By : Abhimanyu parashar
• Electroconvulsive therapy (ECT), formerly known
• 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 neuropsychiatrists Ugo Cerletti and Lucio Bini, and gained
widespread use as a form of treatment in the 1940s and
• Electroconvulsive therapy can differ in its application in
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
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
• 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 longterm 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
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
• "no absolute health contraindications"
• the most common adverse effects are confusion and
• 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 wellcontrolled
• Some patients experience muscle soreness after ECT.
This is due to the muscle relaxants given during the
procedure and rarely due to muscle activity.
• 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
• 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
• Seizure threshold is determined by trial and error ("dose
• 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