“ELECTRO-CONVULSIVE THERAPY (ECT)”
DEFINITION
Electroconvulsive therapy (ECT), also known as electroshock, is a controversial
psychiatric treatment in which seizures are electrically induced in patients for therapeutic
effect.
HISTORICAL PERSPECTIVES
Convulsive therapy was introduced to psychiatry practice in 1934.
Electroconvulsive therapy, commonly called ECT, was developed in 1938 by Ugo
Cerletti and Lucino Bini.
ECT gained widespread use as a form of treatment in the 1940s and 50s.
Replaced by psychotropic drugs introduced in the 1950s and 1960s.
Recalled two decades later to treat pharmacotherapy-resistant cases.
Avid searches to optimize seizure induction and treatment courses, to reduce risks
and fears, to broaden the indications for its use, and to understand its mechanism
of action followed which were severely impeded by a vigorous antipsychiatry
movement.
The use of ECT has increased since the 1970's because of improved treatment
delivery methods, increased safety and comfort measures and enhanced anesthesia
management.
Today, ECT is most often used as a treatment for severe major depression which
has not responded to other treatment, catatonia, schizophrenia and other disorders.
TYPES OF ECT
There are two types of ECT depending upon the placement of electrodes:
Right unilateral treatment: One electrode is placed on the crown of the head and the
other on the right temple.
Bilateral ECT treatment: It involves placing the electrodes on both temples. The
electrodes are placed 1 inch above from the imaginary midline drawn from the outer
canthus of eye to the targus of ear.
INDICATIONS:
Major diagnostic indications
• Severe depression, unipolar and bipolar Psychotic depression, in particular
• Mania, including mixed episodes
• Schizophrenia with acute exacerbation Catatonic subtype, particularly
• Schizoaffective disorder
Other diagnostic indications
• Parkinson's disease
• Neuroleptic malignant syndrome
• Intractable seizure disorder
Clinical indications
Primary use
• Rapid definitive response required on medical or psychiatric grounds
• Risks of alternative treatments outweigh benefits
• Patient preference
• Past history of poor response to psychotropics or good response to ECT
Secondary use
• Failure to respond to pharmacotherapy in the current episode
• Intolerance of pharmacotherapy in the current episode
• Rapid definitive response necessitated by deterioration of patient's condition
MECHANISMS OF ACTION
• Electroconvulsive therapy involves applying a brief electrical pulse to the scalp
while the patient is under anesthesia. This pulse excites the brain cells causing
them to fire in unison producing a seizure.
• One of the several theory suggests that the seizure activity itself causes an
alteration of the chemical messengers in the brain known as neurotransmitters.
CONTRAINDICATIONS:
• Absolute contraindications: - Increased intracranial pressure (from brain tumor,
recent Cardio-vascular accidents or cerebro-vascular lesions).
• Systemic diseases are no longer considered to preclude its use.
• High risk conditions: - MI or CVA within preceding 3 months, Aortic or
cerebral aneurysm, Severe hypertension, Congestive heart failure, Severe
osteoporosis, acute & chronic pulmonary disorders and High – risk or
complicated pregnancy.
THE NUMBER OF TREATMENTS NEEDED
• Treatments are normally administered three times a week.
• A course of ECT normally ranges from 6 to 12 treatments. The average number of
treatment being 9.
• The number of treatments needed is determined by the severity of symptoms and
onset of response.
• Mild improvements can be noticed following the first 3 to 6 treatments.
• The improvements include an increase in activity level, improved sleeping
patterns, and a mild increase in appetite.
THE TREATMENT TEAM AND THEIR ROLES
Typically, ECT is performed by a team of medical professionals specifically trained in
the delivery of ECT. This team consists of:-
1. Psychiatrist
2. Anesthesiologist
3. Nursing staff
4. Technician
The psychiatrist delivers the ECT stimulation. The anesthesia team administers
medications and monitors the medical status throughout the procedure. The nursing staff
monitors progress until patient returns to the inpatient or outpatient unit. The technician
assists the treatment team in administration of ECT.
THE PROCEDURE: The nursing responsibility is divided into following:
PRE ECT NURSING CARE:
Ensure about legal consent.
Provide need based information to patient and attendants.
The night before treatment patient is kept NPO after midnight.
Withhold medications that increase seizure threshold like benzodiazepines, anti-
convulsants.
No oil should be there in hair or scalp so patients are asked to wash hair.
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Thorough physical examination including cardio vascular, pulmonary, laboratory
blood & urine test.
A skeletal history and X-ray assessment.
Assess for allergy, dentures, loose tooth.
Remove any metallic object, nail paint, make up, jewelry, eyeglasses or hairpins.
Medications in the morning can be given with a sip of water for headache, high
blood pressure, stomach reflux, or other significant medical conditions.
Setting of the ECT room: it includes:
Well equipped with sophisticated machinery facilities like:
ECT Machine
Cardiac monitor
Anesthetic appliance
Suction apparatus
Defibrillator
Accessories-
Oxygen cylinder with adjustable valve
AMBU bag
Curved tongue depressor
Mouth gag-well padded with cotton and gauze
Resuscitation apparatus
Syringes of 2ml, 5ml, 10ml
Oral airway
Endotracheal tubes
Laryngoscope
Intracath of different sizes
Suction catheter
Intravenous set
Intravenous fluid like normal saline
Adhesive tape
Scissors
Spirit swabs
BP Apparatus
Emergency drugs like Injection :–
Lignocaine, sodium bicarbonate, adrenaline, dexona, hydrocortisone, diclofenac, Calcium gluconate,
atropine, heparin, deriphylline, dopamine, diazepam, lasix, nitroglycerine, avil, potassium chloride
ECT Injections:-
1. Inj. Glycopyrrolate (Pyrrorlate)
Action-Anticholinergic
1ml=0.2mg
Route-I/V
2. Inj. Thiopentone (Thiosol)-500mg
Action: - Anaesthetic agent
Recommended dose: - 3 to 5 mg/kg of body weight
Route: - I/V
Preparation: - a. Dilute the drug in 10 ml of sterile water (10 ml. =500mg)
b. Take 5 ml (250 mg) from vial & add 5ml of sterile water, it will become-
10 ml=250mg
1 ml=25 mg
3. Inj. Succinylcholine (sucol, succa)
Action-Muscle-relaxant
Route-I/V
10ml=500mg
1ml=50mg
Recommended dose-0.5 to 1mg/kg of body weight
AMOUNT OF CURRENT:-
70-120 VOLTS of 50 cycles of alternating current passed for 0.3-1.5 seconds through electrodes.
NURSING CARE DURING ECT:
Shortly after patient arrives in the ECT treatment area, an ECT team member
inserts a catheter into vein for administering medications.
A blood pressure cuff is placed on both arms. The cuff on one arm will be used to
monitor blood pressure. Other blood pressure cuff is applied to the forearm or just
above the ankle and inflated to a level above the anticipated maximum systolic
pressure (>250 mm Hg) to prevent anesthetics from affecting muscle contraction
in the distal limb.
Oxygenation is provided using 100 percent O2 via mask and is administered
under positive pressure when respirations have stopped secondary to anesthesia
medications.
Anticholinergic medications, such as atropine and glycopyrrolate, are used to dry
secretions that may interfere with respiration under anesthesia and to decrease the
vagally mediated bradycardia and even asystole that may occur immediately after
the electrical stimulus is administered.
Ultra brief general anesthetics are used to induce unconsciousness while muscle
relaxants are in effect and during seizure elicitation e.g. Thiopental, Propofol,
Ketamine, and Methohexital.
A muscle relaxant commonly Succinylcholine is administered to prevent muscles
from twitching.
Two electrodes are placed on scalp and a pulse of electricity is administered.
A bite block is placed in the mouth just before the delivery of the electrical
stimulus to protect the teeth and oral soft tissues as the application of the electrical
stimulus directly stimulates contraction of the jaw muscles,
Seizures vary, but are generally in the 25 to 45 second range. Seizures longer than
3 minutes, with motor or EEG monitoring, are considered prolonged and should
be actively controlled using intravenous (IV) anticonvulsants, such as the short-
acting barbiturate used to induce anesthesia or benzodiazepines.
Seizures of less than 15 seconds can occur close to seizure threshold and are often
considered abortive. After the patient is conscious and vital signs are stable;
patient is transferred to the recovery area.
Certain medicines e.g. antihypertensive, inhalers for pulmonary conditions, and
steroid can be given in morning on the day of ECT. The administration of β-
blockers pre-ECT should be carefully evaluated because of the propensity of this
class of agents to enhance bradycardia or to precipitate asystole; use of atropine
pre-ECT should be considered in this circumstance. Lidocaine and its analogs can
interfere with seizure induction and should be withheld.
Medications that should be held until after recovery are hypoglycemic including
insulin, depending on an individual evaluation of the patient's needs, and long-
acting cholinesterase inhibitors for glaucoma that may interfere with anesthesia
recovery.
Close monitoring during and immediately after this treatment is done.
The ECT treatment generally lasts only 10 to 20 minutes.
In the recovery area, the nurse has to closely monitor blood pressure and level of
consciousness for another 20 to 30 minutes after which patient is shifted to his
bed.
Nursing care After ECT:
Vital signs and level of consciousness are checked again.
Food and beverages are provided and assisted with dressing as needed.
If ECT is done on outpatient basis, patient is send along with relatives.
If patients are admitted in ward, he is encouraged to participate in unit activities,
or continued to rest if feeling tired.
COMMON SIDE EFFECTS AFTER TREATMENT
Occasionally, a patient may have a headache, muscle aches, or nausea after the
treatment. These side effects can be treated with medications before or after the
ECT.
Additionally, some people may exhibit mental confusion resulting from the
combination of anesthesia and/or ECT treatment.
Acute confusion, if it occurs, typically lasts for 30 minutes to 1 hour.
Mortality: 2 / 100,000 treatments.
POSSIBLE MEMORY SIDE EFFECTS:
Memory loss is one of the greatest concerns of people who receive ECT. Two different
kinds of memory loss may occur during the course of ECT treatments.
1. Short-term memory loss during the period of time that you are having ECT
treatments.
Recent past events (2 to 6 weeks before treatment) are more sensitive to ECT.
COMMON SIDE EFFECTS AFTER TREATMENT
Occasionally, a patient may have a headache, muscle aches, or nausea after the
treatment. These side effects can be treated with medications before or after the
ECT.
Additionally, some people may exhibit mental confusion resulting from the
combination of anesthesia and/or ECT treatment.
Acute confusion, if it occurs, typically lasts for 30 minutes to 1 hour.
POSSIBLE MEMORY SIDE EFFECTS
Memory loss is one of the greatest concerns of people who receive ECT. Two different
kinds of memory loss may occur during the course of ECT treatments.
1. The first is the loss of short-term memory loss during the period of ECT
treatments. Examples: - forgetting what patient had for lunch or not remembering
talking to someone earlier in the day. The ability to remember new information
will generally return to normal level within a few weeks to a few months after the
treatments are finished.
2. The second type of memory loss that may occur involves memory loss for past
events. Recent past events (2 to 6 weeks before treatment) are more sensitive to
ECT. However, some patients may describe "spotty" memory loss for events that
occurred as far back as 6 months before beginning ECT. This memory
impairment is potentially permanent. Although it is rare, some patients have
reported a more severe memory loss of events which date back further than the 6
months preceding ECT treatments.
THE SAFETY OF ECT
The potential risks include cardiac or respiratory arrest. The risk of respiratory
or cardiac arrest resulting in death during ECT is negligible (less than 1 in 10,000
cases).
MAINTENANCE ECT
Continuation treatment, that is, treatment for 6 months beyond remission of an acute
episode of illness to prevent relapse, is standard practice for the major syndromes that are
somatically treated. At least one-half of ECT responders relapse without continuation
treatment, particularly in the first several weeks post-treatment, and aggressive
continuation treatment should be initiated as soon as remission is evident, possibly even
earlier during the ECT course itself. Patients may experience repeated episodes of
depression even if they respond very well to ECT. The treatments often begin weekly,
and the interval is gradually extended between treatment sessions, as tolerated, to
monthly or even less often. It is thought that, if patients remain well 2 months or more,
they are out of episode, and the discontinuation of continuation treatment can be
entertained. Continuation ECT is almost always given in an outpatient setting. Cognitive
functioning should be monitored, as well as the status of psychiatric symptoms and
medical fitness for each session. A common taper of ECT is treatments once a week for a
month, once every 2 weeks for two months, once every 3 weeks for two months, and
once every month for two-four months.
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