Electroconvulsive Therapy (ECT) : Dr. Altaf Qadir Khan Professor of Psychiatry PGMI/ LGH, Lahore

ELECTROCONVULSIVE THERAPY
(ECT)
Dr. Altaf Qadir Khan

Professor of Psychiatry
PGMI/ LGH, Lahore
Electro Convulsive Therapy
Electro Convulsive Therapy (ECT) is a treatment for severe
mental illness in which a brief application of electrical stimulus
is used to produce a generalized seizure
History of convulsive therapy
It was introduced in the late 1930s on the basis of the
mistaken idea that epilepsy and schizophrenia do not occur
together, it seemed to follow that induced fits should lead to
improvement in schizophrenia
.
When the treatment was tried it became apparent that the
most striking changes occurred not in schizophrenia but in
severe depressive disorder and brought substantial reduction
in chronicity and mortality
Chemically induced seizures-
(camphor, pentylenetetrazol)
Insulin Therapy
Depressed patients were given an overdose of insulin to
cause a convulsion
Difficulties in determining the proper dosage of insulin

led to a decline in use of this therapy
Was replaced by Electroconvulsive Therapy (ECT)

History of Convulsive Therapies
1938 – Lucio Cerletti and Ugo Bini induced seizures in Rome
using electrical stimuli in catatonic patients and produced
successful results .
1940 – Renato Almansi and David Impasto administered ECT at

Columbus Hospital in NYC. Lothar Kalinowsky started giving
ECT at Psychiatric Institute
Cerletti and Bini (1934): Electricity
Initially done without

muscle blocker or
anesthetic
.
1958-First controlled study in unilateral ECT
1960-Randomised clinical trials of the efficacy of ECT versus

medication in the treatment of depression yielded response
rates that were significantly higher with ECT
Early ECT
Asylums
Few effective medications
Many often severe side effects
In 1950’s antidepressant and antipsychotic medications
significantly decreased utilization of ECT
Introduction
Excellent safety profile
Superior Efficacy
Economic benefits
Stigmatization
Introduction to ECT
ECT has changed substantially during the past decades. The
use of general anesthesia has promoted the interest in ECT
ECT become more complex , more precise and safer procedure

(mortality rate 1/1000 early to 3-4/100,000 now)
Introduction to ECT
Generalized seizures can be induced by adjusting waveform,
frequency, duration of electrical stimuli.
Seizure should last at least 30 -60 seconds in duration
Good therapeutic effect is generally not achieved until 400-

700 seizure seconds
.
ECT is usually given twice a week , even thrice a week but has
little therapeutic effect over a twice weekly regimen
Length of course depends on clinical experience
Course of ECT is usually 6 to a maximum of 12 treatments

.
Progress should be reviewed after each treatment
If response is rapid fewer treatments may be given
If there is no response after six to eight treatments course

should be abandoned
Memory should be assessed after each treatment

.
75 – 90% of patients exhibit a dramatic and sustained
improvement
Transient neurological dysfunction does occur but permanent

neuronal injury is questionable
Indications
Major Depressive Disorder
Catatonic Schizophrenia
Post-partum psychosis
Some studies have shown efficacy in treating
 OCD
 Delirium
 NMS
 Chronic pain syndromes
 Intractable seizure disorders
Major Depressive Disorder
Major depressive disorder; when associated with:
Suicide
Stupor
Life threatening dehydration
Marked psychomotor retardation
Depressive delusions and hallucinations
ECT may be considered 2nd or 3rd line treatment if not
responsive to antidepressants
.
Non response to one or more adequate trials of
antidepressants or intolerance of therapeutic dosages
Prophylaxis or attenuation of recurrent major depression
Prevention of relapse of major depression

.
Depressed phase of bipolar disorder
Atypical depression (patients with atypical depression were

2.6 times more likely to have remission with ECT treatment
than those with other types of depression )
.
ECT may be considered for the treatment of mania associated
with :-
Life threatening physical exhaustion
Mania that has not responded appropriate drug treatment

.
ECT may be considered for the treatment of acute
schizophrenia as a 4th line option for treatment resistant
schizophrenia after treatment with two antipsychotic drugs
and then Clozapine has proved ineffective
Patients with catatonia where treatment with benzodiazepine

(Lorazepam) has proved ineffective
.
First episode psychosis (after non response to one or more
adequate drug trial )
Parkinson’s disease
NMS
Status Epilepticus
Tardive dyskinesia
Refractory OCD
.
Post partum psychosis, second line of treatment after non-
response to antidepressants and / or antipsychotics
Safe in all trimesters but need:

Obstetrical consultation
Fetal monitoring and precaution of increase of GERD
General Comments
Consider ECT early in the treatment algorithm
In the presence of very serious illness
May be first line treatment for very severe depression or

mania
No specific risks, benefits or contraindications attributable to

age
Informed Consent
Fully explain the risks and benefits of procedure and answer
questions from patients or their relatives
Information sheets
Reduce patient’s anxiety and help establish good patient-

doctor relationship
Pre ECT Workup
Nursing implication
Physical examination
Head CT
CXR
CBC
EKG
Nursing implication
Patient must be kept NPO (especially for solid foods )
approximately 8 hours before treatment
Continuous observation to be required
Dentures must be removed before treatment
Observe and monitor vitals until patient is recovered, oriented

and alert before discharge
.
Should be advised not to operate motor vehicle or potentially
dangerous equipment and tools until the day after each
treatment
Outpatients should be escorted home after treatment
Limit the use of sedatives and hypnotics the night before and
the morning of treatment
.
IV line should be established
Bite block is inserted in the mouth before the treatment to

protect teeth and tongue during seizure
100 percent oxygen is administered at the rate of 5 litter a

minute during the procedure until spontaneous respiration
returns
Contraindications
No Absolute Contraindications
Relative Contraindications:
 Recent MI, fever, Brain Mass, Increased Intracranial Pressure,
significant arrhythmias, extreme hypertension, recent stroke,
retinal detachment, unstable angina, severe pulmonary disease
Technique
Two types:
Direct ECT –administered in the absence of muscular

relaxation and general anesthesia, now a days very
infrequently used
Modified ECT –by drug induced muscular relaxation and

general anesthesia administered by anesthetist
.
Succinylcholine 1mg/kg
Atropine (0.6mg )is given IV before Tx to decrease oral

secretions and to prevent vagal stimulation during ECT which
can cause cardiac arrest
Propofol (0.75-2.5 mg /kg ) or
Thiopentone (2.5 mg /kg )

.
Electrodes are moistened with saline or 25 percent

bicarbonate solution and are applied to head according to the
position of electrodes
Types of ECT :-
 Bilateral ECT --- most commonly used
 Unilateral ECT – placed on one side non- dominant side
(Fink M. Electroshock revisited. American Scientist. March-April 2000.)
Electrode Placement
Bilateral (BL) - most common, most effective, most
cognitive dysfunction
Right unilateral (RUL) - less cognitive effect, may be less

clinically effective
Bifrontal (BF) – may be as effective as BL with less cognitive

effect
Bilateral RUL Bifrontal
Response rate BL vs UL
Response rates:
Low-dose RUL - 17%

High-dose RUL - 43%
Low-dose BL - 65%
High-dose BL - 63%
Risks/Side Effects
Muscle contractions: can result in fractures and
dislocations; prevented by small doses of muscle relaxants
Injury to teeth, tongue or lips: stimulus causes intense

contraction of the masseter muscles and forceful
movement of the jaw; use a bite block
Electrical injury to the staff or patient

Risks/Side effects
Postictal Headache (45%) and muscle ache
Short-term memory loss and cognitive deficits
Difficult relationship with patients: frightened; withdrawn;

suspicious; uncooperative
Anaesthesia related problem: i.e. air way issue (more

patient with OSA); aspiration
Risks/Side effects
Common: transient confusion, headache, nausea, myalgia,
retrograde and anterograde amnesia
Uncommon: cardiac arrest, unstable arrhythmias,

ischemia, severe hypertension or hypotension, stroke,
prolonged apnoea, aspiration, laryngospasm, prolonged
seizures (status), fractures, malignant hyperthermia
Death: 1:80,000 Txs (1:10,000 patients)

.
.
.
THANK YOU

Electroconvulsive Therapy (ECT) : Dr. Altaf Qadir Khan Professor of Psychiatry PGMI/ LGH, Lahore

Uploaded by

Copyright:

Available Formats

Electroconvulsive Therapy (ECT) : Dr. Altaf Qadir Khan Professor of Psychiatry PGMI/ LGH, Lahore

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Electroconvulsive Therapy (ECT) : Dr. Altaf Qadir Khan Professor of Psychiatry PGMI/ LGH, Lahore

Uploaded by

Copyright:

Available Formats

ELECTROCONVULSIVE THERAPY

Dr. Altaf Qadir Khan

Difficulties in determining the proper dosage of insulin

Was replaced by Electroconvulsive Therapy (ECT)

1940 – Renato Almansi and David Impasto administered ECT at

Initially done without

1960-Randomised clinical trials of the efficacy of ECT versus

ECT become more complex , more precise and safer procedure

Seizure should last at least 30 -60 seconds in duration

Good therapeutic effect is generally not achieved until 400-

Length of course depends on clinical experience

Course of ECT is usually 6 to a maximum of 12 treatments

If response is rapid fewer treatments may be given

If there is no response after six to eight treatments course

Memory should be assessed after each treatment

Transient neurological dysfunction does occur but permanent

Prophylaxis or attenuation of recurrent major depression

Prevention of relapse of major depression

Atypical depression (patients with atypical depression were

Patients with catatonia where treatment with benzodiazepine

Safe in all trimesters but need:

In the presence of very serious illness

May be first line treatment for very severe depression or

No specific risks, benefits or contraindications attributable to

Reduce patient’s anxiety and help establish good patient-

Continuous observation to be required

Dentures must be removed before treatment

Observe and monitor vitals until patient is recovered, oriented

Outpatients should be escorted home after treatment

Bite block is inserted in the mouth before the treatment to

100 percent oxygen is administered at the rate of 5 litter a

Direct ECT –administered in the absence of muscular

Modified ECT –by drug induced muscular relaxation and

Atropine (0.6mg )is given IV before Tx to decrease oral

Propofol (0.75-2.5 mg /kg ) or

Thiopentone (2.5 mg /kg )

Electrodes are moistened with saline or 25 percent

Right unilateral (RUL) - less cognitive effect, may be less

Bifrontal (BF) – may be as effective as BL with less cognitive

Low-dose RUL - 17%

Injury to teeth, tongue or lips: stimulus causes intense

Electrical injury to the staff or patient

Short-term memory loss and cognitive deficits

Difficult relationship with patients: frightened; withdrawn;

Anaesthesia related problem: i.e. air way issue (more

Uncommon: cardiac arrest, unstable arrhythmias,

Death: 1:80,000 Txs (1:10,000 patients)

You might also like