Treatment for severe psychiatric illnesses.
Utilizes sedation, muscle paralysis, ventilation with oxygen and brief pulse electrical stimulation.
Performed under general anesthesia and uses muscle relaxation.
Uses passage of an electrical current through the brain inducing modified seizures to achieve therapeutic response.
Electroconvulsive therapy is associated with an increase in glial cell line derived neurotrophic factor.
Modern management has eliminated previous risks of fracture and transient cognitive dysfunctions.
Current protocols are safe, with a few contraindications.
Mortality rate about 2 deaths per 100,000 treatments, no greater than minor operative procedures involving general anesthesia.
Efficacious for severe depressive disease.
Presently used mainly to treat severe depression, bipolar disorder, schizophrenia, schizoaffective disorder, delirium, and neuroleptic malignant syndrome.
Electroconvulsive therapy (ECT) can improve level of consciousness and temperature in patients with neuroleptic malignant syndrome.
ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or bipolar, but about half of people who respond relapse within twelve months.
It may also be useful in treating the underlying psychiatric disease in patients who are unable to take neuroleptics.
The rationale for the use of ECTincludes its efficacy in treating malignant catatonia and improving parkinsonism.
Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia.
Advancements in ECT, including administration while the patient is in the brief anesthesia, unilateral electrode placement, and refined techniques for seizure elicitation such as ultra brief pulse stimulation have enabled it to be more commonly performed as an outpatient procedure.
Immediately following treatment, the most common adverse effects are confusion and memory loss.
Common side effects include: post ictal confusion with both Anterograde and retrograde amnesia.
A controversial treatment and considered by many experts a last resort treatment for patients with ineffective or poorly tolerated response to psychotropic medications.
Current administration techniques, such as unilateral electrode placement with a brief pulse substantially reduces risk of amnesia and cognitive symptoms typically resolve after completion of ECT.
Patients with cardiovascular or pre-existing neurologic disease are at an increased risk for ECT-related memory problems.
Standard practice in the US is three times a week, and in many other countries two times.
Most patient’s clinical disease remits with 6 to 12 treatments, but some require as few as three treatments and others 20 or more.
Mechanism of action is unknown.
Increases the release of monoamine neurotransmitters, particularly, serotonin, and norepinephrine.
Enhances monoamine transmission by desensitizing presynaptic adrenergic autoreceptors.
When compared with medication use, can lead to a substantial effective and rapid clinical improvement, particularly severely ill individuals, the elderly, and physically debilitated.
Electroconvulsive therapy is a last line of intervention for major depressive disorder.
Electroconvulsive therapy as treatment of the elderly is effective although less so than among the rest of the adult population.
ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or bipolar,but about half of people who respond relapse within twelve months.
The general physical risks of ECT are similar to those of brief general anesthesia, with the most common adverse effects are confusion and memory loss.
ECT is considered one of the least harmful treatment options available for severely depressed pregnant women.
ECT is administered under anesthetic with a muscle relaxant, and involves multiple administrations, typically given two or three times per week until the patient is no longer suffering symptoms.
After ECT, drug therapy is usually continued, and some patients receive maintenance ECT.
In the short term ECT has an anticonvulsant effect mostly in the frontal lobes.
Longer term effect of ECT is via neurotrophic effects primarily in the medial temporal lobe.
Utilization can lead to effective and rapid clinical improvement, particularly in severely ill, elderly and physically impaired patients.
Remission rates of 55-86% involving major unipolar depression, with a mean age of 55-59 years, 70% female patients compared with initial remission rate of 30% with patients treated with citalopram, 23% with bupropion, 21% with sertraline, and 25% with venlafaxine.
Relapse of depressive illness is frequent and continuation of electroconvulsive is useful for patients who relapse on medications or who cannot tolerate such agents.
Columbia University Consortium (CUC) remission rate of 55%.
CUC maintenance treatment for responders resulted in 84% relapse rate by 6 months for placebo patients, 60% for nortriptyline and 39% for combination of medications.
CORE (Consortium for Research in ECT) study of 394 patients revealed an 86% response rate.
The CORE study also treated responders with combination of lithium and nortriptyline versus continuation ECT on a rigid schedule and found the 6 month relapse rate was 32% for the drug combination and 37% for ECT, and a slight advantage for ECT in terms of time to relapse of 9.1 weeks vs 6.7 weeks for the drug combination.
Remissions are earlier and improved in patients with underlying psychosis, 95% vs 83% in the CORE study, making ECT treatment the primary management for psychotic depression.
No absolute contraindication to use.
Relative contraindications include: unstable or severe cardio secular diseases, recent MI, unstable angina, CHF, severe aortic stenosis or other heart valvular disease, susceptible brain aneurysm, A-V malformation, increased intracranial pressure, recent brain infarct, severe COPD, asthma, pneumonia, retinal detachment, and acute narrow angle glaucoma,
Pregnancy by itself is not a contraindication to its use.
ECT is considered one of the least harmful treatment options available for severely depressed pregnant women.
The presence of a seizure or another psychiatric condition does not represent a significant risk factor for use of ECT.