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Electro Convulsive Therapy

Electro Convulsive Therapy. Mohammed Jafferany, MD Resident H-R Psychiatry Program. Introduction. Recent resurgence in past decade Excellent safety profile Superior Efficacy Economic benefits Less stigmatization. History. Early Theories Theory of Biological Antagonism

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Electro Convulsive Therapy

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  1. Electro Convulsive Therapy Mohammed Jafferany, MD Resident H-R Psychiatry Program

  2. Introduction • Recent resurgence in past decade • Excellent safety profile • Superior Efficacy • Economic benefits • Less stigmatization

  3. History • Early Theories • Theory of Biological Antagonism • Insulin Shock Therapy • Electrically induced seizures • Improvements in Anesthesiology

  4. Early Theories • Hippocrates: Documented the cure of insane patient following malaria-induced seizures. • Swiss physician “Paracelsus” in 1500s, induced seizures with oral camphor to treat mania and psychosis.

  5. Biological Antagonism Theory • Hungarian physician Meduna in 1934 reported an inherent biological antagonism between schizophrenia and epilepsy. • He reported beneficial effects of seizures induced by camphor in catatonic patient.

  6. Insulin Shock Therapy • Manfred Sakel, a Viennese physician in 1920s. • He documented insulin therapy for schizophrenia. • Insulin was administered in patients to induce a hypoglycemic state.

  7. Electrically induced Seizures • In 1937, Italian physicians Cerletti & Bini applied electricity to head to induce therapeutic seizures. • First patient had catatonia and he improved. • Safer than chemically induced seizures. • Widespread acceptance through out Europe and USA.

  8. Improvements in Anesthesiology • Early period complications like bone fractures and patient discomfort. • Use of Curare, as muscle relaxant, by Bennett in 1940 allowed complete paralysis of patient during seizure. • Development of short acting IV barbiturates in 1950s allowed rapid induction of sedation and amnesia surrounding procedure.

  9. Mechanism of Action • Psychodynamic theories • Placebo effects • Memory Eraser • Seizure as curative agent • Biochemical changes • Therapeutic effects of rise in seizure threshold • Hippocampal Neurogenesis

  10. Psychodynamic Theories • The beneficial effect of ECT is to its fulfillment of the need for punishment in the self loathing, depressed patient.

  11. Placebo Effect • The beneficial effects are due to wishful thinking on the part of the staff and the patient

  12. Memory Eraser • Beneficial effects of ECT are related to its ability to disturb recent memory, thereby erasing the recall of recent traumas, that led to depressive episode.

  13. Seizure, as Curative event • ECT is ineffective when seizure is sub-threshold or pharmacologically blocked. • Having a generalized seizure, is crucial to antidepressant effect of ECT.

  14. Biochemical Theory • Variety of biochemical changes in neurotransmitters, that are also implicated in the therapeutic effect of antidepressant medications. • Serotonin , Norepinephrine • Alteration in concentration or up-regulation of their receptors.

  15. Rise in seizure threshold • The chemical changes responsible for terminating the generalized seizure may play larger role in ECT effect. • These chemical changes lead to gradual rise in the seizure threshold over a course of ECT.

  16. Hippocampal Neurogenesis • Some neuroimaging studies have shown reduced hippocampal volumes in depressed patients. • Increased brain derived neurotrophic factor (BDNF) levels in hippocampus. • Increased mossy fiber sprouting and and neurogenesis in the hippocampus

  17. Indications for ECT • Major depression, particularly with psychotic features. • Bipolar illness (depressed, manic and mixed states) • Schizophrenia (acute exacerbations) • Catatonia

  18. Other indications • Parkinsonism • Status epilepticus • Neuroleptic Malignant syndrome

  19. Indications in Depression • Medication failure • Medically ill, where antidepressants are precluded (arrhythmias) • Delusionally depressed • Previous ECT responders • Requesting ECT

  20. Contraindications • Absolute • None • Relative • Cardiovascular (Coronary artery disease, HTN, aneurysms, arrhythmias) • Cerebrovascular effects (Recent strokes, space occupying lesions, aneurysms) • Other conditions like Pregnancy and high anesthesia risk

  21. Pretreatment Evaluation • Complete medical and psychiatric history. • Physical examination • CBC • Electrolytes • EKG • CXR

  22. Informed Consent • Fully explain the risks and benefits of procedure and answer questions from patients or their relatives. • Videotapes • Information sheets • Reduce patient’s anxiety and help establish good patient-doctor relationship

  23. Concurrent medications • Psychotropic medications are discontinued during a course of ECT to avoid interactions. • Early morning hours • NPO for 6-8 hours prior to ECT

  24. Antidepressants • TCAs and MAOIs are discontinued to minimize possible CVS complications. • Newer generation SSRIs may be safer during ECT. • Lithium may cause delirium when co-administered with ECT.

  25. Anticonvulsants • They are not contraindicated but raise the electrical stimulus necessary to induce seizure. • For patients with pre-existing seizure disorder, it is safe to continue anticonvulsants and simply use a higher intensity stimulus.

  26. Benzodiazipines • Usually withheld because they raise the seizure threshold and may increase the degree of post-ictal confusion particularly in the elderly patient. • Pre-ECT anxiety or insomnia may be managed by Benadryl or low dose neuroleptic.

  27. Use of Anesthesia • Rapid induction with Amnesia • Methohexitol, 0.5-1 mg/kg, agent of choice, rapid onset and short duration of action, little impact on seizure threshold. • Propofol, 0.5-2mg/kg, it raises the seizure threshold. • Prevention of injury from seizure • Succinylcholine, the most commonly used agent today. • Attenuation of sympathetic response • Beta blocker like labetolol 10-20 mg IV, prior to induction.

  28. Seizure induction • Electrode placement • Two standard electrode placements • In unilateral, both electrodes are placed on the same hemisphere, typically on non dominant right hemisphere. • In bilateral, electrodes are placed symmetrically over the frontotemporal areas. • Stimulus intensity • Newer devices deliver constant-current brief-pulse stimulus of electricity • Seizure properties • The induced seizure must generalize. The optimal duration is more than 25 seconds. • EEG monitoring is used to determine the nature of the induced seizure.

  29. Complications • Mortality • 1-3/10,000 • Majority of ECT related deaths are due to cardiovascular complications. • Cognitive complications • Post-treatment confusion: A brief (15-30 minutes) period of confusion immediately following treatment is seen in 10%. • Delirium: Seen in elderly, with pre-existing dementia, with neurological impairment and with bilaterally applied ECT • Memory loss: Associated with anterograde (returns to baseline 2-6 months post-ECT) and retrograde amnesia

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