Title: Electroconvulsive Therapy
1Electroconvulsive Therapy
- Harold McGrath MD,
- Chairman of Psychiatry
- Christ\Advocate Medical Center
2History of ECT
Hippocrates saw that insane patients
showed reduced symptoms after
suffering from convulsions brought on by
malaria.
There is an account in ad 47, of a
physician using an electric eel to cure
migrane headaches of the Roman Emperor
Claudius.
3Cerletti and Bini (1934)
- Ugo Cerletti, M.D., inspired by the successful
biological treatments, decided to induce
convulsions by applying electricity directly to
the brain. -
- Cerletti and his assistant Lucio Bini selected
patients with schizophrenia for their trials and
enjoyed a record of success
4Electroconvulsive Therapy
- Ugo Cerletti had seen electroshock used to
anesthetize pigs before being butchered
5Early ECT Techniques
- Initially the treatment was done without muscle
blocker or anesthetic - Many, often severe side effects of treatment
including bone fractures and ruptured tendons
6Early ECT
- In 1940, curare was introduced to prevent
vertebrae-cracking force of the seizures - Succinylcholine was introduced in 1952.
- In the early 1940s, it became customary to
anaesthetize patients with barbiturate
injections. - In 1949, Goldman introduced unilateral ECT,
placing the electrode over the right hemisphere
in order to avoid the speech areas.
7Major Advances in ECT Since 1938
- Up to 40 percent of patients suffered from
various complications, the most common being
vertebral compression fractures. With present
techniques, these risks have been virtually
eliminated. - In one recent study of almost 25,000 treatments,
a complication rate of 1 per 1,300 to 1,400
treatments was found. - These included laryngospasm, circulatory
insufficiency, tooth damage, vertebral
compression fractures, status epilepticus,
peripheral nerve palsy, skin burns, and prolonged
apnea.
8Major Advances in ECT Since 1938
- The introduction of modern anesthesia including
neuromuscular blocking agents - The development of the pulse wave machine which
allowed for careful energy dosing and
determination of seizure threshold - The advances in lead placement which maintained
efficacy and reduced side-effects - The appreciation of the importance of seizure
morphology not seizure duration as a determinant
of efficacy
9ECT Basics
10Brief Pulse Stimulus Parameters
Frequency (Hz)
Pulse width (ms)
Pulse pairs per second
Peak current (amperes)
Duration (seconds)
Charge pulse width x twice frequency x duration
x peak current (in millicoulombus) Energy
charge x peak current x dynamic impedance / 1000
(in Joules)
11ECT Indications
- Major Depression with or without psychotic
features - Bipolar disorder - manic or depressed phase
- Catatonic schizophrenia
- Some studies have shown efficacy in treating OCD,
delirium, NMS, chronic pain syndromes, and
intractable seizure disorders - Parkinsons Disease (bradykinesia, tremor,
rigidity, gait disturbance, postural instability)
12ECT in late-life Depression
- Electroconvulsive Therapy (ECT) has a special
role in the treatment of late-life depression and
other psychiatric conditions in the elderly. - A national survey of inpatients psychiatric
facilities conducted by the National Institute of
Mental Health (NIMH) indicated that patients aged
61 and older comprised the largest age group
receiving ECT - (Thompson and Blaine, 1987)
13ECT in late-life Depression
- 15.6 of inpatients with mood disorders received
ECT if they were 65 years of age or older, while
the rate was only 3.4 among younger inpatients
with mood disorder.. - ECT is believed to present less medical risk,
making its use particularly likely in elderly
and medically compromised patients - (OConnor et al., 2001)
14ECT in late-life Depression
- It is highly doubtful that any pharmacological
strategy produces as rapid symptomatic
improvement as ECT. - (Nobler et al., 1997 Sackeim et al., 1995
Segman et al., 1995) -
- In the Unites States, a schedule of three
treatment per week is standard, and the typical
ECT course requires eight or nine treatments to
achieve full response.
15BL-ECT vs. RUL-ECT
- At this time no patient should be considered ECT
resistant unless he or she has not benefited from
a course of either higher dosage RUL (right
unilateral ECT or BL-ECT - In the case of RUL-ECT, this is defined as
treatment at least six times the seizure
threshold. In the case of BL-ECT, it is defined
as treatment that is administered at 2.5 times
the seizure threshold.
Sackeim HA et al (2000). A prospective,
randomized, double-blind comparison of bilateral
and right unilateral electroconvulsivetherapy at
different stimulus intensities. Arch Gen
Psychiatry 57 425-434.
16Risk Factors
- There are no absolute contraindications to ECT
- Risk/Benefit ratio is the important factor
- Ineffectively treated depression has a high
mortality rate. This should be weighed when
considering any treatment for the disorder
including ECT
17Tonic phase of seizure
Clonic phase of seizure
Postictal Suppression
18What Happens During The ECT?
- Electrical Stimulation
- Centrally mediated vagal discharge
bradycardia/asystole - Grand mal convulsion (20-40 sec)
- Peripherally mediated vagal discharge -
bradycardia - Fall in blood pressure
- Tachycardia
- Rise in blood pressure, CSF pressure
- Minor arrhythmias increased parasympathetic tone
- atrial arrhythmias. increased sympathetic tone
- PVC, SVT
19Mechanism of Action
- Increase in blood flow in frontal lobes
- Electron microscope studies on monkeys showed
curling of microfibrille - Increase in GABA in CNS following ECT
- Evidence of up-regulation of specific mu-opiate
binding sites in CNS - Generalized seizure to diencephalon is essential
- Postictal prolactin rise correlates with efficacy
20Cognitive Impairment
- Retrograde amnesia - for events nearest time of
treatment - Anterorade amnesia up to 6 months post-treatment
in some studies - Greatest with bilateral
- Greatest with sine wave
- Interictal delirium
- greatest in elderly
- reduced by decreasing frequency, and unilateral
electrode placement
21Determinants of Post-ECT Confusion
- Age of patient
- Electrode placement
- Stimulus dose
- Length of seizure
- Adequacy of oxygenation
- History of substance abuse-regardless of
remission time
22Adverse Effects
- Mortality rate 2 in 100000 patients (less than
0.002) - Sore Muscles
- Headache
- Short term cognitive impairment
23ECT Cognitive Side Effects
- The severity and persistence of these acute
effects are exquisitely sensitive to technical
factors in ECT administration (electrode
placement, oxygenation, anesthesia used) - These factors determine, whether patients on
average require a few minutes to achieve full
reorientation following seizure elicitation or
several hours.
24Bilateral ECT Right Unilateral ECT
Orange and yellow areas show increased blood flow
during ECT
Blumenfeld and Ostroff (2000)
25Bifrontal ECT
Red color - increased blood flow following
bilateral ECT
Blumenfeld, Ostroff, et al., 2003
26Blood flow in Bifrontal vs Bitemporal ECT
Yellow shows area where blood flow is higher with
BF ECT, blue shows area where blood flow higher
with BT leads
Blumenfeld H, McNally KA, Ostroff RB, et al.
Targeted prefrontal cortical activation with
bifrontal ECT. Psychiatry Res. 2003
27Summary
- ECT is relatively safe and effective procedure
- In most of the cases works faster than
psychopharmacology and psychotherapy - ECT is effective in treatment resistant
depressions