Electroconvulsive therapy (ECT) is a somatic treatment introduced in 1938 to treat severe mental illnesses. It involves inducing a seizure through electrical stimulation of the brain under anesthesia. Key events in the history and development of ECT included the introduction of muscle relaxants and anesthesia in the 1950s to make it more humane. ECT remains an effective and commonly used treatment for severe depression, catatonia and other mental disorders when other options have failed or are contraindicated. It works by inducing neuroplasticity and altering neurotransmitter and neuroendocrine activity in the brain.

1. ELECTRO CONVULSIVE THERAPY
Mr. Nithiyanandam. T, M. Sc in Psychiatric Nursing, : nithiyuday@gmail.com
… a Somatic Treatment for Mental Illnesses !!!

2. INTRODUCTION
 Electroconvulsive therapy (ECT), formerly
known as ”electroshock”.
 It was first introduced in 1938 by Italian Neuro-
Psychiatrists Ugo Cerletti and Lucio Bini, and
gained widespread use as a form of treatment
in the 1940s and 1950s.

3. MILESTONES OF ECT

4. Years Events
1934 - 1936 Convulsive therapy (Camphor-in-Oil  Pentylenetetrazole – Metrazol)
1938 Electroconvulsive therapy (ECT)
1950 & 1951
Anaesthetic modification with pentothal sodium (1950) & Muscle
relaxant – Succinyl Choline (1951)
1953 Hamilton Cuff Monitoring Method
1958 Right unilateral ECT
1968
Pulsed Direct Current (Developed by Liberson in 1945 fell into disuse
but regained popularity in late 1960’s

5. 1976
Association for Convulsive Therapy now called International Society of
ECT & Neurostimulation
1978 First American Psychiatric Association Task Force on ECT
1981 & 1982 ECG Monitoring of seizures in ECT
1985 Stimulus related to threshold
1985 Convulsive Therapy Journal now called Journal of ECT since 1998
1985 APA consensus Conference
1989 Royal College of Psychiatrists (RCP) Guidelines (Memorandum – 1977)

6. 1990 APA Guidelines
1969 - 1990
Bifrontal ECT (Devised by James Inglis 1969  popularized by
Letemendia in 1990)
2001 APA Mandates EEG Monitoring
2005 RCP Mandates EEG Monitoring
2013 Indian Mental health Care Draft Bill mandates Modified ECT

7. MYTHS AND FACTS ABOUT ECT
MYTH FACT
ECT is given to make people forget
everything.
Temporary forgetfulness is a side-effect which in
largely mild, reversible and limited to recent events.
The ability to remember will remain intact after ECT
course is complete.
If someone gets admitted in a
psychiatric hospital, he/she would be
given ECT without his/her permission.
ECT is always given after the doctor discusses with
patient and the family and they agree for it.
ECT experience is painful & horrifying.
ECT is given under anaesthesia and so the patient
does not feel pain or electric shock.
ECT causes brain damage and may
reduce the intelligence or change the
personality.
ECT does not cause brain damage. It may cause
temporary memory lapses of events around course of
ECT. ECT does not affect personality or overall
intelligence.

8. …CONTD/-
ECT is given as a Punishment
ECT is not a punishment. It is administered
to treat one’s psychiatric condition. Moreover,
it is not a painful procedure.
If ECT has been suggested by the doctor, it
means that other treatments are not working
and the condition is hopeless.
ECT is generally suggested by the doctors as,
among the available options, it is best for
that patient at that moment. If one does not
wish to receive ECT, doctors would suggest
next best option.

9. 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 frontotemporal region, or
unilaterally on the non-dominant side
(Right side of the head in a right –
handed individual).

10. PARAMETERS OF ELECTRICAL
CURRENT APPLIED
Standard dose according to American Psychiatric Association,
1978:
 Voltage: 70 – 120 volts
 Duration: 0.7 – 1.5 Seconds

11. TYPE OF SEIZURE PRODUCED
 Grandmal Seizure – Tonic Phase lasting for 10 – 15 seconds.
 Clonic Phase lasting for 30 – 60 seconds.

12. 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 to stabilize the
neurotransmitters in the Brain.

13. ELECTRO CHEMICAL CHANGES DURING ECT

14. …CONTD/-
 Neuro plasticity refers to the ability
of the brain to form new neural
connections and networks.
 This happens through remodelling of
synapses, generation of new
neurons, proliferation of glial cells
and improvement in blood supply in
specific brain areas.
 Recent Research has suggested that
ECT can stimulate the growth of new
cells and nerve pathways in certain
areas of the brain.
NEUROPLASTICITY

15. …CONTD/-
According to the Anticonvulsant Theory,
A gradual increase in seizure threshold occurs over the
course of successive ECT sessions; post-ictal suppression will
occur.
The plasma levels of inhibitory neurotransmitters GABA
and Glutamate were increased, following ECT
neurotransmitters has been shown to normalize.
CONTIBUTION OF EEG

16. …CONTD/-
Hypothesis related to Connectivity Resetting,
ECT decreased blood flow to the medial frontal cortex,
and increased blood flow to the thalamus. It Stimulates the
thalamocortical loop, takes over the thalamic pacemaker
function, resets it, and restores the functional connectivity
and control between various brain areas.
CONTIBUTION OF EEG

17. …CONTD/-
Hypothesis related to Reducing Hyperconnectivity,
NEUROPHYSIOLOGY
It can be assumed that ECT
reduces the ‘hyperconnectivity’
secondary to depression in the
frontal cortex. The post-ictal
suppression, ictal power and delta
coherence have been found to
predict treatment efficacy.

18. …CONTD/-
ECT has been found to affect 5-HT, Dopamine and
adrenergic system. The effect appears to be more
pronounced on Dopamine than on 5-HT and adrenaline.
ECT has been shown to increase dopamine release
consistently in the striatum and inconsistently in the frontal &
occipital regions.
NEUROTRANSMITTERS
It resulting in increased
secretion of catecholamines,
whereas effect on 5-HT is
inconsistent.

19. …CONTD/-
It is currently postulated that ECT improves depressed
mood and disrupted vegetative functions by transient
activation of the Hypothalamic Pituitary Adrenal (HPA)
system, thereby leading to prompt release of ACTH and
cortisol.
The seizure induce increase in blood brain barrier
permeability during ECT, enables these neurohormones to
act on brainstem structures.
Simultaneously, release of other neurohormones such
as, prolactin, endorphins, oxytocin and vasopressin may also
contribute to neuroendocrine effects of ECT.
NEUROENDOCRINOLOGY

20. TYPES OF ECT
Direct ECT:
In this, ECT is given in the absence of anaesthesia and
muscular relaxants. This is not a commonly used method
now.
Modified ECT:
Here ECT is modified by drug
induced muscular relaxation &
general anaesthesia.

21. FREQUENCY AND
NUMBER OF ECT
NEEDED
Frequency: Three times per
week or as indicated.
Total number: 6 to 10; upto 25
may be preferred as indicated.

22. APPLICATION OF ELECTRODES
Bilateral ECT: Each Electrode is placed 2.5 – 4 cm (1 – 1
1
2
inch) above
the mid point of the, on the line joining the tragus of the ear and the
lateral canthus of the eye.

23. …CONTD/-
Unilateral ECT: Electrodes are placed only 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 impairments.

24. INDICATIONS FOR ECT
 Major Depression: With Suicidal risk, Stupor, Poor intake of
food & fluids, Melancholia with psychotic features,
Unsatisfactory response to drugs or where drugs are
contraindicated or have serious side effects.
 Severe Catatonia (Functional): With Stupor, Poor intake
of food & fluids, Unsatisfactory response to drugs or where
drugs are contraindicated or have serious side effects.
 Severe Psychosis (Schizophrenia or Mania): With risk of
Suicide, Homicide or danger of physical assault, Depressive
features, Unsatisfactory response to drug therapy or where
drugs are contraindicated or have serious side effects.
 Organic mental Disorders: Organic Mood Disorders,
Organic Psychosis.

25. …CONTD/-
 Other Indications: ECT is
preferred to antidepressant therapy
in some cases, such as for patients
with Cardiac disease; when tricyclics
are contraindicated because of the
potential for dysrhythmias and
congestive cardiac failure and for
pregnant women, in whom
antidepressants place the foetus at
risk for congenital defects.

26. CONTRAINDICATIONS FOR ECT
ABSOLUTE
 Raised ICP (Intra Cranial
Pressure)
RELATIVE
 Cerebral Aneurysm
 Cerebral Haemorrhage
 Brain Tumour
 Acute Myocardial Infarction
 Congestive cardiac failure
 Pneumonia
 Aortic Aneurysm
 Retinal Detachment

27. 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.

28. ADVERSE EFFECTS OF ECT
• Memory Impairments
• Drowsiness, Restlessness and
Confusion
• Poor Concentration, Anxiety
• Headache, Weakness / Fatigue,
backache, Muscle aches
• Dryness of Mouth, Palpitations,
Nausea, Vomiting
• Unsteady Gait
• Tongue Bite & Incontinence

29. ECT TEAM
 Psychiatrist
 Anaesthesiologist
 Trained Nurses and aides
should be involved in the
administration of ECT.

30. TREATMENT FACILITIES
There should be a suite of three rooms :
 A pleasant, comfortable waiting room (Pre – ECT Room)
 ECT Room, which should be equipped with ECT machine
and accessories, an anaesthetic 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.
 A well equipped Recovery Room.

31. ARTICLES REQUIRED TO ADMINISTER ECT
ARTICLES PURPOSES
Electrode paste and gel alcohol, preps,
saline.
Concentrated saline is a good conductor of
electricity, there by it facilitates in
producing convulsion.
Electroencephalogram. Recording of electrical activity of brain
through surface electrodes.
Blood pressure cuff (two) peripheral nerve
stimulator and pulseoxymeter.
To monitor vital parameter.
Stethoscope. To check the heart beats.
Reflex hammer. To check the muscle tone.
Intravenous and venipuncture supplies. To introduce the anesthetic drug and
Intravenous fluid.

32. …CONTD/-
Mouth gag or tongue depressor. To prevent biting of tongue or injury to
lips.
Stretcher with firm matters and side rails. To prevent injury.
Suction device. To prevent the patient from aspiration
pneumonia.
Ventilation equipment's including tubing,
masks, ambu bag, oral airways, and
intubations equipment with an oxygen
delivery system capable of providing
positive pressure oxygen.
To prevent the patient from respiratory and
cardiac complication.
Emergency and other medications as
recommended as recommended by
anesthesia staff.
To handle the emergency situation during
electro convulsive therapy.

33. ROLE OF NURSE
IN ECT

34. BEFORE GIVING ECT
NURSING INTERVENTION RATIONALE
Check that a through physical examination chart including ECG,
lung, bone, blood for Hemoglobin, Urine for sugar and other
tests and albumin and x-rays is completed.
To select the patient for ECT
therapy.
Written consent or declaration for the treatment from the
nearest relative after explaining the method of treatment and
risks. Do not tell the patient that ECT will be given. The word
current may cause fear in the patient. He may be told that
“injection” will be given unless he is aware of the treatment
relatives should be explained in detail.
For legal protection.
Explanation to the relatives will
avoid them from shock and fear
of therapy.
The patient should be given nothing orally before treatment. If
he is to be treated in an emergency it should be Nursing
intervention before giving ECT.
To prevent vomiting and
aspiration after the treatment
rational.
Two to Three hours after breakfast or meals. To prevent vomiting and
aspiration after the treatment.

35. …CONTD/-
Remove metallic articles from his or her body for
example watch bangles ring.
To prevent the electrical current passing on
unwanted areas. Metal is a good conduct of
electricity.
Remove artificial dentures. To prevent if from dislodging and blocking
the respiratory passage.
Remove lipstick, nail polish or any other make
up.
To check for cyanosis. These colors will mask
the change in the patient.
Loosen the tight clothes like necktie in men and
blouse or other tight garments in women,
preferably give hospital clothes.
To help in facilitating respiration and meet
any emergency.
Replace the long acting sedative with hypnotics. To enhance the effectiveness of ECT.
Encourage the patient to empty his bladder &
bowels. He/she should void immediately before
the treatment.
To reduce his/her embarrassment after the
treatment. If the bladder is full he may spoil
the bed due to a relevant effect of the drug.

36. …CONTD/-
Encourage the patient to maintain his personal
hygiene. Remove oil from hair.
To help patient to develop a feeling that he
is going for treatment oil is a bad
conductor of electricity.
Give pre-medication to the patient, Injection
Atropine and Calmpose.
To reduce anxiety of the patient and
achieve effectiveness.
Take the patient on a stretcher to the waiting
room.
Prepare him or her psychologically that he
or she is producing for treatment.
The patient is transferred on a trolley from the
waiting room to the ECT room on a well padded
bed and placed in a comfortable dorsal position. A
small pillow is placed under the lumbar curve.
To prevent injury of well padded bed is
given ECT treatment is given in a dorsal
position or supine position.
Give a short acting anesthetic agent. Thiopental
25 gm to 5 gms. I/V and scoline
(Succinylcholine) 30 to 50 mg. (check
prescriptions) the dose of drugs may vary from
patient to patient.
To help the patient to anaesthetized
quickly, to reduce his anxiety and cause
less vigorous convulsions, thereby prevent
complications.

37. DURING ECT
NURSING INTERVENTION RATIONALE
Well padded mouth gag or tongue depressor is
placed in between the teeth.
To prevent biting of tongue or injury to
lips.
Support the shoulder and arms lightly, restraint the
thigh with the help of a sheet.
To prevent fracture tight pressure on any
of these areas may lead to fracture of
numerous or femur.
Hyper extension of the head with support to the
chin by nurse.
To prevent jaw dislocation or fracture and
for patient air-way.
Give a few breaths of oxygen to the patient. To help the patient to overcome a phase
of apnea faster after convulsions.
Provide electrodes dipped in saline water or jelly for
placing on the temporal region.
Concentrated saline is a good conductor
of electricity thereby if facilitates in
producing convulsions.

38. …CONTD/-
Make an observation of grant mal seizures the
presence of the initial tonic stage which lasts for
10-15 seconds followed by convulsions lasting for
25 to 30 seconds. The, there is phase of muscular
relaxation with torturous respiration.
To ensure that there are no stuns or sub
shocks and the treatment is successful.
Do suction immediately. To keep airway patient and prevent the
patient from aspirations.
Restore respiration by giving Oxygen by mask, if
required.
To prevent the patient from respiratory and
cardiac complications.

39. POST ECT
NURSING INTERVENTION RATIONALE
Observe the record the respiration pulse and blood
pressure of the patient.
To prevent any respiratory or cardiac
complication.
Put the railings and place the patient on a side lying
position, wipe the secretions.
To protect the patient from fall as he
may become restless to avoid
aspiration of secretions.
Transfer the patient to the recovery room only when
she can answer a simple question i.e. “open your
mouth Shanti Devi”.
To ensure that the patient has come
out of the phase of unconsciousness.
Record pulse, respiration blood vessels pressure and
the level of consciousness every is minutes once these
vital signs are stabilized, record after 30 minutes till
the patient recovers completely.
To make an early nursing diagnosis of
the patient going into complication.
Allow the patient to sleep for 30 minutes to one hour if
he/she wants to sleep.
To help the patient to overcome
physical exhaustion.

40. …CONTD/-
Make a note of any injuries or complaint of
pains by the patient body pain or headache.
To detect any type of complication, specially
fractures.
Encourage the patient to go for a shower bath
and change his/her clothes.
To give the patient a sense of well being and
freshness.
Allow the patient to take clear tea, followed by
breakfast, if he/she does not vomit.
To meet the nutritional needs of the patient
as he /she has not taken any thing orally
since morning.
Help the patient to carry on his daily activity to
planned he should be allowed go to the day
care room.
To enable the patient
To resume his daily work
To understand that ECT is also a part of the
treatment.
Make observation of any change. To note the significant change in the behavior
of the patient.

41. MANAGING THE ECT SEIZURE

42. PROLONGED SEIZURE Seizure augmentation
 Hyperventilation
 Caffeine
 Changing the anaesthetic
agent from Barbiturates to
Ketamine's.
Index ECT
 Frequency
 Multiple monitored ECT
 Number

43. Guidelines on

44. The Mental Health Care Bill, 2013

45. …CONTD/-

46. Mental Health Act 2013 & ECT

47. …CONTD/-

48. ANY QUERIES ?