Dr.faisal Electro Convulsive Therapy

8/12/2019 Dr.faisal Electro Convulsive Therapy

1/29

Electro Convulsive Therapy

(ECT)


2/29

Introduction

Recent resurgence in past decade

Excellent safety profile

Superior Efficacy

Economic benefits Less stigmatization


3/29

History

Early Theories

Theory of Biological Antagonism

Insulin Shock Therapy

Electrically induced seizures Improvements in Anesthesiology


4/29

Early Theories

Hippocrates: Documented the cure of insane patientfollowing malaria-induced seizures.

Swiss physician Paracelsus in 1500s,induced

seizures with oral camphor to treat mania andpsychosis.


5/29

Biological Antagonism Theory

Hungarian physician Meduna in 1934reported aninherent biological antagonism betweenschizophrenia and epilepsy.

He reported beneficial effects of seizures induced bycamphor in catatonic patient.


6/29

Insulin Shock Therapy

Manfred Sakel, a Viennese physician in 1920s.

He documented insulin therapy for schizophrenia.

Insulin was administered in patients to induce a

hypoglycemic state.


7/29

Electrically induced Seizures

In 1937, Italian physicians Cerletti & Bini appliedelectricity to head to induce therapeutic seizures.

First patient had catatonia and he improved.

Safer than chemically induced seizures.

Widespread acceptance through out Europe andUSA.


8/29

Improvements in Anesthesiology

Early period complications like bone fractures andpatient discomfort.

Use of Curare, as muscle relaxant, by Bennett in

1940allowed complete paralysis of patient duringseizure.

Development of short acting IVbarbituratesin1950sallowed rapid induction of sedation and

amnesia surrounding procedure.


9/29

Mechanism of Action

Psychodynamic theories

Placebo effects

Memory Eraser

Seizure as curative agent

Biochemical changes

Therapeutic effects of rise in seizure threshold

Hippocampal Neurogenesis


10/29

Psychodynamic Theories

The beneficial effect of ECT is to its fulfillment of theneed for punishmentin the self loathing, depressedpatient.


11/29

Placebo Effect

The beneficial effects are due to wishful thinking onthe part of the staff and the patient


12/29

Memory Eraser

Beneficial effects of ECT are related to its ability todisturb recent memory, thereby erasing the recall ofrecent traumas, that led to depressive episode.


13/29

Seizure, as Curative event

ECT is ineffective when seizure is sub-threshold orpharmacologically blocked.

Having a generalized seizure, is crucial to

antidepressant effect of ECT.


14/29

Biochemical Theory

Variety of biochemical changes in neurotransmitters,that are also implicated in the therapeutic effect ofantidepressant medications.

Serotonin, Norepinephrine Alteration in concentration or up-regulation of their

receptors.


15/29

Rise in seizure threshold

The chemical changes responsible for terminatingthe generalized seizure may play larger role in ECTeffect.

These chemical changes lead to gradual rise in theseizure threshold over a course of ECT.


16/29

Hippocampal Neurogenesis

Some neuroimaging studies have shown reducedhippocampal volumesin depressed patients.

Increased brain derived neurotrophic factor (BDNF)levels in hippocampus.

Increased mossy fiber sprouting and andneurogenesis in the hippocampus


17/29

Indications for ECT

Major depression, particularly with psychoticfeatures.

Bipolar illness (depressed, manic and mixed states)

Schizophrenia (acute exacerbations) Catatonia


18/29

Other indications

Parkinsonism

Status epilepticus

Neuroleptic Malignant syndrome


19/29

Indications in Depression

Medication failure

Medically ill, where antidepressants are precluded(arrhythmias)

Delusionally depressed Previous ECT responders

Requesting ECT


20/29

Contraindications

Absolute None

Relative Cardiovascular(Coronary artery disease, HTN, aneurysms,

arrhythmias) Cerebrovascular effects(Recent strokes, space occupying

lesions, aneurysms)

Other conditions like Pregnancyand high anesthesia risk


21/29

Pretreatment Evaluation

Complete medical and psychiatric history.

Physical examination

CBC

Electrolytes EKG

CXR


22/29

Informed Consent

Fully explain the risks and benefits of procedure andanswer questions from patients or their relatives.

Videotapes

Information sheets Reduce patients anxiety and help establish good

patient-doctor relationship


23/29

Concurrent medications

Psychotropic medications are discontinued during acourse of ECT to avoid interactions.

Early morning hours

NPO for 6-8 hours prior to ECT


24/29

Antidepressants

TCAs and MAOIsare discontinued to minimizepossible CVS complications.

Newer generation SSRIs may be safer during ECT.

Lithiummay cause delirium when co-administeredwith ECT.


25/29

Anticonvulsants

They are not contraindicated but raise the electricalstimulus necessary to induce seizure.

For patients with pre-existing seizure disorder, it is

safe to continue anticonvulsants and simply use ahigher intensity stimulus.


26/29

Benzodiazipines

Usually withheld because they raise the seizurethreshold and may increase the degree of post-ictalconfusion particularly in the elderly patient.

Pre-ECT anxiety or insomnia may be managed byBenadryl or low dose neuroleptic.


27/29

Use of Anesthesia

Rapid induction with Amnesia Methohexitol, 0.5-1 mg/kg, agent of choice, rapid onset

and short duration of action, little impact on seizurethreshold.

Propofol, 0.5-2mg/kg, it raises the seizure threshold.

Prevention of injury from seizure Succinylcholine, the most commonly used agent today.

Attenuation of sympathetic response Beta blocker like labetolol 10-20 mg IV, prior to

induction.


28/29


29/29

Complications

Mortality 1-3/10,000

Majority of ECT related deaths are due to cardiovascularcomplications.

Cognitive complications Post-treatment confusion:A brief (15-30 minutes) period of

confusion immediately following treatment is seen in 10%.

Delirium:Seen in elderly, with pre-existing dementia, withneurological impairment and with bilaterally applied ECT

Memory loss:Associated with anterograde (returns to baseline 2-6

months post-ECT) and retrograde amnesia

Documents

Dr.faisal Electro Convulsive Therapy