ECT was first used in 1938 to treat psychiatric disorders and involves inducing a seizure via electric shock under anesthesia. It remains an effective treatment for severe depression, bipolar disorder, and other conditions when medications are ineffective. ECT is generally safe but can cause short-term memory loss and other cognitive side effects. Recent research indicates that electrode placement and dosage affect efficacy and side effects, with bilateral placement being more effective but also more likely to cause memory issues than unilateral right placement. Guidelines recommend ECT only for treatment-resistant cases and that it be administered properly by credentialed psychiatrists.

1. A research review ofElectroconvulsive Therapy and its effects on depression and other psychological disorders relevant to Acute In-patient physical therapy Steve Chmielewski, SPT

2. History 3,8ECT was first introduced as a treatment for psychiatric disorders in 1938 by a neurologist named Urgo Cerletti.Performed ECT on dogs and other animals to induce epileptic attacksThought of concept while watch pigs being killed via electric shockFirst used on schizophrenic patientsBegan injecting CSF from electrically shocked pig brains showing positive resultsLater replaced with the drug Metrazol Widespread by 40’s and 50’s with fine tuning of procedureDecline in popularity in 60’s due to pharmacological treatments and the negative media image

3. Primary Indications for ECT1Patients with moderate to severe depression Lack of a response to or intolerance of antidepressant medications A good response to previous ECT The need for a rapid and definitive response (e.g., because of psychosis or a risk of suicide).

4. Patient Populations 8ECT can be used safely in elderly patients and in persons with cardiac pacemakers or implantable cardioverter–defibrillators. ECT can also be used safely during pregnancy, with proper precautions.

5. Specific Clinical Disorders 1,5,6,7,9Severe mania (too much talking, insomnia)DepressionSchizophrenia (that doesn’t respond to meds)Suicidal drive conditionsImpulsive behaviorsNeuroleptic Malignant SyndromeContinuous screamingFibromyalgia (fatigue, anxiety, depression)Vegetative dysregulationUnipolar and bipolar disorders (catatonic)Psychosis

6. Depression: Clinical Facts814 million adults in the United States each year 1 to 2% in the general population of elderly persons1 to 3% among those living in the community10 to 12% among those in outpatient primary care and inpatient settings

7. Symptoms of Depression 4PainMuscle/joint achesInactivityPoor physical conditionDisturbed body appearanceTensionAnxietyRestlessnessSlownessPostural issuesRestricted breathing

8. Depression: Pathophysiology8Genetic, developmental, and environmental factors.Brain changes in depression in the elderlyAbnormalities in frontostriatal limbic circuits, can reduce the response to medications Dysregulation in corticolimbic circuits affecting Regional brain structure and functionNeurotransmitter functionNeuroendocrine regulation

9. Depression: Pathophysiology8

10. Depression: Pathophysiology8Abnormalities in the hippocampusatrophy is correlated with the duration of depression in days Abnormalities in prefrontal cortexatrophy is associated with familial depressionHyperintensitiesnotably in depression in the elderly vascular lesions in white matter disrupt key pathways, leading to a “disconnection syndrome”

11. Depression: Pathophysiology8Neurotransmitter FunctionPresynaptic and postsynaptic abnormalitiesserotonin-receptor expression deficiencies in GABA

12. Effects of ECT on Depression Mechanism8Increases cortical GABA concentrationsEnhances serotonergic function Affects the hypothalamic–pituitary–adrenal interactions

13. ECT Theories 8 Neurophysiological theoryElectrical shock causes seizureStimulates a long term release of neurotransmittersImprove brain cells functioning and increases chemical messengersPunishment Theory (Weak)Patients see treatment as punishment for behaviorImprove to avoid further punishment

14. ECT: Preparation 2,8 Consent form Physical examHeart and Lung exam AnesthesiaBlood testElectrocardiogramAnticonvulsants and antidepressant drugs are often discontinued

15. ECT Procedure/Dosage1In-patient or Out-patient procedureAnesthetic (IV)Muscle relaxer (IV)- prevent injuryHR, BP, breathing are closely monitoredMedicines/ restraints to secure the body during seizure1-2 second shock- just enough to induce seizureSeizure typically lasts 40 secondsTotal duration 5-10 minutes3-4 times per weekTypically 6-12 treatments relieve depression symptoms

17. ECT Electrode PlacementBifrontaltemporal (bilateral)Right UnilateralBifrontal

18. Which is more effective?2,8Bilateral electrode placement was moderately more effective than right unilateral placement Greater cholinergic surgeEfficacy of right unilateral ECT is dose-sensitive …(studies may be affected by this to few?)No difference long term

19. Which is more effective?2,8Right unilateral and bifrontal placementreduce the burden of side effectsbilateral placement may be selected if the right unilateral or bifrontal positions are unlikely to be effective 8

20. ECT: Post Procedure1Antidepressant Medications are continued to prevent relapse

21. Predicting ECT Efficacy 9Short Term60-80% success rate50% relapse rate if antidepressants are not used correctly

22. Adverse Effects 8Initial anterograde amnesia Short term disorientation or delirium (1hr)Long term retrograde amnesiaSleep disturbancesDeathMemory gaps mostly of interpersonal eventsPhysical effectsHeadachesmuscle achesAcute BP/HR changes- immediately treatednauseaFatigueAnatomical damage

23. Anatomical Damage 8Thalamic hemorrhages

24. ECT Uncertainties 8How to prevent relapse after a remissionReduction of cognitive side effectsShorter pulse of electricity?Placement of Electrodes ?

25. ECT: APA Guidelines 8Administered by properly qualified psychiatrists Recommend ECT only for difficult-to-treat depression (5-6 unsuccessful attempts)Use of ECT for relapse prevention Not recommend ECT as maintenance therapyDetailed criteria for patient selection, medical screening, ECT procedures, and training in ECT Must be credentialed by their local hospital or or board certification for ECT practice in the US

26. ECT Contraindications 8Ischemiaarrhythmiascerebrovascular diseasecerebral hemorrhage or strokeIncreased intracranial pressure

27. Application to Practice6Physical therapy interventions for depression are important but will not be affective if neurological deficits limit the patient mobilityECT is ALWAYS secondary treatment to pharmaceutical interventions Is the individual’s consent valid if they require ECT?

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29. References 1). Frederikse M, Petrides G, Kellner C. Continuation and maintenance electroconvulsive therapy for the treatment of depressive illness: a response to the National Institute for Clinical Excellence report. J ECT. 2006;22:13-17.2). Asystole during electroconvulsive therapy: a case report. Australian and New Zealand Journal of Psychiatry [serial online]. June 2001;35(3):382-385. Available from: E-Journals, Ipswich, MA. Accessed June 10, 2009. 3). http://www.informatics.susx.ac.uk/research/groups/nlp/gazdar/teach/atc/1999/web/seans 4). Nyboe Jacobsen L, Smith Lassen I, Friis P, Videbech P, Wentzer Licht R. Bodily symptoms in moderate and severe depression. Nordic Journal of Psychiatry [serial online]. August 2006;60(4):294 5). A, Oktayoglu P, Current Pharmaceutical Design [Curr Pharm Des], ISSN: 1873-4286, 2008; Vol. 14 (13), pp. 1274-94; PMID: 18537652 6). Susman, Virginia L.. Psychiatric Quarterly, Dec2001, Vol. 72 Issue 4, p325, 12p; (AN 11303889) 7). Snowdon, John; Meehan, Tom; Halpin, Rhonda. International Journal of Geriatric Psychiatry, Nov94, Vol. 9 Issue 11, p929-932, 4p; (AN 12114218) 8). Lisanby, SH, New England Journal of Medicine (USA), Feb 2007, vol. 357, pp. 1939-1945 9). Kato N, Asakura Y, Mizutani M, Kandatsu N, Fujiwara Y, Komatsu T. Anesthetic management of electroconvulsive therapy in a patient with a known history of neuroleptic malignant syndrome. Journal of Anesthesia [serial online]. November 2007;21(4):527-528. Available from: Academic Search Premier, Ipswich, MA. Accessed June 10, 2009. 10). http://www.informatics.susx.ac.uk/research/groups/nlp/gazdar/teach/atc/1999/web/seans