psychiatry unit 5

1. Presented by:
Mr. P. Vethadhas M.Sc (N),
Assistant Professor,
Dept.of Mental Health Nursing.

2. Electroconvulsive Therapy
Electroconvulsive therapy is a type of somatic treatment first
introduced by Bini and Cerletti in April 1938. From 1980 onwards
ECT is being considered as a unique psychiatric treatment.
Electroconvulsive therapy is the artificial induction of a grandmal
seizure through the application of electrical current to the brain. The
stimulus is applied through electrodes that are placed either bilaterally
in the fronto-temporal region, or unilaterally on the non-dominant side
(right side of head in a right-handed individual).

3. Parameters of Electrical Current Applied
Standard dose according to American Psychiatric Association,
1978:
Voltage : 70-120 volts
Duration: 0.7-1.5 seconds

4. Type of Seizure Produced
Grandmal seizure-tonic phase lasting for 10 - 15 seconds
Clonic phase lasting for 30-60 seconds

5. Mechanism of Action
The exact mechanism of action is not known. 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 the
hypothalamus.

6. Types of ECT
• Direct ECT: In this, ECT is given in the absence of
anesthesia and muscular relaxation. This is not a commonly
used method now.
• Modified ECT: Here ECT is modified by drug induced
muscular relaxation and general anesthesia.

7. Frequency and Total Number of ECT
• Frequency: Three times per week or as indicated.
• Total number: 6 to 10; upto 25 may be preferred as
indicated.

8. Application of Electrodes
• Bilateral ECT: Each electrode is placed 2.5 - 4 cm (1-1 ½
inch) above the midpoint, on a line joining the tragus of the
ear and the lateral canthus of the eye.
• Unilateral ECT: Electrodes are placed only on one side of
head, usually non-dominant side (right side of head in a
right-handed individual). Unilateral ECT is safer, with much
fewer side effects particularly those of memory impairment

9. Indications

10. 1. Major depression:
• With suicidal risk
• with stupor
• with poor intake of food and fluids
• melancholia with psychotic features with unsatisfactory
response to drugs
• where drugs are contraindicated or have serious side-effects .

11. 2. Severe catatonia (functional):
• With stupor
• with poor intake of food and fluids
• with unsatisfactory response to drug therapy
• when drugs are contraindicated or have serious side-effects.

12. 3. Severe psychosis (schizophrenia or
mania):
• With risk of suicide
• homicide or danger of physical assault
• with depressive features
• with unsatisfactory response to drug therapy
• when drugs are contraindicated or have serious side-effects.

13. 4. Organic mental disorders:
• Organic mood disorders
• Organic psychosis

14. 5. Other indications:
ECT is preferred to antidepressant therapy in some
cases, such as for clients with cardiac disease; when
tricyclics are contraindicated because of the potential for
dysarrythmias and congestive heart failure; and for pregnant
women, in whom antidepressants place the fetus at risk for
congenital defects.

15. Contraindications
A. Absolute:
• Raised ICP (intracranial
pressure)
B. Relative:
• Cerebral aneurysm
• Cerebral hemorrhage , Brain tumor
• Acute myocardial infarction
• Congestive heart failure
• Pneumonia or aortic aneurysm
• Retinal detachment

16. Complications of ECT
• Life-threatening complications of ECT are rare.
• ECT does not cause any brain damage.
• Fractures can sometimes occur in elderly patients with
osteoporosis.
• In patients with a history of heart disease, dysrhythmias and
respiratory arrest may occur.

17. Side Effects of ECT
Memory impairment
Drowsiness, confusion and restlessness
Poor concentration, anxiety
Headache, weakness or fatigue, backache, muscle aches
Dryness of mouth, palpitations, nausea, vomiting
Unsteady gait
Tongue bite and incontinence

18. ECT Team
• Psychiatrist
• Anesthesiologist
• Trained nurses and aides should be involved in the
administration of ECT.

19. Treatment Facilities
There should be a suite of three rooms:
1. A pleasant, comfortable waiting room (pre ECT room).
2. ECT room, which should be equipped with ECT machine and
accessories ,an anesthetic appliance, suction apparatus, face masks,
oxygen cylinders with adjustable flow valves, curved tongue
depressors, mouth gags, resuscitation apparatus and emergency
drugs. There should be immediate access to a defibrillator.
3. A well-equipped recovery room.

20. Role of the Nurse

21. a). Pre-treatment evaluation
• Detailed medical and psychiatric history, including history of allergies
• Assessment of patient's and family's knowledge of indications, side-effects,
therapeutic effects and risks associated with ECT
• An informed consent should be taken. Allay any unfounded fears and
anxieties regarding the procedure
• Assess baseline vital signs
• Patient should be on empty stomach for 4-6 hours prior to ECT
• Withhold night doses of drugs, which increase seizure threshold like
diazepam, barbiturates and anticonvulsants

22. Cont..,
• Withhold oral medications in the morning
• Head shampooing in the morning since oil causes impedance of
passage of electricity to brain
• Any jewellery, prosthesis, dentures, contact lens, metallic objects and
tight clothing should be removed from the patient's body
• Empty bladder and bowel just before ECT
• Administration of 0.6 mg atropine IM or SC 30 minutes before ECT, or
IV just before ECT

23. b). Intra-procedure care
• Place the patient comfortably on the ECT table in supine position
• Stay with the patient to allay anxiety and fear
• Assist in administering the anesthetic agent (thiopental sodium 3-5 mg/kg
body weight) and muscle relaxant (1mg/kg body weight of succynylcholine)
• Since the muscle relaxant paralyzes all muscles including respiratory
muscles, patent airway should be ensured and ventilatory support should be
started
• Mouth gag should be inserted to prevent possible tongue bite.

24. Cont…,
• The place(s) of electrode placement should be cleaned with normal
saline or 25 percent bicarbonate solution, or a conducting gel applied
• Monitor voltage, intensity and duration of electrical stimulus given
• Monitor seizure activity using cuff method
• 100percent oxygen should be provided
• During seizure monitor vital signs, ECG, oxygen saturation, EEG, etc
• Record the findings and medicines given in the patient's chart.

25. c). Post-procedure care
• Monitor vital signs
• Continue oxygenation till spontaneous respiration starts
• Assess for post-ictal confusion and restlessness
• Take safety precautions to prevent injury (side lying position and
suctioning to prevent aspiration of secretions, use of side rails to
prevent falls)

26. Cont…,
• If there is severe post-ictal confusion and restlessness, IV diazepam
may be administered
• Reorient the patient after recovery and stay with him until fully
oriented
• Document any findings as relevant in the patient's record

27. Thank you