Can be given Twice a week.
• In general.
3 times/week given.
• Course of ECT includes 6-12 treatments.
• Little response until 2-3 treatments.
• If no response after 6-8 treatments , course should be abandoned.
• Prevention of relapse:-
• In depression high relapse rate until continuation therapy
with anti-depressants.
• Maintenance ECT
• At reduced frequency.
• Fortnightly or monthly.

34. Thank you
•Hope it was not an
ELECTRIC SHOCK for
YOU