ECT Lect1

Electroconvulsive Therapy: 

Electroconvulsive Therapy Introduction Dr Marija Axiak MD MRCPsych

ECT Module: 

ECT Module

ECT Module - Structure: 

ECT Module - Structure E-Lectures Practical Procedural Skills ECT Log Book to include Written reports reviewing 3 patients identified for ECT prior to commencing ECT Follow-up the progress of the same patients during the ECT course of treatment, and after the end of the ECT course of treatment Documentation of ECT administration where you will be expected to administer a minimum of 5 ECTs

Online Lecture List: 

Online Lecture List 1. Introduction (History of ECT, Seizure mechanisms, Mode of Action of ECT, The ECT Team) 2. Indications & Contraindications for ECT (Pt assessment prior to ECT, Psychiatric Disorders where ECT is indicated, Contraindications to ECT) 3. Applying ECT I (Electrode placement (Bilateral / Unilateral), Treatment dose, Seizure monitoring (Clinical Seizure / EEG), Management of inadequate seizure, Postictal Recovery) 4. Applying ECT II (Treatment Duration & Frequency, Maintenance ECT, Medication & ECT (Anaesthetic agents / Effect of medication on ECT), Types of ECT Machines) 5. ECT Outcome Assessment (Assessment of therapeutic response, Side Effects of ECT (Short-term / Long-Term; Physical / Cognitive); Monitoring for S/E) 6. ECT in Special Patient Populations (Children & Adolescents, Pregnancy, Elderly, Learning Disability, Issues on Consent to Treatment)

ECT Module - Assessment: 

ECT Module - Assessment Logbook and written report feedback – 30% Practical ECT administration exam – 40% MCQs – 30% Certificate of completion of ECT training using ECTRON apparatus will be handed out to successful candidates

E-Lecture 1 - Introduction: 

E-Lecture 1 - Introduction

History of ECT: 

History of ECT 1500 – Parcelsus induces seizures by administering camphor by mouth to treat psychotic illness. 1934 – Ladislaus Meduna begins the modern era of convulsive therapy by using IM injection of camphor for catatonic schizophrenia 1938 – Lucio Cerletti and Ugo Bini conduct the first electrical induction of a series of seizures in a catatonic patient and produce a successful treatment response.

History of ECT: 

History of ECT 1956 Antipsychotics introduced more discriminate use of ECT began New developments focused on: General anaesthetic Muscle relaxants Safety Minimising cognitive side effects

History of ECT: 

History of ECT 1960s & 1970s Unilateral ECT very popular Underpowered machines Effectiveness doubted

History of ECT: 

History of ECT 1970s & 1980s Doubts about unilateral High close bilateral favoured Severely ill ECT trials began in earnest Sine wave 1985 the NIMH and National Institutes of Health ..whilst ECT was the most controversial treatment in psychiatry and had significant side-effects, it had been shown to be effective for a narrow range of severe psychiatric disorders..

History of ECT: 

History of ECT 1990s Convulsions only effective if close of electricity significantly above that to produce bilateral seizure Brief pulse ECT Continuous current 1995 1 st Royal College of Psychiatrist Special Committee on ECT reported on stimulus dosing Now implemented throughout UK & EU

Novel developments in ECT: 

Novel developments in ECT Focal electrically administered seizure therapy (FEAST) Sackeim et al have started investigating the effects of unidirectional ECT stimulus. As this involves a current flowing in one direction only, one electrode is an anode and the other a cathode. Furthermore, by using a small anode (placed at the nasion ) and large cathode (located at the vertex), much more focal electrical stimulation of the brain can be achieved. Preliminary trials with FEAST in non-human primates have demonstrated that localized seizures with ictal activity evident in prefrontal EEG recording can be elicited in the absence of a generalized seizure.

Novel developments in ECT: 

Novel developments in ECT Magnetic seizure therapy ( MST ). This uses the same principle as transcranial magnetic stimulation (TMS), that is, using magnetic fields to transfer energy across the scalp, and resulting in induced eddy currents in underlying cortex, but with machines capable of generating a much more intense magnetic field. Seizures are generated, but these are induced more focally than with traditional ECT.

Novel developments in ECT: 

Novel developments in ECT Lisanby et al. reported preliminary data from a trial with a limited number of MST sessions In all cases seizures resulted and subjective side-effects were significantly lower for the MST treatment. In addition, performance on tasks of attention, and measures of retrograde amnesia and category fluency were all superior following the MST treatments conferring apparent advantages in cognitive side-effects, although its efficacy is yet to be established

Seizure Mechanisms: 

Seizure Mechanisms The goal of the physician during ECT is to deliver an electrical stimulus large enough to induce an adequate seizure while minimizing the risk of significant side effects. The electrical stimulus can be delivered in a number of ways utilizing different modes of delivery, stimulus types, and stimulus intensities.

Seizure Mechanisms: 

Seizure Mechanisms Beginning in the late 1970s, the brief pulse (B) waveform replaced the sine wave stimulus ( A) Like the sine wave stimulus, the brief pulse waveform is bidirectional (i.e., has alternating positive and negative phases). However, as opposed to the continuously undulating sine wave, the brief pulse consists of a series of instantaneously rising and falling rectangular pulses of current, with adjacent pulses separated by brief periods of no electrical activity

Seizure Mechanisms: 

Seizure Mechanisms Seizure threshold is the total amount of electricity necessary to induce a seizure and it is a parameter that is integral to stimulus dosing in clinical practice Evoking a generalized seizure using a brief pulse device typically requires much less overall stimulus intensity than does a sine wave stimulus

Ohm’s Law: 

Ohm’s Law current = voltage/resistance Current is the number of electrons per second flowing through a circuit (ECT machine, the stimulus cables, the stimulus electrodes, and the patient’s head) Voltage is the force that drives the flow of electrons during the stimulus. It is the push of the system Impedance is a measure of the obstacle to the current flow. It is the level of resistance to be overcome Charge , represents the product of the amount of current in a single pulse and the number of pulses delivered in the series, and is measured in millicoulombs ( mC ).

Mode of Stimulus Delivery: 

Mode of Stimulus Delivery Because current is now recognized as being of greater physiological importance than voltage in ECT, constant-current devices are preferable because they allow the user a greater control over stimulus intensity. The practitioner predetermines the amount of current the patient will receive The electrical impedance during the passage of the stimulus current is a very important measure. It can differ substantially across patients, and it can vary from treatment to treatment in the same patient

Causes of variation in impedance: 

Causes of variation in impedance Causes of high impedance Causes of low impedance Poor contact of electrodes with scalp Stimulus electrodes are too close together Poor preparation of scalp Low impedance pathway (sweat, conducting gel) Faulty connection of electrodes To estimate whether impedance during the passage of the stimulus current will be too high or too low, brief pulse devices incorporate a self-test procedure. This feature involves the passage of a very low current through the entire electrical circuit pertinent to ECT (i.e., cable, leads, electrodes, and patient), allowing an estimation of impedance prior to stimulation.

Mode of Action : 

Mode of Action The use of ECT is often criticised on the basis that the mode of action of the treatment is unknown But then the use of lime juice to prevent scurvy was practised a century before the discovery of vitamin C!

Mode of Action: 

Mode of Action Enhances the activity of dopaminergic systems, which explains some of its effectiveness not only in depressive disorder but also in Parkinson’s disease. It has potent anticonvulsant properties, which it shares with the anticonvulsant drugs now used in the treatment and prophylaxis of bipolar disorder. It has powerful effects on excitatory amino acid systems, which are increasingly implicated in psychosis

Mode of Action: 

Mode of Action Recent studies in animals suggest that ECT has potent effects in bolstering neuronal survival, in sharp contradiction to the commonly held but unfounded view that ECT must somehow harm neurons. It even promotes the production of new neurons and new neural processes in areas of the brain known to be involved in cognitive and emotional function. In common with chemical antidepressant treatments, ECT enhances the expression of a neuroprotective protein, brain-derived neurotrophic factor (BDNF), which antagonises the neurotoxic effects of stress on the brain.

The ECT team: 

The ECT team Psychiatrist (you..) Nurse with training in anaesthesia Anaesthetist Nurse accompanying patient