6 Insulin Shock TherapyIn the 1930’s , Dr Sakel developed Insulin Shock Therapy
7 Cerletti and Bini (1934): Electricity Initially done without muscle blocker or anesthetic
8 Early ECT Assylums Few effective medications Many often severe side effects1950’s- ether, and curare extract developed (Abram Bennett- a psychiatrist helped develop a method for extracting curare).In 1950’s antidepressant and antipsychotic meds introduced- significantly decreased utilization of ECT
9 Electrophysiological Principles Ohm’s Law: I=E/R (I=current, E=voltage, and R=resistance)Dose of electricity in ECT= milliCoulombsBrain has low impedance (resistance), skull has very high impedance. Only 20% of applied charge actually enters the brain.Seizure involves propagation of action potentials in a large percentage of neurons.
10 Mechanism of ActionNeurotransmitter levels all increased in CSF after seizure. Results in down regulation of Beta adrenergic receptors.During seizure- PET studies show an increase in BBB permeability and in cerebral blood flow and metabolism.After seizure, blood flow and metabolism is decreased especially in the frontal lobes. Research shows this correlated w/ response.
11 Indications Major Depression w/ or w/o psychotic features Bipolar disorder - manic or depressed phaseAcute or Catatonic SchizophreniaSome studies have shown efficacy in treating OCD, Delirium, NMS, Chronic pain syndromes, and intractable seizure disorders
12 Major Depression Efficacy vs antidepressants When is it a first line treatment consideration?Length of Antidepressant effectMaintenance ECT
13 Bipolar Mania Efficacy vs Lithium Indications for First Line Treatment:-Recent Myocardial Infarction w/ Acute Mania-Pregnancy w/ Acute mania
14 Pre ECT Workup Physical Exam Head CT CXR CBC, Basic Chem EKG ? Spinal Films
16 TreatmentsPremedicate w/ Glycopyrrolate, consider short acting Beta blockerPatient not intubatedBite blockCuff leg to monitor szEEG and EMGLength of sz- 20 sec to 1 min.
17 Number and Spacing of ECT 2-3x/wk- efficacy vs less memory impairment5-12 sessions/ treatment (although up to 20 is possible)Point of maximum improvement- no more improvement after 2 further treatments.
18 Adverse EffectsMortality rate: .002% per treatment session, .01% per patient.Sore MusclesHead acheShort term confusion/ deliriumMemory
19 Transcranial Magnetic Stimulation (TMS) Rt Frontal lobe- TMS pulses suppress activity and causes happiness and increased energyLeft Frontal lobe- TMS pulses suppress activity and leads to sadness4/250 had seizure10Hz stimulation 20x/day, 11/17 patients w/ Major Depression showed significant improvement.
20 TMS continuedSo far positive effects have not lasted as long as positive effects from ECTHandful of case reports show efficacy w/ anxiety disorders.