• Clinical science

Electroconvulsive therapy (ECT…)

Summary

Electroconvulsive therapy (ECT) involves unilateral (sometimes bilateral) electrode placement over the nondominant hemisphere to induce tonic-clonic seizures under sedation. Although not fully understood, ECT likely causes anticonvulsant effects, brain remodeling, and improves brain perfusion. ECT is indicated for refractory cases, life-threatening symptoms (e.g., suicide risk), or special patient groups (e.g., pregnant patients) with certain mental disorders; including depression, schizoaffective disorder, and bipolar mood disorder. Complications include reversible memory loss, tension headaches, and transient muscle pain.

Indications

Usually indicated in the following conditions for refractory cases, life-threatening symptoms, or if medication is contraindicated (e.g., pregnancy):

ECT is the most effective treatment for severe major depressive disorder!
References:[1][2][3]

Contraindications

Pregnancy and pacemakers are not a contraindication for ECT!

References:[3][5]

We list the most important contraindications. The selection is not exhaustive.

Procedure/application

  1. General preparation and procedure
    • Unilateral electrode placement over the nondominant hemisphere
    • EEG as well as constriction of the contralateral arm via blood pressure cuff for monitoring the seizure
    • Administration of oxygen via face mask + preparation for emergency intubation if necessary
    • ECG and pulse oximetry allow for monitoring further vital signs.
  2. Administration of premedications:
    1. Anticholinergic (e.g., atropine) to reduce dysrhythmias and oral/respiratory secretions
    2. A mild sedative and hypnotic (e.g., methohexital) to relieve anticipatory anxiety
  3. Short-term general anesthesia, including a muscle relaxant (e.g., succinylcholine) to avoid risk of fractures
  4. An electric current is passed from one side of the cerebral cortex to the other.
  5. 6–12 sessions in total consisting of generalized tonic-clonic convulsions lasting 25–30 seconds, usually 2–3 times per week
  6. Treatment sessions can be discontinued once symptoms improve.
  7. Maintenance may be implemented once every 1–8 weeks.

References:[6][6][7][8][5]

Side effects

  • More common
    • Reversible memory loss: retrograde more often than anterograde amnesia
    • Tension headache
    • Nausea
    • Transient muscle pain
  • Less common
    • Skin burns
    • Temporary, short-term functional disorders (such as amnesic aphasia)
    • Prolonged seizure

References:[6][6][9][10][5]

Prognosis

  • ECT itself is generally considered a safe procedure; the risk of mortality (due to cardiac or pulmonary compromise) is associated with anesthesia.
  • If properly conducted, ECT is one of the safest procedures involving sedation.
  • To date, no brain damage has been reported with the current method!

References:[11]

  • 1. Luchini L, Medda P, Mariani MG, Mauri M, Toni C, Perugi G. Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response. World J Psychiatry. 2015; 5(2): pp. 182–192. doi: 10.5498/wjp.v5.i2.182.
  • 2. Kellner C, Roy-Byrne PP, Solomon D. Unipolar Major Depression in Adults: Indications for and Efficacy of Electroconvulsive Therapy (ECT). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/unipolar-major-depression-in-adults-indications-for-and-efficacy-of-electroconvulsive-therapy-ect. Last updated May 16, 2017. Accessed July 29, 2017.
  • 3. Kalapatapu RK. Electroconvulsive Therapy. In: Popeo DM. Electroconvulsive Therapy. New York, NY: WebMD. https://emedicine.medscape.com/article/1525957-overview. Updated January 12, 2015. Accessed May 18, 2018.
  • 4. Le T, Bhushan V,‎ Sochat M, Chavda Y, Abrams J, Kalani M, Kallianos K, Vaidyanathan V. First Aid for the USMLE Step 1 2019. New York, NY: McGraw-Hill Medical.
  • 5. Sadock BJ, Sadock VA, Ruiz P. Synopsis of Psychiatry. New York, NY: Wolters Kluwer Health; 2014.
  • 6. Ganti L, Kaufman MS, Blitzstein SM. First Aid for the Psychiatry Clerkship. McGraw Hill Professional; 2016.
  • 7. Mahdian M, Noorizad S, Akasheh G, Mousavi G, Omidi A. Atropine premedication in Electroconvulsive Therapy. url: http://psrcentre.org/images/extraimages/4.%201211435.pdf Accessed July 29, 2017.
  • 8. Wolfson AB, Hendey GW, Ling LJ, Rosen CL, Schaider J, Sharieff GQ. Harwood-Nuss'Clinical Practice of Emergency Medicine. Philadelphia, PA: Wolters Kluwer; 2009.
  • 9. Kellner C, Roy-Byrne PP, Solomon D. Overview of Electroconvulsive Therapy (ECT) for Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-electroconvulsive-therapy-ect-for-adults. Last updated August 24, 2016. Accessed August 8, 2017.
  • 10. Rosner MH, Lazar AE. NMS Review for USMLE Step 3 (National Medical Services Review). Baltimore, MD: Lippincott Williams and Wilkins; 2009.
  • 11. Schatzberg AF, Nemeroff CB. The American Psychiatric Association Publishing Textbook of Psychopharmacology. Arlington, VA: American Psychiatric Association Publishing; 2017.
  • Kaplan Medical. USMLE Step 1 Lecture Notes 2017: Behavioral Science and Social Sciences. New York, NY: Kaplan Medical; 2017.
  • Department of Psychiatry. Electroconvulsive Therapy. https://medicine.umich.edu/dept/psychiatry/programs/neuromodulation/electroconvulsive-therapy. Accessed August 8, 2017.
last updated 03/21/2019
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