ELECTRO CONVULSIVE THERAPY

Electro convulsive therapy is a type of somatic treatment, first introduced by Bini and cerletti in April
1938. From 1980 onwards ECT is being considered as a unique psychiatric treatment.

Electro convulsive therapy is the artificial induction of a grandmal seizure through the
application of electrical current to the brain. The stimulus is applied through electrodes that are
placed either bilaterally in the fronto – temporal region, or unilaterally on the non-dominant side
(right side of head in a right – handed individual).

Historical perspective: - The first electroconvulsive therapy treatment was performed in April 1938
by Italian psychiatrists Ugo Carletti and Lucio Bini in Rome. Other somatic therapies had been tried
before that time, in particular insulin coma therapy and pharmacoconvulsive therapy.

Insulin coma therapy was introduced by the German psychiatric Manfred Sakel in 1933. His
therapy was used for client with schizophrenia. The insulin injection treatment would induce a
hypoglycaemic coma, which Sakel claimed was effective in alleviating schizophrenic symptoms.

Pharmacoconvulsive therapy was introduced in Budapest in 1934 by Ladislas Meduna (fink,

2009).he induced convulsions with intramuscular injections he camphor in oil in client with
schizophrenia. He based his treatment on clinical observation and on his theory that there was a
biological antagonism between schizophrenia and epilepsy.

Parameters of electric current applied: - standard dose according to the American psychiatric
association 1978 :

 Voltage 70 – 120 volts

 Duration 0.7 – 1.5 seconds

Types of seizure produced: -

 Grandma seizure – tonic phase lasting for 10 – 15 seconds.

 Clonic phase lasting for 30 – 60.

Mechanism of action: - the exact mechanism of action is not known. One hypothesis states that ECT
possibly affects the catecholamine pathways between diencephalon ( from where seizure
generalization occurs ) and limbic system ( which may be responsible for mood disorders ), also
involving the hypothalamus.

Types of ECT:

 Direct ECT: - In this, ECT is given in the absence of anaesthesia and muscular relaxation. This
is not commonly used method now.
 Modified ECT: - Here ECT is modified by drug induced muscular relaxation and general
anaesthesia.
Frequency of total anaesthesia:

 Bilateral ECT: - Each electrode is placed 2.5-4 cm (1-1.5 inch) above the midpoint, on a line
joining the tragus of the ear and the lateral can thus of the eye.
 Unilateral ECT: - Electrodes are placed only on one side of head, usually non-dominant side
(right side of the head in a right hand individual).
Unilateral ECT is safer, with much fewer side effects particularly those of memory
impairment.
 In schizophrenia clients 12-15 ECTs may be required.
 MDP cases 6-8 ECTs may be needed.

Indications: - the indications for electro convulsive therapy are:

1. Major severe depression :

 ECT is effective treatment in severe depression with suicidal risk.
 With stupor.
 With melancholia.
 Psychotic feature.
 With unsatisfactory response to drug therapy.
 Where drugs are contraindicated, or have serious side- effect.

2. Severe catatonia :
 With stupor.
 With poor intake of food and fluids.
 With unsatisfactory response to drug therapy.
 Where drugs are contraindicated, or have serious side- effects.
 Where speedier recovery is needed.

3. Severe psychoses :
 Schizophrenia or Mania.
 With risk of suicide, homicide or danger of physical assault.
 With unsatisfactory response to drug therapy.
 Where drugs are contraindicated, or have serious side effect.
 With very prominent depressive features e.g. schizoaffective disorder.

In 1990, American psychiatric association’s task force on ECT has also defined as suggestive
indication the following disorders:

 Organic mental disorders (e.g. organic mood syndrome, organic psychotic syndrome and
delirium)
 Medical disorder ( e.g. organic catatonia, narcoleptic malignant syndromes and
Parkinsonism)
Relative contraindications: -

 Raised intracranial pressure.

 History of cerebral infarction, aneurysm.
 Myocardial infarction.
 Brain tumor.
 Cardiac disease.
 Pulmonary disease (T.B., pneumonia, bronchial asthma etc.)
 Cerebrovascular accident (CVA)
 Retinal detachment.
 Congestive heart failure.

Administration

ECT can be administered in a hospital, clinic, or in nursing homes. ECT is usually administered in
the morning hours.

Consent

Informed consent for ECT must be obtained from patients, preferably in writing. If a patients
psychological state does not permit this, consent may be obtained from patient’s legal guardian.
Procedure of obtaining consent gives opportunity to educate the patient and family about ECT.

ECT team

Psychiatrist, anaesthesiologist, trained nurses and aides should be involved in the

administration of ECT.

Treatment facilities

There should be a suite of three rooms:

 A pleasant, comfortable waiting rooms (pre ECT room).

 ECT room should be equipped with ECT machine and accessories, an anaesthetic appliance,
suction apparatus, face masks, oxygen cylinders with adjustable flow valves, resuscitation
apparatus and emergency drugs. There should be immediate access to a defibrillator.
 A well- equipped recovery room.

Role of psychiatric nurse in ECT: -

Pre ECT care: -

 The client is instructed to be accompanied by a relatives / friends for ECT procedure.

 An informed consent is taken to overcome the fear, confusion and anxiety associated with
procedure.
 Nurse should explain the risks and complication related to procedure.
 4-6 hours of starvation of the client for the NBM; longer period of starvation is preferable.
 To collect the detailed history of the client and recorded it, e.g. medical, psychiatric,
allergies.
  Through physical examination is absolute necessary.
 Complete neurological check up is carried out.
 Fundus examination of the eye.
 Chest x-ray is taken.
 Blood, urine analysis are done.
 Check and record the vital signs.
 Withhold night doses of drugs like diazepam, barbiturates, anticonvulsants which increases
the threshold of the seizure.
 Withhold morning drugs (oral medications).
 Advice head shampooing as application of hair oil can result impedance of passage of
electricity to the brain.
 Remove the objects like jewel, metallic objects, prosthesis, dentures and contact lens.
 Physical restraints may be necessary in acute cases to prevent powerful body jerky
movements/ injury / fall during procedure.
 Tongue depressor or mouth gag is placed within the mouth to prevent tongue bite or lip bite.
 Injection atropine 1/100 grams or 0.6 mg subcutaneous or I.M. is administered before ECT.

Intra procedure care

 Place the client in supine position over the hard bed (as it facilitates the control of body
movements).
 Stay with client to overcome the anxiety and fear.
 Assist in administering (I.M.) and anaesthetic agent injection pentathol sodium 100-200 mg
dissolved in distilled water and injection succinyl scoline 30-60 mg (I.V.).
 Maintain patient airway.
 Muscle relaxant will paralyse all the muscles including respiratory muscles, hence ventilator
support has to be kept ready.
 Bladder and bowel are emptied before ECT.
 Monitor and record the voltage intensity duration of electric stimuli, seizure pattern,
condition of the client and medicines administered.
 Check the vital signs; if required oxygen has to be supplemented.

Post procedure care

 Client must be shifted to post-procedure room after the procedure.

 Check the post vital sign every 15 minutes until client’s condition stabilizes.
 If client become aggressive / confused / excited / violent administer 8-10 ml of injection
paraldehyde or 50-100 mg of choropromazine diazepam 5-10 mg I.V. to control client’s
behaviour.
 If any respiratory difficulty, continue oxygen supplementation till spontaneously respiration
starts.
 Use side-rail cot to prevent fall or injury.
 Be with the client; if not possible allow aid or attender to be client until recovery.
 After recovery, reorient the client.
 Relevant findings are documented.
 Bibliography
 Mary C. Townsend, psychiatric mental health nursing, Concepts of care in evidenced – based
Practice, 8th edition, page no.310-313.

 Dr. K.Lalitha, mental health and psychiatric nursing an Indian prospective, V.M.G. book
house, page no:- 269-276.

 R Sreevani , a Guide to mental health and psychiatric nursing, 3rd edition, Jaypee , page no.
129-131.

 K P Neerja, essential of mental health and psychiatric nursing, volume 1, 1 st edition, Jaypee.
page no 224-227.