Clinical Psychiatry

Electroconvulsive therapy (ECT) ‫هالة رعد‬.‫د‬

‫نفسية عملي‬
Indications for ECT:
✓ In severe depressive illness, ECT may be the treatment of choice when
the illness is associated with:
❖ Refusal of food or drink
❖ High suicide risk
❖ Stupor
❖ Marked psychomotor retardation
❖ Presence of delusions and hallucinations

✓ ECT may be considered as second or third- line treatment of depressive

illness not responding to antidepressant drugs
✓ ECT may be considered for the treatment of mania :
❖ That is associated with life threatening physical exhaustion
❖ That is not responded to appropriate drug treatment

✓ ECT may be considered for the treatment of acute

schizophrenia as a fourth-line option for treatment-resistant
schizophrenia after treatment with two antipsychotic drugs and
then clozapine has proved ineffective.

✓ ECT may be indicated in patients with catatonia where

treatment with a benzodiazepine (usually lorazepam) has
proved ineffective.

Contraindication to ECT:
• Recent cerebrovascular accident ( within 1 month )
• Recent myocardial infarction ( within 3 months)
• Raised intracranial pressure
• Uncontrolled heart failure
• Untreated cerebral aneurysm
• Untreated phaeochromocytoma
• Acute respiratory infection

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 • Unstable major fracture

Types of ECT:
According to electrode placement

✓ Bilateral ECT
• Used when speed of response is priority.
• Electrodes placed 4 cm above the mid point of the line
between external auditory meatus and the lateral angle of the
eye.
• The optimal frequency is twice per week.

✓ Unilateral ECT
• Used where minimizing memory problem is priority and
speed of response less important
• The first electrode is placed on the non- dominant side, 4 cm
above the mid point of the line between external angle of the
eye and external auditory meatus. The second electrode is
placed 10 cm above the first one on the same side.
• The optimal frequency is twice per week.

According to use of anesthesia

✓ Modified ECT: using general anesthesia
✓ Plain ECT: without anesthesia

Investigations to be completed prior to ECT

● Full blood count

● Urea and electrolytes
● Blood pressure and weight
● Urinalysis
● Blood sugar levels (if urinalysis is positive)
● ECG for patients with known cardiovascular disease, all patients
over the age of 50 years and those with diabetes aged over 40
years.
● Chest X-ray for patients with suspected chest infection,
congestive heart failure and cardiomegaly.

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Seizure duration

ECT should induce the type of generalized cerebral seizure activity and
the seizure activity could be questioned if the convulsion lasted less than
15 seconds or the EEG recording showed seizure activity lasting less than
25 seconds.

Unwanted effects after ECT

❖ Brief retrograde amnesia as well as loss of memory for up to
30 minutes after the fit.
❖ Brief disorientation
❖ Headache
❖ Some patients complains of confusion, nausea, and vertigo for
a few hours after the treatment.
❖ muscle pain, especially in the jaws, which is probably
attributable to the relaxant

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 ❖ Fractures, including crush fractures of the vertebrae, have
occurred occasionally when ECT was given without muscle
relaxants.
❖ Cardiac arrhythmia, pulmonary embolism, aspiration
pneumonia, and cerebrovascular accident are rare and mostly
occur in people with physical illness. Prolonged apnoea is a
rare complication of muscle relaxant.

Memory disorder after ECT

Short-term effects. As already mentioned, the immediate effects of ECT
include loss of memory for events shortly before the treatment
(retrograde amnesia), and impaired retention of information acquired
soon after the treatment (anterograde amnesia). These effects depend on
both electrode placement (unilateral versus bilateral) and electrical dose,
but electrode placement appears to be the more important factor.

The mortality of ECT

The death rate attributable to ECT has been estimated to be less than
1 per 70,000 treatments. This is similar to that seen with general
anaesthesia for minor surgical conditions. The risks are related to the
anaesthetic procedure, and are greatest in patients with
cardiovascular disease. When death occurs it is usually due to
ventricular fibrillation or myocardial infarction.

Psychiatric drugs and ECT

1. Antidepressants: prolongation of seizure, need to be

reduced gradually to minimum.
2. Antipsychotics: tend to reduce seizure threshold,
clozapine should be withheld with 12 hrs before the
procedure.
3. Benzodiazepines: increase seizure threshold so make
seizure occurrence less likely and it decrease
antidepressant effect of ECT.
Lowest dose possible to be used.
4. Anticonvulsants: raise seizure threshold so make seizure
induction difficult so need to be discontinued, while if
used as antiepileptics keep them.
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