1. Dr. Shailendra Mohan Tripathi,
Electroconvulsive therapy
Dr. Shailendra Mohan Tripathi,
Assistant Professor
DGMH,KGMU, Lucknow

2. Introduction
Over the years electroconvulsive therapy (ECT) has established its usefulness as a rapidly acting treatment for schizophrenia, bipolar disorders and unipolar depression among others
Yet its use has remained controversial
At times, rejected because it is widely perceived as invasive and coercive
Lack of understanding of its mechanism of action

3. History of ECT
Use of camphor reported as early as the 16th century and several accounts of camphor convulsive therapies from the late 1700s to the mid 1800s
LADISLAUS MEDUNA hypothesized that there might be a biological antagonism between convulsions and schizophrenia
In 1934, the first catatonic psychotic patient successfully treated using intramuscular injections of camphor in oil
1938 – UGO CERLETTI and LUCIO BINI induce seizures in Rome using electrical stimuli
A.E. BENNETT uses curare for muscle relaxation with Metrazol convulsive therapy

4. History of ECT contd….
1952 – HOLMBERG uses succinylcholine as a muscle relaxant with ECT
In 1949, Goldman introduced unilateral ECT
By late 1950s, efficacy in disorders other than schizophrenia had been demonstrated
In the 1980s and 1990s, efforts to ensure uniformly high standards of practice were under way

5. Mechanism of action The mechanism of action of ECT is not fully known.
ECT affects multiple central nervous system components, including hormones, neuropeptides, neurotrophic factors, and neurotransmitters.
The induction of a bilateral generalized seizure is required for both the beneficial and adverse effects of ECT. An increase in gamma-aminobutyric acid (GABA) transmission and receptor antagonism has been observed, which raises the seizure threshold during ECT.

6. Indications Major depressive disorder
- Considered for patients in the acute phase of major depressive disorder who have a high degree of symptom severity and functional impairment or who have psychotic symptoms or catatonia.
- Also be the treatment of choice for patients in whom treatment response is urgently needed, such as patients who are suicidal or those who are refusing food and are nutritionally compromised.

7. Bipolar disorder
- Patients with severe or treatment-resistant manic or mixed episodes of bipolar disorder
- ECT may be efficacious in patients with rapid cycling bipolar disorder.
In patients with life-threatening inanition, suicidality,or psychosis, ECT is a reasonable alternative treatment
For patients who have depression with psychotic or catatonic features, ECT should be considered.
Maintenance ECT may be considered for patients whose acute episode of depression responded to ECT.

8. Schizophrenia
- Effective for symptoms of acute schizophrenia but is not effective for chronic schizophrenia
-In combination with antipsychotics, ECT may be considered for patients with severe psychosis that has not responded to treatment with antipsychotic medications
- Patients with prominent catatonic features that have not responded to lorazepam
-For patients with comorbid depression, ECT may be beneficial if depressive symptoms are treatment- resistant or if features such as suicidal ideation and behaviors or inanition are present

9. Cont…. Other psychotic disorders
In the stable phase of schizophrenia, responded well to ECT but not maintaining well on drug treatment.
May be especially effective when marked positive and affective symptoms are present.
Other psychotic disorders
Effective for psychotic disorders related to schizophrenia, such as schizophreniform disorder and schizoaffective disorder.

10. Cont…. Comorbid disorders Other disorders and indications
-Not recommended for the treatment of obsessive-compulsive disorder (OCD) but may be considered for treating comorbid disorders such as major depressive disorder, mania, and schizophrenia in patients with OCD.
Other disorders and indications
-ECT has been effective in the treatment of catatonia, neuroleptic malignant syndrome,depression associated with Parkinson disease,pain, particular cases of delirium
-It has also been effective in treating patients with intellectual disabilities who have treatment-resistant mood or psychotic disorders.

11. contraindications Electroconvulsive Therapy with Comorbidity
ECT has no absolute contraindications
Many medical conditions place patients at an increased risk for complications and warrant closer monitoring, however
Electroconvulsive Therapy with
Comorbidity
Neurological comorbidities
- Caution is advised for patients with space-occupying intracranial lesions, as these individuals are at increased risk for edema and brain herniation after ECT.
- Patients with intracerebral lesions that lack a mass effect can safely undergo ECT

12. Cont….
- ECT increases intracranial pressure and blood flow to the brain.
- Patients who have increased intracerebral pressure or are at risk for cerebral bleeding, such as those with cerebrovascular disease and aneurysms, are at increased risk during ECT. Patients with very recent strokes are of special concern
- ECT has been safely used after coil embolization of a cerebral aneurysm.
- ECT has been used in the presence of Charcot- Marie-Tooth disease, arachnoid cysts, epilepsy, myasthenia gravis,and multiple sclerosis.

13. Cont…. Cardiac comorbidities
-Patients with cardiac disease should be evaluated by a cardiologist who can assist with the patient’s management during the course of ECT.
- In patients with unstable angina, uncompensated congestive heart failure, uncontrolled hypertension, high- grade atrioventricular block, and symptomatic ventricular arrhythmias, ECT raises the risk of symptoms from these cardiac conditions. Patients with hypertension should be stabilized with antihypertensive medications before undergoing ECT.
- Patients with a recent myocardial infarction (MI) are at high risk of cardiac complications such as MI, although the risk is greatly decreased 2 weeks after the MI and is further reduced 3 months after the MI.

14. Cont….
- With a proper pre-ECT cardiac and pacemaker/defibrillator assessment, patients with cardiac pacemakers and implantable cardioverter defibrillators can safely undergo ECT.
- ECT has been used in the presence of severe aortic stenosis, and it has been used after heart transplantation, though further studies are needed.
Other comorbidities
-Patients who have medical disorders associated with autonomic sensitivity (eg, clinically evident hyperthyroidism, pheochromocytoma), with sensitivity to anesthesia (eg, amyotrophic lateral sclerosis, porphyria, pseudochE deficiency), or with cognitive sensitivity (eg, traumatic brain injury) may require more extensive workup and closer monitoring during ECT.

15. Cont….
- Patients with gastroesophageal reflux disease may experience worsening symptoms during ECT, due to stimulation of the vagus nerve.
- Patients with diabetes, metabolic disorders (eg, hyperkalemia, hypokalemia, hyponatremia), chronic obstructive pulmonary disease, hypercoagulable states, glaucoma, and renal disease require close monitoring during ECT.

16. Preparation Anesthesia
- Since the late 1950s, however, ECT has been performed under general anesthesia.The goal is to produce a "light level" of anesthesia.
- Anesthetic medications used in ECT include the following:
Methohexital (barbiturate)
Thiopental (barbiturate)
Etomidate (nonbarbiturate)
Ketamine (nonbarbiturate)
Alfentanil (opioid)
Propofol (nonbarbiturate)
The cognitive outcome after ECT may be affected by the choice of the anesthetic medication

17. Cont….
Equipment
- The ECT treatment and recovery areas should contain equipment to monitor vital signs and provide initial management of medical emergencies.An optimal treatment site includes separate functional areas for waiting, treatment, and recovery
- A stethoscope, a blood pressure measurement device, electrocardiographic and pulse oximetry measurement devices, and an oxygen delivery system should be present. Supplies for inducing anesthesia, providing ventilation, monitoring physiologic functions (including seizure activity), and performing resuscitation should be present

19. Positioning
Common electrode positions in ECT include the bifrontotemporal, right unilateral, and bifrontal positions.Further research is needed for the asymmetric bilateral position.

20. Informed Consent
No patient with a capacity to give voluntary consent should be treated with ECT without his or her written, informed consent.
The use of involuntary ECT is rare. Involuntary ECT should be reserved for patients who need emergency treatment and who have a legally appointed guardian who has agreed to the use of ECT.
The informed-consent process should be documented in the patient's medical record and should include a discussion of the disorder, its natural course, and the option of receiving no treatment.

21. Electroconvulsive Therapy in the Elderly
In elderly patients, ECT has been used to treat catatonia, bipolar mania, and psychotic disorders.
Generally, geriatric patients with depression have better outcomes with ECT than do younger patients.
ECT is especially indicated for patients with depression who are at risk for harm because of psychosis, suicidal ideation, or severe malnutrition, but it is also helpful for treatment- resistant nonpsychotic major depression.
Seizure threshold may rise with increasing age, and effective seizures may be hard to induce.
Geriatric patients may be at a higher risk for persistent confusion and greater memory deficits during and after ECT.

22. Frequency of Treatments
ECT is most commonly performed 3 times per week regardless of electrode placement. More frequent regimens are not justified.
Treatments 2 times per week may result in less memory impairment than treatments 3 times per week.
Compared with treatments administered 3 times per week, twice-weekly treatments result in the same degree of final clinical improvement, although possibly at a slower rate of response.
Multiple monitored ECT (MMECT) involves treatment in which more than one adequate seizure is induced in the same session under continuous anesthesia.
Urgent clinical scenarios such as neuroleptic malignant syndrome may warrant MMECT, but routine use is not recommended.

23. Number of Treatments it varies widely.
Although the typical number of treatments is 6-12, some patients may respond after a few treatments, and some patients may not respond until after 10 treatments.
The total number should be a function of the patient's degree and rate of clinical improvement, as well as the severity of cognitive adverse effects.
Treatment is stopped when maximal improvement is reached.

24. Cont…. Cognitive adverse effects
Major limitations to the use of ECT. The most severe effects are observed postictally, with a brief period of disorientation and impairments in attention, praxis, and memory. The effects reverse over time.
Anterograde and retrograde amnesia may result from ECT. After ECT, anterograde amnesia resolves rapidly. With retrograde amnesia, deficits are greatest for events closest to the time of treatment.
Postictal delirium may occur in a minority of patients.

25. Future Directions
In terms of the effect we need to answer the question as to what is treated by the ECT – psychosis or depression or a common element to the two conditions & what explains the effectiveness of the ECT in delirium
The undesirable or side effects of the ECT need to be experimentally documented and their amelioration through appropriate approaches to be established
We need answers to questions like
What is the necessary and/or sufficient therapeutic component - the generalised seizure or the postictal slow-wave state?
What is the effective seizure - only a generalised/grandmal or a circumscribed one limited to one set of neurons/region?

26. The bioethics of ECT - is this a safe, effective procedure or should it be banned?

27. "ECT has a higher success rate for severe depression than any other form of treatment.”
-Dr. Dimitris Popolos
Since the 1960s, the methods of ECT have changed somewhat and it seems to be safer. It is known to produce some memory loss, but seems to be the most effective treatment for people with severe depression.

28. THANK
YOU