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brain-stimulation:ect [on May 27, 2019]
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 ====== Electroconvulsive Therapy (ECT) ====== ====== Electroconvulsive Therapy (ECT) ======
 +{{INLINETOC}}
 ===== Primer ===== ===== Primer =====
-**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 including for depression, bipolar mania/​depression,​ schizophrenia,​ and catatonia.+<WRAP group> 
 +<WRAP half column>​ 
 +**Electroconvulsive Therapy (ECT)** is a form of [[brain-stimulation:​home|brain stimulation]] ​performed under general anesthesia, in which electrical ​currents are passed through the brain, intentionally triggering a brief seizure. The indications for treatment with ECT are numerousincluding for [[mood:1-depression:home|major depressive disorder]][[bipolar:​bipolar-i|bipolar]] ​mania/​depression, ​[[psychosis:​schizophrenia-scz|schizophrenia]], and [[cl:0-catatonia|catatonia]]. 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<catlist brain-stimulation::​ -columns:1 -noAddPageButton -sortAscending -noNSInBold>​ 
 +</​WRAP>​ 
 +</​WRAP>​
  
 == History == == 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.[([[http://​bjp.rcpsych.org/​content/​197/​2/​162.2|Rollin,​ H. R. (2010). Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness.]])] 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 used extensively and indiscriminately in the first three decades of it discovery, 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 ECTcharacterized 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.+<WRAP group> 
 +<WRAP half column>​ 
 +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.[([[http://​bjp.rcpsych.org/​content/​197/​2/​162.2|Rollin,​ H. R. (2010). Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness.]])] 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. 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<callout type="​info"​ title="​A Dark History"​ icon="​true">​ 
 +ECT was used extensively and indiscriminately in the first three decades of it discovery, due to the lack of psychiatric medications at the time (the pre-[[meds:​antipsychotics:​home|antipsychotic]] and [[meds:​antidepressants:​home|antidepressant]] era). This indiscriminate use came with serious complications and valid concerns. The public ​perception ​of ECT later became ​characterized in numerous movies (e.g. - //One Flew Over The Cuckoo'​s Nest//), and was portrayed 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 ​with serious mental illness. 
 +</​callout>​ 
 +</​WRAP>​ 
 +</​WRAP>​
  
 == Current Practice == == Current Practice ==
-Today, ECT is used effectively to treat severe mood disorders (i.e. - severe depression with melancholic features, psychotic depression, and severe, acute mania). Techniques and safety protocols for administering ECT have also changed dramatically. ECT is now an anesthetic procedure, and requires the use of general anesthesia and muscle relaxants. The patient is therefore fully anesthetized and asleep during the procedure. Serious or persistent side effects now extremely rare. Although, ECT is often considered a treatment of last resort, in most jurisdictions,​ it remains under-utilized due to stigma. ECT can be extremely effective and, at times, a life-saving procedure. ECT remains a first-line treatment for many psychiatric disorders.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27486154|Milev,​ Roumen V., et al. "​Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments."​ The Canadian Journal of Psychiatry 61.9 (2016): 561-575.]])]+Today, ECT is used effectively to treat various psychiatric disorders, including ​severe mood disorders (i.e. - severe depression with melancholic features, psychotic depression, and severe, acute mania). Techniques and safety protocols for administering ECT have also changed dramatically. ECT is now an anesthetic procedure, and requires the use of general anesthesia and muscle relaxants. The patient is therefore fully anesthetized and asleep during the procedure. Serious or persistent side effects now extremely rare. Although, ECT is often considered a treatment of last resort, in most jurisdictions,​ it remains under-utilized due to stigma. ECT can be extremely effective and, at times, a life-saving procedure. ECT remains a first-line treatment for many psychiatric disorders.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27486154|Milev,​ Roumen V., et al. "​Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments."​ The Canadian Journal of Psychiatry 61.9 (2016): 561-575.]])]
  
-==== Safety ==== 
-Overall, ECT is very safe and rapid acting. Out of all medical procedures involving anesthesia, it is the lowest risk procedure.[([[https://​www.ices.on.ca/​Publications/​Journal-Articles/​2017/​September/​Low-medical-morbidity-and-mortality-after-acute-courses-of-electroconvulsive-therapy|Blumberger,​ D. M., Seitz, D. P., Herrmann, N., Kirkham, J. G., Ng, R., Reimer, C., ... & Mulsant, B. H. (2017). Low medical morbidity and mortality after acute courses of electroconvulsive therapy in a population‐based sample. Acta Psychiatrica Scandinavica.]])] The mortality rate from ECT has been estimated to be less than 1 death per 98,000 treatments, which is similar to the background rate associated with anesthetic induction for any surgical procedure.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​25166734|Østergaard,​ S. D., Bolwig, T. G., & Petrides, G. (2014). No causal association between electroconvulsive therapy and death: a summary of a report from the Danish Health and Medicines Authority covering 99,728 treatments. The journal of ECT, 30(4), 263-264.]])] Some studies have shown a lower overall mortality rate from natural causes in inpatients who have received ECT compared to those who did not.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17470959|Munk-Olsen,​ T., Laursen, T. M., Videbech, P., Mortensen, P. B., & Rosenberg, R. (2007). All-cause mortality among recipients of electroconvulsive therapy: register-based cohort study. The British Journal of Psychiatry, 190(5), 435-439.]])] 
  
 ==== Indications ==== ==== Indications ====
-Current indications ​for ECT include: ​treatment-refractory ​and medication-resistant ​depression, depression ​with psychotic features, ​refractory OCD, catatonia, psychosis, Parkinson'​s Disease, ​status epiplepticus,​[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17435572|Zeiler,​ F. A., Matuszczak, M., Teitelbaum, J., Gillman, L. M., & Kazina, C. J. (2016). Electroconvulsive therapy for refractory status epilepticus:​ a systematic review. Seizure, 35, 23-32.]])] ​severe ​suicidality, and neuroleptic malignant syndrome.+Indications ​for ECT include: 
 +  * Treatment-refractory ​[[bipolar:​bipolar-i|mania]] 
 +  * [[mood:1-depression:home|Major depressive disorder]] (unipolar or bipolar depression) 
 +    * ECT is generally recommended as a second-line treatment for major depressive disorder because of the increased risk for adverse events. 
 +    * HoweverECT can also be used as a first-line treatment in certain clinical situations including: acute suicidal ideation, [[mood:1-depression:psychotic|psychotic features]]treatment-resistant depressionrepeated medication intolerance,​ [[cl:0-catatonia|catatonic features]]prior favourable response to ECT, rapidly deteriorating physical status, during [[psychosis:​z-postpartum|pregnancy]] (for any of the above indications)and patient preference.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994792/​|Milev,​ R. V., Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & CANMAT Depression Work Group. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. The Canadian Journal of Psychiatry, 61(9), 561-575.]])] 
 +  * Refractory [[ocd:​1-ocd|obsessive-compulsive disorder (OCD)]] 
 +  * [[cl:​0-catatonia|Catatonia]] 
 +  * Refractory psychosis, from [[psychosis:​schizophrenia-scz|schizophrenia]] or [[psychosis:​schizoaffective|schizoaffective]] disorder 
 +  * [[geri:​parkinsons|Parkinson'​s Disease]][([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4655896/​|NarangP.Glowacki, A., & Lippmann, S. (2015). Electroconvulsive Therapy Intervention for Parkinson'​s Disease. Innovations in clinical neuroscience,​ 12(9-10), 25–28.]])] 
 +  * Refractory [[neurology:​approach-seizures|status epilepticus]][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17435572|Zeiler,​ F. A., Matuszczak, M., Teitelbaum, J., Gillman, L. M., & Kazina, C. J. (2016). Electroconvulsive therapy for refractory status epilepticus:​ a systematic review. Seizure, 35, 23-32.]])] 
 +  * Severe [[teaching:​suicide|suicidality]] 
 +  * [[meds:​antipsychotics:​nms-neuroleptic-malignant-syndrome|Neuroleptic malignant syndrome]]
  
 ==== Contraindications ==== ==== Contraindications ====
-There are no absolute contraindications to ECT, only relative contraindications.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27486154|Milev,​ R. V., Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & MacQueen, G. M. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. The Canadian Journal of Psychiatry, 61(9), 561-575.]])] Relative contraindications include: ​space-occupying cerebral ​lesions, ​increased intracranial pressure, recent ​myocardial infarction, recent ​cerebral hemorrhage, unstable ​vascular aneurysms or malformations, pheochromocytoma,​ and class 4 or 5 anaesthesia risk (ASA IV, ASA V).[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27486154|Milev,​ R. V., Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & MacQueen, G. M. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. The Canadian Journal of Psychiatry, 61(9), 561-575.]])]+  * **There are no absolute contraindications to ECT, only relative contraindications.**[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27486154|Milev,​ R. V., Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & MacQueen, G. M. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. The Canadian Journal of Psychiatry, 61(9), 561-575.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​19339723/​|Tess,​ A. V., & Smetana, G. W. (2009). Medical evaluation of patients undergoing electroconvulsive therapy. New England Journal of Medicine, 360(14), 1437-1444.]])] 
 +  * Relative contraindications include: 
 +    * Space-occupying cerebral ​lesion with increased intracranial pressure ​or mass effect 
 +    * Recent ​myocardial infarction ​(if <''​1''​ month ago) 
 +    * Recent stroke or cerebral hemorrhage ​(if <''​1''​ month ago) 
 +    * Unstable ​vascular aneurysms or malformations 
 +    * Pheochromocytoma 
 +    * Class 4 or 5 anaesthesia risk (ASA IV, ASA V) 
 +    * Recent orthopedic injury with unstable fracture/​dislocation (if <''​1''​ month ago) 
 + [([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27486154|Milev,​ R. V., Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & MacQueen, G. M. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. The Canadian Journal of Psychiatry, 61(9), 561-575.]])]
  
-==== Number of Treatments ==== 
-ECT treatment ranges between 6 to 18 treatments, and can be delivered 2-3 times per week. Administering ECT only 2 times per week confers a better cognitive profile. If after 12 sessions there is no response, no further ECT should be pursued. 
  
 ==== Mechanism of Action ==== ==== Mechanism of Action ====
-<​imgcaption image1|>​{{ :​brain-stimulation:​ect_sine_wave_brief.png?​nolink&​500|Sine Wave, Brief Pulse, and Ultra Brief Pulse ECT}}</​imgcaption>​ +  * ECT delivers an electrical stimulus, which induces an action potential in the neurons in the brain. 
-ECT delivers an electrical stimulus, which induces an action potential in the neurons in the brain. ​Before the invention of newer techniques, older sine wave machines were used. Now, brief pulse or ultra brief pulse ECT is used, which provides a more efficient delivery of electrical energy (see <imgref image1>​). ​The exact mechanism of action of ECT's antidepressant effects remains unknown, ​and is hypothesized to be due to its effects on various central nervous system functionsincluding neurotrophic factorsneurotransmitters, hormones, and neuropeptides. +  * The exact mechanism of action of ECT's antidepressant effects remains unknown, ​but it is hypothesized ​that the induced seizure leads to changes in neurotransmittersneuroplasticityfunctional connectivity,​ increased levels of brain-derived neurotrophic factor (BDNF), hormones, and/or neuropeptides.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994792/​|MilevR. V.Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & CANMAT Depression Work Group. ​(2016). Canadian Network for Mood and Anxiety Treatments ​(CANMAT2016 clinical guidelines for the management of adults with major depressive disorder: section 4Neurostimulation treatments. The Canadian Journal of Psychiatry61(9), 561-575.]])]
- +
-The delivery of the electrical stimuli depends on the placement of the electrodesThe electrodes can be bifrontalbilateralor right unilateral ​(RUL) (see <imgref image2>). TypicallyRUL is used because it results in less cognitive side effects.+
 ===== Physiological Effects ===== ===== Physiological Effects =====
 == Cardiac == == Cardiac ==
-ECT affects autonomic nervous system activity, which causes rapid hemodynamic changes. The heart rate goes down (as ECT causes a parasympathetic drive). The effects of ECT on the heart is similar to a brief period of “vigorous exercise.”[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​22481560|Kurup,​ V., & Ostroff, R. (2012). When cardiac patients need ECT—challenges for the anesthesiologist. International anesthesiology clinics, 50(2), 128-140.]])]+  * ECT affects autonomic nervous system activity, which causes rapid hemodynamic changes. The heart rate goes down (as ECT causes a parasympathetic drive). The effects of ECT on the heart is similar to a brief period of “vigorous exercise.”[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​22481560|Kurup,​ V., & Ostroff, R. (2012). When cardiac patients need ECT—challenges for the anesthesiologist. International anesthesiology clinics, 50(2), 128-140.]])] 
 == Brain == == Brain ==
-During ECT, cortical blood flow increases by up to 300%, which increases intracranial pressure (ICP). Cerebral oxygen demand also increases up to 200% during seizure activity. ECT remains safe in patients with brain tumours and intracranial masses provided that there is not significant cerebral edema (Hence, increased ICP is a relative contraindication).[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​10868329|Patkar,​ A. A., Hill, K. P., Weinstein, S. P., & Schwartz, S. L. (2000). ECT in the presence of brain tumor and increased intracranial pressure: evaluation and reduction of risk. The journal of ECT, 16(2), 189-197.]])] Brain volumes //​increase//​ with ECT treatment,​[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​26395813|Bouckaert,​ F., De Winter, F. L., Emsell, L., Dols, A., Rhebergen, D., Wampers, M., ... & Vandenbulcke,​ M. (2016). Grey matter volume increase following electroconvulsive therapy in patients with late life depression: a longitudinal MRI study. Journal of psychiatry & neuroscience:​ JPN, 41(2), 105.]])] and there is also an increase in Brain Derived Neurotrophic Factor (BDNF) levels.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16757154|Bocchio-Chiavetto,​ L., Zanardini, R., Bortolomasi,​ M., Abate, M., Segala, M., Giacopuzzi, M., ... & Gennarelli, M. (2006). Electroconvulsive Therapy (ECT) increases serum Brain Derived Neurotrophic Factor (BDNF) in drug resistant depressed patients. European Neuropsychopharmacology,​ 16(8), 620-624.]])][([[https://​www.tandfonline.com/​doi/​abs/​10.3109/​15622975.2014.892633|Brunoni,​ A. R., Baeken, C., Machado-Vieira,​ R., Gattaz, W. F., & Vanderhasselt,​ M. A. (2014). BDNF blood levels after electroconvulsive therapy in patients with mood disorders: a systematic review and meta-analysis. The World Journal of Biological Psychiatry, 15(5), 411-418.]])] +  * During ECT, cortical blood flow increases by up to 300%, which increases intracranial pressure (ICP). Cerebral oxygen demand also increases up to 200% during seizure activity. ECT remains safe in patients with brain tumours and intracranial masses provided that there is not significant cerebral edema (Hence, increased ICP is a relative contraindication).[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​10868329|Patkar,​ A. A., Hill, K. P., Weinstein, S. P., & Schwartz, S. L. (2000). ECT in the presence of brain tumor and increased intracranial pressure: evaluation and reduction of risk. The journal of ECT, 16(2), 189-197.]])] Brain volumes //​increase//​ with ECT treatment,​[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​26395813|Bouckaert,​ F., De Winter, F. L., Emsell, L., Dols, A., Rhebergen, D., Wampers, M., ... & Vandenbulcke,​ M. (2016). Grey matter volume increase following electroconvulsive therapy in patients with late life depression: a longitudinal MRI study. Journal of psychiatry & neuroscience:​ JPN, 41(2), 105.]])] and there is also an increase in Brain Derived Neurotrophic Factor (BDNF) levels.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16757154|Bocchio-Chiavetto,​ L., Zanardini, R., Bortolomasi,​ M., Abate, M., Segala, M., Giacopuzzi, M., ... & Gennarelli, M. (2006). Electroconvulsive Therapy (ECT) increases serum Brain Derived Neurotrophic Factor (BDNF) in drug resistant depressed patients. European Neuropsychopharmacology,​ 16(8), 620-624.]])][([[https://​www.tandfonline.com/​doi/​abs/​10.3109/​15622975.2014.892633|Brunoni,​ A. R., Baeken, C., Machado-Vieira,​ R., Gattaz, W. F., & Vanderhasselt,​ M. A. (2014). BDNF blood levels after electroconvulsive therapy in patients with mood disorders: a systematic review and meta-analysis. The World Journal of Biological Psychiatry, 15(5), 411-418.]])] ​During ​ECT, the brain will try to achieve homeostasis in response to the electrical ​current, and will release GABA to suppress seizures.[([[https://​pubmed.ncbi.nlm.nih.gov/​12611844/​|Sanacora,​ G., Mason, G. F., Rothman, D. L., Hyder, F., Ciarcia, J. J., Ostroff, R. B., ... & Krystal, J. H. (2003). Increased cortical GABA concentrations in depressed patients receiving ECT. American Journal of Psychiatry, 160(3), 577-579.]])] The release of GABA is thought to play a role in the antidepressant effect of ECT as well.
- +
-===== Procedure ===== +
-<WRAP group> +
-<WRAP half column>​ +
-== Phases of ECT == +
-  - Anesthesia  +
-  - Muscle relaxant  +
-  - The electrical ​stimulus  +
-  ​
Seizure 
 +
-  - Post-ictal recovery+
  
 +===== Pre-ECT =====
 ==== Informed Consent ==== ==== Informed Consent ====
 It is important to inform patients about the risks and benefits of ECT. Below is a template for informed consent: It is important to inform patients about the risks and benefits of ECT. Below is a template for informed consent:
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   * Limitations with treatment (no driving for 24 hours, time off work/​school)   * Limitations with treatment (no driving for 24 hours, time off work/​school)
  
-</WRAP+==== Medications ==== 
-<WRAP half column>+Some medications should be stopped prior to starting ECT, while others should be continued. 
 + 
 +<panel type="​info"​ title="​Medication indications and contraindications"​ no-body="​true"​> 
 +^ Medications to continue ​                                                                                                    ^ Medications to stop or hold                                                                                                                  ^ 
 +| Antihypertensives (reduce hypertension during procedure) ​                                                                   | Anticonvulsants (taper dose, or discontinue completely) ​                                                                                     | 
 +| Heartburn medications (e.g., proton pump inhibitors, H2 blockers) (reduce gastric secretions and the\\ risk of aspiration) ​ | Stimulants (taper and discontinue completely) ​                                                                                               | 
 +| Glaucoma medications ​                                                                                                       | Lithium (discontinue 36-48 hours prior to treatment, because **there is a risk of developing delirium while on lithium** and receiving ECT)  | 
 +| Antipsychotics (Haloperidol,​ clozapine, risperidone - may be beneficial in combination with ECT)                            | MAOIs (consider dose reduction) ​                                                                                                             | 
 +| Antidepressants ​                                                                                                            | Benzodiazepines (should be held by 17:00, the day before each ECT treatment) ​                                                                | 
 +| Bronchodilators (to optimize their respiratory function for the procedure) ​                                                 | Diuretics (hold in the morning to help prevent patients from having episodes of urinary incontinence during the procedure) ​                  | 
 +</panel> 
 + 
 +===== Procedure =====
 ==== Checklist ==== ==== Checklist ====
-<​WRAP ​col2>+<callout icon="​true"​ type="​warning">​ 
 +**Never forget**: give the anesthetic first, and THEN give the muscle relaxant! 
 +</​callout>​ 
 + 
 +<WRAP group> 
 +<​WRAP ​half column> 
 +== 1. Confirm and Check ==
   - Confirm ID of patient (name, age, patient diagnosis)   - Confirm ID of patient (name, age, patient diagnosis)
   - Let anesthesia know of medication doses   - Let anesthesia know of medication doses
Line 67: Line 108:
   - Prep ECT electrodes   - Prep ECT electrodes
   - Place EEG monitoring electrodes appropriately   - Place EEG monitoring electrodes appropriately
 +
 +== 2. Anesthesia ==
   - Anesthesia to obtain IV access   - Anesthesia to obtain IV access
   - Anesthesia to administer IV meds   - Anesthesia to administer IV meds
   - Anesthesia to pre-oxygenate   - Anesthesia to pre-oxygenate
 +
 +== 3. Muscle relaxant ==
   - Ensure appropriate muscle relaxant (wait at least 60 seconds from the administration of succinylcholine)   - Ensure appropriate muscle relaxant (wait at least 60 seconds from the administration of succinylcholine)
 +</​WRAP>​
 +
 +<WRAP half column>
 +== 4. Placement ==
   - Anesthesia to place bite block   - Anesthesia to place bite block
   - Place ECT electrodes   - Place ECT electrodes
 +
 +== 5. Electrical stimulus ==
   - Administer stimulus   - Administer stimulus
 +
 +== 6. Seizure ==
   - Monitor motor seizure activity (time, strength)   - Monitor motor seizure activity (time, strength)
   - Monitor EEG seizure (time, resolution, post-ictal suppression)   - Monitor EEG seizure (time, resolution, post-ictal suppression)
   - Anesthesia to ensure appropriate oxygenation,​ with suction of airway if necessary   - Anesthesia to ensure appropriate oxygenation,​ with suction of airway if necessary
 +
 +== 7. Post-ictal recovery ==
   - Administer any post-treatment medications   - Administer any post-treatment medications
   - Monitor vitas post-treatment   - Monitor vitas post-treatment
Line 82: Line 137:
   - Ensure patient is accompanied home once recovery monitoring complete   - Ensure patient is accompanied home once recovery monitoring complete
   - Ensure documentation complete   - Ensure documentation complete
-</​WRAP>​ 
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
  
 +==== Parameters ====
 +Treatment parameters for ECT include:
 +  - Electrode placement and position
 +  - Electrical intensity/​stimulus
 +  - Pulse width
  
 ==== Electrode Placement ==== ==== Electrode Placement ====
-<​imgcaption image2|>​{{ :​brain-stimulation:​ect-placement-bl-rul-bf.png?​nolink&​600|ECT electrode placement}}</​imgcaption>​ +<callout type="​tip"​ title="​Electrode Placement Tip" icon="​true">​ 
-ECT can be delivered via three placements: bilateral (bitemporal), bifrontal, or right unilateral ​placements. Typically, ​right unilateral ECT is given first due to its favourable ​cognitive ​profile. The D’Elia placement ​(i.e. - Right Unilateral) is the preferred standard ​for unilateral ECTLeft unilateral ECT can be cognitively sparing ​in those who rely on right hemispheric function ​(visualspatialfor their livelihood.+  * Use concave electrode plates for bifrontal (BF) and right unilateral (RUL) 
 +  * Use flat electrode plates for bitemporal (BT) 
 +</​callout>​ 
 +<WRAP group> 
 +<WRAP half column>​ 
 +  * ECT can be delivered via one of 3 placements: right unilateral placement (RUL), bifrontal (BF), or bitemporal (BT). 
 +  * Right unilateral (also called the //​D'​Elia placement//​) ECT is typically tried first due to its more favourable cognitive profile. Right unilateral ECT is also preferred over left unilateral, since most individuals are left-hemisphere dominant. Left unilateral ECT can be considered in patients if cognitive sparing of right hemispheric function (especially visual-spatial) is important for their livelihood. 
 +    * If unilateral ECT fails after 6 to 10 treatments, or there is a history of treatment failure, then one should consider moving onto bilateral ECT. 
 +  * Bifrontal ECT may be as effective as bitemporal, but is more cognitively advantageous.  
 +  * Bitemporal ECT has a greater incidence of anterograde and retrograde amnesia. Ultimately, bilateral ECT should be used if there is greater urgency for improvement or life threatening situations. 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<​imgcaption image2|> 
 +{{ :​brain-stimulation:​ect-placement-bl-rul-bf.png?​nolink&​600|ECT electrode placement}} 
 +</​imgcaption>​ 
 +</​WRAP>​ 
 +</​WRAP>​ 
 +<​mobiletable 1> 
 +<panel type="​info"​ title="​ECT Electrode Placement"​ subtitle="​Adapted fromRapoport, M. J. (2016). Geriatric psychiatry review and exam preparation guide: A case-based approach."​ no-body="​true"​ footer="">​ 
 +^ Placement ​              ^ Advantages ​                                                                                                                                                                                                                                                                      ^ Disadvantages ​                                                                                                                                                                             ^ 
 +^ Right Unilateral (RUL)  | • Response rates comparable to BT and BF\\ • Ultrabrief pulse width ECT has good evidence for benefit\\ • Fewer cognitive side effects\\ • Good for patients with cognitive impairment while receiving ​bilateral ​ECT, or a history of cognitive side effects with bilateral ECT  | • Need higher dosages ​(4-6x seizure threshold), so may not be able to deliver therapeutic dose for elderly with high seizure thresholds\\ • Slower response than with bilateral placement ​ | 
 +^ Bifrontal (BF)          | • Faster response than RUL\\ • Possibly fewer cognitive side effects\\ compared to BT in elderly patients ​                                                                                                                                                                       | • More cognitive side effects compared to RUL                                                                                                                                              | 
 +^ Bitemporal (BT)         | • Faster response than RUL\\ • Considered gold standard\\ • Good for patients who need rapid response ​                                                                                                                                                                           | • More cognitive side effects compared to RUL                                                                                                                                              | 
 +</​panel>​ 
 +</​mobiletable>​ 
 +==== Electrical Stimulus ==== 
 +<WRAP group> 
 +<WRAP half column>​ 
 +  * The electrical intensity is based on the minimum intensity to produce a generalized seizure, called the seizure threshold (ST) 
 +  * Before the invention of newer techniques, older sine wave machines were used, which delivered long pulse width, and was associated with greater side effects. 
 +  * Now, brief pulse (BP) or ultra brief pulse (UBP) (i.e. - a pulse width < 0.5 ms) ECT is used, which provides a more efficient delivery of electrical energy with less side effects (see <imgref image1>​).  
 +  * The amount of electrical stimuli delivered depends on the placement of the electrodes. 
 +    * The electrodes can be bifrontal, bilateral, or right unilateral ​(RUL) (see <imgref image2>). 
 +    * Typically, ​RUL is used because it results in less cognitive ​side effects. 
 +  * The delivered electrical pulse is recommended to be: 
 +    * 6 times above the seizure threshold for patients receiving RUL ECT, and  
 +    * 2 times above the seizure threshold for BF or BT ECT.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2742986/​|Sackeim,​ H. A., Prudic, J., Nobler, M. S., Fitzsimons, L., Lisanby, S. H., Payne, N., ... & Devanand, ​D. P. (2008)Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapyBrain stimulation,​ 1(2), 71-83.]])
 +  * Higher age is associated with a higher seizure threshold, and stimulus intensity may need to be increased ​for these individuals.[([[https://​pubmed.ncbi.nlm.nih.gov/​25066532/​|Yasuda,​ K., Kobayashi, K., Yamaguchi, M., Tanaka, K., Fujii, T., Kitahara, Y., ... & Motohashi, N. (2015). Seizure threshold and the half‐age method ​in bilateral electroconvulsive therapy in Japanese patients. Psychiatry and clinical neurosciences,​ 69(1)49-54.]])
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<​imgcaption image1|>​{{ :​brain-stimulation:​ect_sine_wave_brief.png?​nolink&​500 |Sine Wave, Brief Pulse, and Ultra Brief Pulse ECT}}</​imgcaption>​ 
 +</​WRAP>​ 
 +</​WRAP>​
  
-Bilateral ​(bitemporalECT has a greater incidence of anterograde ​and retrograde amnesiaBifrontal ECT may be as effective as bitemporal but is more cognitively advantageousUltimatelybilateral ECT should be used if there is greater urgency for improvement or life threatening situationsAlsoif unilateral ECT fails after to 10 treatments or there is a history ​of failure, then one should consider bilateral ​ECT.  +<panel type="​info"​ title="​Recommendations for Delivery of Electroconvulsive Therapy"​ subtitle="​Milev,​ R. V. et al. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4Neurostimulation treatmentsThe Canadian Journal of Psychiatry61(9), 561-575." no-body="​true"​ footer="​BF = bifrontalBT = bitemporal, RUL = right unilateral">​ 
-==== Dosing ​==== +^ 1st line  | • Brief pulse RUL (at 5-6× seizure threshold)\\ • Brief pulse BF (at 1.5-2.0× seizure threshold) ​                                                                                                                                                                                                                                                                                                                                        | 
-The electrical pulse to be delivered ​is recommended ​to be 6 times above the seizure threshold for patients recieving unilateral ECT, and 2.5 times above the seizure ​threshold for bilateral ECT.[([[https://​www.ncbi.nlm.nih.gov/​pmc/articles/PMC2742986/|SackeimHA., PrudicJ., NoblerM. S., FitzsimonsL., LisanbySH., PayneN., ... & DevanandD. P. (2008). Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. ​Brain stimulation1(2), 71-83.]])]+^ 2nd line  | • Ultrabrief pulse RUL (up to 8× seizure threshold) or ultrabrief pulse BF (at 1.5-2× seizure threshold)\\ • Brief pulse BT (at 1.5-2× seizure threshold) ​                                                                                                                                                                                                                                                                               | 
 +^ 2nd line  | • Twice weekly ​ECT sessions have similar efficacy to thrice weekly but have longer duration of treatment ​                                                                                                                                                                                                                                                                                                                                | 
 +^ 2nd line  | • If no response to RUL after to treatments, switch to bilateral ECT (BT or BF)                                                                                                                                                                                                                                                                                                                                                      | 
 +^ 2nd line  | • For maintenance pharmacotherapy post-ECT, use an antidepressant that has not been tried prior to ECT or [[meds:​antidepressants:​tca:​nortriptyline|nortriptyline]] plus [[meds:​mood-stabilizers-anticonvulsants:​1-lithium|lithium]] or [[meds:​antidepressants:​snri:​venlafaxine|venlafaxine]] plus lithium.\\ • Maintenance use of ECT is as effective as pharmacotherapy in preventing relapse/​recurrence after an acute course ​of ECT.  | 
 +</​panel>​ 
 +==== Seizure Duration ​==== 
 +<WRAP group> 
 +<WRAP half column>​ 
 +  * An adequate seizure in ECT is one that lasts around or greater than ''​30''​ seconds. 
 +  * If the seizure duration is less than this, there are several things ​to consider: 
 +    * If it is a brisk seizure with prominent motor activity, a higher dose of succinylcholine should ​be considered 
 +    * Review which anesthetic agents ​the patient is on, and the potential effects on seizure ​duration 
 +  * If there is a poor seizure response, you can consider: 
 +    * Using hyperventilation to augment the seizure duration[([[https://​www.ncbi.nlm.nih.gov/​pubmed/18772703|Sawayama,​ E., Takahashi, M., Inoue, A., Nakajima, K., Kano, A., Sawayama, T., ... & Miyaoka, H. (2008). Moderate hyperventilation prolongs electroencephalogram seizure duration of the first electroconvulsive therapy. The journal of ECT, 24(3), 195-198.]])] 
 +  * During the next ECT session, you can also suggest the following:​ 
 +    * Increase hydration 
 +    * Administering caffeine to increase the duration of seizures[([[https://​pubmed.ncbi.nlm.nih.gov/3631318/|ShapiraB., Lerer, B., GilboaD., DrexlerH., Kugelmass, ​S., & CalevA(1987). Facilitation of ECT by caffeine pretreatment. The American journal of psychiatry144(9)1199.]])] 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<panel type="​info"​ title="​Medications and Impact on Seizure Duration"​ subtitle=""​ no-body="​true"​ footer="">​ 
 +^ Increased seizure duration ​ | Etomidate, ketamine,​[([[https://​pubmed.ncbi.nlm.nih.gov/​22622291/​|WangX., ChenY., Zhou, X., Liu, F., Zhang, T.ZhangC. (2012). Effects of propofol ​and ketamine as combined anesthesia for electroconvulsive therapy ​in patients with depressive disorderThe journal of ECT28(2), 128-132.]])] caffeine ​ | 
 +^ No effect ​                  | Methohexital,​ remifentanil,​ alfentanil ​                                                                                                                                                                                                                                                                               | 
 +^ Shortened seizure duration ​ | Propofol, midazolam, lorazepam, thiopental, thiamylal, lidocaine ​                                                                                                                                                                                                                                                     | 
 +</​panel>​ 
 +</​WRAP>​ 
 +</​WRAP>​
  
  
- 
-==== Medications ==== 
-Some medications should be stopped prior to starting ECT, while others should be continued. 
-<panel type="​info"​ title="​Medications indications and contraindications"​ no-body="​true">​ 
-^ 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 ​                                                                                                | Benzodiazepines (should be held the day before each treatment) ​                                                | 
-</​panel>​ 
  
 ===== Post-ECT ===== ===== Post-ECT =====
 ==== Response ==== ==== Response ====
-ECT has the best response rate in geriatric depression, patients with a greater severity of illness, psychotic depression, and when there is an absence of personality disorders. In individuals with borderline personality disorder, the rates of ECT response are significantly lower, this is an important risk/​benefit consideration that needs to be discussed with patients.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​15514409|Feske,​ U., Mulsant, B. H., Pilkonis, P. A., Soloff, P., Dolata, D., Sackeim, H. A., & Haskett, R. F. (2004). Clinical outcome of ECT in patients with major depression and comorbid borderline personality disorder. American Journal of Psychiatry, 161(11), 2073-2080.]])] The effects of ECT are also dose-dependent,​ with a better response at higher doses.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​10807482|Sackeim,​ H. A., Prudic, J., Devanand, D. P., Nobler, M. S., Lisanby, S. H., Peyser, S., ... & Clark, J. (2000). A prospective,​ randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Archives of General Psychiatry, 57(5), 425-434.]])] Patients can expect improvement in symptoms by the third treatment, and achieve remission beginning by the seventh treatment.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​15119910|Husain,​ M. M., Rush, A. J., Fink, M., Knapp, R., Petrides, G., Rummans, T., ... & Zhao, W. (2004). Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for Research in ECT (CORE) report. The Journal of clinical psychiatry.]])] Suicidal ideation also similarly decreases greatly by around the fourth treatment.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​15119910|Husain,​ M. M., Rush, A. J., Fink, M., Knapp, R., Petrides, G., Rummans, T., ... & Zhao, W. (2004). Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for Research in ECT (CORE) report. The Journal of clinical psychiatry.]])] ECT also improves quality of life measures significantly for patients post-treatment.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29461332|Giacobbe,​ P., Rakita, U., Penner-Goeke,​ K., Feffer, K., Flint, A. J., Kennedy, S. H., & Downar, J. (2018). Improvements in Health-Related Quality of Life With Electroconvulsive Therapy: A Meta-analysis. The journal of ECT, 34(2), 87-94.]])] +  * ECT has the best response rate in geriatric depression, patients with a greater severity of illness, psychotic depression, and when there is an absence of personality disorders. 
- +  * In individuals with [[personality:​borderline|borderline personality disorder]], the rates of ECT response are significantly lower, ​and this is an important risk/​benefit consideration that needs to be discussed with patients.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​15514409|Feske,​ U., Mulsant, B. H., Pilkonis, P. A., Soloff, P., Dolata, D., Sackeim, H. A., & Haskett, R. F. (2004). Clinical outcome of ECT in patients with major depression and comorbid borderline personality disorder. American Journal of Psychiatry, 161(11), 2073-2080.]])] 
-The best and strongest predictor of //​non-response//​ to ECT is the degree of non-response to previous antidepressant medications. Response rates are about 50% in those who have treatment-resistant depression and up to 90% in treatment-naive patients.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​22900754|Nordenskjöld,​ A., von Knorring, L., & Engström, I. (2012). Predictors of the short-term responder rate of Electroconvulsive therapy in depressive disorders-a population based study. BMC psychiatry, 12(1), 115.]])]+  * The effects of ECT are also dose-dependent,​ with a better response at higher doses.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​10807482|Sackeim,​ H. A., Prudic, J., Devanand, D. P., Nobler, M. S., Lisanby, S. H., Peyser, S., ... & Clark, J. (2000). A prospective,​ randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Archives of General Psychiatry, 57(5), 425-434.]])] 
 +  * Patients can expect improvement in symptoms by the third treatment, and achieve remission beginning by the seventh treatment.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​15119910|Husain,​ M. M., Rush, A. J., Fink, M., Knapp, R., Petrides, G., Rummans, T., ... & Zhao, W. (2004). Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for Research in ECT (CORE) report. The Journal of clinical psychiatry.]])] Suicidal ideation also similarly decreases greatly by around the fourth treatment.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​15119910|Husain,​ M. M., Rush, A. J., Fink, M., Knapp, R., Petrides, G., Rummans, T., ... & Zhao, W. (2004). Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for Research in ECT (CORE) report. The Journal of clinical psychiatry.]])] ECT also improves quality of life measures significantly for patients post-treatment.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29461332|Giacobbe,​ P., Rakita, U., Penner-Goeke,​ K., Feffer, K., Flint, A. J., Kennedy, S. H., & Downar, J. (2018). Improvements in Health-Related Quality of Life With Electroconvulsive Therapy: A Meta-analysis. The journal of ECT, 34(2), 87-94.]])] 
 +  ​* ​The best and strongest predictor of //​non-response//​ to ECT is the degree of non-response to previous antidepressant medications. Response rates are about 50% in those who have treatment-resistant depression and up to 90% in treatment-naive patients.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​22900754|Nordenskjöld,​ A., von Knorring, L., & Engström, I. (2012). Predictors of the short-term responder rate of Electroconvulsive therapy in depressive disorders-a population based study. BMC psychiatry, 12(1), 115.]])] 
 +==== Number of Treatments ==== 
 +  * ECT treatment ranges between 6 to 18 treatments, and can be delivered 2 to 3 times per week.  
 +    * Administering ECT only 2 times per week confers a better cognitive profile. 
 +    * More than 3 treatments per week are not recommended,​ as they are associated with higher frequency of cognitive side effects. 
 +  * If after 12 sessions there is no response, no further ECT should be pursued.
  
 ==== Follow Up Treatment ==== ==== Follow Up Treatment ====
-About 50% of patients will relapse with depressive symptoms at the 12-month mark, after a successful course of ECT.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​23774532|Jelovac,​ A., Kolshus, E., & McLoughlin, D. M. (2013). Relapse following successful electroconvulsive therapy for major depression: a meta-analysis. Neuropsychopharmacology,​ 38(12), 2467.]])] Patients who receive ongoing pharmacotherapy ​have significantly lower relapse ​rates compared to patients who do not have any treatment post-ECT (most studies were done using venlafaxine ​and nortriptyline in these studies). Thus it is recommended that patients ​recieve ​pharmacotherapy (and psychotherapy) after their first ECT treatment.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​23303417|Prudic,​ J., Haskett, R., McCall, W. V., Isenberg, K., Cooper, T., Rosenquist, P. B., ... & Sackeim, H. A. (2013). Pharmacological strategies in the prevention of relapse following electroconvulsive therapy. The journal of ECT, 29(1), 3.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17146008|Kellner,​ C. H., Knapp, R. G., Petrides, G., Rummans, T. A., Husain, M. M., Rasmussen, K., ... & Biggs, M. (2006). Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Archives of general psychiatry, 63(12), 1337-1344.]])] Post-ECT pharmacotherapy should be continued for at least 12-24 months. Antidepressant choice should be the one that the patient responded the best to in the past. In absence of an effective antidepressant,​ venlafaxine ​(first choice) or nortriptyline (second choice) should be used.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29419559|Gill,​ S. P., & Kellner, C. H. (2018). Clinical Practice Recommendations for Continuation and Maintenance Electroconvulsive Therapy for Depression: Outcomes From a Review of the Evidence and a Consensus Workshop Held in Australia in May 2017. The journal of ECT.]])]+  * About 50% of patients will relapse with depressive symptoms at the 12-month mark, even after a successful course of ECT.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​23774532|Jelovac,​ A., Kolshus, E., & McLoughlin, D. M. (2013). Relapse following successful electroconvulsive therapy for major depression: a meta-analysis. Neuropsychopharmacology,​ 38(12), 2467.]])] 
 +  * Patients who receive ongoing ​antidepressant ​pharmacotherapy ​reduce their relapse ​rate by approximately half compared to patients who do not have any treatment post-ECT.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994792/​|Milev,​ R. V., Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & CANMAT Depression Work Group. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT2016 clinical guidelines for the management of adults with major depressive disorder: section 4Neurostimulation treatments. The Canadian Journal of Psychiatry, 61(9), 561-575.]])] 
 +    * Thus it is recommended that patients ​receive ​pharmacotherapy (and psychotherapy) after their first ECT treatment.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​23303417|Prudic,​ J., Haskett, R., McCall, W. V., Isenberg, K., Cooper, T., Rosenquist, P. B., ... & Sackeim, H. A. (2013). Pharmacological strategies in the prevention of relapse following electroconvulsive therapy. The journal of ECT, 29(1), 3.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17146008|Kellner,​ C. H., Knapp, R. G., Petrides, G., Rummans, T. A., Husain, M. M., Rasmussen, K., ... & Biggs, M. (2006). Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Archives of general psychiatry, 63(12), 1337-1344.]])] 
 +  * Post-ECT pharmacotherapy should be continued for at least 12 to 24 months. Antidepressant choice should be the one that the patient responded the best to in the past. In absence of an effective antidepressant, ​nortriptyline plus lithium, or venlafaxine ​plus lithium is recommended.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29419559|Gill,​ S. P., & Kellner, C. H. (2018). Clinical Practice Recommendations for Continuation and Maintenance Electroconvulsive Therapy for Depression: Outcomes From a Review of the Evidence and a Consensus Workshop Held in Australia in May 2017. The journal of ECT.]])]
 ==== Maintenance ECT ==== ==== Maintenance ECT ====
-Maintenance ECT (prophylactic ECT) should be added after an individual has gone through a second course of ECT. In addition to maintenance ECT, augmentation with an antidepressant,​ plus lithium should be considered.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17146008|Kellner,​ C. H., Knapp, R. G., Petrides, G., Rummans, T. A., Husain, M. M., Rasmussen, K., ... & Biggs, M. (2006). Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Archives of general psychiatry, 63(12), 1337-1344.]])] Again, post-ECT pharmacotherapy should be continued for at least 12-24 months.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29419559|Gill,​ S. P., & Kellner, C. H. (2018). Clinical Practice Recommendations for Continuation and Maintenance Electroconvulsive Therapy for Depression: Outcomes From a Review of the Evidence and a Consensus Workshop Held in Australia in May 2017. The journal of ECT.]])]+  * Maintenance ECT ("prophylactic ECT") should be added after an individual has gone through a second course of ECT. In addition to maintenance ECT, augmentation with an antidepressant,​ plus lithium should be considered.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17146008|Kellner,​ C. H., Knapp, R. G., Petrides, G., Rummans, T. A., Husain, M. M., Rasmussen, K., ... & Biggs, M. (2006). Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Archives of general psychiatry, 63(12), 1337-1344.]])] 
 +  * The most commonly used maintenance ECT schedule involves weekly treatments for 4 weeks, then biweekly for 8 weeks, and then monthly treatments. If signs of relapse occur, more frequent treatments should be given.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994792/​|Milev,​ R. V., Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & CANMAT Depression Work Group. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. The Canadian Journal of Psychiatry, 61(9), 561-575.]])] 
 +  * Again, post-ECTpharmacotherapy should be continued for at least 12-24 months.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29419559|Gill,​ S. P., & Kellner, C. H. (2018). Clinical Practice Recommendations for Continuation and Maintenance Electroconvulsive Therapy for Depression: Outcomes From a Review of the Evidence and a Consensus Workshop Held in Australia in May 2017. The journal of ECT.]])] ​There is evidence to support maintenance ECT as an augmentation treatment to psychopharmacological treatment in mood disorders.[([[https://​pubmed.ncbi.nlm.nih.gov/​30346352/​|Hausmann,​ A., Post, T., Post, F., Dehning, J., Kemmler, G., & Grunze, H. (2019). Efficacy of continuation/​maintenance electroconvulsive therapy in the treatment of patients with mood disorders: a retrospective analysis. The journal of ECT, 35(2), 122-126.]])] 
 +===== Side Effects and Adverse Events ===== 
 +Possible side effects and adverse events during ECT and post-ECT include:
  
-===== Side Effects ===== +<panel type="​info"​ title="​Common and Rare ECT Side Effects ​and Adverse Events"​ subtitle=""​ no-body="​true"​ footer="">​ 
-Possible side effects and adverse events from ECT include: +<​mobiletable 1> 
-  ​* Dental injuryorobuccal lacerations ​(using a bite block prevents this) +^                                       ^ Phase of ECT      ^ Incidence ​                                                                                                                                                                                                                                                                                                                                                                                                                                             ^ Notes                                                                                                                                                                                                                                                                                                                                                                         ^ 
-  * Post-ictal confusion ​(lasting 15-60 minutes) +^ Transient asystole ​                   | During procedure ​ | 65.8%[([[https://​pubmed.ncbi.nlm.nih.gov/​9659953/​|BurdJ., & Kettl, P. (1998). Incidence of asystole in electroconvulsive therapy in elderly patients. The American Journal of Geriatric Psychiatry, 6(3), 203-211.]])]                                                                                                                                                                                                                               | Older patients are actually less likely to experience this than younger patients. Considered self-limiting and not associated with any untoward outcomes.[([[https://​pubmed.ncbi.nlm.nih.gov/​9659953/​|Burd,​ J., & Kettl, P. (1998). Incidence ​of asystole in electroconvulsive therapy in elderly ​patients. The American Journal of Geriatric Psychiatry, 6(3), 203-211.]])] ​ | 
-  * Memory loss (retrograde) +^ Bradycardia ​                          | During procedure ​ | Common ​                                                                                                                                                                                                                                                                                                                                                                                                                                                | Self-limiting. Very rare case reports ​of bradycardia persisting post-ECT.[([[https://​pubmed.ncbi.nlm.nih.gov/​33067732/|KadoiY., MichizakiM., SaitoT., OtaJ., Saito, S., & Sameshima, T. (2020). Severe bradycardia at the termination of seizure during electroconvulsive therapy. JA Clinical Reports, 6(1), 1-4.]])] ​                                               | 
-  * Subjective memory worsening is reported by a minority ​of patients (young women are at greater risk of experiencing these symptoms.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/27930429|BrusO., NordanskogP., BåveU., CaoY., Hammar, Å., Landén, M., ..& Nordenskjöld,​ A. (2017). Subjective memory immediately following electroconvulsive therapy. The journal of ECT, 33(2), 96-103.]])]) +^ Transient hypertension ​               | During procedure ​ | Up to 67% in patients over age 85                                                                                                                                                                                                                                                                                                                                                                                                                      | Self-limiting. ​                                                                                                                                                                                                                                                                                                                                                               | 
-  ​* ​Headaches +^ Dental injury, orobuccal lacerations ​ | During procedure ​ | 0.02% to 0.3%[([[https://​pubmed.ncbi.nlm.nih.gov/​31972668/​|Göterfelt,​ L., Ekman, C. J., Hammar, Å., Landén, M., Lundberg, J., Nordanskog, P.& Nordenskjöld,​ A. (2020). The Incidence of Dental Fracturing in Electroconvulsive Therapy in Sweden. The journal of ECT, 36(3), 168.]])]                                                                                                                                                                | Use a bite block prevents this, and overall incidence is very rare.                                                                                                                                                                                                                                                                                                           | 
-  * Myalgias (Muscle ​pain in the back is due to succinylcholine) +Headaches ​                            | Post-procedure ​   | 45%                                                                                                                                                                                                                                                                                                                                                                                                                                                    | Typical over the counter pain medications can be used to address this. Rocuronium should be considered over succinylcholine for patients with prominent myalgia and headaches ​                                                                                                                                                                                                | 
-  * Nausea and vomiting +^ Myalgia ​                              | Post-procedure ​   | 20%                                                                                                                                                                                                                                                                                                                                                                                                                                                    | Note that muscle aches and pain is due to succinylcholine ​from anesthesia, not the ECT itself. ​                                                                                                                                                                                                                                                                               | 
-  * Jaw pain (due to contraction of masseter muscle due to direct electrical contraction)+Jaw pain                              | Post-procedure ​   | Common ​                                                                                                                                                                                                                                                                                                                                                                                                                                                | Due to contraction of masseter muscle due to direct electrical contraction ​                                                                                                                                                                                                                                                                                                   | 
 +^ Falls                                 | Post-procedure ​   | • 14% (age 65 to 80)[([[https://​pubmed.ncbi.nlm.nih.gov/​11005046/​|de Carle, A. J., & Kohn, R. (2000). Electroconvulsive therapy and falls in the elderly. The journal of ECT, 16(3), 252-257.]])]\\ • 36% (age >​80) ​                                                                                                                                                                                                                                   | Having a falls prevention plan and follow up is important in older adults. Less of a concern in younger patients. ​                                                                                                                                                                                                                                                            | 
 +^ Nausea and vomiting ​                  | Post-procedure ​   | 1 to 25%                                                                                                                                                                                                                                                                                                                                                                                                                                               | Can give ondansetron post-ECT for management. ​                                                                                                                                                                                                                                                                                                                                | 
 +^ Post-ictal confusion ​                 | Post-procedure ​   | 10%[([[https://​pubmed.ncbi.nlm.nih.gov/​19335388/​|Kikuchi,​ A., Yasui‐Furukori,​ N., Fujii, A., Katagai, H., & Kaneko, S. (2009). Identification of predictors of post‐ictal delirium after electroconvulsive therapy. Psychiatry and clinical neurosciences,​ 63(2), 180-185.]])] ​                                                                                                                                                                        | Typically lasts 15-60 minutes post-ECT, and self-limiting. However, any episodes lasting >60 minutes should be treated as a post-ictal [[cl:​1-delirium|delirium]],​ and all ECT treatments should be held!                                                                                                                                                                     | 
 +^ Manic switch ​                         | Post-procedure ​   | 7%[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994792/​|Milev,​ R. V., Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & CANMAT Depression Work Group. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. The Canadian Journal of Psychiatry, 61(9), 561-575.]])] ​ | These individuals may have a history of bipolar disorder or hypomanic episodes. ​                                                                                                                                                                                                                                                                                              | 
 +</​mobiletable>​ 
 +</​panel>​
  
-== Memory and Cognition == +==== Memory and Cognition ​==== 
-Cognition is a broad term that encompasses several components, including: attention, anterograde memory (inability ​to remember ​any new information),​ retrograde memory (inability ​to remember past memory), procedural memory, and reaction time. ECT does have an amnestic ​effect ​in particular ​for retrograde ​memory. The amnestic effects of ECT are greatest and most persistent for knowledge about the world (impersonal memory) compared with knowledge about the self (personal memory). ​There is also more cognitive impairment with more frequent ECT administration (i.e. - 2 sessions per week vs. 3 sessions). ​Overall, ECT is associated with short-term cognitive effects, but cognition eventually returns or surpasses their pre-ECT baseline.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​20673880|Semkovska,​ M., & McLoughlin, D. M. (2010). Objective cognitive performance associated with electroconvulsive therapy for depression: a systematic review and meta-analysis. Biological psychiatry, 68(6), 568-577.]])] The majority of evidence suggests that ECT given over a period of years will not cause cumulative cognitive deficits. There are also reduced rates of dementia in geriatric patients with mood disorders who receive ECT.+<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See also article: **[[cognitive-testing:​memory|]]** 
 +</​alert>​ 
 +  * [[:​cognitive-testing|Cognition]] is a broad term that encompasses several components, including: attention, anterograde memory (ability ​to remember new information),​ retrograde memory (ability ​to remember past memory), procedural memory, and reaction time. 
 +  * Memory loss (both retrograde and anterograde) is a known side effect ​from ECT, particularly around the time of ECT treatment:​[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994792/​|Milev,​ R. V., Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & CANMAT Depression Work Group. (2016). Canadian Network ​for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. The Canadian Journal of Psychiatry, 61(9), 561-575.]])] 
 +    * Subjective ​memory ​worsening is reported by a minority of patients, and those at greatest risk are:  
 +      * Young women[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27930429|Brus,​ O., Nordanskog, P., Båve, U., Cao, Y., Hammar, Å., Landén, M., ... & Nordenskjöld,​ A. (2017). Subjective memory immediately following electroconvulsive therapy. The journal of ECT, 33(2), 96-103.]])] 
 +      * Individuals with prexisting cognitive impairment 
 +      * Older adults 
 +      * Those receiving bitemporal ECT 
 +      * More frequent ECT administration (i.e. - 2 sessions per week vs. 3 sessions) 
 +      * Use of lithium during ECT treatment 
 +      * Higher anesthetic doses 
 +    * The amnestic effects of ECT are greatest and most persistent for knowledge about the world (impersonal memory) compared with knowledge about the self (personal memory). ​ 
 +  * Overall, ECT is associated with short-term cognitive effects, but cognition eventually returns or surpasses their pre-ECT baseline.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​20673880|Semkovska,​ M., & McLoughlin, D. M. (2010). Objective cognitive performance associated with electroconvulsive therapy for depression: a systematic review and meta-analysis. Biological psychiatry, 68(6), 568-577.]])] 
 +  * The majority of evidence suggests that ECT given over a period of years will not cause cumulative cognitive deficits. 
 +  * There are also reduced rates of [[geri:dementia:​home|dementia]] ​in geriatric patients with mood disorders who receive ECT. 
 +    * Importantly,​ this means ECT does not increase the risk of dementia in the elderly, making it a safe and appropriate option.[([[https://​www.thelancet.com/​journals/​lanpsy/​article/​PIIS2215-0366(18)30056-7/​fulltext|Osler,​ M., Rozing, M. P., Christensen,​ G. T., Andersen, P. K., & Jørgensen, M. B. (2018). Electroconvulsive therapy and risk of dementia in patients with affective disorders: a cohort study. The Lancet Psychiatry, 5(4), 348-356.]])] 
 +  * It is important to note however, in rare cases, some individuals can experience significant and distressing memory loss, and this remains an under-researched area in ECT. 
 +  * If there are cognitive side effects from ECT, you can try to: 
 +    * Reduce the frequency of treatments (i.e. - 3× per week to 2× per week) 
 +    * Reduce the electrical stimulus intensity during treatment
  
-Most importantly,​ ECT does not increase the risk of dementia in the elderly, making it a safe and appropriate option.[([[https://​www.thelancet.com/​journals/​lanpsy/​article/​PIIS2215-0366(18)30056-7/​fulltext|Osler,​ M., Rozing, M. P., Christensen,​ G. T., Andersen, P. K., & Jørgensen, M. B. (2018). Electroconvulsive therapy and risk of dementia in patients with affective disorders: a cohort study. The Lancet Psychiatry, 5(4), 348-356.]])] 
  
-===== Pearls ===== +==== Safety and Mortality ​==== 
-  * An adequate seizure in ECT is one that lasts around or greater than 30 seconds. +  * Overall, ​ECT is very safe and rapid actingOut of all medical procedures involving anesthesia, it is the lowest risk procedure.[([[https://​www.ices.on.ca/​Publications/​Journal-Articles/​2017/​September/​Low-medical-morbidity-and-mortality-after-acute-courses-of-electroconvulsive-therapy|BlumbergerD. M., Seitz, D. P., Herrmann, N., Kirkham, J. G., Ng, R., Reimer, C., ... & Mulsant, B. H. (2017). Low medical morbidity and mortality after acute courses ​of electroconvulsive therapy in a population‐based sample. Acta Psychiatrica Scandinavica.]])] 
-  * If the patient has a very brisk seizure with prominent motor activitya higher dose of succinylcholine should be considered +  * The mortality rate from ECT has been estimated to be less than 1 death per 98,000 treatments, which is similar to the background rate associated with anesthetic induction ​for any surgical procedure.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​25166734|ØstergaardS. D.BolwigT. G.& PetridesG. (2014). No causal association between electroconvulsive therapy and death: a summary of a report from the Danish Health and Medicines Authority covering 99,728 treatments. The journal of ECT30(4)263-264.]])] 
-  * Rocuronium should ​be considered ​for patients with prominent myalgia and headaches +  * Several studies have shown overall lower all-cause mortality in those who receive ECT: 
-  * Anesthetic agents and seizure duration: +    * One study showed a lower overall mortality rate from natural causes in inpatients who have received ECT compared ​to those who did not.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17470959|Munk-OlsenT., LaursenT. M., VidebechP., MortensenP. B., & RosenbergR(2007). All-cause mortality among recipients of electroconvulsive therapy: register-based cohort study. The British Journal of Psychiatry190(5)435-439.]])] 
-    * Increased: Etomidate +    * In one studyolder adults with [[mood:​1-depression:​geriatric|geriatric depression]],​ those who ECT treatment had overall lower mortality than those on antidepressants.[([[https://​pubmed.ncbi.nlm.nih.gov/​962487/​|Avery,​ D., WinokurG. (1976). Mortality in depressed patients treated with electroconvulsive therapy ​and antidepressantsArchives ​of general psychiatry33(9), 1029-1037.]])]
-    * No Effect: Methohexitalketamineremifentanilalfentanil +
-    * Shortened: Propofolmidazolamlorazepamthiopentalthiamylallidocaine +
-  * Hyperventilation can also be used to augment seizure duration[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​18772703|SawayamaE., Takahashi, M., InoueA., NakajimaK., KanoA., SawayamaT., ... & MiyaokaH. (2008). Moderate hyperventilation prolongs electroencephalogram seizure duration of the first electroconvulsive therapy. ​The journal ​of ECT24(3), 195-198.]])]+
  
 +==== Brain Damage ====
 +  * No clinical studies have shown damage to the brain structures related to ECT.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994792/​|Milev,​ R. V., Giacobbe, P., Kennedy, S. H., Blumberger, D. M., Daskalakis, Z. J., Downar, J., ... & CANMAT Depression Work Group. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. The Canadian Journal of Psychiatry, 61(9), 561-575.]])]
 +===== Comparison with Other Brain Stimulation Therapies =====
 +==== Depression ====
 +{{page>​brain-stimulation:​tdcs#​depression&​nouser&​noheader&​nodate&​nofooter}}
 ===== Resources ===== ===== Resources =====
 <WRAP group> <WRAP group>
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   * [[http://​www.canects.org/​patients.php|Introductory ECT Video for Patients (UBC) (Multilang.)]]   * [[http://​www.canects.org/​patients.php|Introductory ECT Video for Patients (UBC) (Multilang.)]]
   * [[https://​www.youtube.com/​watch?​v=oEZrAGdZ1i8|TED Talk: Dr. Sherwin Nuland: How electroshock therapy changed me]]   * [[https://​www.youtube.com/​watch?​v=oEZrAGdZ1i8|TED Talk: Dr. Sherwin Nuland: How electroshock therapy changed me]]
 +  * [[https://​www.youtube.com/​watch?​v=AcmarVpo2xE|YouTube:​ The truth about electroconvulsive therapy (ECT) - Helen M. Farrell]]
 </​WRAP>​ </​WRAP>​
 <WRAP third column> <WRAP third column>
 ==== For Providers ==== ==== For Providers ====
-  * [[http://​assets.cambridge.org/​97805218/​83887/​excerpt/​9780521883887_excerpt.pdf|Scientific and experimental bases +  ​* [[https://​www.cambridge.org/​core/​journals/​the-british-journal-of-psychiatry/​article/​abs/​electroconvulsive-therapy-for-depression-80-years-of-progress/​EA419A2EDF02EB803D8417B437779060|Kirov,​ G. et al. (2021). Electroconvulsive therapy for depression: 80 years of progress. The British Journal of Psychiatry, 1-4.]] 
-of electroconvulsive therapy (PDF)]]+  ​* [[http://​assets.cambridge.org/​97805218/​83887/​excerpt/​9780521883887_excerpt.pdf|Scientific and experimental bases of electroconvulsive therapy (PDF)]]
 </​WRAP>​ </​WRAP>​
 <WRAP third column> <WRAP third column>