ELECTROCONVULSIVE THERAPY

ELECTROCONVULSIVE THERAPY

Jon Lehrmann MDAssistant Professor of PsychiatryMedical College of WIVAMC Milwaukee, WI

Mental Health Care Pre-1930’s

History of ECT

• Von Meduna (1934)- Autopsies of patients w/ Seizure disorders and of patients w/ Schizophrenia.

• Difference in Glial cell proliferation

Chemically induced seizures- (camphor, pentylenetetrazol)

Insulin Shock Therapy

• In the 1930’s , Dr Sakel developed Insulin Shock Therapy

Cerletti and Bini (1934): Electricity

Initially done without muscle blocker or anesthetic

Early ECT

• Assylums

• Few effective medications

• Many often severe side effects

• 1950’s- ether, and curare extract developed (Abram Bennett- a psychiatrist helped develop a method for extracting curare).

• In 1950’s antidepressant and antipsychotic meds introduced- significantly decreased utilization of ECT

Electrophysiological Principles

• Ohm’s Law: I=E/R (I=current, E=voltage, and R=resistance)

• Dose of electricity in ECT= 100-500 milliCoulombs

• Brain has low impedance (resistance), skull has very high impedance. Only 20% of applied charge actually enters the brain.

• Seizure involves propagation of action potentials in a large percentage of neurons.

Mechanism of Action

• Neurotransmitter levels all increased in CSF after seizure. Results in down regulation of Beta adrenergic receptors.

• During seizure- PET studies show an increase in BBB permeability and in cerebral blood flow and metabolism.

• After seizure, blood flow and metabolism is decreased especially in the frontal lobes. Research shows this correlated w/ response.

Indications

• Major Depression w/ or w/o psychotic features

• Bipolar disorder - manic or depressed phase

• Acute or Catatonic Schizophrenia

• Some studies have shown efficacy in treating OCD, Delirium, NMS, Chronic pain syndromes, and intractable seizure disorders

Major Depression

• Efficacy vs antidepressants

• When is it a first line treatment consideration?

• Length of Antidepressant effect

• Maintenance ECT

Bipolar Mania

• Efficacy vs Lithium• Indications for First Line Treatment:• -Recent Myocardial Infarction w/ Acute Mania• -Pregnancy w/ Acute mania

Pre ECT Workup

• Physical Exam

• Head CT

• CXR

• CBC, Basic Chem

• EKG

• ? Spinal Films

Contraindications?

• No Absolute Contraindications

• Relative Contraindications: Recent MI, Berry Aneurysm, Brain Mass, Increased Intracranial Pressure

Treatments

• Premedicate w/ Glycopyrrolate, consider short acting Beta blocker

• Patient not intubated

• Bite block

• Cuff leg to monitor sz

• EEG and EMG

• Length of sz- 20 sec to 1 min.

Number and Spacing of ECT

• 2-3x/wk- efficacy vs less memory impairment

• 5-12 sessions/ treatment (although up to 20 is possible)

• Point of maximum improvement- no more improvement after 2 further treatments.

Adverse Effects

• Mortality rate: .002% per treatment session, .01% per patient.

• Sore Muscles

• Head ache

• Short term confusion/ delirium

• Memory

Transcranial Magnetic Stimulation (TMS)

• Rt Frontal lobe- TMS pulses suppress activity and causes happiness and increased energy

• Left Frontal lobe- TMS pulses suppress activity and leads to sadness

• 4/250 had seizure• 10Hz stimulation 20x/day, 11/17 patients w/

Major Depression showed significant improvement.

TMS continued

• So far positive effects have not lasted as long as positive effects from ECT

• Handful of case reports show efficacy w/ anxiety disorders.