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1. Electro Convulsive Therapy
Nabina Paneru

2. Definition
• Electro convulsive therapy is the induction of Grand-mal seizure through
the application of electrical current to the brain.
• An electric current is applied for a fraction of a second through electrodes
placed on the temporal region. This immediately produces two stage
seizure or convulsion (tonic and colonic stage)
• The usual dose for obtaining an adequate seizure response is 90-150 volts
(average 110 volts) for 0.1-1.0 seconds (average 0.6 seconds). The usual
amount of current passed in an ECT session is 200-1600 mA.

3. Duration of Therapy
• The total duration and number of treatments given depends on the
diagnosis, presence of side effects, and the response to treatment.
• Usually 6-10 treatments are sufficient, although up to 15 treatments can
be given if needed.
• The treatments should be spaced, so that no more than 3 ECTs are given
per week.

4. Brief History
1934
• Von Meduna, in 1934, used 25% camphor in oil intramuscularly to produce convulsions for the
first time for therapeutic purposes.
• Later, he used pentylenetetrazol (metrazol) for the same purpose.
1938
• A much safer form of convulsive therapy was used by Cerletti and Bini in 1938
• They called it EST or electroshock therapy. Later, this method of treatment came to be known as
ECT or electroconvulsive therapy
1970
• Widespread criticism of ECT, with many legislations passed in the US states (e.g. in California,
1975), restricting the use of ECT.
• Following this, widespread modifications in the ECT technique made it even safer mode of
treatment.

5. Contd.
1974
• The American Psychiatric Association’s (APA’s) Council on Research and Development
appointed a Task Force on ECT.
• The APA Task Force on ECT, in 1976, gave its report which provided clear guidelines for
use of ECT and declared it to be a safe and effective method of treatment when used by
professionals
1990
• APA Task Force Report on ECT redefined the indications gave guide lines for obtaining
consent and set standards for training, treatment and privileging of ECT.
2001
• The most recent version of this task force report became available

6. Technique
According to technique
i. Direct ECT is administered in the absence of muscular relaxation and
general anaesthesia.
ii. Modifi ed ECT is modified by drug-induced muscular relaxation and
general anaesthesia administered by an anaesthetist.

7. Contd.
According to placement of elctrodes
i. Bilateral: This is the standard form of ECT used most commonly. Each
electrode is placed 2.5-4.0 cm (1-1½") above the midpoint, on a line
joining the tragus of the ear and the lateral canthus of the eye.
• Unilateral ECT: In this type, electrodes are placed only on one side of
head, usually the non-dominant side (right side of head in right-handed
individual).

9. Mechanism of Action
• The efficacy of ECT is linked with production of generalized tonic-clonic
seizures though, as stated above, there is some recent doubt about the need for
a seizure duration of 25-30 sec.
• Although the exact mechanism is unclear, one hypothesis states that ECT
possibly affects the catecholamine pathways between diencephalon (from
where seizure generalization occurs) and limbic system (which may be
responsible for mood disorders), also involving hypothalamus.

10. Indication
Depression, Severe catatonia, Severe psychosis, Organic mood or
psychotic disorder
i. With suicidal risk (This is the fi rst and most important indication for
ECT)
ii. With stupor
iii. With poor intake of food and fl uids

11. Contd.
iv. With psychotic features
v. With unsatisfactory response to drug therapy
vi. Where drugs are contraindicated, or have serious side effects
vii. Where speedier recovery is needed.

12. Contraindication
Absolute
• The only absolute contraindication is
the presence of raised intracranial
tension
Relative
• Recent myocardial infarction (MI)
• Severe hypertension
• Cerebrovascular accident (CVA)
• Severe pulmonary disease
• Retinal detachment, and
• Pheochromocytoma.

13. Side effects
• Memory disturbances (both anterograde and retrograde) are very
common.
• Confusion may occur in the postictal period.
• Other side effects include headache, prolonged apnoea, prolonged seizure,
cardiovascular dysfunction, emergent mania, muscle aches and
apprehension.
• ECT does not cause any brain damage.

14. Contd.
• Side effects are associated with general anaesthesia: Deaths during ECT
are usually due to the general anaesthesia, succinylcholine (in patients
with deficiency of pseudo-cholinesterase) or druginteractions.
• According to the APA Task Force Report (2001), the approximate
mortality rate is 1:10,000 patients (or 1:80,000 treatments), which is
similar to any operative procedure under anaesthesia.

15. Role of care Provider in ECT
Pre ECT Care
• Informed consent
• Assess baseline vital signs
• NPO for 4-6hrs prior to ECT
• Withhold night doses of drugs, which increase seizure threshold like
diazepam, barbiturates and anticonvulsants
• Withhold oral medications in the morning
• Advice patient to wash hair

16. Contd.
Pre ECT Care Contd.
• Any jewelry, prosthesis, dentures, contact lens, metallic objects and tight
clothing should be removed from the client’s body.
• Empty bladder ad bowel just before ECT
• Administration of atropine 30 minutes before ECT

17. Contd.
During ECT Care:
• Place the patient comfortably on the ECT table in supine position.
• Assist in administering the anesthetic agent and muscular relaxant.
• Mouth gag should be inserted to prevent possible tongue bite.
• Monitor voltage, intensity and duration of electrical stimulus given.

18. Contd.
During ECT Care Contd.
• Monitor seizure activity.
• 100% Oxygen should be provided
• Monitor vital signs, ECG, oxygen saturation, EEG and seizure etc.
• Record the finding and medicines given in the client’s chart.

19. Contd.
After ECT Care
• Continue oxygenation till spontaneous respiration starts and monitor vital
signs.
• Assess for confusion and restlessness.
• Take safety precautions to prevent injury (side lying position and
suctioning to prevent aspiration or secretion, use of side rails to prevent
falls).

20. Contd.
After ECT Care Contd.
• Reorient the client after recovery and stay with him/her until fully
oriented.
• Document any finding as relevant in the client’s record.