Electroconvulsive Therapy

Introduction

Electroconvulsive therapy formerly known as electroshock therapy is a psychiatric treatment in which seizures in the brain are electrically induced in patients. Typically, 70 to 120 volts are applied externally to the patient's head resulting in eight hundred milliamperes of direct current passed through the brain, for one hundred milliseconds to 6 seconds duration, either from temple to temple (bilateral electroconvulsive therapy) or from front to the back of one side of the head (unilateral electroconvulsive therapy), bi-frontal electroconvulsive therapy is a new technique.

Efficacy

Schizophrenia

It is effective for patients who have acute psychosis, especially those with marked positive symptoms. In schizophrenia, it is used for patients presenting in catatonic states or depressed affect. We also use it in patients exhibiting violence.

A recent Cochrane review suggested based on moderate‐quality evidence that relative to standard care, electroconvulsive therapy has a useful effect on the medium‐term clinical response for individuals with treatment‐resistant schizophrenia. For other outcomes, the evidence also was inconclusive on the advantage or disadvantage of adding electroconvulsive therapy to standard care. 

Electroconvulsive therapy for treatment-resistant schizophrenia. 

Major Depressive Disorder

We still base the efficacy of electroconvulsive therapy in major depressive disorder on the findings of the meta-analysis from the UK ECT review group. Therapeutic effects are greatest in severe depressive disorders, especially those in which there is marked weight loss, early-morning waking, retardation, and delusions. Delusions and (to a lesser extent) retardation distinguish patients who respond to electroconvulsive therapy. The following table summarizes the findings from the UK ECT review group.
                   

Treatment Comparison Effect Size HDRS change (CI)
Super to antidepressant 0.46 5.2 (1.4–8.9)
Bilateral superior to unilateral 0.32 3.6 (2.2–5.2)
Higher dose superior 0.57 4.1(2.4-5.9)
CI, 95% Confidence interval; HDRS, Hamilton Depression Rating Scale.

1.Group UER. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. The Lancet. 2003;361(9360):799-808. doi:10.1016/S0140-6736(03)12705-5

Predictors of Response to Electroconvulsive Therapy (ECT)


Parameters Associated with the Effectiveness
Seizure duration Over 15-20 seconds
Electrical stimulus Higher more effective
Seizure threshold Up to 2.5 x with bilateral 6 x with unilateral
Placement Bilateral more effective
Medication Patients on antidepressants respond better


Physiological changes

Without anticholinergic premedication, the pulse first slows then raises abruptly to about 130-190 beats/min, the decreases to resting rate or even lower. Finally, there is a less less-marked tachycardia which continues for a few minutes. There is a marked elevation in blood pressure. The systolic blood pressure can rise to 200 mm Hg, cerebral blood flow is raised up to 200%.

Elevation in blood pressure and cerebrospinal fluid pressure occurs as a response to the seizure activity. First, there is the vagal response, which leads to bradycardia, then the blood pressure drops. This is followed by rebound tachycardia and a hypertensive response.

Dexamethasone, atropine, glycopyrrolate, and antihypertensive are management choices.

NICE Recommendations 

NICE recommends using electroconvulsive therapy (ECT) only to attain quick and short-term improvement of severe symptoms if an adequate trial of other options has not been effective and/or when the condition is potentially life-threatening, in individuals with:
  • Catatonia 
  • A prolonged or severely manic episode.
  1. For an individual, consider a documented assessment of the risks and potential benefits to the individual before recommending electroconvulsive therapy.
  2. Exercise caution when considering electroconvulsive therapy during pregnancy, in older people, and in children and young people.
  3. Get informed consent in all cases where the individual can grant or refuse consent. 
  4. The individual and the clinician(s) responsible for the treatment should jointly decide to use electroconvulsive therapyconsidering
    1.  Informed discussion after full information about the risks and potential benefits, 
    2. without pressure or coercion, 
  5. Aim to involve patient advocates and/or carers in the decision.
  6. If informed consent is not possible, take advance directives fully into account. 
  7. Assess clinical status following each electroconvulsive therapy session
  8. Stop treatment when the patient responds to treatment, or 
    1. Sooner if there is evidence of adverse effects.
  1. Monitor the cognitive function actively, and at a minimum at the end of each course of treatment.

    Repeat Course 

    Consider a repeat course under the circumstances for patients who previously responded. In patients who have not previously responded, we should undertake a repeat trial only after all options have been considered and following discussion with individual/carer/advocate.

    Schizophrenia 

    Do not recommend electroconvulsive therapy to patients with schizophrenia.

    Depression 


    Overview | Guidance on the use of electroconvulsive therapy | Guidance | NICE

    Indications

    Electroconvulsive therapy is a major treatment in psychiatry with well-defined indications, not to be reserved for use only as a “last resort”. The speed and efficacy of electroconvulsive therapy are factors that influence its use as a primary intervention. Particularly in major depression and acute mania, substantial clinical improvement often occurs soon after the start of electroconvulsive therapy. When a rapid or a higher prospect of response is required, as when patients are severely medically ill or at risk to harm themselves or others, practitioners should consider the primary use of electroconvulsive therapy. Other considerations for the first-line use of electroconvulsive therapy involve the patient’s medical status, treatment history, and treatment preference. For example, in patients with postpartum psychosis, where quick recovery is essential for both the baby and the mother. Patients in a state of stupor where the risk to the patient is high because of inadequate food intake.

    Secondary

    The most common use of electroconvulsive therapy is with patients who do not improve with other treatments. Intolerance of side effects, deterioration in the psychiatric condition, or the appearance of suicidality are other reasons to consider the use of electroconvulsive therapy. In the treatment of patients with refractory schizophrenia, it is one option, when patients do not respond to clozapine and an augmentation strategy.  In patients with treatment-refractory depression, it is one option when patients do not respond to first-line choices.


Steps of Application of Electroconvulsive therapy (ECT)

Step-1: Preparing the patient

Get consent, pass the intravenous line, and perform a physical examination. Get the patient nil-by-mouth at midnight.

Before shifting the patient to the electroconvulsive therapy room, Check case notes including the medication chart for medications that affect seizure threshold or interact with anesthesia, the outcome of earlier electroconvulsive treatments, especially seizure duration and complications. Check for the placement—whether unilateral or bilateral—agreed. Confirm, there is a valid consent form. 

The nursing staff checks vital signs, have the patient void, remove dentures, jewelry, hairpins, eyeglasses, and change into a gown. 

Step-2: Pre-procedure

When the patient enters the treatment room, introduce yourself, put the patient at the ease, and confirm their identity. Also, confirm the patient has been nil-by-mouth for at least 5-hours. Confirm, the patient continues to consent. Check vital signs. 

Electroconvulsive therapy without anesthesia

The world health organization recommends modified-electroconvulsive therapy in countries where anesthetists are deficient. If we perform the procedure without anesthesia, ensure emergency-trolley passive, pressure oxygen supply, and emergency drugs.

Step-3 The procedure

  1. Give atropine sulfate or glycopyrrolate. 
  2. Request the anesthetist to induce anesthesia. 
  3. Put the blood pressure cuff on the lower leg inflated to just above systolic pressure. 
  4. Administer a muscle relaxant/paralytic agent. 
  5. Start assisted ventilation. 
  6. Apply electrical stimulus, unilaterally/bilaterally. 
  7. Confirm seizure activity and note the duration of the seizure.

Step-4 Recovery

Shift to recovery and monitor until the patient recovers. 

Electrode Placement

Overall, bilateral electroconvulsive therapy has superior efficacy to unilateral electroconvulsive therapy.

However, bilateral treatment is associated with more cognitive impairment. When right unilateral electroconvulsive therapy is dosed to about six times the seizure threshold, its efficacy approaches that of bilateral electroconvulsive therapy, but the associated cognitive impairment is also similar (Kellner et al., 2010). These data suggest that the appropriate electrode placement for electroconvulsive therapy should balance efficacy against cognitive disturbance according to the needs of the individual patient. If the need for improvement is particularly urgent, bilateral electroconvulsive therapy should be considered, dosed to about 2.5 times the seizure threshold. For a meta-analytical review of treatment factors that affect the efficacy of electroconvulsive therapy (2)

Bifrontal electroconvulsive therapy is a newer approach developed to mitigate the cognitive impairment associated with bilateral ECT but Kellner et al., 2010 (1) found no advantage over the other approaches. 

Recent research has shown a lower risk of cognitive impairment with right unilateral placement with ultrabrief pulse (0.3 ms) compared to the usual pulse (0.1 ms), but with a lower efficacy. 

  • Recommend right unilateral for patients who are right-handed, OR 
  • Bilateral to patients who are left-handed, or in whom handedness is unknown. 

References

1: Kellner CH, Tobias KG, Wiegand J. Electrode placement in electroconvulsive therapy (ECT): A review of the literature. J ECT. 2010 Sep;26(3):175-80. 
2. Group UER. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. The Lancet. 2003;361(9360):799-808. doi:10.1016/S0140-6736(03)12705-5
3.Loo CK, Sainsbury K, Sheehan P, Lyndon B. A comparison of RUL ultrabrief pulse (0.3 ms) ECT and standard RUL ECT. International Journal of Neuropsychopharmacology. 2008;11(7):883-890. doi:10.1017/s1461145708009292
Tor PC, Bautovich A, Wang MJ, Martin D, Harvey SB, Loo C. A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression. J Clin Psychiatry. 2015 Sep;76(9):e1092-8. doi: 10.4088/JCP.14r09145. PMID: 26213985.

Post-Treatment Management

Continuation therapy, typically comprising psychotropic medications or electroconvulsive therapy, is indicated for all patients. 

Maintenance pharmacotherapy 

The underlying illness, consideration of side effects, and response history to medication treatment should help determine the choice of agent. 

Continuation or maintenance of electroconvulsive therapy:

We should administer maintenance electroconvulsive therapy at the minimum frequency compatible with sustained remission, often at 1-3-week intervals. The need for continued maintenance electroconvulsive therapy should be reassessed at least every three months.

Petrides et al., 2011, reviewed the literature regarding maintenance and continuation of electroconvulsive therapy and concluded these are valuable treatment modalities to prevent relapse and recurrence of mood disorders in patients who have responded to an index course of ECT. maintenance and continuation of electroconvulsive therapy are underused and insufficiently studied despite the positive clinical experience of over 70 years. Studies that are currently underway should allow more definitive recommendations regarding the choice, frequency, and duration of maintenance and continuation of electroconvulsive therapy following acute treatment.

As defined in the article:

An index course is we give the initial series of treatments to relieve acute symptoms of the illness. 

Continuation electroconvulsive therapy: A course that begins after the index course, lasts up to 6 months and prevents relapse of the episode (return of the symptoms to full syndromal criteria before the end of the natural duration of the illness). 

Maintenance electroconvulsive therapy: A course that begins after C-ECT and should prevent the recurrence of an episode (a new episode)

We mostly perform electroconvulsive therapy two or three times per week. Some practitioners may use higher frequencies of treatments, particularly in cases of severe symptom presentation; however, continued use of daily treatments increases the risk of cognitive impairments. And there is no advantage of giving treatments over two times per week. 

  1. The total number of treatments administered should be a function of both the degree and rate of clinical improvement and the severity of the cognitive adverse side effects. 
  2. The evaluation of the response should focus on the target symptoms, with an assessment made between each treatment. 
  3. There is a little-to-no response until we have given two or three treatments, after which increasing improvement occurs. 
  4. If the response is more rapid than this, we may give fewer treatments.  
  5. If no improvement occurs after 3-4 treatments, we may consider:
    1. Bilateral electrode placement. 
    2. Medications to potentiate the clinical response. 
  6. The treatment course should stop as soon as they have reached maximal improvement. While the typical electroconvulsive therapy course in patients with a mood disorder is between 6-12 treatments. 
  7. In the absence of significant clinical improvement after 6-8 treatments, we should stop the treatment. We may consider 
    1. Modification of the technique,
    2. Medications to potentiate the clinical response, or
    3. Discontinuation of the electroconvulsive therapy.
  8. No evidence supports:
    1. That repeated courses of electroconvulsive therapy cause permanent structural damage, or 
    2. That a maximum limit on the lifetime number of treatments with electroconvulsive therapy applies. 
We should also assess clinical change and memory after each treatment. It is better to use reliable, validated scales for this purpose. For a clinical change, the Clinical Global Impression of Improvement is suitable, and we should also note the patient’s subjective report. Measurement of the various aspects of memory in a routine clinical setting is more difficult. 

NICE (2003) has recommended the Mini-Mental State Examination, which will capture the confusion and short-term memory impairment but not, for example, autobiographical memory loss. Significant cognitive impairment should lead to a reappraisal of the electrical dose and electrode placement.

Brief Answer Questions

You are planning electroconvulsive therapy for a 27-year-old man with a five-year history of hearing voices, suspiciousness, social withdrawal, loss of self-care and disorganized behavior. The patient has not responded to several antipsychotics, including clozapine at the maximum tolerated dose that he used for a sufficient period.

  1. Does evidence support your treatment plan? 
  2. What could be the contraindications of electroconvulsive therapy in this patient? 
  3. What adverse effects of electroconvulsive therapy are most relevant to this patient?
  4. How would you adjust his current treatment? 

References

1.Sinclair DJ, Zhao S, Qi F, Nyakyoma K, Kwong JS, Adams CE. Electroconvulsive therapy for treatment-resistant schizophrenia. The Cochrane database of systematic reviews. 2019;3(3): CD011847-CD011847. doi:10.1002/14651858.CD011847.pub2

Course curriculum

  • 1

    Introduction

  • 2

    Efficacy overview

  • 3

    Mechanisms and effects

    • Physiological changes

    • Quiz-2

    • Central nervous system
  • 4

    Indications

  • 5

    Interactions

    • Use of psychotropics
  • 6

    Contraindications

    • Contraindications
  • 7

    Adverse effects and complications

    • Complications

    • Risk of Mortality

    • Cognitive Dysfunction

    • Treatment-Emergent Mania
  • 8

    Use in special populations

    • Comorbidity

    • Elderly

    • Pregnancy

    • Children and Adolescent
  • 9

    Preparing the patient

    • Recommending to patients

    • Obtaining consent

    • Informational care

    • Pre-treatment Evauluation
  • 10

    Practice

  • 11

    Induction

    • Methohexital | Methohexitone

    • Muscle relaxation

    • Glycopyrrolate
  • 12

    Dose of electricity

  • 13

    The Seizure

    • Appearance

    • Detection with electroencephalography

    • Detection by limb Isolation method

    • Duration