Electroconvulsive Therapy

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Electroconvulsive Therapy

• Harold McGrath MD,
• Chairman of Psychiatry
• Christ\Advocate Medical Center

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History 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.
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Cerletti 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

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Electroconvulsive Therapy

• Ugo Cerletti had seen electroshock used to
  anesthetize pigs before being butchered

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Early 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

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Early 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.

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Major 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.

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Major 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

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ECT Basics
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Brief 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)
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ECT 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)

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ECT 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)

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ECT 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)

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ECT 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.

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BL-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.
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Risk 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

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Tonic phase of seizure
Clonic phase of seizure
Postictal Suppression
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What 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

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Mechanism 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

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Cognitive 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

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Determinants 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

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Adverse Effects

• Mortality rate 2 in 100000 patients (less than
  0.002)
• Sore Muscles
• Headache
• Short term cognitive impairment

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ECT 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.

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Bilateral ECT Right Unilateral ECT
Orange and yellow areas show increased blood flow
during ECT
Blumenfeld and Ostroff (2000)
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Bifrontal ECT
Red color - increased blood flow following
bilateral ECT
Blumenfeld, Ostroff, et al., 2003
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Blood 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
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Summary

• 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