Electroconvulsive Therapy

1. Electroconvulsive Therapy Stephanie Freeman January 29, 2003

2. Case 1 • 72 year old white female with anxiety, depression, CAD, HTN ,and history of anoxic brain injury secondary to MI is brought to ED by family. She has been experiencing increasing anxiety, anger, crying spells, paranoid ideation, confusion. Pt has been also experiencing decreased sleep. She was admitted to the psychiatry service. An Internal Medicine and ECT consult was obtained

3. Case 2 • 59 year old white male with history of GERD, hiatal hernia, irritable bowel disease, and depression has presented to the ED numerous times complaining of chest pain. He was admitted to the psychiatry service and an Internal Medicine consult was obtained to evaluate patient’s abdominal and chest discomfort. Patient could not tolerate antidepressant medications, and ECT was initiated.

4. Introduction • What is ECT ? • What are the indications? • How effective is it? • How is it performed? • What are the medical implications?

5. Definition • Electroconvulsive therapy (ECT) is a procedure in which electrical currents are used to induce seizures.

6. Indications • Depression • Treatment of major depression that is refractory to antidepressants is the major indication for ECT. • Psychotic depression, catatonic stupor, severely suicidal, food refusal, pregnancy • Remission rate 60-80%

7. Indications • Other psychiatric conditions • Schizophrenia • Bi-polar disorder • Mania • Atypical Psychosis

8. Indications • Particularly useful in elderly patients with depression. • Especially depression characterized by prominent social withdrawal and psychomotor retardation • ECT is associated with higher 5-10 year survival compared with treatment with to antidepressants.

9. Electroconvulsive Therapy

10. Technique • Electrodes placed unilaterally or bilaterally on scalp. • Thirty to sixty seconds of a generalized tonic-clonic seizure. • Two to three times weekly for 6-12 treatments.

11. Technique • General Anesthesia • Short acting IV agents: methohexital or propofol • Succinylcholine for neuromuscular blockade to prevent musculoskeletal injuries (fractures) • Airway control with bite block and mask ventilation • Anticholinergic agent, atropine or glycopyrolate before procedure to decrease bradycardia and salivation

12. Morbidity and Mortality • Low mortality • 4 deaths / 100,000 treatments • No absolute contraindications

13. Morbidity and Mortality • Conditions associated with increased risk • Unstable or severe cardiovascular disease • Space occupying intracranial lesion with evidence of elevated intracranial pressure • Recent cerebral hemorrhage or stroke • Bleeding or otherwise unstable vascular aneurysm • Severe pulmonary conditions • ASA class IV or V

14. Cardiovascular Effects • Tonic phase of seizure • 15 to 20 second parasympathetic discharge • Arrhythmias: bradycardia, atrial arrhythmias, PACs, PVCs, AV block, asystole • Asystole • Can occur anytime during course • Not predicted by HTN, Ischemic EKG changes, use of CCB, NTG, Ace inhibitors, diuretics • Patients with heart block or rhythm disturbances are less likely to develop asystole.

15. Cardiovascular Effects • Clonic phase of seizure • Catecholamine surge • Tachycardia and hypertension • Duration of tachycardia corresponds to length of seizure • Resolves within 10-20 minutes of the seizure

16. Cardiovascular Effects • All patients are followed by continuous EKG monitoring during procedure. • ECT may cause transient depression of EF in healthy patients. • Cardiac complications are rare and almost always occur in patients with underlying cardiovascular disease.

17. Cardiovascular Effects • Even patients at high risk for CV complications can tolerate ECT. • If complications occur and are treated, patients can go on to complete the course

18. Cardiovascular Risk Reduction • ACC defines ECT as low risk procedure. • Pre-operative cardiac risk assessment • ACC/AHA algorithm • ACP algorithm

19. Cardiovascular Risk Reduction • Most patients can undergo ECT with appropriate medical management except those with: • Unstable Angina • Decompensated Heart Failure • Severe Valvular Disease • Malignant Arrhythmias

20. Cardiovascular Risk Reduction • Beta Blockers • Used to treat post ECT tachycardia and HTN • Give atropine or glycopyrrolate to prevent bradycardia • Prophylactic use is controversial • No studies have shown a decrease in CV complications with the use of short acting beta blockers prior to ECT

21. Cardiac Conditions • Heart Failure • Delay in patient with decompensated heart failure or significant valvular disease. • For compensated heart failure, an echo is recommended. • In systolic dysfunction continue diuretics, vasodilators, etc • In diastolic dysfunction, control BP. Prompt control of post seizure HTN is important

22. Pacemakers Patients with pacemakers can safely undergo ECT. Must be prepared to deactivate it if necessary AICD Deactivate before induction Reactivate after seizure Cardiac Conditions

23. Pulmonary Disorders • Asthma and COPD • Bronchospasm • Give bronchodilators before each treatment • Pay special attention to oxygenation during the procedure. • Prolonged Seizures • May occur in patients taking theophylline • Discontinue theophylline before ECT • If unable to stop theophylline, give dosage that will maintain lowest therapeutic level.

24. CNS Effects • Memory Loss • Retrograde or anterograde • Improves in several weeks • Disorientation • 20-30 minutes after ECT patient is severely obtunded • Obtundation progresses to disorientation which lasts minutes to hours.

25. CNS Effects • Delirium • 10 % of patients • Usually resolves in one hour • Associated conditions • Recent CVA • Parkinson’s • Advanced Age

26. Neurological Conditions • Brain Tumors • Used to be considered an absolute contraindication to ECT • ECT causes increased cerebral blood flow which could cause increased ICP and result in neurological demise • ECT can be performed in patients with brain tumors as long as there is no evidence of increased ICP. • Neurologic and neurosurgical consultation recommended.

27. Neurological Conditions • Stroke • ECT can be performed safely in patients who have had strokes. • Unclear about how soon ECT can be performed after the event. • Dementia • ECT is effective in patients with dementia • Delirium is a side effect

28. Conclusions • ECT is a safe and effective treatment for several psychiatric disorders. • It can be used safely in patients with medical comorbidities. • With appropriate evaluation and monitoring before, during, and after the procedure, complications can be minimized.