At the end of this lecture each student should able to:

1) Define electroconvulsive therapy.

2) Discuss indications, contraindications, mechanism of
action, and side effects of electroconvulsive therapy.
3) Identify risks associated with electroconvulsive therapy.
4) Describe the nurse role before, during and after the
administration of electroconvulsive therapy.
• Electroconvulsive therapy (ECT) was the first device-based treatment to
become available for psychiatric disorders in the 1940s (Cusin, 2016, p.79).
• ECT is currently used in clinical practice; however, an accurate estimate of
the number of patients undergoing ECT in the USA is lacking (Cusin, 2016,
p.79).
• A reported study about using of ECT in 1994 found that more ECT is
performed than coronary artery bypass or appendectomy in the USA
(Thompson et al., 1994). Furthermore, meta-analysis data have indicated that
ECT may be more effective than antidepressants (Pagnin et al., 2004; Kellner
et al., 2009)
Electroconvulsive Therapy :
• Definition:
• ECT is the induction of a grand mal seizure through application of
an electric stimulus to the surface of the head “fronto- temporal area”
either unilateral or bilateral, with the aim of inducing a seizure. Thus,
when convulsions occurred, there was remission of symptoms in
patient with depression and/or psychotic behaviors.

• Treatments are performed on an inpatient basis for those who

require close observation and care (e.g., Clients who are suicidal,
agitated, delusional, catatonic, or acutely manic). While, those at less
risk may have the option of receiving therapy at an outpatient
treatment facility.
1- Indications for ECT:
ECT is a useful therapy for many psychiatric disorders, and the
number of indications for which it is used is expanding (table 1.1 )
(Saito, 2016; p. 2).
1- cont..

ECT is considered a first-line treatment according to the following

listed criteria in (Table 1.2) (Saito, 2016; p. 3).
2- Contraindications :
• ECT is contraindicated in some conditions (Saito, 2016, p.3).
• For instance, INTRACRANIAL HYPERTENSION is an absolute
contraindication.
• Other medical conditions may increase the risks of adverse events related to
ECT, for example :
1) Recent myocardial infarction.
2) Uncompensated congestive heart failure.
3) Severe valvulopathy.
4) Unstable angina.
5) Brain lesions with increased intracranial pressure.
6) History of recent stroke.
7) Severe pulmonary conditions.
8) Tumors of the oral or nasal cavity.
9) severe osteoporosis.
10) high-risk or complicated pregnancy.
3- Predictors of Response:

• Older age (above 65) and depression severity have historically been
considered predictors of good outcome, together with the presence
of melancholic features, psychotic features, and psychomotor
retardation (Cusin, 2016).
• Among the predictors of non-remission for an acute ECT trial are
chronicity of depression, longer episode duration, and very high level
of medication resistance (Prudic et al., 1996; Dombrovski et al., 2005),
while bipolar subtype, presence of manic symptoms during depression,
low level of severity of depressive symptoms, and protracted duration
of the episode were associated with lack of response in a sample of
patients with affective disorders (Perugi et al., 2012) .
4- Adverse Effects:
• Common adverse effects of ECT are usually temporary and include:
– Arrhythmias.
– Headaches.
– Muscle aches.
– Minor dental and tongue injuries.
– Nausea .
• Serious medical complications, such as myocardial infarction, stroke,
or death, are exceedingly rare, with an estimated ECT-related
mortality rate of less than 1 death per 73,440 treatments.
• The most common cognitive side effects produced by ECT is:
– Acute cognitive impairment with compromised orientation, attention,
and memory that usually lasts minutes to hours.
– Different forms of amnesia, either anterograde or retrograde.
5- Maintenance ECT:
• Continuation or maintenance ECT is often provided as a strategy for post-ECT relapse
prevention.
• Relapse rates as high as 64–84 % have been reported in controlled studies,
predominantly occurring within the first 6 months after a successful treatment course
(Sackeim et al., 2001).
• The treatment is administered two to three times per week, and the patient
requires an escort, due to driving restrictions after the treatment (Cusin and
Dougherty, 2012).
• According to the condition of case & the response to therapy most clients require an
average of 6 to 10 treatment but but some may require up to 20 treatments.
• Treatments are usually administered every other day, 3 times per week.
• The course should not be excess than 25 times.
• The voltage:
– The volts used 70-125 volts.
• Duration:
– 0.7 to 1.5 second.
• The duration of the seizure should be at least 15 to 25 seconds.
 6- Mechanisms of Action of ECT:

• A number of researchers have demonstrated that electric stimulation

results in significant increases in the circulating levels of several
neurotransmitters.
• These neurotransmitters include serotonin, norepinephrine, and
dopamine the same biogenic amines that are affected by antidepressant
drugs.
• Theory holds that the electric shock produces minimal brain damage,
which destroys the specific area containing memories related to the
events surrounding the development of the psychotic condition.
6.1: PHYSIOLOGIC RESPONSES TO ECT:
• An electrical current applied to the brain via transcutaneous
electrodes induces a systemic tonic-clonic seizure, usually comprising
a tonic phase lasting 10–15 s and a tonic phase for 30–60 s.
• During the tonic phase, the parasympathetic nervous system is
activated, resulting in bradycardia and hypotension.
• Immediately afterwards, the clonic phase activates the sympathetic
nervous system, resulting in tachycardia and hypertension.
• Although changes that appear similar to myocardial ischemia on
electrocardiogram occur immediately after electrical stimulus, cardiac
enzyme levels usually do not increase.
• Electrical stimulus and subsequent seizure increase both cerebral
blood flow and cerebral metabolism, leading to intracranial
hypertension.
• Intraocular pressure and gastric pressure also increase after mECT.
7- Clinical Application of ECT:
7.1- ECT Technique:
• Before ECT:
– a general anesthetic is administered to the patient together with a short-
acting muscle-paralyzing agent in order to prevent injuries.
– Hyperventilation is generally obtained via bag valve mask prior to the
administration of the stimulus.
– patient’s vital signs are closely monitored throughout the procedure.
– titrating parameters of the electric stimulus The sites of application of the
stimulus can be bilateral (BL), right unilateral (RUL), or bifrontal (Fig. 1.1 ).
• The EEG recorded during the seizure usually presents patterned
sequences consisting of high-voltage sharp waves and spikes, followed by
rhythmic slow waves that in most cases end abruptly.
• Regarding the schedule of administration, there is no consensus
worldwide on this issue, with two treatments per week recommended in
some countries (e.g., the UK), while ECT is usually given three times per
week in the USA and Australia.
PHASES OF THE CONVULSION OF ECT:
– 1.The cry phase:
– Sudden contraction of the respiratory and abdominal muscles forces air
through the larynx producing a loud sound known as “epileptic cry”.
– 2.The tonic phase:
– In this phase eyes are opened upward pupils dilated, respiration are arrested
temporarily, cyanosis at the same time muscle of the body contract and
remain in its spasm from 10-15 seconds.
– 3.The clonic phase:
– It can be noticed in the muscles of the face especially around the eye &
tremors of the hands & feet “peripheral system seizure”. There is also saliva
escaped from mouth & bleeding may be observed from the mouth due to
betting of tongue, lips or oral mucosa a there is also alternating contraction
& relaxation of the voluntary muscles it take 30-60 seconds.
– 4.The recovery phase:
– “Phase of consciousness regained” some pt sleep a few hours & some still
confused & some other are mentally alert there are variation in mental
alertness state most pt awake within 10 or 15 minutes of the treatment and
are confused & disoriented, some pts with sleep 1-2 hrs per day.
EQUIPMENTS/ARTICLES:

1. ECT machine, electrode 7.Mouth gag and tongue

2. ECG monitor depressor

3. Pulse oximeter 8.Sterile syringes and needles

4.Defibrillator 9.IV stand

5.Suction 10.Emergency drugs

6.Oxygen cylinder and AMBU 11.Kidney basin

bag 12.Electroconductive gel
7. NURSING ROLE:
A- PATIENT PREPARATION:
• Psychological Preparation:
• Education of and discussion with
patient and family. This should be
repeated as often as requested.
• Video and written information
should be offered that might be
viewed or read afterwards.
• Memory diaries can be employed
as a way of helping the individual
re-orientate themselves following
treatment.
• Physical Preparation:
• Tests need to be done to ensure
physical fitness prior to a general
anaesthetic: chest x ray, ECG, EEG,
ESR.
• Ensure the patient understands
that they need to fast for 6 hours
before general anaesthetic to
prevent regurgitation and
inhalation of undigested food
during the anaesthesia.
• Patients prescribed cardiac and
antihypertensive drugs may take
these with sips of water only.
Day of Treatment:
• Ensure that the patient has fasted.
• Property should be deposited for
safe keeping
• Loose, comfortable cloths should be
worn
• Spectacles may be worn, but not
contact lenses.
• Hair must be cleaned and dry for
optimal electrode contact. And hair
ornaments removed to prevent
contact with electrode.
• Nail varnish and makeup should be
removed to allow monitoring of
changes in color which may indicate
cardiovascular functioning.
• Measure the patient's T, P, R, & BP.
• Immediately prior to treatment, ask
the patient to visit the toilet to
empty their bladder.
Outpatient Preparation
• Patients should be encouraged to
report to day surgery of the ECT
clinic well before treatment
commences.
• Patients are advised how long they
will be in clinic and are asked to be
accompanied by a relative/ friend
and not return to an empty house.
• Patient advised to avoid alcohol or
driving for the rest of the day.
• Patient advised not to leave clinic
after treatments until fully
recovered.
SPECIAL CONSIDERATION:

vBefore starting the procedure:

1) Ensuring that informed consent has been obtained from
the client. If the client is clearly unable to consent to the
procedure, permission may be obtained from family or
other legally responsible person.
– For the consent to be deemed valid, it must include the information about
benefits and risks of the treatment, the information about alternatives to
ECT, the risks and benefits of receiving no treatment, and an assessment of
the patient’s decision-making capacity.
1) Check for supply of electricity.
2) Ensure that ECT machine in good working condition.
3) Suction is available and in working condition.
B- CARE DURING PROCEDURE:
1) The patient is accompanied from the waiting area into the ECT suite and introduced
to the member of the ECT team.
2) The patient removes foot wear and any aids this allows for the placement of blood
pressure cuff on an ankle and clear observation of the patient's extremities during the
treatment.
3) Patient is encouraged to lie on their back.
4) The treatment nurse may place cardiac monitoring leads on the patient's chest. EEG
leads may be positioned. A pulse oximeter is clipped to the patient's finger to monitor
oxygen saturation. Blood pressure monitoring throughout the treatment is
accomplished by a manual or automatic cuff.
5) The treating psychiatrist or nurse cleans areas of the patient's head with alcohol and
gel at the sites of electrode contact. The area may be wetted with saline as well. This
cleansing process facilitates optimal stimulus electrode contact during treatment. The
areas being cleaned will be either both temples, if bilateral electrode placement is to be
used, or the right temple and top of the head 1 inch to the right of the midline, if
unilateral placement is used.
6) Provide electrodes dipped in gel for placement.
(Electrodes may be placed as bilateral, unilateral or bifrontal).
7) The anaesthetist inserts a peripheral Venus line to deliver the muscle relaxant
(usually succinylcholine 0.75 mg/kg) and IV anesthesia (usually Thiopenton
Sodium).The drug is titrated to the patient's age, weight, and physical condition.
8) When the patient is sleep, the blood pressure cuff on the ankle is inflated,
allowing it to serve as a tourniquet. Because the tourniquet is in place on one
ankle, the succinylcholine is not effective in that extremity. This is a desired effect
because it is used in detecting a motor response to the seizure.
9) As muscle relaxant takes effect the anesthetist provides oxygen by mask using
positive pressure ventilation.
10) A bite block may be inserted as the patients jaw muscles are directly stimulated
by ECT and clench. The bite block should be placed with the thick rubber
portion between the upper and lower teeth, with the front rim separating the
lips and teeth.
11) The treating psychiatrist is responsible for the electrical stimulation and seizure monitoring.
12) Observe grand mal seizures.
§ Initial tonic stage lasts for 10-15 seconds,
§ followed by convulsions lasting for 25-30 seconds.
§ Then there is a phase of muscular relaxation.
13) A seizure lasting 30 – 60 seconds is generally considered adequate. A seizure longer than 120
seconds should be terminated using a benzodiazepine (such as valium) or thiopental sodium
(Pentothal) to prevent a prolonged postictal state.
14) Anesthesia staff continuously ventilates the patient with pure oxygen throughout the
procedure until the effects of the anesthetic and muscle relaxant subside and the patient is
able to breathe spontaneously.
15) Vital signs should be monitored by the nurse both before and after the ECT treatment. Once
the patient is stabilized, the anesthesiologist clears the patient for transfer to the recovery
area.
C- CARE AFTER THE PROCEDURE :
1) The patient is placed in the three quarter prone recovery position and
a clear air way maintained.
2) T, P, R, and BP are monitored every 15 minutes
3) Patients who are fully conscious and responsive to verbal commands
and willing to move should be accompanied to a quite area in the ECT
suit and given refreshment.
4) The patient should be asked if there are any unwanted effects such as
headache or nausea.
5) Night staff continue to observe the patient the night following
treatment
6) Continued monitoring and discussion of side effects is important and
may indicate a need to alter prescribed treatments.
7) As assessment of mental state between treatments is essential to
monitor improvement.
NURSING DIAGNOSIS:
– Anxiety related to impeding therapy.
– Deficit knowledge related to necessity for & side
effects or risks of ECT.
– Risk for injury related to risks associated with ECT
– Risk for aspiration related to altered level of
consciousness immediately following treatment
– Disturbed thought processes related to side effects of
temporary memory loss and confusion
– Risk for activity intolerance related to post-ECT
confusion and memory loss
SUMMARY:
REFERENCES:
UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-
analysis. Lancet. 2003;361:799–808.
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Neurotherapeutics: Contemporary Surgical and Device-Based Treatments. New York, NY: Springer New York.
Cusin, C., & Dougherty, D. D. (2012). Somatic therapies for treatment-resistant depression: ECT, TMS, VNS, DBS. Biology of mood
& anxiety disorders, 2, 14. doi:10.1186/2045-5380-2-14
Saito, S. ed., 2016. Anesthesia Management for Electroconvulsive Therapy: Practical Techniques and Physiological Background. Springer.

Thompson JW, Weiner RD, Myers CP. Use of ECT in the United States in 1975, 1980, and 1986. Am J Psychiatry. 1994;151:1657–
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Pagnin D, de Queiroz V, Pini S, Cassano GB. Efficacy of ECT in depression: a meta-analytic review. J ECT. 2004;20:13–20.
Kellner CH, Tobias KG, Jakubowski LM, Ali Z, Istafanous RM. Electroconvulsive therapy for an urgent social indication. J ECT.
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antidepressant medications and short-term clinical response to ECT. Am J Psychiatry. 1996;153(8):985–92.
Dombrovski AY, Mulsant BH, Haskett RF, Prudic J, Begley AE, Sackeim HA. Predictors of remission after electroconvulsive therapy
in unipolar major depression. J Clin Psychiatry. 2005;66(8):1043–9.
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Sackeim HA, Haskett RF, Mulsant BH, Thase ME, Mann JJ, Pettinati HM, Greenberg RM, Crowe RR, Cooper TB, Prudic J.
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Cusin, C., & Dougherty, D. D. (2012). Somatic therapies for treatment-resistant depression: ECT, TMS, VNS, DBS. Biology of mood
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