Electroconvulsive Therapy

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Contents 1 Introduction 2 Biochemistry 3 Indications 4 Contraindications 5 Procedure 6 Complications 7 Management 8 More General Terms 9 Additional Terms 10 References

Introduction

• A low- voltage alternating current is sent to the brain to induce a convulsion or seizure, which accounts for the therapeutic effect.

Biochemistry

• changes in neurotransmitters

• acetylcholine
• norepinephrine
• dopamine
• serotonin

• down-regulation of beta-adrenergic receptors
• may decrease Ca+2 levels in cerebrospinal fluid ( CSF

Indications

• refractory or severe depression

• very severe or psychotic/delusional depression
• failure of 2 courses of drug therapy
• actively suicidal patients
• previous good response to ECT

• manic states that often are not responsive to medication treatment
• may be useful in treatment of catatonia
• may be helpful in overlapping depression & Parkinson's disease or dementia
• may be useful in neuroleptic malignant syndrome

Contraindications

• no absolute contraindications
• can be given to pregnant women
• effective in the elderly [5]
• anticoagulation is NOT a contraindication [5,6]
• relative contraindications:

• intracranial space-occupying lesion
• increased intracranial pressure (most important caution)
• cardiovascular disease

• myocardial infarction within 6 weeks
• uncontrolled heart failure
• cardiac arrhythmia
• pacemaker is NOT a contraindication [5]

• uncontrolled hypertension
• unstable vascular aneurysm or malformation
• recent cerebral hemorrhage or infarction (within 3 weeks)
• severe pulmonary condition
• history of complications of general anesthesia
• uncontrolled intraocular pressure ( glaucoma)

Procedure

• ECT is typically administered in a series of treatments 2-3 times/week until resolution or maximal improvement of symptoms
• a treatment course generally consists of 6-12 treatments
• continuation theray for prevention of relapse [7]

• 10 treatments at 1.5 X seizure threshold weekly for 4 weeks, biweekly for 8 weeks, monthly for 2 months

• the ECT treatment team consists of a treating psychiatrist, an anesthetist & a recovery nurse
• INFORMED CONSENT is mandated
• general anesthesia with:

• endotracheal intubation
• IV access
• protection of the teeth & other oral structures
• ultra-brief light general anesthetic - i.e. methohexital
• skeletal muscle relaxant
• muscarinic anticholinergic agent

• prevent vagally-mediated bradycardia or asystole
• atropine
• glycopyrrolate may be preferred in the elderly

• monitor

• blood pressure
• electrocardiogram
• electroencephalogram

• constant current brief pulse stimulus

Complications

• cardiovascular

• arrhythmia
• myocardial infarction
• hypertension
• vasovagal response
• congestive heart failure

• general anesthesia
• transient anterograde & retrograde amnesia
• delirium

• generally resolves quickly
• falls may occur with delirium

• transient decrease in arterial oxygen saturation
• no evidence that ECT causes structural brain changes

Management

• premedication with beta-blocker or other antihypertensive agent for patient at risk of myocardial ischemia
• follow-up evaluation of cognitive function

• subsequent ECT should be postponed until mental status returns to baseline

• prognosis:

• response rate is up to 90% [5]

More General Terms

• clinical procedure

Additional Terms

• catatonia
• dementia
• major depression
• mania (manic state)
• neuroleptic malignant syndrome
• Parkinson's disease (paralysis agitans)

References

1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 715-716
3. Kelly & Zisselman, J Am Geriatrics Soc 48:560, 2000
4. UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
5. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
6. Mehta V et al, Safety of Electroconvulsive Therapy in Patients Receiving Long-term Warfarin Therapy, Mayo Clin Proc 79(11): 1396, 2004
7. Kellner CH et al, Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: A multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry 2006, 63:1337 PMID: [1]
8. van der Wurff FB, Stek ML, Hoogendijk WJ, Beekman AT The efficacy and safety of ECT in depressed older adults: a literature review. Int J Geriatr Psychiatry. 2003 Oct;18(10):894-904. Review. PMID: [2]
9. National Guideline Clearinghouse
   - Guidance on the use of electroconvulsive therapy. National Institute for Clinical Excellence (NICE) ngc-guideline: [3]

electroconvulsive therapy (ECT)