Electroconvulsive Therapy - PowerPoint PPT Presentation
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Electroconvulsive Therapy
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Title: Psychotherapy and ECT Author: bwood Last modified by: Morrow, Louann Created Date: 11/8/2004 12:36:05 AM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation
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Title: Electroconvulsive Therapy
1
Electroconvulsive Therapy
- Brian E. Wood, D.O.
- Associate Professor and Chair,
- Department of Neuropsychiatry and Behavioral
Sciences - Edward Via Virginia College of Osteopathic
Medicine - Associate Professor of Clinical Psychiatric
Medicine - University of Virginia School of Medicine
- Department of Psychiatric Medicine
- brwood6_at_vcom.vt.edu
2
What is Electroconvulsive Therapy?
- The passing of electrical energy through the
brain under clinically controlled circumstances,
thus producing a controlled seizure for
therapeutic purposes. - The oldest surviving biological treatment in
psychiatry. - Interestingly, probably one of the most
efficacious but misunderstood treatments in
psychiatry.
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History of ECT
- Use of convulsions to treat schizophrenia was
proposed in the early 1930s by Ladislas Von
Meduna (1896 1964) a Hungarian physician and
researcher who performed most of his work at the
University of Budapest. - In the 1920s several researchers had noted that
epileptic patients who developed schizophrenia
had marked decrease in frequency of seizures thus
postulating an antagonistic effect of
schizophrenia on epilepsy. - Von Meduna was very interested in these studies
but proposed the converse hypotheesis.
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History of ECT
- Historical accounts of inducing seizures by use
of camphor and therapeutic benefits in the
treatment of psychiatric disorders. - Use of camphor was documented by early alchemists
to cure lunacy. - Von Meduna ultimately achieved a 40 50 success
rate in treatment of patients with Dementia
Praecox - Insulin Coma therapy was developed around the
same time by Sackel and lobotomy was also being
utilized and studied by Walter Freeman.
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History of ECT
- Other researchers hypothesized that electricity,
now becoming widely available, could be used in a
more controlled and easier way to induce
seizures. Modern use of electricity to induce
seizures for therapeutic purposes dates from 1938
when two Italian physicians induced seizures in a
39 y/o male patient diagnosed with Schizophrenia. - Several aborted attempts at ECT were made and
after one subconvulsive stimulus, the team
discussed whether to administer another. The man
reportedly responded not again its murderous!
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History of ECT
- ECT was initially administered without anesthesia
or muscular paralysis (unmodified) - Most induction anesthetic agents were longer
acting and less predictable than today. - Tolerability was significantly improved with the
routine use of general anesthesia and
neuromuscular blockade. Many ECTs were performed
from the 1940s until the late 1950s when
antipsychotic and later antidepressant drugs
became available.
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As ECT Develops
- In the 1950s the chlorpromazine revolution.
- More availability of well tolerated drugs
initially decreased prevalence of ECT however,
clinicians began to differentiate response to
available therapies. - Since the 1960s the use of ECT has continued to
rise.
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Modern ECT
- Present day ECT is a safe effective procedure
with relatively few side effects - Efficacy for depression is higher than drugs and
onset of action is shorter. - The patient is anesthesitized with a short acting
induction agent and paralysed with succinyl
choline. - There is usually an amnestic period surrounding
the actual treatment but persistent memory
impairment is rare.
10
Modern ECT
- Pt. Is monitored throughout procedure with EEG,
EKG, EMG, Pulse oximeter, etc. - Usual duration of seizure is 30 to 60 seconds for
established efficacy. - Patient is recovered per anesthesia protocol.
- Most procedures are done in the hospital in OR or
recovery settings although many are done as
outpatient procedures.
11
The ECT Procedure
- Bilateral ECT
- Electrodes are placed bitemporally and
electricity is passed through both hemispheres of
the brain simultaneously - Associated with greater efficacy
- Unilateral ECT
- Electrodes are placed at the vertex and near the
non-dominant temple (right). Electricity is
passed through the nondominant hemisphere with
generalization to both hemispheres. - Associated with less memory disturbance.
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The ECT Procedure
- Electricity is administered with several variable
parameters - Wave form
- Sine wave- originial studies
- Brief pulse square wave used in all modern
treatments. - Frequency
- Stimulus duration
- Goal is to provide a threshold stimulus (to
induce seizure) without excess dose. - Dosing is primarily dependent on patients
individual CNS characteristics, skull thickness,
body water composition and age.
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Physiology of ECT
- Known to affect multiple neurotransmitter systems
in the brain. - Catecholamine surge theory
- Differential recovery theory
- Distinct mechanism of action remains unknown.
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Applications of ECT
- Depression
- Severe
- With psychotic symptoms
- With catatonia
- Primary psychotic disorders with catatonia
- Acute mania
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Contraindications of ECT
- Almost all are relative contraindications
- Only absolute contraindication is increased
intracranial pressure. - Usually not performed with space occupying CNS
lesions. - Relatively contraindicated with recent MI because
of increased risk of ventricular rupture.
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Side effects of ECT
- Most important is memory loss.
- Usually only amnestic for time period around
treatment. - Amestic period typically widens with successive
treatments and can be worse with preexisting
cognitive disorders - Muscle soreness or tension usually due to
incomplete neuromuscular blockade. - Fractures or dental complications are relatively
rare but still do occur.
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Potential Benefits of ECT
- Rapid response.
- Greater efficacy (particularly in some
populations and syndromes) - May increase efficacy of other treatments.
- May be used in patients that cannot tolerate
other antidepressant treatments.
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Advantages in the Elderly?
- Patients are often more physically fragile with
higher morbidity associated with depression. - Increased risk of medication intolerance or side
effects. - ? Higher rates of psychotic symptoms associated
with mood disorders in the elderly - ? Differential response in the elderly
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The Future of ECT
- Probable continuation of focus on safety and
minimization of cognitive side effects - Increasing focus on economics of healthcare.
- Possible future for non-convulsive techniques
such as TMS but may be fading.
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TMS
- Magnetic impulses that produce electrical
conductivity in the brain. - When administered at sub threshold non-convulsive
levels (lt1 Hz) is termed TMS. - Equivocal findings re efficacy in depression
- Probably not near the efficacy of ECT.
- Does not require anesthesia so may be used in
patients with general anesthesia risks.
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Summary
- Modern ECT is an effective and safe procedure
when applied to appropriate patients and has some
advantages over pharmaceutical agents. - There are relatively few contraindications to ECT
when carefully observed and monitored. - Alternative therapies such as TMS may prove to be
an alternative to ECT in some patients in the
future. - ECT has remained and probably will remain an
important tool in the psychiatric armamentarium.
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