This document discusses the history and procedure of electroconvulsive therapy (ECT). It begins by defining ECT as the application of electric current to the head to induce a seizure for improving abnormal mental states. It then outlines the early history of inducing seizures for psychiatric treatment from the 16th century through various chemical methods. It describes the development of ECT in the 1930s-1940s by Cerletti and Bini who applied electricity directly to humans. The document covers the mechanisms, electrical principles, electrode placements, indications, contraindications, pretreatment, effects and risks of the modern ECT procedure.

1. ECT
Dr.D.Raj Kiran.

2. What is ECT
• ECT- Application of electric current to the
head with the aim of inducing a controlled
tonic-clonic seizure, usually at regular
intervals, to achieve an improvement in an
abnormal mental state.
• Modified ECT- Induction of cerebral
seizure under anaesthesia.
• Unmodified ECT- Induction of cerebral
seizure without anaesthesia.

3. History
• In 16th century, the
Swiss alchemist
Paracelsus gave
camphor by mouth to
induce convulsions and
“cure lunacy.”
• In 18th & 19th century,
several cases of
convulsions induced by
chemical means were
documented.

4. History
• Manfred Sakel was the
developer of insulin
shock therapy.
• He noted that insulininduced coma and
convulsions had a change
in the mental state of
drug addicts and
psychotics.
• Complications were high.

5. History
• In 1934, Lazlo Meduna, a
Hungarian psychiatrist,
injected camphor in oil
into a catatonic
schizophrenia, causing
grand mal seizure.
• After series of such
treatments pts recovered.
• Later Camphor was
replaced by
pentylenetetrazol.

6. History
• Pentylenetetrazol
caused lot of
unpleasant
sensations.
• The concept of
applying electricity
was developed.
• Swiss scientists
induced seizures in
dogs using direct
electrical current.

7. Birth of ECT
• Italian scientists, Cerletti and Bini
subsequently succeeded in applying
electricity directly to the human scalp.
• In 1938, they treated an unidentified
39-year-old man who was found
delusional in a train station.
• He recovered fully after 11 treatments
without adverse Effects.

8. Birth of ECT
Ugo Cerletti
Cerletti’s ECT machine

9. Effects of ECT
• During ECT, brain imaging showsHypermetabolic state
– increases in cerebral blood flow (CBF).
– increase cerebral metabolic rate (CMR).
• Post-ictal state- functional suppression
– decreases in CBF.
– decrease in CMR.
• Also during & after ECT, there are δ waves
indicating reduction in neural activity.

10. Mechanism of action
• No “definitive theory” regarding the
mechanisms of action.
• Psychological theories- patient
expectation, placebo effects, forced
regression, and contribution of
retrograde amnesia to clinical response.
• These were proved to be incorrect.

11. Mechanism of action
• Biological theories- they are related to
ECT's anticonvulsant effects.
• These effects manifest during a course
of ECT.
• They include
–
–
–
–
progressive increases in seizure threshold.
progressive decrease in seizure duration.
increases in inhibitory neurotransmitters.
decreases in excitatory neurotransmitters.

12. Mechanism of action
• Recent studies– Transient induction of increased proinflammatory cytokines,
– Increased expression of brain-derived
neurotrophic factor (BDNF),
– Gene polymorphism,
– Enhanced activity in the GABAergic,
glutaminergic and dopaminergic systems,
– Enhance neurogenesis, synaptogenesis and
remodelling of synapses in hippocampus.

13. Electrical principles
• Waveforms
– Sine wave- more cognitive deficits
– Brief square wave- better efficacy & less
adverse effects.
• An adequate seizure is defined as
–
–
–
–
Motor seizure > 25 sec.
EEG seizure of 30-120 sec.
Rise of HR by > 50% during seizure.
Post-ictal rise in PRL.

14. Electrode placement
Bilateral
Unilateral
• Electrodes are placed
apart over each
hemisphere.
• More rapid therapeutic
response.
• Mc- Bitemporal,
Bifrontal.
• Both electrodes placed
apart over non dominant
hemisphere.
• Less marked cognitive
deficits.
• Mc- Right unilateral.

15. Electrode placement
• Bilateral- electrode
is placed 2.5 -4cm
above the midpoint
of line joining tragus
& lateral canthus.
• Unilateral- another
electrode at vertex.

16. Indications
•
•
•
•
•
•
•
•
•
•
Major depression.
Mania.
Schizophrenia.
Catatonia.
Parkinson’s disease.
Intractable seizures.
Delirium.
Gilles de la tourette syndrome.
Hallucinogen induced psychosis.
Neuroleptic malignant syndrome (NMS).

17. Contra-indications
• Absolute- “none”
• Relative–
–
–
–
–
–
–
–
Space occupying intracranial lesion.
Raised ICP.
Recent MI with unstable cardiac function.
Vascular aneurysm.
Recent Intra cranial hemorrhage.
Retinal detachment.
Pheochromocytoma.
Anesthesia risk.
• Pregnancy is not a contraindication.

18. Pretreatment
• Informed consent
• Evaluation– History & Examination.
– Medical evaluation- systemic examination, fundus,
ECG, electrolytes.
– Anaesthetic evaluation.
• Bite block
• Anaesthetic agents- thiopental/propofol,
muscle relaxant (SCh), anticholinergics.

19. Adverse effects
• Nausea, vomiting, headache.
• CNS– Post-ictal confusion.
– Memory problems- retrograde > anterograde.
• Fractures & Muscle injuries- direct ECT.
• Death- 1 in 25,000. causes could be MI,
Ventricular arrhythmias, respiratory
complications.

20. Video….
• Video on Modified ECT