Electroconvulsive Therapy ECT

1. Electroconvulsive Therapy(ECT) Indications and Procedures

2. Late 19th to Early 20thCentury Nosology Neurosyphilis (dementia paralytica) Dementia praecox (schizophrenia) Manic-depressive insanity Late 19th to Early 20thCentury Treatments No effective treatments A History of ECT is�A History of Modern Psychiatry

3. Early Treatments Seclusion in large state supported hospitals Chains, restraining chairs, cold and hot baths Sedate �Experimental� interventions Infectious Theories: �Treatment� was removal of teeth, tonsils, gall bladder, and large intestine Eugenic Theories: �Treatment� was surgical removal of sexual organs � salpingectomy and vasectomy In 1907, state lawmakers in Indiana made mandatory the sterilization of �criminals, idiots, imbeciles and rapists� By 1940, 30 US states had sterilized more than 18,000 people

4. Early Neurosyphilis TreatmentExample of early linking of clinical observations with a putative illness theory and treatment Chronic and progressive syphilis has no fever Professor Wagner-Jauregg of Vienna Transfused blood of malarial seamen to 9 neurosyphilitic men Three of the patients recovered, three improved, three showed no change

5. Early Convulsive Therapy Observed Clinical Pattern: Patients with dementia praecox who developed epileptic seizures after a head injury or after encephalitis were occasionally had notable symptomatic improvement

6. Dr. Ladislas Meduna (1930s)Hungarian Neuropathologist Observed postmortem that patients with dementia praecox had fewer than normal neuroglia Observed postmortem that epileptic patients had more neuroglia than normal Question: Can induced cortical seizures help patients with dementia praecox, perhaps related to an increase in neuroglia?

7. First Patient Treated: Zoltan 33 year old psychotic mute who had been withdrawn for four years � catatonic and required a feeding tube January 23, 1934 Dr. Meduna injected camphor in oil IM (known to cause non-lethal seizure in animals) After 45 minutes (typical 15-60 minute lag time), Zoltan had a 60 second seizure

8. Dr. Ladislas Meduna�s journal entry a few weeks later

9. Metrazol Alternative to camphor in oil Produces seizures within minutes Patient�s thoughts begin to race Patient�s hears beats more rapidly Patient experiences feeling of terror and impending doom This is not pleasant

10. Alternative to Metrazol - Electricity 39 year old patient suffering from a manic and psychotic episode admitted to University Hospital in Rome Prior success with Metrazol April 11, 1938 Drs. Ugo Cerletti and Luigi Bini By 1940 electroconvulsive treatment (ECT) was as popular as Metrozol

11. Early versions of ECT Why Negative Image? No informed consent Against wishes No muscle relaxant No sedative Excessive dose of electricity

12. Modern ECT Informed Consent Patient is Sedated Patient has Oxygen Patient has muscle relaxant to prevent fractures Patient had dentures removed and a �bite block� to prevent tongue biting Patient is monitored by the anesthesiologist Least amount of electricity of used (1/7 to shock a patient in cardiac arrest)

13. What occurs during ECT?

14. Diagnostic Indications for ECT Major Depressive Episode Bipolar Disorder, Depressed Bipolar Disorder, Mania Schizophrenia - Catatonic subtype Schizoaffective Disorder Delirium

16. ECT is Treatment of Choice for: Actively suicidal depressed patients who may not live until anti-depressants work Depressed patients (particularly the elderly) whose medical condition makes administration of antidepressants risky. Seriously depressed patients who have had an adequate trial of antidepressants

17. Contraindications Very High Risk ? intracranial pressure (brain tumor, infection) Recent MI (Vagal arrhythmias producing postictal PVCs and extravagal arrhythmias producing PVCs anytime during the procedure) Moderate Risk Severe osteoarthritis, osteoporosis Retinal detachment CV disease (HTN, Angina) Recent CVA Pheochromocytoma

18. Typical Procedure Prepare patient NPO after midnight, discontinue meds Patient�s vital signs are monitored throughout ECT Atropine premedication (to decrease gastric secretions) Provide 100% O2 (to prevent hypoxia) Give methohexital (Brevital) (barbiturate anesthetic) Give succinylcholine (Anectine) (short acting paralytic) Give electroconvulsive stimulus Unilateral (less memory loss) or Bilateral (more effective) Monitor patient until stable (15-30 min) Provide diazepam (Valium) for agitation

19. Side effects of ECT Amnesia (retrograde and anterograde) Variable after 3-4 treatments Lasting 2-3 months Headache, muscle aches, nausea Dizziness, confusion

20. Side effects of ECT medications Anesthesia risks Atropine ? worsens narrow angle glaucoma Succinylcholine ? prolonged by pseudocholinesterase deficiency states Class 1A and 1B anti-arrhythmics can potentiate succinylcholine Methohexital can precipitate an attack of acute intermittent porphyria

21. How does ECT work? No one really knows. Perhaps related to elevated neurotransmitters in CNS Clearly true: Seizures must be repeated 2 �3 times per week A single seizure is not useful Full treatment must be done (typically 10 - 12 sessions) Relapse is possible

22. Points to counter ECT stigma Effective Painless Rapidly Acting Low Mortality Rate (0.01% - 0.03%) Usually due to CV deaths related to anesthesia