Electroconvulsive Therapy (ECT) and other procedures

Objectives Gain an understanding of the origins of ECT as an EBP for psychiatric symptoms/d/o’s Analyze the use, indications, mechanism of action, and adverse effects of Electroconvulsive therapy (ECT), Phototherapy, Deep brain stimulation, and Vagal Nerve Stimulation as treatment for psychiatric illness

History of ECT Intervention Seizures were known to produce improvement of psychiatric symptoms for hundreds of years. Camphor-induced seizures were used in the 16th Century to reduce psychosis & mania. ECT was formally introduced in Italy in 1938 by Cerletti & Bini.

Mechanism of Action ECT produces rapid improvement in affective symptoms. Exact mechanism of action is unknown. Theories improves dopaminergic, serotonergic, and adrenergic neurotransmission Increases in brain-derived neurotrophic factor (BDNF) (regulates neuro cell growth and involved with NE and serotonin) Anticonvulsant effect r/t antidepressant effect

Main Indications Major Depressive Disorder 80% response rate is better than antidepressant meds. Acute mania or affective disorders with psychosis Schizophrenia Abrupt onset Catatonia

Factors to consider Need for rapid, definitive response Acute SI ruminations & behavior Risks of other tx’s Previous positive results from ECT Pregnancy; elderly Lower morbidity/mortality than with antidepressant mediations Medication trials failed

Side Effects Brief episodes of hypo- or hypertension, brady-or tachycardia & minor arrhythmias may occur. Common short term SE: headache, N/V, & muscle pain Lengthy seizures may contribute to more disorientation and confusion Increased falls risk following the procedure Memory loss is a troublesome long-term effect in some. Mostly, confusion and memory loss is short-term during tx Mostly recently learned material and that acquired during time of ECT treatments Most memory problems pass within several weeks Minimal difficulty may last up to 6 months Some information can never be retrieved, including experience of the treatment itself and events just before the procedure Distressing for the patient

Contraindication for ECT Patients with increased: Intracranial pressure Aortic and cerebral aneurysms Recent CVA Caution with cardiac conduction problems Retinal detachment Caution with certain brain tumors Pt’s with high risk for complications from anesthesia. High-risk pregnancy

Nurse’s Role Maintain NPO status Obtain Informed Consent Emotional support and education Knowledge of available RX options, risks & consequences of procedure Monitoring Medication administration

ECT Procedure https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml#part_152877

The Procedure Done in OR theater During ECT Emergency supplies (e.g., crash cart) IV access; monitor vitals; bite guard (EEG is monitored by physician) IM atropine approx 30 min prior Give short acting anesthesia (i.e., methohexital) & muscle relaxant (i.e., succinylcholine). 100% O2 is given by ambu-bag/airway Oxygen is given throughout the procedure. A brief electrical current is passed through the brain to produce a generalized seizure lasting 15-20 seconds Procedure is done 2-3x wk, for 9 to 12.

Post ECT Recovery Room Care Oxygen Suction Monitor vital signs Pulse oximeter Emergency equipment Orientation & reassurance MSE returned to acceptable level

Post ECT Unit Care Observation of Mental status q 15 min Vital signs q 15 min Level of orientation q 30 min until mental status returns to baseline Assess gag reflex, if present medications may be given and a meal Remove IV Allow to rest in room

Other procedures Repetitive magnetic stimulation Approved for major depression that has not responded to at least one antidepressant drug More specific areas of the brain less SE’s No anesthesia 30-60 minutes SE’s: HA, lightheaded, scalp discomfort, rare seizures National Institute of Mental Health (n.d.). Brain stimulation therapies. Accessed on August 31, 2013 at http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml

Other procedures Vagus nerve stimulation (VNS) Implanted device under the skin Sends pulses via the vagus nerve every 5 minutes for duration of 30 seconds Appear to alter NT’s that affect mood such as 5HT, NE, GABA, glutamate Approved for treating major depression that has lasted at least 2 years, 4 other treatments were unsuccessful SE’s: voice changes/hoarseness, cough, sore through, neck pain breathing problems, difficulty swallowing

VNS

Other procedures Deep Brain Stimulation Electrodes surgically implanted into abnormally functioning areas of the brain Pulse generators implanted below the collarbone Thought to interrupt obsessions, distressing moods, and anxieties Approved for tremors and Parkinson disease Under study for depression and OCD SE’s: seizures, bleeding, muscle contractions, adverse effect on mood, memory, and cognition

Other procedures Phototherapy Broad-spectrum fluorescent lamps used daily Seasonal Affective Disorder (SAD) Based on biological rhythms SE’s: eye strain, headaches, irritability, insomnia, fatigue, nausea, dye eyes and mucus membranes Caution is advised with ophthalmic conditions