Electroconvulsive Therapy

Electroconvulsive Therapy (ECT), also known as electroshock or electroplexy therapy.

Electroconvulsive therapy (ECT) was first described in 1938 as a treatment for schizophrenia, when it was believed that people with epilepsy were rarely schizophrenic, and it was thought that convulsions could cure schizophrenia.

Other somatic therapies had been tried before that time, in particular insulin coma therapy and pharmacoconvulsive therapy. Von Meduna, in 1934, used 25% camphor oil intramuscularly to produce convulsions for the first time for therapeutic purposes. Later, he used pentylenetetrazol (Metrazol) for the same purpose.

ECT is actually more effective for mood disorders than for schizophrenia (PAYNE & PRUDIC, 2009).

Electroconvulsive therapy is a type of somatic treatment, first introduced by BINI & CERLETTI in April 1938.

ECT has been used continuously for more than 50 years, longer than any other physical treatment available for mental illness.

Definition

Electroconvulsive therapy is the artificial induction of grand mal seizure through the brain. The stimulus is applied through electrodes that are placed either bilaterally in the front temporal region, or unilaterally on the non-dominant side.

OR

Electroconvulsive therapy is a treatment in which grand mal seizure is artificially induced in an anesthetized patient by passing an electrical current through electrodes applied to the patient’s head.

Articles Needed For ECT

• Articles for anesthesia
• Suction apparatus
• Face mask
• Oxygen cylinder
• Tongue depressor
• Mouth gag
• Resuscitation apparatus
• Full set of emergency drugs, ECT drugs
• Defibrillator

Parameters

Standard Dose According to American Psychiatric Association, 1978

• Voltage: 70-120 volts (The usual amount of current passed in ECT is 200-1600 Mah)
• Duration: 0.7-1.5 sec.

Types of Seizure Produced:

• Grand mal seizure- Tonic phase lasting for 10-15 seconds
• Clonic phase lasting for 30-60 seconds

Frequency & Total Number of ECT:

• Frequency: 3 times per week or as indicated
• Total Number: 6 to 10; up to 25 may be preferred as indicated.

Primary indication for ECT is major depression (WEINER & FALCONE, 2011)

1. MAJOR DEPRESSION:
   • With suicidal risk, stupor;
   • Poor intake of food & fluids,
   • Melancholia with psychotic features,
   • Unsatisfactory response to drugs or where drugs are contraindicated or have serious side effects.
2. SEVERE CATATONIA (Functional):
   • With stupor;
   • Poor intake of food & fluids,
   • Unsatisfactory response to drugs or where drugs are contraindicated or have serious side effects.
3. SEVERE PSYCHOSIS (Schizophrenia or mania):
   • With risk of suicide, homicide or danger of physical assault;
   • Depressive features;
   • Unsatisfactory response to drug therapy, or when drugs are contraindicated or have serious side effects.
4. ORGANIC MENTAL DISORDERS:
   • Organic mood disorders
   • Organic psychosis
5. OTHER INDICATIONS:

   ECT is preferred to antidepressant therapy in some cases, such as for patients with cardiac disease; when tricyclics are contraindicated because of the potential for dysarrythmias & congestive heart failure, & for pregnant women, in whom antidepressants place the fetus at risk for congenital defects.

• DIRECT ECT: In this, ECT is given in the absence of anesthesia & muscular relaxation. This is not commonly used method now.
• MODIFIED ECT: Here ECT is modified by drug-induced muscular relaxation & general anesthesia.

Application of Electrodes

BITEMPORAL ECT/POSITION: Each electrode is placed 2.5-4 cm above the midpoint, on a line joining the tragus of the ear & the lateral canthus of the eye.

UNILATERAL ECT/POSITION: Electrodes are placed only on one side of the head, usually non-dominant side. Unilateral ECT is safer, with much fewer side-effects, particularly those of memory impairment.

Alternative electrode placement is now routinely used, including bifrontal and unilateral. Studies of the new form of unilateral ECT, called Focal Electrically Administered Seizure Therapy (FEAST) appears to minimize cognitive effects of ECT even further (PIERCE et al, 2008).

The exact mechanism of action is not known.

One hypothesis states that ECT possibly affects the catecholamine pathways between the diencephalon (from where seizure generalization occurs) & limbic system (which may be responsible for mood disorders) also involving the hypothalamus.

According to the Biochemical Theory, ECT increases the level of some neurotransmitters (Serotonin, norepinephrine, dopamine) in some areas of the mind.

ABSOLUTE:

• Raised ICP

RELATIVE:

• Cardiovascular (Coronary artery disease, acute myocardial infarction, congestive heart failure, HTN, aneurysms, arrhythmias)
• Cerebrovascular effects (Recent strokes, space-occupying lesions, cerebral aneurysms, cerebral hemorrhage)
• Severe pulmonary diseases (T.B, Pneumonia, Asthma)

Side Effects of ECT

• Memory impairment
• Drowsiness, confusion & restlessness
• Poor concentration, anxiety
• Headache, weakness/fatigue, backache, muscle aches
• Dryness of mouth, palpitations, nausea, vomiting
• Unsteady gait
• Tongue bite & incontinence

Complications

Life-threatening complications of ECT are rare.

ECT does not cause any brain damage.

Fractures can sometimes occur in elderly patients with osteoporosis.

In patients with a history of heart disease, dysrhythmias and respiratory arrest may occur.

ECT Team

• Psychiatrist
• Anesthesiologist
• Trained nurses
• Nursing aids
• ECT assistant

Treatment Facilities

There should be a suite of three rooms:

1. A pleasant, comfortable waiting room (Pre ECT room)
2. ECT room, which should be equipped with ECT machine & accessories, an anesthetic appliance, suction apparatus, face masks, oxygen cylinders with adjustable flow valves, curved tongue depressors, mouth gags, resuscitation apparatus & emergency drugs. There should be immediate access to defibrillator.
3. A well-equipped recovery room.

WAITING ROOM OR SETTING ROOM:

• In this room, the patient is asked to wait or take rest before Electroconvulsive therapy. The room should be calm with dim lights and light-colored walls.
• Put some flowers to give pleasant feelings to the patient.
• There should be some magazines to read, so that the patient can divert his mind and reduce anxiety.
• A lavatory (toilet) should be attached because the patient needs to empty his bladder & bowel before getting Electroconvulsive Therapy.
• The nurse should always be available in the room so that the patient & relative can clarify their doubts, pre-anesthetic drugs should be kept ready.

TREATMENT ROOM/ ECT ROOM:

In this treatment room, the nurse needs to do the following preparation of articles for the comfort of the patient. The room should be near to the waiting room, for privacy a bedside screen should be present.

Articles for Preparation of Patient:

• Small pillows to put under the patient's waist to prevent injury.
• Mouth gag to prevent injury to the tongue during convulsions and to keep the airway patent.
• Tongue spatula, endotracheal tube & sterile catheter for suction.
• Oxygen cylinder & ambu bag to give oxygen immediately after the therapy to give artificial respiration if required.

Articles for the Procedure:

• A trolley with an E.C.T. machine in working order. Check all the electric plug points.
• Jelly or Normal Saline for putting an electrode, as Normal Saline is a good conductor of electricity and facilitates in passing current.
• Emergency drugs & resuscitation tray, mouth wipes, B.P. apparatus, sterile syringe, spirit swabs and adequate light.
• Doctor should be present in the E.C.T room.

Recovery Room/After Care Room:

• When the patient responds to a painful stimulus, he/she is transferred to the recovery room.
• Observation of vital signs such as Temperature, Pulse, Respiration, and Blood pressure.
• Toilet facilities should be available in the recovery room.
• E.C.T. Equipment should always be available in the psychiatric ward or unit to meet emergency situations.
• Once the patient becomes oriented he/she can be transferred to his/her ward.
• Electroconvulsive therapy involves significant responsibility of the nursing personnel:
  • The patient care before giving E.C.T.
  • The patient care during E.C.T.
  • The patient care after giving E.C.T.

Before E.C.T.:

• Detailed medical and psychiatric history including any allergic history
• Assessment of knowledge of patient and family
• Take written consent for ECT
• Informed Consent: Consent given by a well-advised and mentally competent patient to be treated by the care provider or randomized into a research study.
• Substituted Consent: Consent given by legal guardian, if patient is not capable of giving their own consent.
• Explain risks & benefits
• Answer all the questions
• Reduce patient anxiety & help in establishing a good relationship
• Assess vital signs
• Patient should be on an empty stomach for 4-6 hours prior to E.C.T.
• Withhold night doses of drugs which increase seizure threshold.
• Withhold oral medications in the morning.
• Do head shampooing in the morning (As oil is a bad conductor of electricity)
• Remove jewellery, prosthesis, dentures, contact lens, metallic objects & tight clothing.
• Empty bowel & bladder just before ECT.
• Administer 0.6 mg of Atropine I.M. or SC 30 minutes before ECT, or I.V. just before ECT (To decrease pharyngeal secretions and counteract the effect of bradycardia).

During E.C.T.:

• Place the patient on ECT table in supine position.
• Stay with the patient to allay anxiety & fear.
• Assist in administering anesthetic agent (thiopental sodium 3-5 mg/kg body weight/0.25-0.50 gm) for short term anesthetic effect immediately before ECT.
• Assist in administering muscle relaxant (Succinylcholine 1mg/kg body weight/ 30-50 mgs) to prevent fracture and dislocation.
• Since the muscle relaxant paralyzes all muscles, patient airway should be ensured & ventilatory support should be started.
• Mouth gag should be inserted to prevent possible tongue bite.
• Electrode should be cleaned with normal saline or 25% bicarbonate solution, or conducting gel applied. Monitor voltage, intensity & duration of electrical stimulus given.
• Monitor seizure activity using cuff method.
• Provide 100% oxygen.
• During seizure monitor vital signs, ECG, Oxygen saturation, EEG, etc.
• Record the findings & medicines given in the patient’s chart.

After E.C.T.:

• Place the patient in a side-lying position on a railing cot to avoid aspiration of secretions.
• Monitor vital signs.
• Continue oxygenation till spontaneous respiration starts.
• Assess for post-ictal confusion and restlessness.
• Take safety precautions to prevent injury.
• Administer I.V. diazepam in case of severe post-ictal confusion & restlessness.
• Reorient the patient & stay with him/her until fully oriented.
• Document any findings as relevant in the patient’s record.