Electroconvulsive therapy and its present status. A Short seminar on the indications, process of Electroconvulsive therapy and its current status in society as a form of treatment.

1. ELECTROCONVULSIVE THERAPY AND ITS
PRESENT STATUS
DR. SUBRATA NASKAR
MD PSYCHIATRY PGT
EMAIL: nsubrata09@gmail.com

2. PLAN OF PRESENTATION
 INTRODUCTION
 HISTORY
 ELECTROPHYSIOLOGY IN ECT
 INDICATIONS
 CONTRAINDICATIONS
 PRE-ECT PREPARATION AND EVALUATIONS
 THE PROCEDURE
 EFFICACY
 SIDE EFFECTS
 CONTINUATION & MAINTAINEANCE THERAPY
 RESEARCH & FUTURE DIRECTIONS
 BIBLIOGRAPHY

3. INTRODUCTION
ELECTROCONVULSIVE THERAPY (ECT), FORMERLY KNOWN AS
ELECTROSHOCK, IS A STANDARD PSYCHIATRIC TREATMENT IN
WHICH SEIZURES ARE ELECTRICALLY INDUCED IN PATIENTS TO
PROVIDE RELIEF FROM PSYCHIATRIC ILLNESSES.

4. HISTORY
 ELECTROCONVULSIVE THERAPY IS ONE OF THE OLDEST TREATMENT
FOR MENTAL ILLNESS WHICH IS STILL IN CONTINUOUS USE.
 1500 A.D - SWISS PHYSICIAN PARACELSUS FIRST USED CAMPHOR TO
INDUCE ARTIFICIAL SEIZURE TO TREAT MENTAL ILLNESS.
 1934 – LADISLAS J. MEDUNA BEGAN THE MODERN ERA OF ECT BY
USING IM INJECTION OF CAMPHOR FOR CATATONIC
SCHIZOPHRENIA. CAMPHOR WAS SOON REPLACED BY
PENTYLENETETRAZOL.
 1938 – MODERN ECT WAS FIRST INTRODUCED IN BY ITALIAN
NEUROPSYCHIATRISTS UGO CERLETTI AND LUCIO BINI.
 1940 – ECT WAS INTRODUCED IN U.S. WITH USE OF CURARE AS A
MUSCLE RELAXANT.
 1951 – INTRODUCTION OF SUCCINYLCHOLINE.
 1970 – THE MOST COMMON ELECTRODE POSITION FOR RIGHT
UNILATERAL ECT IS DEVELOPED.
 1970 – 2001 – VARIOUS RCT STUDIES HAVE SHOWN THE EFFICACY
OF ECT IN VARIOUS MENTAL ILLNESS.

5. ELECTROPHYSIOLOGY
 NEURONES MAINTAIN A RESTING MEMBRANE POTENTIAL ACROSS PLASMA MEMBRANES.
 NORMAL BRAIN ACTIVITY IS DESYNCHRONIZED, NEURONES FIRE ACTION POTENTIAL
ASYNCHRONOUSLY.
 A CONVULSION OR SEIZURE OCCURS WHEN A LARGE PERCENTAGE OF NEURONES FIRE IN
UNISON.
 THE RHYTHMICAL CHANGE IN EXTRACELLULAR POTENTIAL ENTRAIN THE NEIGHBOURING
NEURONES AND PROPAGATES THE SEIZURE ACTIVITY ACROSS THE CORTEX INTO DEEPER
STRUCTURES.
 EVENTUALLY THE ENTIRE BRAIN SHOWS HIGH VOLTAGE SYNCHRONOUS NEURONAL FIRING.

6. HOW DOES AN ARTIFICIAL SEIZURE HELPS IN TREATING MENTAL ILLNESS ?
 PET STUDIES HAVE SHOWN THAT CEREBRAL BLOOD FLOW, USE OF GLUCOSE AND O2 AND
PERMEABILITY OF BLOOD BRAIN BARRIER INCREASES DURING SEIZURES.
 IMMEDIATELY AFTER THE SEIZURE THERE IS A DECREASE IN BLOOD FLOW AND GLUCOSE
METABOLISM ESPECIALLY IN THE FRONTAL LOBES.
 RESEARCH INDICATES THAT THE DEGREE OF DECREASE IN CEREBRAL METABOLISM IS
CORRELATED WITH THE THERAPEUTIC RESPONSE.

7.  ANTICONVULSANT ROLE OF ECT
 ECT ITSELF ACTS AS AN ANTICONVULSANT BECAUSE ITS ADMINISTRATION IS ASSOCIATED WITH
AN INCREASE IN SEIZURE THRESHOLD AS TREATMENT PROGRESSES.
 RECENT DATA SHOWS THAT 1-2 MONTHS FOLLOWING AN ECT SESSION, EEG RECORD A
LARGE INCREASE IN THRE SLOW WAVE DELTA ACTIVITY IN THE PRE-FRONTAL CORTEX.
 DECREASED SLOW WAVE SLEEP HAS BEEN FOUND TO BE ASSOCIATED WITH INCREASED NEGATIVE SYMPTOMS
 ECT HAVE BEEN FOUND TO REGULATE CELLULAR MECHANISM OF MEMORY AND MOOD
REGULATION.
 ITS BEEN HYPOTHESIZED THAT ECT INCREASES BLOOD BRAIN PERMEABILITY RESULTING IN
INCREASED DRUG DELIVERY.

8. ECT & NEUROTRANSMITTERS
 IT HAS BEEN FOUND THAT THERE ARE SUBTLE CHANGES IN THE NEUROTRANSMITTER
RECEPTORS AND SECOND MESSENGER SYSTEM.
 VIRTUALLY ALL THE NEUROTRANSMITTER SYSTEMS ARE AFFECTED.
 A SERIES OF ECT SESSIONS SHOW A DOWNREGULATION OF POSTSYNAPTIC β-
ADRENERGIC RECEPTORS.
 REPORTED CHANGES IN DOPAMINE, MUSCARINIC AND CHOLINERGIC RECEPTORS HAVE
BEEN FOUND.
 HOWEVER, EFFECT OF ECT ON SEROTONERGIC NEURONS REMAINS CONTROVERSIAL.
 IN SECOND MESSENGER SYSTEMS, ECT HAS BEEN REPORTED TO EFFECT THE
• G-PROTEIN COUPLING TO RECEPTORS
• ACTIVITY OF ADENYLYL CYCLASE & PHOSPHOLIPASE C
• REGULATION OF CALCIUM ENTRY INTO NEURONES.

9. INDICATIONS
• MAJOR DEPRESSIVE DISORDER
• FAILED MEDICATION TRIALS
• MEDICATION INTOLERANCE
• SEVERE OR PSYCHOTIC SYMPTOMS
• MELANCHOLIC FEATURES
• ACUTELY SUICIDAL OR HOMICIDAL
• MARKEDLY AGITATED OR STUPOUROUS.
• 70% OF PATIENTS WHERE ANTIDEPRESSANTS HAVE FAILED RESPOND POSITIVELY TO ECT.
• DEPRESSION OF BIPOLAR –I
• ACUTE MANIC EPISODES
• ACUTE EPISODES IN SCHIZOPHRENIA
• CATATONIC SCHIZOPHRENIA

10. • SUICIDAL PATIENTS INCLUDING
• DEPRESSED SUICIDAL PREGNANT PATIENTS WHO CANNOT TAKE MEDICATIONS
• GERIATRIC PATIENTS WHO CANNOT TAKE ANTIDEPRESSANTS
• DEPRESSED SUICIDAL CHILDREN OR ADOLESCENTS WHO ARE NOT RESPONDING TO DRUGS
• EPISODIC PSYCHOSIS
• ATYPICAL PSYCHOSIS
• OBSESSIVE COMPULSIVE DISORDER
• DELIRIUM
• OTHER MEDICAL CONDITIONS:
• NEUROLEPTIC MALIGNANT SYNDROME
• HYPOPITUTARISM
• INTRACTABLE SEIZURE DISORDER
• TREATING DEPRESSION/ ON-OFF PHENOMENON IN PARKINSONISM
THE “ON-OFF” PHENOMENON IN PARKINSON’S
DISEASE (PD) REFERS TO A SWITCH BETWEEN
MOBILITY AND IMMOBILITY IN LEVODOPA-TREATED
PATIENTS, WHICH OCCURS AS AN END-OF-DOSE
OR “WEARING OFF” WORSENING OF MOTOR
FUNCTION OR, MUCH LESS COMMONLY, AS
SUDDEN AND UNPREDICTABLE MOTOR
FLUCTUATIONS.

11. CONTRAINDICATIONS
 ECT HAS NO ABSOLUTE CONTRAINDICATIONS.
 PREGNANCY IS NOT A CONTRAINDICATION.
 FETAL MONITORING IS CONSIDERED UNNECESSARY UNLESS PREGNANCY IS HIGH RISK OR COMPLICATED.
 PATIENTS WITH SOL IN CNS ARE AT INCREASED RISK FOR EDEMA AND BRAIN HERNIATION AFTER ECT.
 SMALL LESION – PRETREATMENT WITH DEXAMETHASONE IS GIVEN.
 INCREASED INTRACRANIAL PRESSURE - INCREASED RISK OF CVA.
 CONTROL BP DURING TREATMENT
 PATIENTS WITH AMI - INCREASED RISK, RISK DECREASES 2 WKS LATER, FURTHER DECREASES AFTER 3 MONTHS.
 PATIENTS WITH HYPERTENSION SHOULD BE STABILIZED.
 PROPANOLOL AND SUBLINGUAL NITROGLYCERINE CAN BE USED TO PROTECT SUCH PATIENTS

12. CLINICAL GUIDELINES
 A PROPER EXPLANATION ABOUT THE BENEFITS AND ADVERSE EFFECTS OF ECT SHOULD BE
GIVEN TO PATIENTS AND THEIR ATTENDANTS
 AN INFORMED CONSENT SHOULD BE TAKEN PROPERLY
 INVOLUNTARY ECT IS ONLY FOR THOSE PATIENTS WHO URGENTLY NEED THE TREATMENT AND
WHOSE LEGALLY APPOINTED GUARDIAN HAS GIVEN A WRITTEN INFORMED CONSENT.
 CLINICIAN MUST BE AWARE OF THE LOCAL, STATE AND FEDERAL LAWS ABOUT ECT USE.

13. CLINICAL GUIDELINES
PRE-TREATMENT EVALUATION:
 STANDARD PHYSICAL
 NEUROLOGICAL
 PRE-ANESTHETIC EXAMINATION
 COMPLETE MEDICAL HISTORY
 ROUTINE EXAMINATION:
 CHEST X-RAY
 ECG
 R/E BLOOD & URINE
 X-RAY SPINE [ IF PATIENT HAS SEIZURE DISORDER OR SOL IS SUSPECTED CT / MRI SPINE HAS TO
BE PERFORMED]
 DENTAL EXAMINATION

14. CLINICAL GUIDELINES
 COGNITIVE EVALUATION AND MONITORING
 PRE-ECT EVALUATION OF :
 MEMORY
 ORIENTATION
 COMPREHENSION
 ATTENTION
 CONCENTRATION
 USE OF A STANDARDIZED SCALE SUCH AS MMSE IS OFTEN HELPFUL.
 SPECIFIC INSTRUMENTS FOR EVALUATION OF ANTROGRADE AND RETROGRADE MEMORY MAY
BE USED.

15. CLINICAL GUIDELINES
CONCOMMITANT MEDICATIONS THAT HAS TO BE DISCONTINUED:

16. CLINICAL GUIDELINES
CONCOMMITANT MEDICATIONS
USAGE OF FOLLOWING DRUGS IS CONSIDERED SAFE:
• TRICYCLICS
• TETRACYCLICS
• MONOAMINE OXIDASE
• ANTIPSYCHOTICS

17. CLINICAL GUIDELINES
 PATIENT SHOULD NOT BE GIVEN ANYTHING ORALLY FOR 6 HOURS BEFORE TREATMENT.
 PATIENTS MOUTH SHOULD BE CHECKED FOR ANY DENTURES OR FOREIGN OBJECTS.
 IV LINE SHOULD BE SECURED
 A BITE BLOCK IS INSERTED JUST PRIOR TO ADMINISTERING THE TREATMENT.
 100% O2 @ 5L/MIN IS ADMINISTERED PRIOR TO AND AFTER THE TREATMENT IS
ADMINISTERED UNTILL SPONTANEOUS RESPIRATION RETURNS.
 EMERGENCY EQUIPMENTS FOR ESTABLISHING AN AIRWAY SHOULD BE AVAILABLE

18. CLINICAL GUIDELINES
MUSCARINIC ANTICHOLINERGIC DRUGS
 MINIMIZE ORAL AND RESPIRATORY SECRETIONS
 BLOCK BRADYCARDIA & ASYSTOLE.
 SHOULD BE USED UNLESS HEART RATE IS ABOVE 90 BEATS/ MIN.
 SHOULD BE USED IN PATIENTS ON β BLOCKERS AND WITH VENTRICULAR ECTOPIC
BEATS.
 MOST COMMONLY USED DRUG IS ATROPINE.
 DOSE: 0.3 TO 0.6 mg I.M OR S.C, 30 – 60 MINS BEFORE OR 0.4 – 1.0 mg I.V, 2-3 MINS
PRIOR TO ADMINISTRATION OF ANESTHETICS.
 ALTERNATIVE DRUG: GLYCOPYROLLATE
 ADVANTAGE: LESS LIKELY TO CROSS BBB AND CAUSE COGNITIVE DYSFUNCTION, NAUSEA
 DISADVANTAGE: LESS CARDIOPROTECTIVE

19. CLINICAL GUIDELINES
ANESTHESIA
 ANESTHESIA REQUIRED: GENERAL ANESTHESIA
 DEPTH OF ANESTHESIA: LIGHT
 MOST COMMONLY USED ANESTHETIC:
 METHOHEXITAL [ DOSE : 0.75 TO 1.0 mg/ Kg IV BOLUS]
 ADVANTAGE: SHORT DURATION OF ACTION
 LOWER POST ICTAL ARRRHYTHMIAS
 OTHER ALTERNATIVE ANESTHETICS USED:
 ETOMIDATE [ 0.15-0.3 mg/kg IM ]
 KETAMINE [6-10 mg/kg IM ]
 ALFENTANIL [2-9 mg/kg IV ]
 PROPOFOL [0.5-3.5 mg/kg IV ] STRONG ANTICONVULSANT PROPERTY

20. CLINICAL GUIDELINES
MUSCLE RELAXANTS
• GIVEN WITHIN MINUTES OF INJECTION OF ANESTHETICS TO REDUCE THE MOTOR
ACTICITIES DURING SEIZURE.
• PREVENTS MUSCLE AND BONY INJURY.
• GOAL IS PROFOUND RELAXATION OF MUSCLES NOT PARALYSIS.
• MOST USED MUSCLE RELAXANT : SUCCINYLCHOLINE [ DOSE : 0.5-1 mg/kg]
• DISAPPEARANCE OF FASCICULATATIONS WHICH OCCURS IN ROSTRO-CAUDAL
DIRECTICTION AFTER PERIPHERAL NERVE STIMULATION INDICATE MAXIMUM MUSCLE
RELAXATION.
• IF THE PATIENT IS KNOWN TO HAVE PSEUDOCHOLINE ESTERASE DEFICIENCY, ATRACURIUM
IS USED INSTEAD OF SUCCINYLCHOLINE.

21. THE PROCEDURE
 ELECTRODE PLACEMENT:
 ECT CAN BE CONDUCTED BY EITHER UNILATERAL OR BILATERAL PLACEMENT OF ELECTRODE
 BILATERAL PLACEMENT –
 INTRODUCED FIRST
 MORE THERAPEUTIC RESPONSE.
 ELECTRODES ARE PLACED SEVERAL CENTIMETERS APART OVER EACH HEMISPHERES OF BRAIN.
 IN TRADITIONAL B/L ECT ELECTRODES ARE PLACED BIFRONTOTEMPORALLY WITH THE CENTRE OF EACH ELECTRODE
ABOUT 1 INCH ABOVE THE MIDPOINT OF AN IMAGINARY LINE DRAWN FROM THE TRAGUS TO EXTERNAL CANTHUS.
 UNILATERAL PLACEMENT –
 LESS MARKED COGNITIVE ADVERSE EFFECTS.
 BOTH ELECTRODES ARE PLACED SEVERAL CENTIMETERS APART OVER THE NONDOMINANT HEMISPHERES
 ONE ELECTRODE IS PLACED OVER THE NONDOMINANT FRONTOTEMPORAL AREA.
 SECOND ELECTRODE IS USUALLY PLACED ON THE NONDOMINANT CENTRO-PARIETAL SCALP, JUST LATERAL TO THE
MIDLINE VERTEX, ALTHOUGH THIS POSITION VARIES.

22. AN ECT MACHINE
POSITION OF ELECTRODE PLACEMENT

23. THE PROCEDURE
ELECTRIC STIMULUS:
 STIMULUS IS GIVEN IN CYCLES.
 EACH CYCLE CONTAINS A POSITIVE AND NEGATIVE WAVE.
 OLD MACHINES USED SINE WAVES.
 MODERN ECT MACHINES USE A BRIEF PULSE WAVEFORM
 USUALLY IN 1-2 MILLISECONDS @ 30-100 IMPULSES A SECOND.
 A COMMON TECHNIQUE IS TO INITIATE TREATMENT AT A STIMULUS LESS THAN THE SEIZURE
THRESHOLD.
 THEN GRADUALLY THE INTENSITY IS INCREASED BY 100% FOR UNILATERAL PLACEMENT AND 50%
FOR BILATERAL PLACEMENT TILL SEIZURE THRESHOLD IS REACHED.

24. INDUCED SEIZURE
A BRIEF MUSCLE CONTRACTION USUALLY STRONGEST IN PATIENT’S JAW
AND FACIAL MUSCLES IS SEEN CONCURRENTLY WITH THE FLOW OF
STIMULUS CURRENT, REGARDLESS OF WHETHER A SEIZURE OCCUR OR NOT
THE FIRST BEHAVIOURAL SIGN OF SEIZURE IS OFTEN A PLANTER EXTENSION
WHICH LASTS FOR 10-20 SECONDS AND MARK THE TONIC PHASE
THE TONIC PHASE IS MARKED BY A HIGH FREQUENCY, SHARP EEG
ACTIVITY ON WHICH A HIGH FREQUENCY MUSCLE ARTIFACT MAY BE
SUPERIMPOSED.
RTHYTHMIC/CLONIC CONTRACTION THAT DECREASE IN FREQUENCY
AND FINALLY DISAPPEARS
DURING THE CLONIC PHASE BURST OF POLYSPIKY ACTIVITY OCCUR
SIMULTANEOUSLY WITH THE MUSCLE CONTRACTION.

26. WHAT IF THERE IS FAILURE TO INDUCE SEIZURE ?
 UPTO 4 ATTEMPTS TO INDUCE SEIZURE CAN BE TRIED DURING THE COURSE OF TREATMENT.
 SOMETIMES, THE ONSET OF SEIZURE ACTIVITY IS DELAYED BY 20-40 SECS AFTER INDUCTION OF STIMULUS.
 IF STIMULUS FAILS TO INDUCE SEIZURE, THE CONTACT BETWEEN THE ELECTRODE AND SKIN SHOULD BE
CHECKED.
 INTENSITY OF THE STIMULUS CAN BE INCREASED BY 25-100%.
 ANESTHETIC AGENT CAN BE CHANGED TO REDUCE THE SEIZURE THRESHOLD.
 ADDITIONAL PROCEDURES:
 HYPERVENTILATION.
 ADMINISTRATION OF 500-2000 mg IV CAFFEINE SODIUM BENZOATE 5-10 MINS PRIOR TO STIMULUS.

27. NUMBER AND SPACING OF TREATMENT
 ECT TREATMENTS ARE USUALLY ADMINISTERED 2-3 TIMES/WEEK.
 TWICE WEEKLY TREATMENTS ARE ASSOCIATED WITH LESS MEMORY IMPAIRMENT.
 MDD – 6-12 TREATMENTS
 MANIC EPISODES - 8-20 TREATMENTS.
 SCHIZOPHRENIS - MORE THAN 15 TREATMENTS.
 CATATONIA - 1-4 TREATMENTS
 DELIRIUM- 1-4 TREATMENTS
 TREATMENT SHOULD CONTINUE UNTIL THE PATIENT ACHIEVES WHAT IS CONSIDERED THE
MAXIMAL THERAPEUTIC RESPONSE.
 MAXIMAL THERAPEUTIC RESPONSE - THE POINT OF MAXIMAL IMPROVEMENT IS THOUGHT TO OCCUR
WHEN A PATIENT FAILS TO CONTINUE TO IMPROVE AFTER 2 CONSECUTIVE TREATMENTS.
 FURTHER TREATMENT DOES NOT YEILD ANY FURTHER BENEFITS
 PATIENT NOT IMPROVING AFTER 6 TO 10 SESSIONS – BILATERALLY PLACED, HIGH DENSITY
TREATMENT SHOULD BE ATTEMPTED BEFORE ECT IS ABANDONED.

28. MULTIPLE MONITERED ELECTROCONVULSIVE THERAPY (MMECT)
 GIVING MULTIPLE ECT STIMULI DURING A SINGLE SESSION .
 MOST COMMONLY 2 BILATERAL STIMULI WITHIN 2 MINUTES.
 INDICATED IN :
 SEVERELY ILL PATIENTS THOSE IN RISK FROM ANESTHETIC PROCEDURES.
 MMECT IS ASSOCIATED WITH MOST FREQUENT OCCURENCES OF SERIOUS COGNITIVE
ADVERSE EFFECTS

29. MAINTENANCE TREATMENT
 SHORT TERM COURSE OF ECT INDUCES A REMISSION IN SYMPTOMS BUT DOES NOT, OF
ITSELF, PREVENT A RELAPSE.
 POST ECT MAINTENANCE TREATMENT SHOULD ALWAYS BE CONSIDERED.
 INDICATIONS:
 RAPID RELAPSE AFTER INITIAL ECT.
 SEVERE SYMPTOMS.
 PSYCHOTIC SYMPTOMS
 INABILITY TO TOLERATE MEDICATIONS.

30. FAILURE OF ECT TRIAL
 FAILED ECT PATIENTS SHOULD AGAIN BE TREATED WITH PHARMACOLOGICAL
AGENTS.
 STUDIES HAVE SHOWN THAT PATIENT UNRESPONSIVE TO ANTIDEPRESSANTS PRIORLY
DO RESPOND AFTER A COURSE OF ECT TREATMENT WITH THE SAME MEDICATIONS.

31. MORTALITY
 MORTALITY RATE WITH ECT IS ABOUT 0.002 PERCENT PER TREATMENT.
 0.01 PERCENT FOR EACH PATIENT.
 ECT DEATHS ARE MOSTLY DUE TO CARDIOVASCULAR COMPLICATIONS AND MOST
LIKELY TO OCCUR IN PATIENTS WHOSE CARDIAC STATUS IS ALREADY COMPROMISED.

32. ADVERSE EFFECTS
 CNS :
 HEADACHE
 CONFUSION
 DELIRIUM
 MARKED CONFUSION IN 10% PATIENTS WITHIN 30 MINS OF SEIZURE
 CAN BE TREATED WITH BARBITURATES AND BENZODIAZEPINES.
 DELIRIUM IS USUALLY MORE PRONOUNCED
 AFTER THE FIRST FEW TREATMENTS
 IN PATIENTS WHO RECEIVE BILATERAL ECT
 COEXISTING NEUROLOGICAL DISORDER
 VISUOSPACIAL FUNCTIONING ERRORS
 ERRORS IN WORD FINDING

33. ADVERSE EFFECTS
 MEMORY: MEMORY IMPIRMENT IS THE WORST ADVERSE EFFECT.
 DATA INDICATES THAT ALMOST ALL PATIENTS ARE BACK TO THEIR COGNITIVE BASELINE
AFTER 6 MONTHS.
 SOME PATIENTS COMPLAIN OF PERSISTENT MEMORY DIFFICULTIES.
 MEMORY IMPAIRMENT AND TIME TO RETURN TO BASELINE COGNITIVE FUNCTIONING IS
DIRECTLY PROPORTIONAL TO INTENSITY OF ELECTRICAL STIMULUS.
 NO EVIDENCE HAS BEEN FOUND ON THE FACT THAT WHETHER ECT CAUSES BRAIN DAMAGE
OR NOT.
 PATIENT OF DEMENTIA WITH DEPRESSION ARE AT RISK FOR GREATER ADVERSE COGNITIVE
EFFECTS, DELIRIUM AND CONFUSION.

34. ADVERSE EFFECTS
 RETROGRADE AMNESIA —
 IT IS MOST MARKED FOR EVENTS OCCURING IN THE WEEKS OR MONTHS BEFORE
TREATMENT
 ONE STUDY SHOWING THAT SOME PEOPLE LOSE MEMORIES FROM YEARS PRIOR TO
TREATMENT
 RECOVERY OF SUCH MEMORIES IS “VIRTUALLY COMPLETE” BY SEVEN MONTHS POST
TREATMENT WITH THE ONLY ENDURING LOSS BEING MEMORIES IN THE WEEKS AND
MONTHS PRIOR TO THE TREATMENT.
 ANTEROGRADE AMNESIA —
 IT IS USUALLY LIMITED TO THE TIME OF TREATMENT ITSELF OR SHORTLY AFTERWARDS.
 IN THE WEEKS AND MONTHS FOLLOWING ECT THESE MEMORY PROBLEMS
GRADUALLY IMPROVE
 SOME PEOPLE HAVE PERSISTENT LOSSES ESPECIALLY WITH BILATERAL ECT.

35. RESPIRATORY SYSTEM:
 ALONG WITH CARDIAC DISEASE IT IS A LEADING CAUSE OF MORTALITY AND MORBIDITY.
 ITS EFFECTS ARE MOSTLY ASSOCIATED WITH ANAESTHESIA PROCEDURE.
 MUSCLE RELAXANT CAN CAUSE CEASSATION OF BREATHING.
 THERE MAY BE EXAGGERATION OF ASTHMA OR CHRONIC OBSTRUCTIVE PULMONARY DISEASE
 INCREASED SECRETION, ASPIRATION AND PULMONARY OEDEMA.
 PSEUDOCHOLINESTERASE DEFICIENCY LEADS TO DECREASED METABOLISM OF
SUCCINYLCHOLINE.

36. DENTAL:
 DUE TO DIRECT STIMULATION OF JAW MUSCLE, PATIENT BITE DOWN; UNSTABLE TEETH MAY
BE BROKEN AND DISLODGED.
MUSCULOSKELETAL:
 FRACTURE OF LONG BONE AND SPINE ARE COMMON. IN MODIFIED THEY ARE LESS
COMMON.
 PRECAUTIONS SHOULD BE TAKEN IN ELDERLY PATIENT, OSTEOPOROTIC PATIENT AND
TEMPOROMANDIBULAR JOINT PROBLEM.
 MYALGIA IS COMMON IN FIRST SESSION.

37. OTHER ADVERSE EFFECTS
 POST ICTAL AGITATION:
 ASSOCIATED WITH
 BILATERAL ELECTRODE PLACEMENT
 LOWER ANAESTHETIC DOSE
 CONCOMITANT USE OF MEDICATIONS
 ANXIETY
 PRE ECT AGITATION.
 SHORT ACTING BENZODIAZEPINE, ECT ANAESTHETICS AND RESTRAINS ARE HELPFUL.
 HEADACHE:
 UP TO 50% CASES; UNKNOWN ETIOLOGY; MAY BE THROBBING, MIGRAINEOUS QUALITY.
 NONSTEROIDAL ANTIINFLAMMATORY DRUG AND TRYPTANS ARE HELPFUL.
 NAUSEA:
 MAYBE ASSOCIATED WITH HEADACHE OR ALONE.
 ONDENSETRON ARE HELPFUL.

38. ETHICAL ISSUE
 THE UNION HEALTH MINISTRY OF INDIA HAS DECIDED IN THE MENTAL HEALTH CARE BILL
OF 2010 THAT THEY WILL SCRAP DIRECT ECT.
 THE HEALTH MINISTRY RECOMMENDED A BAN ON THE WHOLE PROCEDURE.
 THE WORLD HEALTH ORGANIZATION, IN ITS 2005 PUBLICATION “HUMAN RIGHTS AND
LEGISLATION WHO RESOURCE BOOK ON MENTAL HEALTH,” SPECIFICALLY STATES, “ECT
SHOULD BE ADMINISTERED ONLY AFTER OBTAINING INFORMED CONSENT.”
PUBLIC OPINION
 THE APA ECT TASKFORCE GUIDELINES REPORT FINDINGS THAT PUBLIC OPINION VARIES
GREATLY ABOUT ECT USE BUT MOSTLY THE GENERAL OPINION IS ON THE NEGATIVE SIDE.

39. PATIENT EXPERIENCE
NICE ECT GUIDELINES REPORT THAT SOME INDIVIDUALS CONSIDER ECT TO HAVE BEEN A
BENEFICIAL AND LIFESAVING TREATMENT, WHILE OTHERS REPORTED FEELINGS OF TERROR,
SHAME AND DISTRESS, AND FOUND IT POSITIVELY HARMFUL AND AN ABUSIVE INVASION OF
PERSONAL AUTONOMY, ESPECIALLY WHEN ADMINISTERED WITHOUT THEIR CONSENT.
HISTORICAL ACCOUNTS
ERNEST HEMINGWAY, AMERICAN AUTHOR, COMMITTED SUICIDE SHORTLY AFTER ECT AT THE
MAYO CLINIC IN 1961. HE IS REPORTED TO HAVE SAID TO HIS BIOGRAPHER,
"WELL, WHAT IS THE SENSE OF RUINING MY HEAD AND ERASING MY MEMORY, WHICH IS MY
CAPITAL, AND PUTTING ME OUT OF BUSINESS? IT WAS A BRILLIANT CURE BUT WE LOST THE
PATIENT...."

40. • A QUESTIONNAIRE SURVEY OF 379 MEMBERS OF THE GENERAL PUBLIC IN AUSTRALIA
INDICATED THAT MORE THAN 60% OF RESPONDENTS HAD SOME KNOWLEDGE ABOUT THE
MAIN ASPECTS OF ECT.
• PARTICIPANTS WERE GENERALLY OPPOSED TO THE USE OF ECT ON DEPRESSED INDIVIDUALS
WITH PSYCHO-SOCIAL ISSUES, ON CHILDREN, AND ON INVOLUNTARY PATIENTS.
• PUBLIC PERCEPTIONS OF ECT WERE FOUND TO BE MAINLY NEGATIVE.
FICTIONAL EXAMPLES
ELECTROCONVULSIVE THERAPY HAS BEEN DEPICTED IN FICTION AND WORKS BASED ON TRUE
EXPERIENCES.
 THESE INCLUDE
 A CLOCKWORK ORANGE
 REQUIEM FOR A DREAM
 A BEAUTIFUL MIND
 ONE FLEW OVER THE CUCKOO'S NEST.

41. WITH THE PUBLIC RAISING THEIR VOICES AGAINST ECT, MOVIES & CONTEMPORARY
LITERATURES HIGHLIGHTING THE NEGATIVE ASPECTS OF ECT AND CONSIDERING THE ADVERSE
EFFECTS, THE QUESTION RISES
SHOULD WE CONTINUE USING ELETROCONVULSIVE THERAPY ?
HOWEVER, TO THOUSANDS OF DRUG RESISTANT CASES OF MENTALLY ILL PATIENTS WHO HAVE
BEEN SHOWN THE LIGHT TO MENTAL WELLBEING, ECT SEEMS LIKE A BOON.
HENCE, THE VALIDITY OF ELECTROCONVULSIVE THERAPY STILL REMAINS A TOPIC OF DEBATE .

42. THANK YOU