Electroconvulsive therapy or ECT, is a medical treatment that involves passing a small electrical current through the brain to induce a seizure. It is typically used to treat severe psychiatric conditions such as major depression, bipolar disorder, and schizophrenia.
Time duration and current used in ECT
Time duration of current passed during ECT is 30-90 seconds.
- If seizures appears for less than 30 seconds. Then there is no need to repeat ECT
- If seizures appears for more than 180 seconds. Then there is risk of hypoxic brain injury. Administration of benzodiazepines is advised in this case.
- Amount of current used during ECT is 200-1600 milliamperes.
- Insufficient current may cause sub shocks.
- Most clients require an average of 6-12 ECT’s. But it largely depends on the patient condition and the healthcare provider.
Goal of ECT
The goal of ECT is to induce a seizure that lasts for a short period of time, typically less than a minute. The exact amount of current required to achieve this goal can vary depending on the individual, and healthcare providers will adjust the dosage and frequency of the treatment as needed to achieve the desired therapeutic effect while minimizing the risk of side effects.
ECT is generally considered a safe and effective treatment for severe psychiatric conditions that have not responded to other forms of therapy. However, like any medical procedure, it does have some risks and potential side effects. Some patients may experience short-term memory loss or confusion following the treatment, and there is a small risk of physical complications such as headache, nausea, and muscle soreness.
Despite these risks, ECT can be a life-saving treatment for individuals with severe psychiatric conditions that have not responded to other forms of therapy. It is typically only recommended after other treatments have been tried and found to be ineffective.
HISTORY
1927
In 1927, an Austrian-American psychiatrist Manfred Sakel, gives Insulin shock therapy, also known as insulin coma therapy. It is a medical treatment that was commonly used to treat various psychiatric conditions, including schizophrenia and depression. The treatment involved injecting large doses of insulin, which caused the patient’s blood sugar levels to drop, leading to a coma-like state. During the coma, the patient would be monitored closely and their blood sugar levels carefully managed. The idea behind the treatment was that the brain would reset itself during the coma, leading to a reduction in psychiatric symptoms. However, insulin shock therapy was controversial and had many risks and potential side effects. Some patients suffered permanent brain damage, seizures, or even died as a result of the treatment. In addition, it was not effective for all patients and had a high relapse rate. As a result of these issues, insulin shock therapy is no longer used as a treatment for psychiatric conditions. It has been largely replaced by other treatments, such as medication and therapy, which are safer and more effective.
1934
Injection Camphore was used by Ladislas J. Meduna, a Hungarian neuropathologist and neuropsychiatrist to produce seizures in the patient.
1938
First time in 1938 Bini and carletti used electric current to produce seizures in the patient. This was termed as Electro convulsive therapy.
Types of seizures produced during ECT
The two main types of seizures that can occur during ECT are generalized tonic-clonic seizures and absence seizures.
Generalised tonic-clonic seizures are the most common type of seizure induced by ECT. They involve a sudden loss of consciousness, followed by stiffening and shaking of the limbs, and then a period of confusion and disorientation.
Absence seizures, on the other hand, are less common and typically occur only in certain individuals with a history of epilepsy. They involve a brief period of loss of consciousness, during which the individual may appear to be staring blankly or daydreaming.
Mechanism of action
The exact mechanism of action of ECT is unknown, complex and not fully understood, but biochemical theory is a most credible theory. Which involves changes in neurotransmitters, neuropeptides (BDNF – Brain Derivative Neuropeptides Factor), and neural networks in the brain, which can help to alleviate symptoms of depression and other psychiatric conditions.
Measurement of seizures produced during ECT
There are two methods used to measure the seizures produced during ECT :
- EEG (Electro-Encephalo Gram)
EEG was given by Hans Berger. Therefore EEG is also known as Berger wave. - BP-cuff method.
Types of ECT.
Direct ECT
- In this form of ECT, electric current is given in the absence of anaesthesia and muscle relaxants.
- Direct ECT is not commonly used in clinical practice now.
- This form of ECT was banned in 2017 under NMHCA (National Mental Health Care Act).
Modified / Indirect ECT
- The goal of modified ECT is to improve the efficacy of the treatment while minimizing the risk of side effects.
- This ECT is modified by using drugs while giving ECT. Examples – muscle relaxants (to avoid complications like fracture) and general anaesthesia (to decrease anxiety).
- This form of ECT is commonly used now.
- Only mild grimace or blepharospasm in tonic phase and fine movement in toes during clonic phase is observed during ECT in modified ECT.
Types of ECT in terms of placement of electrodes.
Bilateral ECT:
In this type of ECT, electrodes are placed on both sides of the head, and an electrical current is passed through the brain, inducing a generalized seizure. Bilateral ECT is the most commonly used type of ECT and is typically effective in treating severe depression and other psychiatric conditions. Most common site of electrodes placement in bilateral ECT – Bifronto-Temporal region.
Unilateral ECT:
In this type of ECT, electrodes are placed on one side of the head, and the electrical current is passed through that side of the brain. Unilateral ECT is typically less effective than bilateral ECT, but it may have fewer side effects and is often used for individuals who are particularly sensitive to the cognitive side effects of ECT. Most common site of electrodes placement in unilateral ECT – Tempo-Perital region also known as Delia position.
Indication of ECT
It is used 2-3 times a week in following conditions-
Most common indication
Major depression & involutional (period of bodily and intellectual decline) melancholia (a term used occasionally for depression, especially for depression complicated by frequent crying, anhedonia and fearfulness).
80-90% patients respond to treatment in above both conditions.
Other indications.
Mania, Schizophrenia, Personality disorder, Obsessive-compulsive disorder (OCD)
Contraindications of ECT
Absolute contraindication
Increased ICP
Other contraindications
Cerebral aneurysm
Severe osteoporosis
Cerebral haemorrhage
History of cardiovascular disease (like MI, CHF or HTN)
Complicated or high risk pregnancy
Metallic implant in body like pacemaker.
Side effects of ECT
Confusion or disorientation (is most common side effect), Palpitation, Headache, Weakness, Dryness of mouth.
Complications of ECT
Most common complication of ECT is amnesia, commonly retrograde amnesia (temporary or reversible memory loss or confusion, recovery can be within 3-6 months). Less memory disturbance into unilateral ECT.
Fracture (mainly vertebrae, femur & humerus) and dislocation (mainly lower jaw) especially in old osteoporotic patient.
Respiratory arrest (rare) and back pain.
Pre-ECT preparation
- Take written consent for ECT
informed consent – consent given by a well-advised and mentally competent patient to be treated by a health care provider or randomised into a research study.
substituted consent – consent given by legal guardians, if patient is not capable of giving their own consent. - Do not tell the patient that ECT will be given.
- Give injection Atropine sulphate and glycopyrrolatte in morning 30 minute before treatment to decrease oropharyngeal secretion and counteract the effect of bradycardia.
- Remove oil from heir by washing it, because oil is bad conductor of electricity.
- Give injection of anaesthetic agent like thiopental sodium (0.25-0.50 gm) or sodium pentothal for short time anaesthetic effect immediately before ECT.
- After anaesthetic agent, administer muscle relaxant, injection succinylcholine (30-50 milligram) to prevent bones fracture and dislocation.
- Place the patient in comfortable dorsal or supine position.
- Give pure oxygen by facial mask / ambu bag to prevent apnea ( respiratory muscles paralysis may occur due to effect of muscle relaxant succinylcholine)
Roll of nurse before ECT procedure.
- Discourage patient for smoking to decrease secretion.
- Keep the patient NPO, 6 hours before treatment to prevent vomiting and aspiration.
- Remove glasses, dentures, contact lenses, jewellery and hair pin before procedure to prevent the passing of electric current on unwanted area.
- Give medicines and oxygen as per instructions.
- Give emotional support to decrease patient anxiety.
- Remove lipstick and nail polish to observe cyanosis.
- Loosen tight cloths to facilitate respiration.
Role of nurse during ECT procedure
- Place the patient in comfortable dorsal or supine position and observe the patient carefully.
- Place mouth gag or tongue depressor to prevent injury to tongue and lips.
- Help to restrain patient carefully to prevent fracture.
- Stay with patient till he awake.
Role of nurse after ECT procedure.
- Keep the patient on side-lying position to avoid aspiration of secretion.
- Reorient the patient about time, place and event.
- Encourage the patient to express feelings about event.
- Check the vital signs every 15 minutes for 1st hour of treatment.
- Give reassurance to the patient because after ECT patient is highly suggestible.