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Electro Convulsive Therapy


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Presentation on ECT. …

Presentation on ECT.
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  • 1. ECT Dr.D.Raj Kiran.
  • 2. What is ECT • ECT- Application of electric current to the head with the aim of inducing a controlled tonic-clonic seizure, usually at regular intervals, to achieve an improvement in an abnormal mental state. • Modified ECT- Induction of cerebral seizure under anaesthesia. • Unmodified ECT- Induction of cerebral seizure without anaesthesia.
  • 3. History • In 16th century, the Swiss alchemist Paracelsus gave camphor by mouth to induce convulsions and “cure lunacy.” • In 18th & 19th century, several cases of convulsions induced by chemical means were documented.
  • 4. History • Manfred Sakel was the developer of insulin shock therapy. • He noted that insulininduced coma and convulsions had a change in the mental state of drug addicts and psychotics. • Complications were high.
  • 5. History • In 1934, Lazlo Meduna, a Hungarian psychiatrist, injected camphor in oil into a catatonic schizophrenia, causing grand mal seizure. • After series of such treatments pts recovered. • Later Camphor was replaced by pentylenetetrazol.
  • 6. History • Pentylenetetrazol caused lot of unpleasant sensations. • The concept of applying electricity was developed. • Swiss scientists induced seizures in dogs using direct electrical current.
  • 7. Birth of ECT • Italian scientists, Cerletti and Bini subsequently succeeded in applying electricity directly to the human scalp. • In 1938, they treated an unidentified 39-year-old man who was found delusional in a train station. • He recovered fully after 11 treatments without adverse Effects.
  • 8. Birth of ECT Ugo Cerletti Cerletti’s ECT machine
  • 9. Effects of ECT • During ECT, brain imaging showsHypermetabolic state – increases in cerebral blood flow (CBF). – increase cerebral metabolic rate (CMR). • Post-ictal state- functional suppression – decreases in CBF. – decrease in CMR. • Also during & after ECT, there are δ waves indicating reduction in neural activity.
  • 10. Mechanism of action • No “definitive theory” regarding the mechanisms of action. • Psychological theories- patient expectation, placebo effects, forced regression, and contribution of retrograde amnesia to clinical response. • These were proved to be incorrect.
  • 11. Mechanism of action • Biological theories- they are related to ECT's anticonvulsant effects. • These effects manifest during a course of ECT. • They include – – – – progressive increases in seizure threshold. progressive decrease in seizure duration. increases in inhibitory neurotransmitters. decreases in excitatory neurotransmitters.
  • 12. Mechanism of action • Recent studies– Transient induction of increased proinflammatory cytokines, – Increased expression of brain-derived neurotrophic factor (BDNF), – Gene polymorphism, – Enhanced activity in the GABAergic, glutaminergic and dopaminergic systems, – Enhance neurogenesis, synaptogenesis and remodelling of synapses in hippocampus.
  • 13. Electrical principles • Waveforms – Sine wave- more cognitive deficits – Brief square wave- better efficacy & less adverse effects. • An adequate seizure is defined as – – – – Motor seizure > 25 sec. EEG seizure of 30-120 sec. Rise of HR by > 50% during seizure. Post-ictal rise in PRL.
  • 14. Electrode placement Bilateral Unilateral • Electrodes are placed apart over each hemisphere. • More rapid therapeutic response. • Mc- Bitemporal, Bifrontal. • Both electrodes placed apart over non dominant hemisphere. • Less marked cognitive deficits. • Mc- Right unilateral.
  • 15. Electrode placement • Bilateral- electrode is placed 2.5 -4cm above the midpoint of line joining tragus & lateral canthus. • Unilateral- another electrode at vertex.
  • 16. Indications • • • • • • • • • • Major depression. Mania. Schizophrenia. Catatonia. Parkinson’s disease. Intractable seizures. Delirium. Gilles de la tourette syndrome. Hallucinogen induced psychosis. Neuroleptic malignant syndrome (NMS).
  • 17. Contra-indications • Absolute- “none” • Relative– – – – – – – – Space occupying intracranial lesion. Raised ICP. Recent MI with unstable cardiac function. Vascular aneurysm. Recent Intra cranial hemorrhage. Retinal detachment. Pheochromocytoma. Anesthesia risk. • Pregnancy is not a contraindication.
  • 18. Pretreatment • Informed consent • Evaluation– History & Examination. – Medical evaluation- systemic examination, fundus, ECG, electrolytes. – Anaesthetic evaluation. • Bite block • Anaesthetic agents- thiopental/propofol, muscle relaxant (SCh), anticholinergics.
  • 19. Adverse effects • Nausea, vomiting, headache. • CNS– Post-ictal confusion. – Memory problems- retrograde > anterograde. • Fractures & Muscle injuries- direct ECT. • Death- 1 in 25,000. causes could be MI, Ventricular arrhythmias, respiratory complications.
  • 20. Video…. • Video on Modified ECT