• Clinical science

Electroconvulsive therapy (ECT…)

Abstract

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][4]

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:[5][5][6][7][4]

Complications

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

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:[5][5][8][9][4]

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!
  • Improvement is directly proportional to increased delta wave activity in the prefrontal cortex.

References:[10]

  • 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. Sadock BJ, Sadock VA, Ruiz P. Synopsis of Psychiatry. New York, NY: Wolters Kluwer Health; 2014.
  • 5. Ganti L, Kaufman MS, Blitzstein SM. First Aid for the Psychiatry Clerkship. McGraw Hill Professional; 2016.
  • 6. 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.
  • 7. Wolfson AB, Hendey GW, Ling LJ, Rosen CL, Schaider J, Sharieff GQ. Harwood-Nuss'Clinical Practice of Emergency Medicine. Philadelphia, PA: Wolters Kluwer; 2009.
  • 8. 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.
  • 9. Rosner MH, Lazar AE. NMS Review for USMLE Step 3 (National Medical Services Review). Baltimore, MD: Lippincott Williams and Wilkins; 2009.
  • 10. 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 11/19/2018
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