ELECTROCONVULSIVE

THERAPY
PSYCHIATRIC NURSING
 ELECTROCONVULSIVE THERAPY
INTRODUCTION

Electroconvulsive 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.

DEFINITION

Electroconvulsive 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 PERSPECTIVES

Early years: 1938-1969

ECT was invented in Italy in 1938. In 1939 it was brought to England and replaced cardiazol (metrazol) as
the preferred method of inducing seizures in convulsion therapy in British mental hospitals. Although
soon established as especially useful in the treatment of depression, it was also used on people with a
wide variety of mental disorders. There was large variation in the amount of ECT used between different
hospitals. As well as being used therapeutically, ECT was used to control the behaviour of patients.
Originally given in unmodified form (without anaesthetics and muscle relaxants) hospitals gradually
switched to using modified ECT, a process that was accelerated by a famous legal case.
Origins of ECT
ECT originated as a new form of convulsive therapy, rather than as a completely new treatment.
Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J Meduna who,
believing that schizophrenia and epilepsy were antagonistic disorders, induced seizures in patients with
first camphor and then cardiazol.
Meanwhile, in Rome, professor of neuropsychiatry Ugo Cerletti was doing research on epilepsy and using
electric shocks to induce seizures in dogs. Cerletti visited the Rome abbatoir where electric shocks were
used to render pigs comatose prior to slaughter. Inspired by the fact that the pigs were not actually killed
by a voltage of 125 volts driving an electric current through the head for a few tenths of a second, he

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decided to experiment on a person. In April 1938 Cerletti tried ECT for the first time on a man who had
been brought to his clinic in a confused state by police. The man was given a total of 11 treatments and
recovered. It later emerged that he had had cardiazol treatment in another hospital three months
previously. Cerletti called his treatment "electroshock" and developed a theory that it worked by causing
the brain to produce vital substances that he called "acro-agonines" (from the Greek for "extreme
struggle"). He put his theory into practice by injecting patients with a suspension of electroshocked pig
brain, with encouraging results. Electroshocked pig brain therapy was used by a few psychiatrists in Italy,
France and Brazil but did not become as popular as ECT. Cardiazol convulsion therapy was soon replaced
by ECT all over the world. Cerletti and Bini were nominated for a Nobel prize but did not get one.

The middle years: 1960–1985

The next two and a half decades saw ECT maintain its place as a commonly used psychiatric
treatment in spite of the introduction of neuroleptics, antidepressants and benzodiazipines into
British psychiatric practice in the late 1950s and early 1960s. In the early 1970s there were an
estimated 50,000 courses annually in the UK; by 1985 this had dropped to about 24,000. This period
saw stirrings of professional and public disquiet over some aspects of ECT use; in response the Royal
College of Psychiatrists produced guidelines and carried out an extensive survey of ECT use.
The Mental Health Act 1983 introduced a legal framework for the use of ECT on non-consenting
patients.

Guidelines

In 1976 the Royal College of Psychiatrists received a request from the regional medical officer of the
South East Thames regional health authority for advice on giving ECT to non-consenting patients.
One of the region’s mental hospitals had been the subject of a committee of enquiry, and the use of
force when giving patients ECT had been criticised. In Parliament, Secretary of State David
Ennals had referred to the death of one woman following ECT as "disturbing".
The Royal College of Psychiatrists duly produced guidelines, in the form of an eleven-page article in
the British Journal of Psychiatry. The guidelines summarised the current state of knowledge about
ECT, set standards for its administration and discussed aspects of consent. ECT was, the guidelines
concluded, an effective treatment for endogenous depression. There was less certainty about its
value in mania, and little evidence for its usefulness in schizophrenia. The guidelines said that the
possibility of long-term memory impairment following ECT had been "too little investigated".
Recommendations for the administration of ECT included: anaesthesia for all patients, a pre-
treatment physical examination, avoidance of currents greatly above seizure threshold and the use
of machines with a choice of waveforms. The question of electrode placement was left open:
evidence of less memory loss with unilateral electrode placement was noted, so too was
psychiatrists’ preference for bilateral electrode placement. The guidelines recommended that
informal patients who were unable or unwilling to consent to ECT should be sectioned and a second
opinion obtained (unless the need for treatment was seen as urgent).

Parameters of Electrical Current Applied

Standard dose according to American Psychiatric Association, 1978:

● Voltage - 70-120 volts.

● Duration - 0.7-1.5 seconds

Type of Seizure Produced

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• grandmal Seizure-tonic phase lasting for 10 - 15 seconds.

• clonic phase lasting for 30-60 seconds

Types of ECT

● Direct ECT: In this, ECT is given in the absence of anesthesia and muscular relaxation. This is
not a commonly used method now.
● Modified ECT: Here ECT is modified by drug induced muscular relaxation and general
anesthesia.

Frequency and Total Number of ECT

Frequency: Three times per week or as indicated. Total number: 6to 10; upto 25 may be preferred as
indicated.

Application of Electrodes

● Bilateral ECT: Each electrode is placed 2.5-4 cm (1-1/2 inch) above the midpoint, on a line
joining the tragus of the ear and the lateral canthus of the eye.
● Unilateral ECT: Electrodes are placed only on one side of head, usually non-dominant side
(right side of head in a right-handed individual). Unilateral ECT is safer, with much fewer side
effects particularly those of memory impairment.

INDICATIONS

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 ● ECT is primarily used in the treatment of severe depression.
a. Major depression: With suicidal risk; with stupor; with poor intake of food and fluids;
melancholia with psychotic features with unsatisfactory response of drugs or where drugs
are contraindicated or have serious side-effects .
b. Severe catatonia (functional): With stupor; with poor intake of food and fluids; with
unsatisfactory response to drug therapy, or when drugs are contraindicated or have serious
side-effects.
c. Severe psychosis (schizophrenia or mania): With risk of suicide, homicide or danger of
physical assault; with depressive features; with unsatisfactory response to drug therapy, or
when drugs are contraindicated or have serious side-effects.
d. Organic mental disorders: • organic mood disorders. • organic psychosis
● It is sometimes administered in conjunction with antidepressant medication, but most
physicians prefer to perform this treatment only after an unsuccessful trial of drug therapy.
● ECT may also be used as a fast-acting treatment for very hyperactive manic clients in danger
of physical exhaustion, and with individuals who are extremely suicidal.

ECT was originally attempted in the treatment of schizophrenia, but with little success in most
instances. There has been evidence, however, of its effectiveness in the treatment of acute
schizophrenia, particularly if it is accompanied by catatonic or affective (depression or mania)
symptomatology (Black & Andreasen, 2011).

CONTRAINDICATIONS

Absolute: ECT should not be used if there is increased intracranial pressure ((resulting from a brain
tumor, recent cardiovascular accident, or other cerebrovascular lesion).

Relative: Other conditions, although not considered absolute contraindications, may render clients
at high risk for the treatment. They are largely cardiovascular in nature and include myocardial
infarction or cerebrovascular accident within the preceding 3 months, aortic or cerebral aneurysm,
severe underlying hypertension, congestive heart failure, cerebral haemorrhage, acute myocardial
infarction, pneumonia, retinal detachment.

MECHANISM OF ACTION

The exact mechanism of action is unknown. However, it is thought that ECT produces biochemical
changes in the brain— an increase in the levels of norepinephrine, serotonin, and dopamine—similar
to the effects of antidepressant medications.

SIDE EFFECTS AND NURSING IMPLICATIONS

• Memory impairment.

• Drowsiness, confusion and restlessness.

• Poor concentration, anxiety.

• Headache, weakness/fatigue, backache, muscle aches.

• Dryness of mouth, palpitations, nausea, vomiting.

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• Unsteady gait.

• Tongue bite and incontinence.

These are the most common side effects of ECT. It is important for the nurse to be present when the
client awakens, to alleviate the fears that accompany this loss of memory.

✔ Provide reassurance that memory loss is only temporary.

✔ Describe to client what has occurred.
✔ Reorient client to time and place.
✔ Allow client to verbalize fears and anxieties related to receiving ECT.
✔ To minimize confusion, provide a good deal of structure for client’s routine activities.

RISKS ASSOCIATED WITH ECT

1. Death. The mortality rate f1rom ECT is about 2 per 100,000 treatments (Marangell et al., 2003;
Sadock & Sadock, 2007). The major cause is cardiovascular complications, such as acute myocardial
infarction or cardiac arrest.

2. Brain Damage. Brain damage is considered to be a risk, but evidence is largely unsubstantiated.

3. Permanent Memory Loss. Most individuals report no problems with their memory, aside from the
time immediately surrounding the ECT treatments.

4. Fractures can sometimes occur in elderly patients with osteoporosis. In patients with a history of
heart disease, dysrhythmias and respiratory arrest may occur.

However, some clients have reported retrograde amnesia extending back to months before
treatment. In rare instances, more extensive amnesia has occurred, resulting in memory gaps dating
back years (Joska & Stein, 2008), Black and Andreasen (2011) suggest that all clients receiving ECT
should be informed of the possibility of permanent memory loss. Although the potential for these
effects appears to be minimal, the client must be made aware of the risks involved before
consenting to treatment.

ECT Team

Psychiatrist, anesthesiologist, trained nurses and aides should be involved in the administration of
ECT.

Treatment Facilities

There should be a suite of three rooms:

1. A pleasant, comfortable waiting room (preECTroom).

2. ECT room, which should be equipped with ECT machine and accessories, an anesthetic appliance,
suction apparatus, face masks, oxygen cylinders with adjustable flow valves, curved tongue
depressors, mouth gags, resuscitation apparatus and emergency drugs. There should be immediate
access to a defibrillator.

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3. A well-equipped recovery room.

Role of the Nurse

a) Pre-treatment evaluation

• Detailed medical and psychiatric history, including history of allergies.

• Assessment of patient's and family's knowledge of indications, side-effects, therapeutic effects and
risks associated with ECT.

• An informed consent should be taken. Allay any unfounded fears and anxieties regarding the
procedure.

• Assess baseline vital signs.

• Patient should be on empty stomach for 4-6 hours prior to ECT.

• Withhold night doses of drugs, which increase seizure threshold like diazepam, barbiturates and
anticonvulsants, withhold oral medications in the morning.

• Head shampooing in the morning since oil causes impedance of passage of electricity to brain.

• Any jewellery, prosthesis, dentures, contact lens, metallic objects and tight clothing should be
removed from the patient's body.

● Empty bladder and bowel just before ECT.

● Administer cholinergic blocking agent (e.g., atropine sulphate 0.6 mg, glycopyrrolate)
approximately 30 minutes before treatment, as ordered by the physician, to decrease
secretions and increase heart rate (which is suppressed in response to vagal stimulation
caused by the ECT).

B. Intra-procedure care

• Place the patient comfortably on the ECT table in supine position.

• Stay with the patient to allay anxiety and fear.

• Assist in administering the anesthetic agent (thiopental sodium 3-5 mg/kg body weight) and
muscle relaxant (1mg/kg body weight of succynylcholine).

• Since the muscle relaxant paralyzes all muscles including respiratory muscles, patent airway should
be ensured and ventilatory support should be started.

• Mouth gag should be inserted to prevent possible tongue bite.

• The place(s) of electrode placement should be cleaned with normal saline or 25 percent
bicarbonate solution, or a conducting gel applied.

• Monitor voltage, intensity and duration of electrical stimulus given.

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• Monitor seizure activity using cuff method.

• 100 percent oxygen should be provided.

• During seizure monitor vital signs, ECG, oxygen saturation, EEG, etc.

• Record the findings and medicines given in the patient's chart.

c. Post-procedure care

• Monitor vital signs.

• Continue oxygenation till spontaneous respiration starts.

• Assess for post-ictal confusion and restlessness.

• Take safety precautions to prevent injury (sidelying position and suctioning to prevent aspiration of
secretions, use of side rails to prevent falls).

If there is severe post-ictal confusion and restlessness, IV diazepam may be administered.

• Reorient the patient after recovery and stay with him until fully oriented.

• Document any findings as relevant in the patient's record.

POTENTIAL NURSING DIAGNOSES ASSOCIATED WITH ECT

1. Risk for injury related to certain risks associated with ECT.

2. Risk for aspiration related to altered level of consciousness immediately following treatment.

3. Decreased cardiac output related to vagal stimulation occurring during the ECT.

4. Disturbed thought processes related to side effects of temporary memory loss and confusion.

5. Deficient knowledge related to necessity for, and side effects and risks of, ECT.

6. Anxiety (moderate to severe) related to impending therapy.

7. Self-care deficit related to incapacitation during postictal stage.

8. Risk for activity intolerance related to post-ECT confusion and memory loss.