1. Electroconvulsive Therapy (ECT) and other procedures

2. 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

3. 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.

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. ECT Procedure

11. 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 seconds
Procedure is done 2-3x wk, for 9 to 12.

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

13. 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

14. 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

15. 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

16. VNS

17. 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

18. 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