ECT

Question 1

definition ECT

Answer 1

• a medical procedure where an electric current is passed briefly through the brain via electrodes applied to the scalp to induce generalized seizure activity
• the person receiving treatment is placed under general anaesthetic; muscle relaxants are given to prevent body spasms
• its purpose is to treat specific types of major mental illnesses

Question 2

Historical context

Answer 2

• early asylum keepers recognized that psychotic symptoms of patients who also suffered from epilepsy seemed to improve after having a seizure
• convulsive therapy: psychiatrist ladislas meduna began experimenting with different with different ways to induce seizures. in 1934 he discovered that Metrazol, a stimulant drug, produced seizures and that his patients’ psychotic symptoms diminished after a metrazol-induced seizure. this novel treatment quickly became known as convulsive therapy (1934)
• 1938: development of first ECT device and treated their first huamn patient, a diagnosed schizophrenic with delusions, hallucinations, and confusion. patients condition improved markedly
• Backlash in 1960s, despite benefits, due to misuse of ECT and lack of muscular relaxants and anaesthesia
• resurgence in 1980s with improved treatment delivery methods

Question 3

mechanism of action of ECT

Answer 3

• no consensus
• we know that:
  1. seizure is crucial component
  2. there is enhanced DA, NA, and 5-HT transmission
  3. results in release of hypothalamic pituitary hormones (restores dexamethasone suppression)
  4. neural growth/ plasticity
• in experimental animals ECT increases neuronal plasticity and neurogenesis

Question 4

indications for ECT (NICE guidelines)

Answer 4

recommends to use ECT: after other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening. In individuals with:
1. catatonia
2. a prolonged or severe manic episode
3. severe depression that is life-threatening and when a rapid response is required, or when other treatments have failed
4. for moderate depression - consider ECT if their depression has not responded to multiple drug treatments and psychological treatment
5. depression in parkinson’s disease
6. Refractory or life-threatening Mania
7. Refractory psychosis

Question 5

absolute and relative contraindications

Answer 5

• no absolute contraindications
• relative contraindications;
  1. unstable or severe cardiovascular conditions such as recent MI, congestive heart failure, and severe valvular disease
  2. aneurysm or vascular malformation that might be susceptible to rupture with increased BP
  3. increased intracranial pressure as may occur with some brain tumours or other space occupying lesions
  4. recent cerebral infarction
  5. pulmonary conditions such as severe COPD, asthma or pneumonia
  6. high risk for anaesthesia

Question 6

procedure - ECT

Answer 6

• ECT is prescribed by treating team
• referral to ECT team, fitness for ECT may need to be discussed with anaesthetist
• ECT pack;
  1. medical check (meds, bloods, ecg, chest x-ray
  2. capacity (1st by consultant)
  3. consent
  4. prescription
  5. monitoring (MOCA, rating scale)

Question 7

which psychotropic drugs are known the reduce seizure threshold

Answer 7

1. bupropion
2. imipramine
3. Clozapine
4. Olanzapine
5. Haloperidol

Question 8

how is ECT done

Answer 8

1. anaesthesia
   - short general anaesthetic (<10 minutes) with muscle relaxant
2. Delivery bilateral or unilateral electrical stimulus
3. seizure duration measured clinical and on EEG
4. Monitoring
   - HR, BP, o2 saturation
5. Recovery
   - reorientation time

Question 9

Course of ECT

Answer 9

• up to 12 sessions
• cognitive assessment after finishing course of ECT
• cognitive assessment about 8 weeks after finishing course of ECT

Question 10

side effects of ECT

Answer 10

1. side effects of anaesthetic
2. short term
   - headaches
   - muscle aches
   - nausea
   - confusion
3. Cognition
   - short term memory and executive functioning - may be impacted during the course, should improve post ECT
   - some evidence for effect on long-term cognitive functioning
   - Bilateral>unilateral

Question 11

can ECT be given against a patients wish ? (ECT and the MHA 2001)

Answer 11

• ECT can be delivered under the MHA
  — need clear indications and consideration of other TX
  —- unable to consent to ECT
  – assessed by two consultants
  – mental health commission form