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brain-stimulation:ect [2019/05/27 08:17]
psychdb
brain-stimulation:ect [2020/09/07 12:49] (current)
psychdb [Side Effects]
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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. **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.
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 ==== 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>+<WRAP group> 
 +<WRAP half column>
 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 functions, including neurotrophic factors, neurotransmitters,​ hormones, and neuropeptides. 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 functions, including neurotrophic factors, neurotransmitters,​ hormones, and neuropeptides.
  
 The delivery of the electrical stimuli 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 delivery of the electrical stimuli 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.
 +</​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>​
 ===== 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 ===== ===== Procedure =====
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   - Post-ictal recovery   - Post-ictal recovery
  
 +
 +</​WRAP>​
 +<WRAP half column>
 ==== 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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 </​WRAP>​ </​WRAP>​
-<​WRAP ​half column>+</WRAP> 
 ==== Checklist ==== ==== Checklist ====
 <WRAP col2> <WRAP col2>
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   - Ensure documentation complete   - Ensure documentation complete
 </​WRAP>​ </​WRAP>​
-</​WRAP>​ 
-</​WRAP>​ 
- 
- 
 ==== Electrode Placement ==== ==== Electrode Placement ====
-<imgcaption image2|>{{ :​brain-stimulation:​ect-placement-bl-rul-bf.png?​nolink&​600|ECT electrode placement}}</imgcaption>+<WRAP group> 
 +<WRAP half column>
 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 ECT. Left unilateral ECT can be cognitively sparing in those who rely on right hemispheric function (visual, spatial) for their livelihood. 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 ECT. Left unilateral ECT can be cognitively sparing in those who rely on right hemispheric function (visual, spatial) for their livelihood.
  
 Bilateral (bitemporal) ECT has a greater incidence of anterograde and retrograde amnesia. Bifrontal ECT may be as effective as bitemporal but is more cognitively advantageous. Ultimately, bilateral ECT should be used if there is greater urgency for improvement or life threatening situations. Also, if unilateral ECT fails after 6 to 10 treatments or there is a history of failure, then one should consider bilateral ECT.  Bilateral (bitemporal) ECT has a greater incidence of anterograde and retrograde amnesia. Bifrontal ECT may be as effective as bitemporal but is more cognitively advantageous. Ultimately, bilateral ECT should be used if there is greater urgency for improvement or life threatening situations. Also, if unilateral ECT fails after 6 to 10 treatments or there is a history of failure, then one should consider bilateral ECT. 
 +</​WRAP>​
 +<WRAP half column>
 +<​imgcaption image2|>​{{ :​brain-stimulation:​ect-placement-bl-rul-bf.png?​nolink&​600|ECT electrode placement}}</​imgcaption>​
 +</​WRAP>​
 +</​WRAP>​
 ==== Dosing ==== ==== Dosing ====
 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/​|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 therapy. Brain stimulation,​ 1(2), 71-83.]])] 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/​|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 therapy. Brain stimulation,​ 1(2), 71-83.]])]
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 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, 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.]])]
 ==== 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.]])] 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.]])] ​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 ===== ===== Side Effects =====
 Possible side effects and adverse events from ECT include: Possible side effects and adverse events from ECT include:
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 == 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. +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. 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.]])]
- +
-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.]])]+
  
 +It is important to note however, in rare cases, individuals can experience significant and distressing memory loss, and this remains an under-researched area in ECT.
 ===== Pearls ===== ===== Pearls =====
 +  * **Never forget**: give anesthetic first, and THEN give muscle relaxant
   * An adequate seizure in ECT is one that lasts around or greater than 30 seconds.   * An adequate seizure in ECT is one that lasts around or greater than 30 seconds.
   * If the patient has a very brisk seizure with prominent motor activity, a higher dose of succinylcholine should be considered   * If the patient has a very brisk seizure with prominent motor activity, a higher dose of succinylcholine should be considered
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     * Shortened: Propofol, midazolam, lorazepam, thiopental, thiamylal, lidocaine     * Shortened: Propofol, midazolam, lorazepam, thiopental, thiamylal, lidocaine
   * Hyperventilation can also be used to augment 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.]])]   * Hyperventilation can also be used to augment 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.]])]
 +  * Electrode plate placement:​ 
 +    * Use concave electrode plates for bifrontal (BF) and right unilateral (RUL) ECT 
 +    * Use flat electrode plates for bitemporal (BT)
 ===== Resources ===== ===== Resources =====
 <WRAP group> <WRAP group>