ECT involves inducing a brief, controlled seizure in patients through the application of electric currents to the brain. It has been used effectively to treat severe depression and other mental illnesses since the 1930s. The document outlines the history, machines, mechanisms of action, indications, techniques, risks, and typical treatment protocols for ECT. It explains that ECT aims to restore normal neuroendocrine and neurotransmitter system functioning through repeated seizures, and is considered very safe when administered properly by a psychiatrist.

1. Electro-Convulsive Therapy (ECT)
Dr.Asma A Rehman
Consultant Psychiatrist

2. Overview
• Definition
• History
• Machines
• Mechanism of action
• Indications
• Technique
• Unwanted effects
• Summary

3. Definition
• ECT is a procedure in which electric currents are passed
through brain, intentionally triggering a brief seizure.
• Formerly known as “ Electric Shock ”
• Safe for all ages, with debilitating illness, and during
pregnancy.

4. History
• Introduced in late 1930’s
• On basis of mistaken idea :
“ Epilepsy and Schizophrenia do not occur together”
• Induced fits should lead to improvement in Schizophrenia.
• Initially chemically fits were induced by using Camphor or Pentylenetetrazol.
• IV Camphor induced seizure in 1934 by Meduna
As procedure was painful so
Then
started on ECT
• IM pentylenetetrazol
• 1st
ECT in 1938
.

5. • 1940, curare was developed for use as a muscle
relaxant during ECT
• Succinylcholine, a depolarizing muscle relaxant, was
introduced in 1951
• 1975 movie “One Flew Over the Cuckoo’s Nest,” with
Jack Nicholson thrashing about, forced against his will
to endure painful, violent seizures
• In 1985, the National Institutes of Health and National
Institute of Mental Health Consensus Conference on
ECT endorsed a role for the use of ECT

6. ECT machines.
• Four machines currently available are recommended by
the College:
1. the Ectron Series 5A,
2. Ectonus (Electron Ltd, Letchworth),
3. Mecta SR2 and JR2 (Mecta Corp., Lake Oswego, OR)
and
4. Thymatron-DGx (Somatics Inc., Lake Bluff, IL) (
Royal College of Psychiatrists, 1995).

7. ECT machine in LNH (ECTONUS)

9. Mechanism Of Action.
• Neuro-endocrine system
• Neuro-endocrine dysregulation Is prominent in Patients
with Mental disorders for which ECT is effective.
• In severely depressed patients, Adrenal glands produce too
much Cortisol.
• The high blood levels disrupts normal diurnal rhythm of
other glandular discharges and the glands do not respond to
usual feed back mechanism.

10. • The most prominent features of depression are distortion of
functions regulated by Neuro-endocrine gland in self-
adjusting feed back.
• Each Seizure stimulates Hypothalamus to discharge its
hormones, which causes Pituitary gland to discharge its
products which then effects level of Cortisol.
• The first effects of this cascade are Transitory, but repeated
Seizures restore the normal interaction of HPA axis.
• Feeding & sleeping becomes normal, followed by motor
activity, mood , memory & thoughts.

11. • After some course of ECT, the return to normal Endocrine
functions.
• At other times, glands revert their abnormal activities, &
mental disorder becomes evident again.
• In these cases repeated stimulation of Hypothalamus &
Pituitary by continuation of ECT restore & sustain normal
glandular function & support normal mental state.

12. • Neuro-transmitter System.
• Almost all neurotransmitters effected by ECT.
• Down regulation of pot-synaptic beta adrenergic receptor
• Increase post-synaptic receptor & change in pre-synaptic
discharge.

13. Indications.
• 1) Treatment of choice :
• Severe depressive illness when associated with :
oLife threatening illness bec of refusal of food & fluids.
oHigh Suicidal risk.
• 2) Considered for:
• Severe Depressive illness associated with:
oStupor.
oMarked Psychomotor retardation.
oDepressive delusions & hallucinations.

14. • 3) 2nd
& 3rd
line of treatment:
• Depressive illness:
o If not responsive to anti-depressant drugs
• 4) Treatment of Mania:
• associated with:
o Life threatening physical exhaustion.
o Not responded to appropriate drug treatment.
• 5) For treatment of Acute Schizophrenia:
• as 4th
line treatment option.
o After trial of 2 anti-psychotics & Clozapine was ineffective
• 6) Catatonia.
o Where treatment with Benzodiazepine ineffective.

15. • Mortality Rate.
• 3-4/100,000 Treatments.
• Due to General Medical conditions or General Anesthesia
complications.
• Contraindications.
• No absolute contraindications.
• Contraindications are due to anesthesia

16. Technique
• Pre-treatment evaluation:
• Complete physical examination
• Dental examination
• Complete Blood Picture.
• Serum Urea/Creatinine/Electrolytes.
• Urine Tests
• Chest X-ray
• ECG
• CT-Scan.
• MRI.
• ECT Clinic:
• Pleasant safe surroundings
• Waiting area should separate from treatment room
• Emergency equipment should be present
• ETT.
• Suction.
• O2 supply.
• Resuscitation.

17. • Arrival of patient:
• Patient should be at ease.
• Check identity
• Check consent form.
• Check drug sheet.
• Administration of Anesthesia.
• NPO for at least 5 hours.
• I/V access maintained.
• Attach Monitor
• Give Muscle relaxant
• Anesthetic agent
• Hyperventilation with O2
• Bite Block.
• Electrode placement and electical dose.
• Managing complications.
• Shift to recovery room till patient concious and stable.

18. Muscrainic anti-cholinergic:
• Administered before anesthetic agent
• To minimize oral and respiratory secretions.
• Atropine 0.3-0.6 mg IM or SC 30-60 minutes before
anesthetic agent
OR
• 0.4-1.0 mg IV 2 or 3 minutes before anesthetic
• Suxamethonium Chloride 0.5-1mg/kg i/v bolus

19. Anesthetic agent.
• Methohexital (BREVITAL) ( most commonly used)
• 0.75-1mg/kg iv bolus
• Thiopental (PENTOTHAL) 2-3mg/kg iv bolus

20. Other anesthetic agents used.

21. Muscle relaxant.
• After onset of anesthetic effect within a minute.
• To minimize risk of bone fractures and other injuries.
• Succinylcholine 0.5-1 mg/kg iv bolus.

22. Application of electrodes.
• Clear skin
• Moist skin ( dry electrodes can cause skin burns/excessive moisture can cause
shortening & prevent seizure exposure.)
• Position of electrodes
• Unilateral electrode:
• On non-dominant side.
• 3cm above mid-point line between external angle of orbit & external
auditory meatus.
• Bilateral electrode:
• 2nd
electrode.
Either of two points can be used.
• i) At least 10cm away from 1st
one. Vertically above meatus of same side.
or
• ii) Electrodes are placed on opposite sides of head.

24. Electical dose.
• For unilateral fixed ECT:
400 milicoloumbs
• For Bilateral ECT:
100-200 milicoloumbs.
• Seizure threshold increased in men.
• For age <40
• Starting dose: 150 milicoloumbs.
• Dose might be increased if seizure was short or
absent.

26. Signs of seizure.
1st
• Muscle of face begin to twitch & mouth drops open.
Then.
• Upper eyelids, thumbs & big toe jerks rhythmically for
1½ minute.
• Seizure duration: 20-50seconds.

27. Monitoring by EEG
• Many modern ECT machines now include EEG
monitoring, which helps to prevent unwarranted re-
stimulation, as well as to detect prolonged seizures.

29. Concomitant medications.
• Anti-depressant & anti-psychotics decrease seizure threshold.
• Benzodiazepine should be withdrawn because of anti-
convulsant effect.
• Valproate & lamotrigine increase threshold.
• Clozapine and Bupropion should be withdrawn because
associated with late appearing seizures.
• Cognitive impairment when ECT given with Lithium.
• SSRIs prolong seizure duration.
• Lidocaine should not be administred as increase seizure
threshold.
• Theophylline contraindicated as increases seizure duration.
• Reserpine also contraindicated as compromise respiratory and
CVS during ECT

30. Complications.
• Prolonged and tardive seizure.
• Duration > 180 seconds.(APA guidelines)
• > 120 seconds ( Royal College’s revised guidelines)
• Status epilepticus.
• Give i/v diazepam 5-10mg immediately.
• Failed stimulation.
• If no seizure occurred
 Check machine.
 Check electrodes.
 Check contact with skin.
• Charge can be increased by 50% & further stimulus can be given.
• Additional procedure to lower seizure threshold include Hyperventilation
and
• administration of 500-2000 mg iv of Caffeine Sodium Benzoate 5-10
minutes before stimulus.

31. Unwanted effects
• Brief Retrograde Amnesia:
loss of memory up-to 30 minutes after ECT.
• Brief disorientation.
• Headache
• Muscle pain esp. jaws.
• Occasional damage to teeth, tongue or lips.
• Small electical burns (due to poor application of electrodes)
These unwanted effects are rare if good anesthetic technique
used.
Other rare complications occur due to co morbid physical
illness.

32. Memory disorder after ECT
Short-Term effects Long-Term effects
Retrograde
Amnesia
Anterograde
Amnesia
Loss of
memory for
personnel and
impersonal
remote
events.
Dec ability to
learn new
information.

33. Frequency and number of treatments
• Can be given Twice a week.
• In general.
3 times/week given.
• Course of ECT includes 6-12 treatments.
• Little response until 2-3 treatments.
• If no response after 6-8 treatments , course should be abandoned.
• Prevention of relapse:-
• In depression high relapse rate until continuation therapy
with anti-depressants.
• Maintenance ECT
• At reduced frequency.
• Fortnightly or monthly.

34. Thank you
•Hope it was not an
ELECTRIC SHOCK for
YOU