Electroconvulsive Therapy - Kaptsan

Question 1

What are the diagnostic indications for ECT?

Answer 1

• Major Depressive Episode
• Bipolar Disorder, Depressed and Manic states
• Severe unipolar depression resistant to medications
• Schizophrenia - Catatonic subtype (paranoid or other states not as effective)
• Schizoaffective Disorder
• Delirium
• Also status epilepticus that is not responsive to anticonvulsives

• Actively suicidal depressed patients who may
not live until anti-depressants work (first line, as well as catatonia, neuroleptic malignancy, previous ECT and pregnancy with severe illness)
• Depressed patients (particularly the elderly)
whose medical condition makes administration
of antidepressants risky.
• Seriously depressed patients who have had an
adequate trial of antidepressants

Question 2

Which diagnoses are ECT not effective for?

Answer 2

Dementia and Amnestic Disorders
Substance-related Disorders
Anxiety and Somatiform Disorders
Factitious Disorders
Dissociative Disorders
Sexual Dysfunctions
Sleep Disorders
Impulse Disorders
Adjustment Disorders
Personality Disorders

Question 3

What are contraindications for ECT?

Answer 3

No absolute contraindications for use.

• Very High Risk
– intracranial pressure (brain tumor, infection)
– Recent MI
• (Vagal arrhythmias producing postictal PVCs and extravagal arrhythmias producing PVCs anytime during the procedure)
• Moderate Risk
– Severe osteoarthritis, osteoporosis
– Retinal detachment
– CV disease (HTN, Angina)
– Recent CVA
– Pheochromocytoma

Question 4

What tests should be done before ECT?

Answer 4

• EKG
• Chest x-ray if clinically indicated <75
• CBC, lytes, BUN, creatinine, Ca, Phos, TFTs (TSH, etc),
LFTs, UA
• Ophthalmoscopy (Fundus)
• EEG and CT generally not indicated

Question 5

What is the protocol for ECT?

Answer 5

• Electrodes placed unilaterally or bilaterally on scalp.
• Thirty to sixty seconds of a generalized tonicclonic seizure.
• Two to three times weekly for 6-12 treatments (4 treatments after improvement).

• General Anesthesia given (methohexital/propofol), neuromuscular blockade (succinylcholine), airway with bite block, anticholinergic only if anesthesiologists deems necessary.

• Brief-pulse square-wave AC
• Voltage approx. 200V (based upon 220 Ω impedance)
• Current 0.9A
• Frequency 30 - 70Hz
• Pulsewidth 0.5 - 2 msec
• Duration 0.1 - 8 sec
• Charge 25 - 504mC (5 - 99J)

Electrode placement:
• Bilateral (BL) - most common, most effective,
most cognitive dysfunction (concentration and memory)
• Right unilateral (RUL- nondominant hemisphere) - less cognitive effect,
may be less clinically effective
• Bifrontal (BF) – may be as effective as BL
with less cognitive effect

Question 6

What are the side effects of ECT?

Answer 6

• Amnesia (retrograde and anterograde)
– Variable after 3-4 treatments
– Lasting 2-3 months (after 6 months generally improve cognitively), elderly may have up to 6 years of amnesia

• Headache, muscle aches, nausea
• Dizziness, confusion (<1-2 hours)

More side effects from anesthesia:

– Atropine worsens narrow angle glaucoma
– Succinylcholine prolonged by pseudocholinesterase deficiency states
– Class 1A and 1B anti-arrhythmics can
interact/potentiate succinylcholine
– Methohexital can precipitate an attack of acute
intermittent porphyria (heme genetic disorder)

Question 7

Which medications do and do not need to be reduced or discontinued before ECT?

Answer 7

Discontinue:
Anticonvulsants (except epileptics)
Stimulants
Lithium
Trazodone (increases seizure threshold)
Reserpine, chlorpromazine

Continue:
Antidepressants (SSRIs, etc.)
Neuroleptics (synergistic)

Question 8

What are the alternatives to ECT?

Answer 8

• Pharmacologic Tx - TCA, MAOI, SSRI, SNRI, Atypical Neuroleptic, Lamictal
• Psychotherapy - CBT
• VNS (Vagus nerve stimulation, FDA approved)
• rTMS (Repetitive Transcranial Magnetic Stimulation, experimental, as effective for nonpsychotic depression as ECT)
• Neurosurgery – DBS (deep brain stimulation, experimental for failed ECT, psychosurgery, drill hole in skulle and apply directly onto brain with device on chest, used for elderly and Parkinsons, longterm)