ECT

ECT
ELECTROCONVULSIVE
THERAPY
04-Mar-16
Presented by
Richard Opoku Asare
MEd(UCC), BEd (Hons)(Health sciences), RN (Dip)-RMN, Cert.Ed
asareor@yahoo.com ©2011 1

OUTLINE OF PRESENTATION
• Short history of ECT
• Definition
• Indications
• Situations that need
immediate use of ECT
• Contraindications
• Course of treatment and
administration
• The core ECT team
• Items needed at the ECT
room
• Medications to be
discontinued before ECT
• Anaesthetic Agents used
in ECT
• Types of ECT
• Forms of ECT
• Complications, risk and
side effects of ECT
• Management of the client
before, during and after
ECT
04-Mar-16 asareor@yahoo.com 2

HISTORY
• Italian Professor of neuropsychiatry Ugo
Cerletti, who had been using electric shocks
to produce seizures in animal experiments,
and his colleague Lucio Bini developed the
idea of using electricity as a substitute for
metrazol (camphor) in convulsive therapy
and, in 1937, experimented for the first time
on a person.

HISTORY – cont’d
• ECT soon replaced metrazol therapy all over the
world because it was cheaper, less frightening
and more convenient.
• ECT is the only form of shock treatment still
performed by modern medicine.
• Today, an estimated 1 million people worldwide
receive ECT every year.
• ECT is the first-line treatment for patients who
have not responded to other interventions such
as medication and psychotherapy.

DEFINITION
 Electroconvulsive therapy (ECT), also known as
electroshock treatment, is psychiatric treatment in
which seizures are electrically induced in
anesthetized patients for therapeutic effect.
 ECT is the introduction of a controlled grand mal
seizure by passing an electrical current through the
brain.
 It is the use of electrically induced seizures for the
safe and effective treatment of severe depression.

DEFINITION – cont’d
• ECT is a way by which a grand mal seizure
is artificially induced in an anaesthetized
patient by passing on electrical current
through electrodes supplied to the
patient’s temples. The current is usually
70–120 volts and it is administered for
11/2 seconds.

MODE/MECHANISM OF ACTION
• NEUROTRANSMITTER THEORY – it acts
like the Tricyclic antidepressants by
increasing neurotransmitters in the
synaptic cleft.
• ECT works like antidepressant
medication, changing the way brain
receptors receive important mood-
related chemicals

MODE/MECHANISM OF ACTION – Cont’d
• ENDOCRINE THEORY – it helps the
release of pituitary hormones like
endorphins, TSH, ADH which make the
client happy.
• The seizure causes the hypothalamus
to release chemicals that cause
changes throughout the body. The
seizure may release a neuropeptide
that regulates mood.

• ANTI-CONVULSANT THEORY – has an
anticonvulsant effect on the brain that
results in an antidepressant effect.
• ECT-induced seizures teach the brain
to resist seizures. The effort to inhibit
seizures dampens abnormally active
brain circuits, establishing mood.

• BRAIN DAMAGE THEORY – Shock
damages the brain, causing memory
loss and disorientation that creates
an illusion that problems are gone,
and euphoria, which is a frequently
observed result of brain injury. Both
are temporary

• PSYCHOLOGICAL THEORY – Depressed
people often feel guilty, and ECT
satisfies their need for punishment.
Alternatively, the dramatic nature of
ECT and the nursing care afterwards
makes patients feel they are being
taken seriously – the placebo effect.

INDICATIONS
• Major depression
• Mania(often in Bipolar
Disorder)
• Catatonia
• Postpartum psychosis
• Motor symptoms of
Parkinson’s disease
• Delirium tremens
• Schizoaffective disorder
• Acute exacerbations of
paranoid schizophrenia
• Undifferentiated
schizophrenia
(accompanied by
perplexity and prominent
affective symptoms)
• Phencyclidine delirium
• To improve tardive
dyskinesia
• For patients who have
failed a trial of drug
treatment

SITUATIONS THAT NEED IMMEDIATE USE
OF ECT
• Depressed patients at immediate risk of suicide.
• Weaked and malnourished patients who might
not survive long enough to experience an
adequate trial of antidepressant.
• Patients whose general medical condition
prohibits the use of antidepressants.

CONTRA-INDICATIONS
• Epileptic
• Intracranial pressure
• Asthmatic
• Fractures of the long
bone
• Children under 10 years
of age
• Respiratory disorders,
e.g., pneumonia, TB, etc
• Severe hypertension
• Tumours of the nervous
system
• Severe cardiac conditions,
e.g., CVA, myocardial
infarctions, CHF, etc
• Aortic or carotid
aneurysm
• Cerebral lesions
• Fissures on the skull
• Poor liver or renal
function
• Retinal detachment

WHY ECT BE USED IN PREGNANCY &
THE ELDERLY?
• Pregnant women and the elderly are far more
susceptible to untoward effects from
medication(s) than to untoward effects from ECT.
• Besides, ECT is considered a safe treatment
alternative in antepartum psychosis and for the
geriatric patients (Hamilton, 1986) with mood
disorders.
• ECT is not contraindicated for pregnant women
and elderly patients.

Preparation before and during ECT for
the pregnant woman
• Conduct pelvic examination.
• Ask client to stop nonessential anticholinergic
medication.
• Conduct uterine tocodynamometry (i.e. measuring the
force and frequency of uterine contractions).
• Ensure intravenous hydration.
• administer a nonparticulate antacid.
• Elevate the pregnant woman's right hip.
• Conduct external foetal cardiac monitoring.
• Carry intubation.
• Avoid excessive hyperventilation.04-Mar-16 asareor@yahoo.com 16

COURSE OF TREATMENT &
ADMINISTRATION
• The number and frequency of therapy consists
of 6–12 treatments,
and
• It is administered 2 or 3 times a week.

THE CORE MEMBERS OF THE ECT
TEAM
• The psychiatrist
• The anaesthesiologist
• The nurse
• The medical/physician assistant, where necessary
• The patient

EQUIPMENT NEEDED AT THE ECT
ROOM
• ECT machine with electrodes
• Electro-contact solution (bowl
of normal saline or gel)
• Muscle relaxants
• Oxygen cylinder
• EEG/ECG machine
• Laryngoscope
• Syringes and needles for
drawing up and injecting drugs
• Tourniquet
• TPR and BP tray with all
necessary equipment
• Firm bed (with side rails)
• Endotracheal tube
• Mouth gag
• Face masks
• Tongue depressors (spatula)
• Dissecting forceps, etc
• Screens
• Ambubag
• Defribillator
• Suction machine
• Resuscitating apparatus
• Emergency drugs
• Sedatives

Drugs to be discontinued before ECT
treatment
• Tricyclic
Antidepressants – They
predispose client to
Arrhythmias.
• Lithium – It enhances
post-ECT confusion.
• Theophylline – Lowers
seizure threshold.
• Benzodiazepines –
Increase seizure
threshold.
• Anticonvulsants – Lead
to a greater electrical
stimulus to induce
seizure.

ANAESTHETIC AGENTS USED IN ECT
• Atropine 0.5–0.6 mg, given 30 minutes before the
procedure. Atropine dry body secretions and prevent
aspiration.
• I.V. Sodium Penthotal (Thiopentone) 150–250 mg, to
relax the muscles.
• Scoline Suxamethonium, as muscle relaxant.
• Pure oxygen (100%) inhalant.

Electroconvulsive therapy (ECT) Machine

TYPES OF ECT
1) BILATERAL ECT: Involves placing the
electrodes of the ECT machine
simultaneously at each temple of the
patient’s head. It means placing the
electrodes on each side of the head at
the region known as the temporal
fossa.

Figure A. Bilateral Placement

BILATERAL ECT
• The disadvantage of this type of
ECT is that it has cognitive side
effects, such as memory loss and
confusion.
• The advantage is that it is very good
as it has a better therapeutic effect.

Administration of ECT (Bilateral Type)

TYPES OF ECT – cont’d
2) UNILATERAL ECT: Involves placing both
electrodes on the same side of the
head (the dominant hemisphere). In
this case, one electrode is placed
midline (the temporal position), and
the other over the non-dominant
hemisphere (the parietal area),
generally presumed to be the right.

Figure B. Right Unilateral Placement

UNILATERAL ECT
• The advantage of this type of ECT is
that it reduces problems of
memory.
• However, patients suffering from
severe depression do not benefit
much from it.

THE FORM OF ADMINISTRATION OF
ECT (MODE OF APPLICATION)
ECT can be administered or applied in Two forms:
Straight/Direct: This is the unmodified form of
ECT where no anaesthetic agent is given to the
client and the electricity is applied through the
electrodes to the head to induce the grand mal
seizure.
Modified: The client is given an anaesthetic agent
before the application of the electricity to induce
the seizure.

Complications, Risk and Side Effects of
ECT
• Memory loss
• Confusion
• Anoxia
• Medical complications: Such as spasms of the
larynx (laryngospasm), circulatory insufficiency,
loss of tooth (if the tooth is weak), fractures of
the vertebra and other bones of the body, severe
headache, nausea, transient bradycardia, and
prolonged apnoea can occur.
• Death – not common.

COMPONENTS (STAGES) OF NURSING
CARE IN ECT
1. Providing educational and emotional support
2. Preparation of the client/Pretreatment Nursing Actions
3. The ECT procedure and management/Intra-procedure care
4. Care of the client after therapy/Post-treatment Nursing
Actions
(Arkan & Ustün , 2008)

MANAGEMENT OF ECT – BEFORE,
DURING AND AFTER
THIS IS AN ASSIGNMENT AS PART OF YOUR
MIDSEMESTER EXAMS. IT SHOULD BE WRITTEN
IN YOUR PSYCHIATRIC NOTE BOOKS AND
SUBMITTED FOR MARKING.
TWENTY PERCENT – BEFORE ECT.
TEN PERCENT – DURING ECT.
TEN PERCENT – AFTER ECT.
TOTAL MARKS OF THIRTY PERCENT

END OF LECTURE
THANK YOU

ECT

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