Electroconvulsive Therapy

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Electroconvulsive Therapy

• Brian E. Wood, D.O.
• Associate Professor and Chair,
• Department of Neuropsychiatry and Behavioral
  Sciences
• Edward Via Virginia College of Osteopathic
  Medicine
• Associate Professor of Clinical Psychiatric
  Medicine
• University of Virginia School of Medicine
• Department of Psychiatric Medicine
• brwood6_at_vcom.vt.edu

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What is Electroconvulsive Therapy?

• The passing of electrical energy through the
  brain under clinically controlled circumstances,
  thus producing a controlled seizure for
  therapeutic purposes.
• The oldest surviving biological treatment in
  psychiatry.
• Interestingly, probably one of the most
  efficacious but misunderstood treatments in
  psychiatry.

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History of ECT

• Use of convulsions to treat schizophrenia was
  proposed in the early 1930s by Ladislas Von
  Meduna (1896 1964) a Hungarian physician and
  researcher who performed most of his work at the
  University of Budapest.
• In the 1920s several researchers had noted that
  epileptic patients who developed schizophrenia
  had marked decrease in frequency of seizures thus
  postulating an antagonistic effect of
  schizophrenia on epilepsy.
• Von Meduna was very interested in these studies
  but proposed the converse hypotheesis.

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History of ECT

• Historical accounts of inducing seizures by use
  of camphor and therapeutic benefits in the
  treatment of psychiatric disorders.
• Use of camphor was documented by early alchemists
  to cure lunacy.
• Von Meduna ultimately achieved a 40 50 success
  rate in treatment of patients with Dementia
  Praecox
• Insulin Coma therapy was developed around the
  same time by Sackel and lobotomy was also being
  utilized and studied by Walter Freeman.

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History of ECT

• Other researchers hypothesized that electricity,
  now becoming widely available, could be used in a
  more controlled and easier way to induce
  seizures. Modern use of electricity to induce
  seizures for therapeutic purposes dates from 1938
  when two Italian physicians induced seizures in a
  39 y/o male patient diagnosed with Schizophrenia.
• Several aborted attempts at ECT were made and
  after one subconvulsive stimulus, the team
  discussed whether to administer another. The man
  reportedly responded not again its murderous!

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History of ECT

• ECT was initially administered without anesthesia
  or muscular paralysis (unmodified)
• Most induction anesthetic agents were longer
  acting and less predictable than today.
• Tolerability was significantly improved with the
  routine use of general anesthesia and
  neuromuscular blockade. Many ECTs were performed
  from the 1940s until the late 1950s when
  antipsychotic and later antidepressant drugs
  became available.

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As ECT Develops

• In the 1950s the chlorpromazine revolution.
• More availability of well tolerated drugs
  initially decreased prevalence of ECT however,
  clinicians began to differentiate response to
  available therapies.
• Since the 1960s the use of ECT has continued to
  rise.

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Modern ECT

• Present day ECT is a safe effective procedure
  with relatively few side effects
• Efficacy for depression is higher than drugs and
  onset of action is shorter.
• The patient is anesthesitized with a short acting
  induction agent and paralysed with succinyl
  choline.
• There is usually an amnestic period surrounding
  the actual treatment but persistent memory
  impairment is rare.

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Modern ECT

• Pt. Is monitored throughout procedure with EEG,
  EKG, EMG, Pulse oximeter, etc.
• Usual duration of seizure is 30 to 60 seconds for
  established efficacy.
• Patient is recovered per anesthesia protocol.
• Most procedures are done in the hospital in OR or
  recovery settings although many are done as
  outpatient procedures.

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The ECT Procedure

• Bilateral ECT
• Electrodes are placed bitemporally and
  electricity is passed through both hemispheres of
  the brain simultaneously
• Associated with greater efficacy
• Unilateral ECT
• Electrodes are placed at the vertex and near the
  non-dominant temple (right). Electricity is
  passed through the nondominant hemisphere with
  generalization to both hemispheres.
• Associated with less memory disturbance.

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The ECT Procedure

• Electricity is administered with several variable
  parameters
• Wave form
• Sine wave- originial studies
• Brief pulse square wave used in all modern
  treatments.
• Frequency
• Stimulus duration
• Goal is to provide a threshold stimulus (to
  induce seizure) without excess dose.
• Dosing is primarily dependent on patients
  individual CNS characteristics, skull thickness,
  body water composition and age.

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Physiology of ECT

• Known to affect multiple neurotransmitter systems
  in the brain.
• Catecholamine surge theory
• Differential recovery theory
• Distinct mechanism of action remains unknown.

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Applications of ECT

• Depression
• Severe
• With psychotic symptoms
• With catatonia
• Primary psychotic disorders with catatonia
• Acute mania

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Contraindications of ECT

• Almost all are relative contraindications
• Only absolute contraindication is increased
  intracranial pressure.
• Usually not performed with space occupying CNS
  lesions.
• Relatively contraindicated with recent MI because
  of increased risk of ventricular rupture.

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Side effects of ECT

• Most important is memory loss.
• Usually only amnestic for time period around
  treatment.
• Amestic period typically widens with successive
  treatments and can be worse with preexisting
  cognitive disorders
• Muscle soreness or tension usually due to
  incomplete neuromuscular blockade.
• Fractures or dental complications are relatively
  rare but still do occur.

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Potential Benefits of ECT

• Rapid response.
• Greater efficacy (particularly in some
  populations and syndromes)
• May increase efficacy of other treatments.
• May be used in patients that cannot tolerate
  other antidepressant treatments.

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Advantages in the Elderly?

• Patients are often more physically fragile with
  higher morbidity associated with depression.
• Increased risk of medication intolerance or side
  effects.
• ? Higher rates of psychotic symptoms associated
  with mood disorders in the elderly
• ? Differential response in the elderly

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The Future of ECT

• Probable continuation of focus on safety and
  minimization of cognitive side effects
• Increasing focus on economics of healthcare.
• Possible future for non-convulsive techniques
  such as TMS but may be fading.

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TMS

• Magnetic impulses that produce electrical
  conductivity in the brain.
• When administered at sub threshold non-convulsive
  levels (lt1 Hz) is termed TMS.
• Equivocal findings re efficacy in depression
• Probably not near the efficacy of ECT.
• Does not require anesthesia so may be used in
  patients with general anesthesia risks.

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Summary

• Modern ECT is an effective and safe procedure
  when applied to appropriate patients and has some
  advantages over pharmaceutical agents.
• There are relatively few contraindications to ECT
  when carefully observed and monitored.
• Alternative therapies such as TMS may prove to be
  an alternative to ECT in some patients in the
  future.
• ECT has remained and probably will remain an
  important tool in the psychiatric armamentarium.