ELECTRO CONVULSIVE THERAPY (ECT)

Dr. Altaf Qadir Khan

Professor of Psychiatry
Ameer ud din Medical College
PGMI/ LGH, Lahore
 Electro Convulsive Therapy
Electro Convulsive Therapy (ECT) is a treatment, for mental
illness in which a brief application of electrical stimulus is used
to produce a generalized seizure
 History of convulsive therapy
It was introduced in the late 1930s on the basis of the
mistaken idea that epilepsy and schizophrenia do not occur
together, it seemed to follow that induced fits should lead to
improvement in schizophrenia
 History of convulsive therapy
When the treatment was tried it became apparent that the
most striking changes occurred not in schizophrenia but in
severe depressive disorder and brought substantial reduction
in chronicity and mortality
Chemically induced seizures-
(Camphor)
 History of Convulsive Therapies

1938 – Lucio Cerletti and Ugo Bini induced seizures in Rome

using electrical stimuli in catatonic patients and produced
successful results

1940 – Renato Almansi and David Impasto administered ECT at

Columbus Hospital in NYC.

Lothar Kalinowsky started giving ECT at Psychiatric Institute

Cerletti and Bini (1934): Electricity

Initially done without

muscle blocker or
anesthetic
 Early ECT
Asylums

Few effective medications

Many often severe side effects

In 1950’s Antidepressant and Antipsychotic medications

significantly decreased utilization of ECT
 Introduction to ECT
ECT has changed substantially during the past decades. The
use of general anesthesia has promoted the interest in ECT

ECT becomes more complex , more precise and safer

procedure (Mortality rate 1/1000 early to 3-4/100,000 now)
 Electro Convulsive Therapy
Excellent safety profile
Superior Efficacy
Economic benefits

Stigmatization
 Duration of ECT
ECT is usually given twice a week , even thrice a week but has
little therapeutic effect over a twice weekly regimen

Course of ECT is usually 6 to a maximum of 12 treatments

 If there is no response after six to eight treatments course

should be abandoned
 Outcome / Side effects
75 – 90% of patients exhibit a dramatic and sustained
improvement

Transient neurological dysfunction does occur but permanent

neuronal injury is questionable
 Trials
1958-First controlled study in unilateral ECT

1960-Randomised clinical trials of the efficacy of ECT versus

medication in the treatment of depression yielded response
rates that were significantly higher with ECT
Indications
Major Depressive Disorder
Catatonic Schizophrenia
Post-partum psychosis

 Some studies have shown efficacy in treating OCD, Delirium,

NMS, Chronic pain syndromes, and intractable seizure disorders
Major Depressive Disorder
Major depressive disorder; when associated with:
Suicide
Stupor
Life threatening dehydration
Marked psychomotor retardation
Depressive delusions and hallucinations
ECT may be considered 2nd or 3rd line treatment if not
responsive to antidepressants
Schizophrenia
Patients with Catatonia where treatment with Benzodiazepine
(Lorazepam) has proved ineffective

ECT may be considered for the treatment of acute

schizophrenia as a 4th line option for treatment resistant
schizophrenia after treatment with two antipsychotic drugs
and then Clozapine has proved ineffective
Post-partum psychosis
Post partum psychosis, second line of treatment after non-
response to Antidepressants and / or Antipsychotics

Safe in all trimesters but need:

Obstetrical consultation
Fetal monitoring and precautions
Other conditions

Parkinson’s disease
NMS
Status Epilepticus
Tardive dyskinesia
Refractory OCD
Delirium
 Informed Consent
Fully explain the risks and benefits of procedure and answer
questions from patients or their relatives

Reduce patient’s anxiety and help establish good patient-

doctor relationship
 Pre-ECT Workup
Nursing implication
Physical examination
Head CT
CXR
CBC
EKG

Contra-indications?
 Contraindications
No Absolute Contraindications

Relative Contraindications:
 Recent MI, fever, Brain Mass, Increased Intracranial Pressure,
significant arrhythmias, extreme hypertension, recent stroke,
retinal detachment, unstable angina, severe pulmonary disease
 Technique
Two types

Direct ECT –administered in the absence of muscular

relaxation and general anesthesia, now a days very
infrequently used

Modified ECT – by drug induced muscular relaxation and

general anesthesia administered by anesthetist
 Response rate BL vs UL

Response rates:

Low-dose RUL - 17%

High-dose RUL - 43%
Low-dose BL - 65%
High-dose BL - 63%
 Risks/Side Effects
Muscle contractions: can result in fractures and
dislocations; prevented by small doses of muscle relaxants

Injury to teeth, tongue or lips: stimulus causes intense

contraction of the masseter muscles and forceful
movement of the jaw; use a bite block

Electrical injury to the patient

 Risks/Side effects
Postictal Headache (45%) and muscle ache

Short-term memory loss and cognitive deficits

Difficult relationship with patients: frightened; withdrawn;

suspicious; uncooperative

Death: 3-4: 100,000

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