Electroconvulsiv Therapy Presentation

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Electroconvulsiv Therapy Presentation

  1. 1. A research review ofElectroconvulsive Therapy and its effects on depression and other psychological disorders relevant to Acute In-patient physical therapy Steve Chmielewski, SPT<br />
  2. 2. History 3,8<br />ECT was first introduced as a treatment for psychiatric disorders in 1938 by a neurologist named Urgo Cerletti.<br />Performed ECT on dogs and other animals to induce epileptic attacks<br />Thought of concept while watch pigs being killed via electric shock<br />First used on schizophrenic patients<br />Began injecting CSF from electrically shocked pig brains showing positive results<br />Later replaced with the drug Metrazol <br />Widespread by 40’s and 50’s with fine tuning of procedure<br />Decline in popularity in 60’s due to pharmacological treatments and the negative media image<br />
  3. 3. Primary Indications for ECT1<br />Patients with moderate to severe depression <br />Lack of a response to or intolerance of antidepressant medications <br />A good response to previous ECT <br />The need for a rapid and definitive response (e.g., because of psychosis or a risk of suicide). <br />
  4. 4. Patient Populations 8<br />ECT can be used safely in elderly patients and in persons with cardiac pacemakers or implantable cardioverter–defibrillators. <br />ECT can also be used safely during pregnancy, with proper precautions. <br />
  5. 5. Specific Clinical Disorders 1,5,6,7,9<br />Severe mania (too much talking, insomnia)<br />Depression<br />Schizophrenia (that doesn’t respond to meds)<br />Suicidal drive conditions<br />Impulsive behaviors<br />Neuroleptic Malignant Syndrome<br />Continuous screaming<br />Fibromyalgia (fatigue, anxiety, depression)<br />Vegetative dysregulation<br />Unipolar and bipolar disorders (catatonic)<br />Psychosis<br />
  6. 6. Depression: Clinical Facts8<br />14 million adults in the United States each year <br />1 to 2% in the general <br /> population of elderly persons<br />1 to 3% among those living <br /> in the community<br />10 to 12% among those in outpatient primary care and inpatient settings <br />
  7. 7. Symptoms of Depression 4<br />Pain<br />Muscle/joint aches<br />Inactivity<br />Poor physical condition<br />Disturbed body appearance<br />Tension<br />Anxiety<br />Restlessness<br />Slowness<br />Postural issues<br />Restricted breathing<br />
  8. 8. Depression: Pathophysiology8<br />Genetic, developmental, and environmental factors.<br />Brain changes in depression in the elderly<br />Abnormalities in frontostriatal limbic circuits, can reduce the response to medications <br />Dysregulation in corticolimbic circuits affecting <br />Regional brain structure and function<br />Neurotransmitter function<br />Neuroendocrine regulation <br />
  9. 9. Depression: Pathophysiology8<br />
  10. 10. Depression: Pathophysiology8<br />Abnormalities in the hippocampus<br />atrophy is correlated with the duration of depression in days <br />Abnormalities in prefrontal cortex<br />atrophy is associated with familial depression<br />Hyperintensities<br />notably in depression in the elderly <br />vascular lesions in white matter disrupt key pathways, leading to a “disconnection syndrome” <br />
  11. 11. Depression: Pathophysiology8<br />Neurotransmitter Function<br />Presynaptic and postsynaptic abnormalities<br />serotonin-receptor expression <br />deficiencies in GABA<br />
  12. 12. Effects of ECT on Depression Mechanism8<br />Increases cortical GABA concentrations<br />Enhances serotonergic function <br />Affects the hypothalamic–pituitary–adrenal interactions<br />
  13. 13. ECT Theories 8 <br />Neurophysiological theory<br />Electrical shock causes seizure<br />Stimulates a long term release of neurotransmitters<br />Improve brain cells functioning and increases chemical messengers<br />Punishment Theory (Weak)<br />Patients see treatment as punishment for behavior<br />Improve to avoid further punishment<br />
  14. 14. ECT: Preparation 2,8 <br />Consent form <br />Physical exam<br />Heart and Lung exam <br />Anesthesia<br />Blood test<br />Electrocardiogram<br />Anticonvulsants and antidepressant drugs are often discontinued<br />
  15. 15. ECT Procedure/Dosage1<br />In-patient or Out-patient procedure<br />Anesthetic (IV)<br />Muscle relaxer (IV)- prevent injury<br />HR, BP, breathing are closely monitored<br />Medicines/ restraints to secure the body during seizure<br />1-2 second shock- just enough to induce seizure<br />Seizure typically lasts 40 seconds<br />Total duration 5-10 minutes<br />3-4 times per week<br />Typically 6-12 treatments relieve depression symptoms<br />
  16. 16.
  17. 17. ECT Electrode Placement<br />Bifrontaltemporal (bilateral)<br />Right Unilateral<br />Bifrontal<br />
  18. 18. Which is more effective?2,8<br />Bilateral electrode placement was moderately more effective than right unilateral placement <br />Greater cholinergic surge<br />Efficacy of right unilateral ECT is dose-sensitive …(studies may be affected by this to few?)<br />No difference long term<br />
  19. 19. Which is more effective?2,8<br />Right unilateral and bifrontal placement<br />reduce the burden of side effects<br />bilateral placement may be selected if the right unilateral or bifrontal positions are unlikely to be effective 8<br />
  20. 20. ECT: Post Procedure1<br />Antidepressant <br />Medications<br /> are continued to prevent <br /> relapse<br />
  21. 21. Predicting ECT Efficacy 9<br />Short Term<br />60-80% success rate<br />50% relapse rate if antidepressants are not used correctly<br />
  22. 22. Adverse Effects 8<br />Initial anterograde amnesia <br />Short term disorientation or delirium (1hr)<br />Long term retrograde amnesia<br />Sleep disturbances<br />Death<br />Memory gaps mostly of interpersonal events<br />Physical effects<br />Headaches<br />muscle aches<br />Acute BP/HR changes- immediately treated<br />nausea<br />Fatigue<br />Anatomical damage <br />
  23. 23. Anatomical Damage 8<br />Thalamic hemorrhages <br />
  24. 24. ECT Uncertainties 8<br />How to prevent relapse after a remission<br />Reduction of cognitive side effects<br />Shorter pulse of electricity?<br />Placement of Electrodes ?<br />
  25. 25. ECT: APA Guidelines 8<br />Administered by properly qualified psychiatrists <br />Recommend ECT only for difficult-to-treat depression (5-6 unsuccessful attempts)<br />Use of ECT for relapse prevention <br />Not recommend ECT as maintenance therapy<br />Detailed criteria for patient selection, medical screening, ECT procedures, and training in ECT <br />Must be credentialed by their local hospital or or board certification for ECT practice in the US<br />
  26. 26. ECT Contraindications 8<br />Ischemia<br />arrhythmias<br />cerebrovascular disease<br />cerebral hemorrhage or stroke<br />Increased intracranial pressure<br />
  27. 27. Application to Practice6<br />Physical therapy interventions for depression are important but will not be affective if neurological deficits limit the patient mobility<br />ECT is ALWAYS secondary treatment to pharmaceutical interventions <br />Is the individual’s consent valid if they require ECT?<br />
  28. 28. ???????????????????????<br />
  29. 29. References <br />1). Frederikse M, Petrides G, Kellner C. Continuation and maintenance electroconvulsive therapy for the treatment of depressive illness: a response to the National Institute for Clinical Excellence report. J ECT. 2006;22:13-17.<br />2). Asystole during electroconvulsive therapy: a case report. Australian and New Zealand Journal of Psychiatry [serial online]. June 2001;35(3):382-385. Available from: E-Journals, Ipswich, MA. Accessed June 10, 2009. <br />3). http://www.informatics.susx.ac.uk/research/groups/nlp/gazdar/teach/atc/1999/web/seans <br />4). Nyboe Jacobsen L, Smith Lassen I, Friis P, Videbech P, Wentzer Licht R. Bodily symptoms in moderate and severe depression. Nordic Journal of Psychiatry [serial online]. August 2006;60(4):294 <br />5). A, Oktayoglu P, Current Pharmaceutical Design [Curr Pharm Des], ISSN: 1873-4286, 2008; Vol. 14 (13), pp. 1274-94; PMID: 18537652 <br />6). Susman, Virginia L.. Psychiatric Quarterly, Dec2001, Vol. 72 Issue 4, p325, 12p; (AN 11303889) <br />7). Snowdon, John; Meehan, Tom; Halpin, Rhonda. International Journal of Geriatric Psychiatry, Nov94, Vol. 9 Issue 11, p929-932, 4p; (AN 12114218) <br />8). Lisanby, SH, New England Journal of Medicine (USA), Feb 2007, vol. 357, pp. 1939-1945 <br />9). Kato N, Asakura Y, Mizutani M, Kandatsu N, Fujiwara Y, Komatsu T. Anesthetic management of electroconvulsive therapy in a patient with a known history of neuroleptic malignant syndrome. Journal of Anesthesia [serial online]. November 2007;21(4):527-528. Available from: Academic Search Premier, Ipswich, MA. Accessed June 10, 2009. <br />10). http://www.informatics.susx.ac.uk/research/groups/nlp/gazdar/teach/atc/1999/web/seans <br />

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