Electroconvulsive Therapy

History
Von Meduna in 1934 used 25% camphor in oil IM to produce convulsions for the first time for therapeutic purpose.Later he used metrazol for the same purpose. ECT was first introduced in 1938 by a neurologist named Urgo Cerletti and Bini. Thought of concept while watching pigs being killed via electric shock Decline in popularity in 60s due to pharmacological treatments and the negative media image

Primary Indications for ECT

A. With major severe depression
1.with suicidal risk 2.With stupor 3.With melancholia 4.Lack of a response to or intolerance of antidepressant medications 5.Where drugs are contraindicated or have serious side effects

B. Severe catatonia 1.Stupor 2.Poor intake of food and fluids 3.With poor response to drug therapy

C. Severe Psychosis 1.With risk of suicide ,homicide 2.With poor response to drug 3.With very prominent depressive features

The 1990 APA task force on ECT also defined as suggestive indications for Organic mental disorders( organic mood synd,organic hallucinosis,delirium) Medical disorders (organic catatonia,neuroleptic malignant synd,parkinsonism)

PRE TREATMENT EVALUATION

Informed consent from patient or guardian Detailed medical and psychiatric history General and systemic physical examination Routine investigations-Hb%,TC,DC,ESR,urine RE,ECG,Chest XRay. Fundus examination Optional EEG and plasma pseudocholinesterase level

Patient Populations
ECT can also be used safely during pregnancy, with proper precautions.
ECT can be used safely in elderly patients and in persons with cardiac pacemakers or implantable cardioverterdefibrillators.

Contraindications
Raised ICT Recent MI Severe HTN CVA Severe pulmonary disease Retinal detachment Pheochromocytoma

TECHNIQUE
Types Direct ECT: in absence of muscular relaxation and GA Modified ECT: modified by drug induced muscular relaxation and GA.

Position of electrode placement

Bilateral ECT: each electrode placed 2.5-4cm above midpoint of a line joining tragus and lateral canthus. Unilateral ECT: placed only on one side of the head (usually non dominant side)

ECT devices:
Earlier ECT devices that used sine wave current. Newer ECT devices use brief pulse waveform that delivers stimulus in 1-2 ms timeperiod @30-100 pulse/s. Stimulus is one and half times the seizure threshold in bilateral ECT and 12 times in unilateral ECT.

ECT Procedure
Administered in morning after overnight fast. Bowel and bladder emptied,dentures and tight clothes removed before treatment. Patient put on well insulated hard bed. Atropine 0.6mg IV Anesthetic (IV)-propofol,thiopentone Muscle relaxer (IV)- prevent injury Mouth gag to prevent tongue bite. Electrodes moistened with saline or 25%bicarb solution. Vitals are closely monitored Restraints to secure the body during seizure 0.1-1 second shock- just enough to induce seizure Seizure typically should last 25-30 seconds

DURATION OF THERAPY
Depends on diagnosis,side effects and response to treatment. Usually 6-10(No more than 3 ECTs per week)

ECT: Post Procedure

Antidepressant Medications are continued to prevent relapse

Mechanism
Exact mechanism remains elusive. Increases BBB permeabilty. Increases neuroplasticity. Increases cortical GABA concentrations Enhances serotonergic function Affects catecholamine pathways between diencephalon and limbic system.

ECT Theories
Neurophysiological theory Electrical shock causes seizure Stimulates a long term release of neurotransmitters Improve brain cells functioning and increases chemical messengers Punishment Theory (Weak) Patients see treatment as punishment for behavior Improve to avoid further punishment

Which is more effective?

Bilateral electrode placement was moderately more effective than right unilateral placement Greater cholinergic surge Right unilateral ECT is safer with less memory impairment. No difference long term

Adverse Effects
Initial anterograde amnesia Short term disorientation or delirium (1hr) Long term retrograde amnesia Sleep disturbances Death Apprehension Physical effects
Headaches muscle aches Acute BP/HR changes Anatomical damage

Anatomical Damage
Fracture/dislocation of long bones. Thalamic hemorrhage.

ECT Uncertainties
How to prevent relapse after a remission
Reduction of cognitive side effects Shorter pulse of electricity? Placement of Electrodes ?

ECT: APA Guidelines

Administered by properly qualified psychiatrists Recommend ECT only for difficult-to-treat depression (5-6 unsuccessful attempts) Use of ECT for relapse prevention Not recommend ECT as maintenance therapy Detailed criteria for patient selection, informed consent, ECT procedures, and training in ECT

Application to Practice
ECT is ALWAYS secondary treatment to pharmaceutical interventions .
The Union Health Ministry of India has decided in the Mental Health Care Bill of 2010 that they will no longer use direct ECT. The Health Ministry recommended a ban on the whole procedure.

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