Electroconvulsive Therapy ECT

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Electroconvulsive Therapy(ECT)

• Indications and Procedures

Paco Aguilar, MSIII July 26, 2000
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A History of ECT isA History of Modern
Psychiatry

• Late 19th to Early 20thCentury Nosology
• Neurosyphilis (dementia paralytica)
• Dementia praecox (schizophrenia)
• Manic-depressive insanity
• Late 19th to Early 20thCentury Treatments
• No effective treatments

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Early Treatments

• Seclusion in large state supported hospitals
• Chains, restraining chairs, cold and hot baths
• Sedate
• Experimental interventions
• Infectious Theories Treatment was removal of
  teeth, tonsils, gall bladder, and large intestine
• Eugenic Theories Treatment was surgical
  removal of sexual organs salpingectomy and
  vasectomy
• In 1907, state lawmakers in Indiana made
  mandatory the sterilization of criminals,
  idiots, imbeciles and rapists
• By 1940, 30 US states had sterilized more than
  18,000 people

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Early Neurosyphilis TreatmentExample of early
linking of clinical observations with a putative
illness theory and treatment

• Chronic and progressive syphilis has no fever
• Professor Wagner-Jauregg of Vienna
• Transfused blood of malarial seamen to 9
  neurosyphilitic men
• Three of the patients recovered, three improved,
  three showed no change

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Early Convulsive Therapy

• Observed Clinical Pattern Patients with
  dementia praecox who developed epileptic seizures
  after a head injury or after encephalitis were
  occasionally had notable symptomatic improvement

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Dr. Ladislas Meduna (1930s)Hungarian
Neuropathologist

• Observed postmortem that patients with dementia
  praecox had fewer than normal neuroglia
• Observed postmortem that epileptic patients had
  more neuroglia than normal
• Question Can induced cortical seizures help
  patients with dementia praecox, perhaps related
  to an increase in neuroglia?

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First Patient Treated Zoltan

• 33 year old psychotic mute who had been withdrawn
  for four years catatonic and required a feeding
  tube
• January 23, 1934
• Dr. Meduna injected camphor in oil IM (known to
  cause non-lethal seizure in animals)
• After 45 minutes (typical 15-60 minute lag time),
  Zoltan had a 60 second seizure

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Dr. Ladislas Medunas journal entry a few weeks
later
Two days after the fifth injection, on February
10 in the morning, for the first time in four
years, he got out of his bed, began to talk,
requested breakfast, dressed himself without
help, was interested in everything around him,
and asked about his disease and how long he had
been in the hospital. When we told him he spent
4 years in the hospital he did not believe it.
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Metrazol

• Alternative to camphor in oil
• Produces seizures within minutes
• Patients thoughts begin to race
• Patients hears beats more rapidly
• Patient experiences feeling of terror and
  impending doom
• This is not pleasant

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Alternative to Metrazol - Electricity

• 39 year old patient suffering from a manic and
  psychotic episode admitted to University Hospital
  in Rome
• Prior success with Metrazol
• April 11, 1938
• Drs. Ugo Cerletti and Luigi Bini
• By 1940 electroconvulsive treatment (ECT) was as
  popular as Metrozol

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Early versions of ECT

• Why Negative Image?
• No informed consent
• Against wishes
• No muscle relaxant
• No sedative
• Excessive dose of electricity

One Flew Over the Cuckoos Nest by Ken Kesey
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Modern ECT

• Informed Consent
• Patient is Sedated
• Patient has Oxygen
• Patient has muscle relaxant to prevent fractures
• Patient had dentures removed and a bite block
  to prevent tongue biting
• Patient is monitored by the anesthesiologist
• Least amount of electricity of used (1/7 to shock
  a patient in cardiac arrest)

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What occurs during ECT?

• Physician induces and epileptic seizure in the
  brain using electricity. While making sure the
  patient is sedated, lungs are filled with oxygen,
  muscles are relaxed, and the physical functions
  are monitored.

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Diagnostic Indications for ECT

• Major Depressive Episode
• Bipolar Disorder, Depressed
• Bipolar Disorder, Mania
• Schizophrenia - Catatonic subtype
• Schizoaffective Disorder
• Delirium

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Diagnoses in Which ECT Is Considered Ineffective
Dementia and Amnestic Disorders Substance-related
Disorders Anxiety and Somatiform
Disorders Factitious Disorders Dissociative
Disorders Sexual Dysfunctions Sleep
Disorders Impulse Disorders Adjustment
Disorders Personality Disorders
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ECT is Treatment of Choice for

• Actively suicidal depressed patients who may not
  live until anti-depressants work
• Depressed patients (particularly the elderly)
  whose medical condition makes administration of
  antidepressants risky.
• Seriously depressed patients who have had an
  adequate trial of antidepressants

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Contraindications

• Very High Risk
• ? intracranial pressure (brain tumor, infection)
• Recent MI
• (Vagal arrhythmias producing postictal PVCs and
  extravagal arrhythmias producing PVCs anytime
  during the procedure)
• Moderate Risk
• Severe osteoarthritis, osteoporosis
• Retinal detachment
• CV disease (HTN, Angina)
• Recent CVA
• Pheochromocytoma

No absolute contraindications for use.
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Typical Procedure

• Prepare patient
• NPO after midnight, discontinue meds
• Patients vital signs are monitored throughout
  ECT
• Atropine premedication (to decrease gastric
  secretions)
• Provide 100 O2 (to prevent hypoxia)
• Give methohexital (Brevital) (barbiturate
  anesthetic)
• Give succinylcholine (Anectine) (short acting
  paralytic)
• Give electroconvulsive stimulus
• Unilateral (less memory loss) or Bilateral (more
  effective)
• Monitor patient until stable (15-30 min)
• Provide diazepam (Valium) for agitation

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Side effects of ECT

• Amnesia (retrograde and anterograde)
• Variable after 3-4 treatments
• Lasting 2-3 months
• Headache, muscle aches, nausea
• Dizziness, confusion

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Side effects of ECT medications

• Anesthesia risks
• Atropine ? worsens narrow angle glaucoma
• Succinylcholine ? prolonged by pseudocholinesteras
  e deficiency states
• Class 1A and 1B anti-arrhythmics can potentiate
  succinylcholine
• Methohexital can precipitate an attack of acute
  intermittent porphyria

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How does ECT work?

• No one really knows.
• Perhaps related to elevated neurotransmitters in
  CNS
• Clearly true
• Seizures must be repeated 2 3 times per week
• A single seizure is not useful
• Full treatment must be done (typically 10 - 12
  sessions)
• Relapse is possible

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Points to counter ECT stigma

• Effective
• Painless
• Rapidly Acting
• Low Mortality Rate (0.01 - 0.03)
• Usually due to CV deaths related to anesthesia

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Thank You