Indications and Contraindications for ECT

Indications and Contraindications for ECT: 

Indications and Contraindications for ECT E-Lecture 2

Indications for ECT: 

Indications for ECT

Reasons to consider ECT as first-line: 

Reasons to consider ECT as first-line When urgent need (either psychiatrically or medically) for a rapid response exists eg severe suicidality or catatonia/NMS) Patient preference (usually previous ECT was proven effective) When ECT poses less risk than other treatment alternatives

ECT for depression: 

ECT for depression 80% response May be effective when drug treatment failed Predictors of good response Biological symptoms Psychomotor retardation Delusions ( Parker et al 1992 ) Speedy response Patients intolerant of drug treatment side effects Past response to ECT Suitable for the elderly

ECT for depression: 

ECT for depression The likelihood of response to ECT is diminished for patients whose depressive episodes occur in the context of a concurrent mental or medical disease (e.g., those with secondary depression

ECT for mania: 

ECT for mania Reviews have reported improvement in approximately 80% of manic patients treated with ECT ( Mukherjee et al. 1994 ). This finding is even more impressive considering that many of these patients were pharmacologically unresponsive. ECT should be considered in mania cases that are acutely treatment refractory ( Sienaert and Peuskens 2006 ) or require aggressive therapy for maintenance stabilization ( Nascimento et al. 2006 ). The main indication of ECT in mania is excited or uncooperative behavior which if untreated may leas to exhaustion or suicide

ECT for schizophrenia: 

ECT for schizophrenia A lack of consensus currently exists on when to use ECT in the treatment of individuals with schizophrenia. The APA Committee on ECT recommended the use of ECT in patients who have a history of a favorable response to ECT or who have abrupt psychotic exacerbations, catatonic schizophrenia, or schizoaffective disorder (where there is a mixture of schizophrenia and mood disorder symptoms) However, the committee recommends against ECT if “negative” symptoms of schizophrenia (e.g., withdrawal, mutism , poor self-care, flat affect) predominate.

ECT in schizophrenia: 

ECT in schizophrenia In its second report, the Royal College of Psychiatrists’ Special Committee on ECT also recommended ECT for patients with schizophrenia who have positive, affective, or catatonic symptoms (Royal College of Psychiatrists 1995). In contrast, NICE (2003) does not recommend the general use of ECT for people with schizophrenia, although catatonia is considered an indication.

ECT for schizophrenia: 

ECT for schizophrenia In essence Effective against positive symptoms Ineffective against negative symptoms No more effective than antipsychotics Remember ECT was initially developed for the treatment of patients with schizophrenia ( Meduna – chemical convulsive therapy)

NICE on indications for ECT: 

NICE on indications for ECT

NICE technology appraisal: 

NICE technology appraisal ECT: ‘Used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with: severe depressive illness catatonia a prolonged or severe manic episode’

Patient assessment prior to ECT: 

Patient assessment prior to ECT

Patient evaluation has five goals..: 

Patient evaluation has five goals..

Prescribing ECT: 

Prescribing ECT Responsibility of RMO Frequency Type (electrode placement) No more than 3 treatments before review Monitor side effects after each treatment Assess progress weekly

Major components of pre-ECT evaluation: 

Major components of pre-ECT evaluation

Pre-ECT clinical work-up: 

Pre-ECT clinical work-up Confirm consent Past medical history Physical examination Record significant findings on ECT form Previous anaesthetic history (slow recovery from anaesthetics ?) Special risks – dental, upper airways, cervical spine problems Medication history – include the previous 3 weeks too ? pregnant

Pre-ECT clinical work-up: 

Pre-ECT clinical work-up Bloods FBC, U&E, creatinine , RBG Sickle cell test if Afro- Caribbean,Asian , Eastern Mediterranean or Middle Eastern Urine dipstick ECG All elderly CV history Antipsychotic medication increased QT by up to 25ms CXR (over 65yrs, lung disease)

Remember..: 

Remember.. Because of the potential for memory impairment as a result of the ECT procedure, at least a bedside measure of cognitive function, including memory performance, should be administered prior to initiating ECT. Assess whether right handed or left handed

Pre-anaesthetic safeguard: 

Pre-anaesthetic safeguard Good control of medical conditions Eg : diabetes, hyptertension , heart failure, asthma Get specialist advice if needed Check for history of hiatus hernia Nil by mouth x 6 hours Antihypertensive treatment MAY be given before treatment In diabetics...Because hypoglycemia increases the metabolic risk of seizures, a fingerstick glucose level should be checked 30 minutes prior to each treatment.

Remember...: 

Remember... Consult other specialities when in doubt Significant medical problems, such as arrhythmias, severe hypertension,CHF , large aneurysms, or insulin-dependent diabetes mellitus, may require specialized medical consultation. Neurological consultation should be considered when problems related to head trauma, intracerebral tumor , stroke, epilepsy, or cerebrovascular malformations are uncovered. Also, because ECT has been associated with a transient increase in intraocular pressure an ophthalmology consultation is needed for the patient with closed-angle glaucoma, poorly controlled open-angle glaucoma, or retinal detachment.

Management of medications prior to ECT: 

Management of medications prior to ECT All medications that a patient takes should be reviewed as part of the pre-ECT evaluation for their possible roles in increasing the morbidity or decreasing the efficacy of ECT Concomitant use of lithium and ECT may increase the risk of cognitive deficits, encephalopathy, and spontaneous seizures Benzodiazepines or other anticonvulsants may raise the seizure threshold and decrease seizure efficacy. Omit benzodiazepines night before.

Contraindications to ECT: 

Contraindications to ECT

Relative contraindications: 

Relative contraindications There is no absolute contraindications to ECT Medical conditions that increase the risk from ECT Recent intracranial hemorrhage Recent thromboembolic stroke Intracranial lesion causing mass effect Recent MI, particularly if sequelae are present Unstable angina or decompensating heart failure Unstable vertebral fracture

Consent for Treatment: 

Consent for Treatment

Informed Consent: 

Informed Consent The first stage of obtaining consent must always be an assessment of a patient’s capacity to give that consent. The current legal test of capacity holds that an adult has capacity to consent (or refuse consent) to medical treatment if he or she can: • understand and retain the information relevant to the decision in question • believe that information • weigh that information in the balance to arrive at a choice.

Local perspective: 

Local perspective Doctor doing pre-ECT workup, has to discuss procedure and side-effects with patient DOCUMENT In the event that patient has not got capacity to consent for treatment, discussion has to be done with relatives DOCUMENT Patients who are capable to give consent and refusing to give it, should be under a Treatment Order for ECT to proceed. In this scenario patient relatives will have to agree with RMO and consent for treatment on behalf of patient DOCUMENT In the event that patient’s relatives refuse to sign consent, a second opinion has to be sought, prior to proceeding with ECT DOCUMENT

Remember...: 

Remember... Consent can we withdrawn by patient at any time during ECT course The continuation of consent should be verbally checked before each treatment. Hence always DOCUMENT that patient is consenting prior to each ECT bout