1. ELECTROCONVULSIVE THERAPY

2. ELECTROCONVULSIVE THERAPY
Jon Lehrmann MD Assistant Professor of Psychiatry Medical College of WI VAMC Milwaukee, WI

3. Mental Health Care Pre-1930’s

4. History of ECT
Von Meduna (1934)- Autopsies of patients w/ Seizure disorders and of patients w/ Schizophrenia.
Difference in Glial cell proliferation

5. Chemically induced seizures- (camphor, pentylenetetrazol)

6. Insulin Shock Therapy
In 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 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

9. 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.

10. 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.

11. 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

12. Major Depression Efficacy vs antidepressants
When is it a first line treatment consideration?
Length of Antidepressant effect
Maintenance 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

15. Contraindications? No Absolute Contraindications
Relative Contraindications: Recent MI, Berry Aneurysm, Brain Mass, Increased Intracranial Pressure

16. 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.

17. 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.

18. Adverse Effects
Mortality rate: .002% per treatment session, .01% per patient.
Sore Muscles
Head ache
Short term confusion/ delirium
Memory

19. 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.

20. 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.