Electrical

must reach the stimulus

seizure threshold (the level of
intensity needed to produce a seizure)
1 to 2 milliseconds at a rate of 30 to 100 pulses a
second.
Establishing a patient’s seizure threshold is not
straightforward
During the course of ECT treatment, a patient’s
seizure threshold may increase 25 to 200 percent.
The seizure threshold is also higher in men than in
women and higher in older than in younger adults.
A common technique is to initiate treatment at an
electrical stimulus that is thought to be below the
seizure threshold for a particular patient and then
to increase this intensity:
by 100 percent for unilateral placement
by 50 percent for bilateral placement
until the seizure threshold is reached.
Induced seizure
A brief muscular contraction, usually
strongest in a patient’s jaw and facial
muscles seen concurrently with the
flow of stimulus current
Plantar extension, which lasts 10 to 20
seconds and marks the tonic phase.
This phase is followed by rhythmic (i.e.
clonic) contractions that decrease in
frequency and finally disappear.
Up to four attempts at seizure induction
can be tried during a course of treatment.
Onset of seizure activity is sometimes
delayed as long as 20 to 40 seconds after
the stimulus administration.

Prolonged and Tardive Seizures:

seizures lasting >180 seconds and status
epilepticus can be terminated either
with additional doses of the barbiturate
anesthetic agent or with IV diazepam
ECT treatments are usually
administered
Number and2-3 times of
spacing pertreatment
week
In general, MDD (6-12 treatments),
manic episodes (8-20), schizophrenia
(>15), catatonia and delirium (1-4)
Treatment should continue until the
patient achieves what is considered the
maximal therapeutic response.
If a patient is not improving after 6 to
10 sessions, bilateral placement and
high-density treatment (three times the
seizure threshold) should be attempted
Continuation or Maintenance treatment
• In some patients maintenance E.C.T. is needed.

• Maintenance therapy is generally pharmacological, but

maintenance ECT treatments (weekly, biweekly, or monthly)
have been reported to be effective relapse prevention
treatments.

• Continuation E.C.T is indicated in certain patients to prevent

relapse of depressive episode after the completion of a course
of E.C.T.

• It may be for up to 1 year of E.C.T. with titration downwards

eg. 2 weekly or monthly treatment session.
Patients who
Failure of failtrial
ECT to improve after a trial
of ECT should again be treated with the
pharmacological agents that failed in
the past.

Many reports indicate that patients who

had previously failed to improve while
taking an antidepressant drug do
improve while taking the same drug
after receiving a course of ECT
treatments, even if the ECT seemed to
Adverse effect
Prolonged seizures ( > 2 mins)
Treat with I/V Benzodiazepine
• Retrograde Amnesia ( Memory loss before E.C.T.)
• Amnesia for Impersonal events is more than Amnesia for personal or
Autobiographical memory

Other adverse effects: Memory functions not affected by E.C.T.

• Headache include:
• Drowsiness
• New learning
• Muscular aches
• Weakness • Intelligence
• Nausea • Judgement
• Anorexia • Abstraction
Psychiatry Behavioral Sciences/Clinical
Psychiatry, 11th edition (pg 2245-2260)
Shorter OxfordReferences
Textbook of Psychiatry, 7th
edition (pg 770-778)
Psychiatric And Mental Health Services
Operational Policy MOH Malaysia (pg
112-116)
https://emedicine.medscape.com/article/15
25957-overview#a1
https://www.psychologytoday.com/us/blog
/freud-fluoxetine/201811/brief-history-
electroconvulsive-therapy
https://www.psychiatry.org/patients-
DEEP BRAIN STIMULATION
(FOR PSYCHIATRIC DISORDERS)
ANNAZATUL ZAIMAH HUSSIN
BMS15091520
4/11/2019
 DBS - INTRODUCTION
• Deep brain stimulation (DBS) is a a surgery to implant a device that
sends electrical signals to brain areas responsible for body movement
• Electrodes are placed deep in the brain and connected to a stimulator
device
• Similar to a heart pacemaker, a neurostimulator uses electric pulses
to regulate brain activities
• DBS can help ease motor symptoms and decrease medication needs
in condition such as Parkinson’s Disease with significant motor
restlessness / dyskinesia (uncontrolled , involuntary movement)
 DBS – PSYCHIATRIC DISORDERS
• Prior to 1950s, no specific medications existed for the treatment of
severe psychiatric disorders
• Given the disabling and often lethal nature of these severe
psychiatric disorders, aggressive and invasive procedures were
pursued including
• Malarial pyrotherapy (Wagner, 1927)
• Hypoglycemic coma (Sakel, 1935)
• Electroconvulsive therapy (Cerletti, 1938)
• Neurosurgery (Burckhardt, 1888)
• Nowadays, DBS has been widely researched to help decrease the
burden of these patients although it is considered as an invasive
neurosurgical intervention
 DBS – METHOD (OVERVIEW)

• Electrodes are placed in the targeted areas of the brain and

connected by wires to a pacemaker device (pulse generator) placed
under the skin of the chest below the collarbone.
• Once activated, the pulse generator sends continuous electrical
pulses to the target areas in the brain, modifying the abnormal
activity in that area of the brain that is causing symptoms.
• The deep brain stimulation system operates much the same way as a
pacemaker for the heart.
• In fact, deep brain stimulation is referred to as “the pacemaker for
the brain.”
The deep brain stimulation system
consists of four parts:
• Leads (thin insulated wires) that end in
electrodes that are implanted in the
brain
• A small pacemaker-like device, called a
pulse generator, that creates the
electrical pulses
• Extension leads that carry electrical
pulses from the device and are
attached to the leads implanted in the
brain
• Hand-held programmer device that
adjusts the device’s signals and can turn
the device off and on.
 DBS - INDICATIONS

Deep brain stimulation is approved by Deep brain stimulation is also

the Food and Drug Administration (FDA) being studied / still in research for
to treat following conditions : the treatment in the following
• Parkinson’s disease conditions:
• Essential tremor • Multiple sclerosis
• Dystonia • Chronic pain syndrome
• Epilepsy Disorders • Traumatic brain injury
• Treatment-resistant depression • Alzheimer’s Disease
• Treatment-refractory obsessive- • Tourette syndrome
compulsive (OCD) • Addiction
• Adult patients who have failed at least • Anorexia nervosa
three selective serotonin reuptake
inhibitors (SSRIs)
 DBS - CANDIDATES
Before being considered as a candidate for DBS, patients must undergo
an extensive evaluation process. Multidisciplinary team of neurologist,
neurosurgeon, neuropsychologist and psychiatrist will assess the
patient

DBS is not considered for patients ;

• Well managed on medications
• Structural abnormalities on MRI
Candidates for DBS are generally patients who meet these criteria:
• Symptoms are not well controlled despite receiving the appropriate
dose of medications.
• Symptoms are significantly reducing a patient’s quality of life.
• Side effects from current medications cannot be tolerated.
 DBS – SIDE EFFECTS

• Potential risk of brain tissue damage (stimulation parameter settings of high

amplitudes and wide pulse widths
• After programming the device, monitor closely for ;
• Autonomic effects (facial flushing, facial muscle contractions, or increased heart rate)
• Sensations (tingling, smell, or taste)
• Increased disease symptoms (depression, anxiety, suicidality, and worsening of
obsessive-compulsive symptoms)
• Loss of coordination in activities such as swimming may occur
• Adverse events related to the therapy, device, or procedure can include ;
• Intracranial hemorrhage, cerebral infarction, CSF leak, pneumocephalus, seseizure
• Surgical site complications (including pain, infection, dehiscence, erosion, seroma,
and hematoma)
• Infections such as meningitis, encephalitis, brain abscess, cerebral edema and aseptic
cyst formation
• Device malfunctions or complications
 REFERENCES
• https://my.clevelandclinic.org/health/treatments/21088-deep-brain-
stimulation
• Deep Brain Stimulation for Psychiatric Disorders
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413475/
• Recent advances in deep brain stimulation in psychiatric
disorders
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5989145/
Vagal Nerve Stimulation
Bridget Lo Yen
Vagal Nerve Stimulation
Indication

1. Chronic or recurrent depression & have

not had an adequate response to 4 or
more antidepressant treatments
 18 years of age or older

2. Epilepsy
Vagal Nerve Stimulation
Procedure
2 incisions are made, one on the chest , and
the other on the left side of the neck

Pulse generator is turned on a few weeks after

the surgery. It deliver electrical impulses to the
vagus nerve at various durations, frequencies
and currents.

The typical stimulation cycle is 40 seconds on,

followed by 5 minutes off.

The stimulator does not detect seizure activity

or depression symptoms.
Vagal Nerve Stimulation
Procedure
When activated, the device sends electrical
signals along the left vagus nerve and induce
bilateral effects in the areas of brain implicated
in depression, including inferior temporal
structures (amygdala) and the prefrontal cortex.

Right vagus nerve not in used due to nerve

supply to the heart (SA nodes).
Vagal Nerve Stimulation
Procedure
Frequent office visits (every 2 to 4 weeks) for
the first several months to monitor patient
tolerability and adjust device parameters.

VNS affects serotonin and norepinephrine

neurotransmitters and brain structures thought
to be involved in mood regulation.
Vagal Nerve Stimulation
Contraindication

1. History of previous left neck surgery

2. Previous bilateral or left cervical vagotomy
3. Pregnancy
Vagal Nerve Stimulation
Side effects
 Temporary hoarseness
 Slight change in voice tone
 Increased coughing
 Shortness of breath during physical exertion
 Tickling in the throat
Transcranial magnetic
stimulation
Chai Xiao Si
 TMS is a non invasive procedure that
uses magnetic fields to stimulate nerve
cells in brain to improve symptoms of
depression

Concept behind :
1)electric pulse generator
|
Connected
|
2)magnetic coil :created magnetic field
|
Connected
|
3) scalp: magnetic field cause second inductance
of inverted electric change within brain itself
Treatment
resistance
depression
Treatment resistance depression
Gold standard : electroconvulsant therapy

Transcranial
magnetic Electroconvulsant therapy
stimulation
Non invasive Method Invasive

No Anesthesia Yes

No Seizure induced Yes

Can drive and work on Cannot drive or work on

Psychosocial impact
the day of treatment same day of treatment

None After effect Mild memory loss

TMS therapeutic uses:
1) Treatment resistance depression
Approximately 50% to 60% of people with depression who have tried and failed to
receive benefit from medications experience a clinically meaningful response with
TMS. About one-third of these individuals experience a full remission, meaning that
their symptoms go away completely

(2008,FDA authorised the use of rTMS as treatment for depression that doesn’t
improve with other measures)

2) Migraine
Dec 2013, FDA approved the use of single pulse TMS for migraine

3) OCD
August 2018 , FDA Approved the use of TMS In treatment of Obsessive-
compulsive disorder
How is an effective TMS performed?

1)anatomical target stimulation

2)stimulation intensity
>>>>
so the stimulation can reach to the dorsolateral prefrontal cortex
(Greatest clinical evidence in which the brain area involved in depression)
Usually 5 session per week needed for several weeks, 20-50min per session
Cost : single session around $350USD
 TMS side effects:
1) common side effects
-headache
-brief period of hypomania
-hearing loss
-cognitive changes
Fainting

2)rare
-seizure