Insulin Shock Therapy In the 1930’s, Dr Sakel developed Insulin Shock Therapy
Cerletti and Bini (1934): Electricity Initially done without muscle blocker or anesthetic
Early ECT Assylums Few effective medications Many often severe side effects 1950’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
Electrophysiological Principles Ohm’s Law: I=E/R (I=current, E=voltage, and R=resistance) Dose of electricity in ECT= milliCoulombs Brain 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.
Mechanism of Action Neurotransmitter 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.
Indications Major Depression w/ or w/o psychotic features Bipolar disorder - manic or depressed phase Acute or Catatonic Schizophrenia Some studies have shown efficacy in treating OCD, Delirium, NMS, Chronic pain syndromes, and intractable seizure disorders
Major Depression Efficacy vs antidepressants When is it a first line treatment consideration? Length of Antidepressant effect Maintenance ECT
Bipolar Mania Efficacy vs Lithium Indications for First Line Treatment: -Recent Myocardial Infarction w/ Acute Mania -Pregnancy w/ Acute mania
Pre ECT Workup Physical Exam Head CT CXR CBC, Basic Chem EKG ? Spinal Films
Treatments Premedicate w/ Glycopyrrolate, consider short acting Beta blocker Patient not intubated Bite block Cuff leg to monitor sz EEG and EMG Length of sz- 20 sec to 1 min.
Number and Spacing of ECT 2-3x/wk- efficacy vs less memory impairment 5-12 sessions/ treatment (although up to 20 is possible) Point of maximum improvement- no more improvement after 2 further treatments.
Adverse Effects Mortality rate:.002% per treatment session,.01% per patient. Sore Muscles Head ache Short term confusion/ delirium Memory
Transcranial Magnetic Stimulation (TMS) Rt Frontal lobe- TMS pulses suppress activity and causes happiness and increased energy Left Frontal lobe- TMS pulses suppress activity and leads to sadness 4/250 had seizure 10Hz stimulation 20x/day, 11/17 patients w/ Major Depression showed significant improvement.
TMS continued So far positive effects have not lasted as long as positive effects from ECT Handful of case reports show efficacy w/ anxiety disorders.