Electroconvulsive Therapy (ECT)

Electroconvulsive Therapy (ECT) is a medical treatment performed under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. The indications for treatment with ECT are numerous.

History

During the late 1930s it was observed that people suffering from both epilepsy and serious mental illnesses exhibited an interesting phenomenon in the aftermath of a seizure. These individuals would have a reduction in psychiatric symptoms, lasting anywhere from days to weeks.[1] Based on these observations, seizures were induced in patients who did not otherwise have epilepsy. It was found that the safest way to accomplish this was by delivering an electrical shock to the head. ECT was use extensively and indiscriminately in the first three decades, due to the lack of psychiatric medications at the time (the pre-antipsychotic and antidepressant era). This indiscriminate use came with serious complications and valid concerns: the public view of ECT, characterized in numerous movies (e.g. - One Flew Over The Cuckoo's Nest) portrayed it as an inhumane, horrific, and frightening procedure. This exaggerated portrayal in popular culture unfortunately stigmatized an effective and often life-saving procedure when used in the right patients.

Current practice

Eventually, clinical experience showed that the best outcomes from ECT were with people with severe mood disorders (i.e., very severe depression with melancholic features; psychotic depressions; and severe, acute mania). In more recent times, techniques for administering ECT have changed dramatically. This currently includes the use of muscle relaxants and general anesthesia. The patient is therefore fully anesthetized. Serious or persistent side effects now extremely rare. ECT is often considered a treatment of last resort, but when used with appropriately diagnosed patients, it can be extremely effective and, at times, a life-saving procedure. ECT also remains the gold standard for severe depression.

Indications

Current indications for ECT include: treatment-refractory and medication-resistant depression, refractory OCD, catatonia, psychosis, Parkinson's Disease, refractory Status epiplepticus, severe suicidality, neuroleptic malignant syndrome, depression with psychotic features.

Safety

Overall very safe and rapid acting. Out of all medical procedures involving anesthesia, it is the lowest risk procedure. The overall safety of ECT is well established. It is a low risk medical procedure.[2] There are no absolute contraindications to the use of ECT.

Stimulus Delivery

ECT can be delivered unilaterally, or bilaterally. The D’Elia placement is preferred standard for unilateral ECT. Bitemporal ECT has a greater incidence of anterograde and retrograde amnesia. Bifrontal ECT may be as effective as bitemporal but is more cognitively advantageous. Left unilateral ECT can be cognitively sparing in those who rely on right hemispheric function (visual, spatial) for their livelihood. Bilateral ECT should be used if there is greater urgency for improvement, although some studies show that a suprathreshold unilateral ECT may be just as efficacious in non-life threatening situations. If unilateral ECT fails after 6-10 treatments or history of failure, then one should consider bilateral ECT.

The length of the pulse width determines seizure generation.

Number of treatments

ECT treatment ranges between 6 to 18 treatments, up to 2-3 times per week. Delivering ECT 2 times per week confers a better cognitive profile.

It is important to inform patients about the risks and benefits of ECT. Below is a template for informed consent:

  1. Introduce self, obtain patient ID, ask about SDM if necessary
  2. Ask patient what they understand about ECT
  3. Explain procedure (# of treatments, what treatments will consist of, what happens just before and after treatment, how they will feel, how long each session lasts)
  4. Explain efficacy (with depression, bitemporal is 65%, RUL is 58%)
  5. Cover serious/life threatening risks (1 per 10,000 treatment deaths, risks of general anesthesia)
  6. Cover common side effects (confusion, headache, muscle pains, HTN, cardiac changes, nausea, cognitive difficulties - specifically memory 1-2 months prior and after procedure may be “hazy”)
  7. Discuss alternate treatment medications (continue with medications, change medications, psychotherapy options)
  8. Discuss next steps (work-place adjustment, change to medications prior to treatment course beginning)
  9. Limitations with treatment (no driving for 24 hours, time off work/school)

Medications

Some medications should be stopped prior to starting ECT, while others should be continued.

Medications indications and contraindications

Medications to continue Medications to stop
Antihypertensives Anticonvulsants (taper dose, or discontinue completely)
Heartburn medications (proton pump inhibitors, H2 blockers) Stimulants (taper and discontinue completely)
Glaucoma medications Lithium (discontinue 36-48 hours prior to treatment, there is a risk of developing delirium while on lithium)
Neuroleptics/Anti-psychotics (Haloperidol, clozapine, risperidone - may be beneficial in combination with ECT) MAOIs (consider dose reduction)
Antidepressants

Procedure Checklist

  1. Confirm ID of patient (name, age, patient diagnosis)
  2. Let anesthesia know of medication doses
  3. Assess patient for symptoms since the last treatment
  4. Ensure patient is NPO at least 8 hours prior to treatment
  5. Confirm ECT parameters
  6. Set parameters on the machine
  7. Obtain BP/HR/O2 sat/ECG monitoring
  8. Prep skin and scalp
  9. Prep ECT electrodes
  10. Place EEG monitoring electrodes appropriately
  11. Anesthesia to obtain IV access
  12. Anesthesia to administer IV meds
  13. Anesthesia to pre-oxygenate
  14. Ensure appropriate muscle relaxant (wait at least 60 seconds from the administration of succinylcholine)
  15. Anesthesia to place bite block
  16. Place ECT electrodes
  17. Administer stimulus
  18. Monitor motor seizure activity (time, strength)
  19. Monitor EEG seizure (time, resolution, post-ictal suppression)
  20. Anesthesia to ensure appropriate oxygenation, with suction of airway if necessary
  21. Administer any post-treatment medications
  22. Monitor vitas post-treatment
  23. Observe patient for 1 hour post-treatment
  24. Ensure patient is accompanied home once recovery monitoring complete
  25. Ensure documentation complete
  • Dental injury, orobuccal lacerations (using a bite block prevents this)
  • Post-ictal confusion (lasting 15-60 minutes)
  • Memory loss (retrograde). Subjective memory worsening is reported by a minority of patients. However, young women are at risk of experiencing these symptoms.[3]
  • Headaches
  • Myalgias (Muscle pain in the back is due to succinylcholine)
  • Nausea and vomiting
  • Jaw pain (due to contraction of masseter muscle due to direct electrical contraction)
References