Electroconvulsive therapy

Electroconvulsive therapyBy : Abhimanyu parashar

4th Pharm.D

introduction• Electroconvulsive therapy (ECT), formerly known

as electroshock.• It is a psychiatric treatment in which seizures are

electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown.

• Today, ECT is most often recommended for use as a treatment for severe depression that has not responded to other treatment, and is also used in the treatment of mania and catatonia

• It was first introduced in 1938 by Italian neuro-psychiatrists Ugo Cerletti and Lucio Bini, and gained widespread use as a form of treatment in the 1940s and 1950s

• Electroconvulsive therapy can differ in its application in three ways:

1. electrode placement

2. frequency of treatments

3. electrical waveform of the stimulus• These three forms of application have significant

differences in both adverse side effects and positive outcomes

Mechanism of action

• The aim of ECT is to induce a therapeutic clonic seizure (a seizure where the person loses consciousness and has convulsions) lasting for at least 15 seconds.

• the exact mechanism of action of ECT remains elusive. ECT doctors claim it may "jumpstart the brain", helping boost neurotransmission while others claim it causes the "euphoric" effects similar to the effects found in "closed head injury" or people with fresh traumatic brain injury.

Guidelines for use

• The American Psychiatric Association (APA) 2001 guidelines give the primary indications for ECT among patients with depression as a lack of response to, or intolerance of, antidepressant medications.

• The decision to use ECT depends on several factors, including the severity and chronicity of the depression, the likelihood that alternative treatments would be effective, the patient's preference and capacity to consent, and a weighing of the risks and benefits

• The APA ECT guidelines state that severe major depression with psychotic features, manic delirium, or catatonia are conditions where there is a clear consensus favouring early ECT.

• The UK's National Institute for Health and Clinical Excellence (NICE) guidelines recommend ECT for patients with severe depression, catatonia, or prolonged or severe mania. It did not recommend the use of ECT as a maintenace therapy in depressive illness as "the long-term benefits and risks ... had not been clearly established

• APA ECT guidelines say that ECT is rarely used as a first-line treatment for schizophrenia, but is considered after unsuccessful treatment with antipsychotic medication, and may also be considered in the treatment of patients with schizoaffective or schizophreniform disorder.

• About 70 percent of ECT patients are women.• This is almost entirely due to women being at twice the

risk of depression.

Duration of effect• ECT on its own does not usually have a sustained benefit.• Half those who remit then relapse within six months. This

is similar to the rate of relapse after discontinuing antidepressant medication, and it has been suggested that it is due to the severity and chronicity of pre-existing illness for which ECT is generally used.

• The relapse rate in the first six months is reduced by the use of psychiatric medications or further ECT, but remains high

Adverse effects•  "no absolute health contraindications" •  the most common adverse effects are confusion and

memory loss.• It can be tolerated by pregnant women who are not

suffering major complications. It can be used with diabetic or obese patients, and with caution in those whose cancers are in remission or under control.

•  It must be used very cautiously in people with epilepsy or other neurological disorders because by its nature it provokes small tonic-clonic seizures, and so would likely not be given to a person whose epilepsy is not well-controlled

• Some patients experience muscle soreness after ECT. This is due to the muscle relaxants given during the procedure and rarely due to muscle activity.

methodology

• Prior to treatment, a patient is given a short-acting anesthetic such as methohexital, etomidate, or thiopental

• a muscle relaxant such as suxamethonium , and occasionally atropine to inhibit salivation.

• Both electrodes can be placed on the same side of the patient's head. This is known as unilateral ECT.

• Unilateral ECT is used first to minimize side effects (memory loss)

• When electrodes are placed on both sides of the head, this is known as bilateral ECT.

•  In bifrontal ECT, an uncommon variation, the electrode position is somewhere between bilateral and unilateral.

• Unilateral is thought to cause fewer cognitive effects than bilateral but is considered less effective.

• The electrodes deliver an electrical stimulus.• The stimulus levels recommended for ECT are in excess

of an individual's seizure threshold , about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT.

• while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe cognitive impairment without additional therapeutic gains

• Seizure threshold is determined by trial and error ("dose titration").

• Some psychiatrists use dose titration, some still use "fixed dose" (that is, all patients are given the same dose) and others compromise by roughly estimating a patient's threshold according to age and sex.

• Older men tend to have higher thresholds than younger women, but it is not a hard and fast rule, and other factors, for example drugs, affect seizure threshold.

• Typically, the electrical stimulus used in ECT is about 800 milliamps and has up to several hundred watts, and the current flows for between one and 6 seconds

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