ECT was developed in the 1930s as a treatment for psychiatric conditions. It involves inducing a seizure through the application of electric currents to the brain under anesthesia. While it was initially thought the seizure itself provided therapeutic effects, modern theories suggest it works through changes in neurotransmitter activity and expression of neuroprotective proteins. ECT is considered an effective treatment for severe depression, mania, and catatonia when other treatments have failed or there are life-threatening risks from withholding treatment. Potential side effects include confusion, memory loss, and headaches, though risks of serious adverse events are low. Treatment involves titrating the dose to induce a seizure while minimizing cognitive side effects.

1. Electro
Convulsive
Therapy
Zahiruddin Othman
Dec 2016

2. History
• In the 1930s three major physical treatments
emerged in what was regarded as a revolution in
psychiatry
1.Convulsive therapy
2.Leucotomy
3.Deep Insulin Coma
Therapy
Jones, K. (2000). Insulin coma therapy in schizophrenia. Journal of the Royal Society of Medicine, 93(3), 147.

3. Convulsive Therapy
• Chemical CT
– Camphor
– Pentylenetetrazol
(metrazol)
– Flurothyl (indoklon)
Fink, M. (2001). Convulsive therapy: a review of the first 55 years. Journal of affective disorders, 63(1), 1-15. doi:10.1016/S0165-0327(00)00367-0

4. Convulsive Therapy
• Electro CT
– Direct
– Modified
• ? Magnetic seizure
therapy

5. Overview of Biophysical Mechanisms
of ECT
Induced
electric field
• Location of
electrode
Action
potentials
• Axon hillock
• Axon synaptic
terminal
Seizure
induction
• Synchronization
• potentiating
excitatory
synapses

7. Mode of Action
• Old theory
– “Convulsion itself was the essential therapeutic
ingredient”
• Contemporary theories
– ↑ Serotonergic, ↑ Noradrenergic and ↓ Cholinergic
activity
– Mood stabilization through the anticonvulsant effect
– ↑ Expression of neuroprotective proteins e.g., BDNF

8. Modified ECT
Electrical
stimulus
Seizure
General
Anaesthesia

9. ECT dosing techniques
ECT stimulus
Seizure
Therapeutic effects
Stimulus waveform
Pulse amplitude, shape,
width, frequency
Train duration
Total charges
Constant current
Electrode, Impedence
Seizure threshold
Generalized seizure
Duration
Psychiatric diagnosis
Previous response

10. ECT dosing techniques
The “Age
Rule”
The “Half-
Age Rule”
Stimulus
dosing
tables
Stimulus
dose titration
Fixed high-
dose
1 or more
factors that
predict seizure
threshold
Individual
seizure
threshold
Fixed high dose

11. Stimulus dose titration
Most accurate Time
consuming
Longer
anaesthetics
Delayed seizure

12. Titration Process
• Males 10%, Females 5% (lower for young,
higher for elderly)
• Increment of 5% until ST, can give 3-4
doses in a session
• Suprathreshold ( 3x RUL, 1.5x BT)

13. Adjusting treatment dose
• Increases indicated
– Asymetrical EEG (poor
generalization)
– Poor EEG progression
– Prolonged recruitment
– Low amplitude EEG
– Post-ictal supression
– Brief EEG seizure

14. Electrode Placement
Unilateral (RUL) Bilateral (BT)
Placement Temporo-parietal over non-
dominant hemisphere
Bi-temporal
Seizure threshold Lower Higher
Efficacy of threshold
stimulation
Similar to sham ECT Moderate
Optimal initial stimulation 4-6 times ST 1.5-2.5 times ST
Average time to re-
orientate after treatment
20 min 45 min
Risk of prolonged
disorientation
<2% >10%

15. Electrode Placement

16. Factors influencing ST
Old age, male,
medication (BDZ,
anticonvulsants),
recent ECT
BDZ/alcohol
withdrawal,
amphetamine,
lithium, AP

17. Indications
• ECT was more efficacious than placebo and
pharmacotherapy in short-term treatment of
depressive illness1
• At least 1/3 reported significant memory loss after
the treatment2
1. The UK ECT Review Group. Efficacy and safety of ECT in depressive disorders: a systematic review and metaanalysis. Lancet 2003; 361: 799-808
2. National Institute for Health and Clinical Excellence. ECT, 2003. Available at: http://www.nice.org.uk/page/aspx?o=TA059guidance

18. ECT in Catatonia
• Effective in 80-100% of all form of
catatonia
• First-line treatment in pts with MC,
NMS, delirious mania or severe
catatonic excitement
• Failure of treatment with BDZ and
amobarbital
Luchini, F., Medda, P., Mariani, M. G., Mauri, M., Toni, C., & Perugi, G. (2015). Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response. World Journal of Psychiatry, 5(2), 182–192.

19. ECT in Major Depression
• Potential TREATMENT OF CHOICE
– Severe depressive illness, a/w
• Attempted suicide
• Strong suicidal ideas or plans
• Life-threatening illness because refusal of food or fluids
• Treatment TO BE CONSIDERED
– Severe depressive illness, a/w
• Stupor
• Marked psychomotor retardation
• Depressive delusions, and/or hallucinations

20. ECT in Major Depression
• SECOND or THIRD-LINE treatment
– Depressive illness that has not been adequately treated by
antidepressant treatment, where social recovery has not been
achieved
• The selection of ECT may be affected by
– Patient choice
– Previous experience of ineffective treatment or intolerable side-
effects
– Previous recovery with ECT

21. ECT in mania
• The treatment of choice for mania is
– A mood-stabilizing drug plus an antipsychotic drug
• ECT may be CONSIDERED for severe mania a/w
– Life-threatening physical exhaustion
– Treatment resistance
• Selection may be affected by
– Patient choice
– Previous experience of ineffective treatment or intolerable side-effects
– Previous recovery with ECT

22. ECT in schizophrenia
• NICE guidance on the use of ECT:
– ECT may be effective in acute episodes of certain types
of schizophrenia and reduce the occurrence of relapses
– ECT is not more effective, and may be less effective,
than antipsychotic medication. The combination of ECT
and pharmacotherapy may be more effective than
pharmacotherapy alone, but the evidence is not
conclusive.

23. Other Indications
• Neurologic conditions
– Catatonia
– Parkinson disease a/w depression
• Neuroleptic malignant syndrome (NMS)1
• NOT INDICATED
– OCD
– Personality disorders
Trollor JN, Sachdev PS. Electroconvulsive treatment of neuroleptic malignant syndrome: a review and report of cases. Aust N Z J Psychiatry. 1999 Oct; 33(5):650-9.

24. Contraindications
• Mortality 2 in 100,000 treatments
• No absolute contraindication
• Coexisting medical condition that increased risk of
ECT include
– ↑ Intracranial pressure
– Recent cerebral infarction
– Severe cardiovascular or pulmonary disease
– Aneurysm or AVM at risk of rupture with ↑ BP
• Special groups: pregnancy, elderly, children1
Consoli A, Benmiloud M, Wachtel L, Dhossche D, Cohen D, Bonnot O. Electroconvulsive therapy in adolescents with the catatonia syndrome: efficacy and ethics. J ECT. 2010 Dec; 26(4):259-65.

25. Frequency And Number Of
Treatments
• Frequency: 2-3 times
weekly
• Number: varies
– Until patient recovers, or
– 2 consecutive treatments
bring no further clinical
improvements
– MDD 6-12; Mania 8-20; Scz
> 15; Catatonia 1-4;

26. Adverse Effects
• Commonest spontaneous complaint after an
individual treatment is muscle pain (8%)
• Over a course of treatment, ⅓ complaint of
headache and 20% of memory problems
• At some point, 5% complaint of confusion and
dizziness and 1-2% nausea and vomiting
• Rarely, prolonged seizure, post-ictal delirium or
patient become hypomania

27. Procedure
• Pretreatment evaluation
– Psychiatric consideration
– Other consideration
– Informed consent
• Initiation of treatment
– Impedance test, dosing etc.
• Continuation and
maintenance ECT

28. Continuation Treatment
• Royal College of Psychiatry
– First 6 months of successful recovery
– Frequency: every 2-4 weeks
• NICE guideline:
– ECT is used only to achieve rapid and short-term
improvement of an individual’s severe symptoms after
an adequate trial of other treatment options has proven
ineffective and/or when the condition is considered to be
potentially life threatening.