ELECTROCONVULSIVE THERAPY Jon Lehrmann MD Assistant Professor of Psychiatry Medical College of WI VAMC Milwaukee, WI.

ELECTROCONVULSIVE THERAPY

ELECTROCONVULSIVE THERAPY

Jon Lehrmann MDAssistant Professor of PsychiatryMedical College of WIVAMC Milwaukee, WI

Mental Health Care Pre-1930’s

History of ECT

• Von Meduna (1934)- Autopsies of patients w/ Seizure disorders and of patients w/ Schizophrenia.

• Difference in Glial cell proliferation

Chemically induced seizures- (camphor, pentylenetetrazol)

Insulin Shock Therapy

• In the 1930’s , Dr Sakel developed Insulin Shock Therapy

Cerletti and Bini (1934): Electricity

Initially done without muscle blocker or anesthetic

Early ECT

• Assylums

• Few effective medications

• Many often severe side effects

• 1950’s- ether, and curare extract developed (Abram Bennett- a psychiatrist helped develop a method for extracting curare).

• In 1950’s antidepressant and antipsychotic meds introduced- significantly decreased utilization of ECT

Electrophysiological Principles

• Ohm’s Law: I=E/R (I=current, E=voltage, and R=resistance)

• Dose of electricity in ECT= 100-500 milliCoulombs

• Brain has low impedance (resistance), skull has very high impedance. Only 20% of applied charge actually enters the brain.

• Seizure involves propagation of action potentials in a large percentage of neurons.

Mechanism of Action

• Neurotransmitter levels all increased in CSF after seizure. Results in down regulation of Beta adrenergic receptors.

• During seizure- PET studies show an increase in BBB permeability and in cerebral blood flow and metabolism.

• After seizure, blood flow and metabolism is decreased especially in the frontal lobes. Research shows this correlated w/ response.

Indications

• Major Depression w/ or w/o psychotic features

• Bipolar disorder - manic or depressed phase

• Acute or Catatonic Schizophrenia

• Some studies have shown efficacy in treating OCD, Delirium, NMS, Chronic pain syndromes, and intractable seizure disorders

Major Depression

• Efficacy vs antidepressants

• When is it a first line treatment consideration?

• Length of Antidepressant effect

• Maintenance ECT

Bipolar Mania

• Efficacy vs Lithium• Indications for First Line Treatment:• -Recent Myocardial Infarction w/ Acute Mania• -Pregnancy w/ Acute mania

Pre ECT Workup

• Physical Exam

• Head CT

• CXR

• CBC, Basic Chem

• EKG

• ? Spinal Films

Contraindications?

• No Absolute Contraindications

• Relative Contraindications: Recent MI, Berry Aneurysm, Brain Mass, Increased Intracranial Pressure

Treatments

• Premedicate w/ Glycopyrrolate, consider short acting Beta blocker

• Patient not intubated

• Bite block

• Cuff leg to monitor sz

• EEG and EMG

• Length of sz- 20 sec to 1 min.

Number and Spacing of ECT

• 2-3x/wk- efficacy vs less memory impairment

• 5-12 sessions/ treatment (although up to 20 is possible)

• Point of maximum improvement- no more improvement after 2 further treatments.

Adverse Effects

• Mortality rate: .002% per treatment session, .01% per patient.

• Sore Muscles

• Head ache

• Short term confusion/ delirium

• Memory

Transcranial Magnetic Stimulation (TMS)

• Rt Frontal lobe- TMS pulses suppress activity and causes happiness and increased energy

• Left Frontal lobe- TMS pulses suppress activity and leads to sadness

• 4/250 had seizure• 10Hz stimulation 20x/day, 11/17 patients w/

Major Depression showed significant improvement.

TMS continued

• So far positive effects have not lasted as long as positive effects from ECT

• Handful of case reports show efficacy w/ anxiety disorders.