Dr Diane Mullins, RCSI Tutor Tutor in Psychiatry, Psychiatry, St Ita’s Ita’s Hospital, Portrane Electroconvulsive therapy (ECT) / therapeutic applications and possible side effects of ECT Mode of action Specific mode of action is unknown ECT causes causes a wide wide range range of effec effects ts on neurot neurotra ransm nsmitt itters ers with with net functi functiona onall incre increase asess in monoamine systems (NA, 5-T, 5-T, !A", #A$A, Ach, endogenous opioids and adenosine Also effects effects the neuroendo neuroendocrine crine system, with release of hypothalam hypothalamic, ic, pituitary pituitary and adrenal adrenal hormones Indications ECT should only %e used after an ade&uate trial of other treatment options has pro'en ineffecti'e andor when the condition is considered to %e potentially life-threatening, in indi'iduals with) o !epressi'e illness Se'ere episodes with delusions, retardation Se'ere postpartum depression Need for rapid antidepressant response (e*g* due to failure to eat or drink in depressi'e stupor" Se'ere suicidal risk +oor response to ade&uate pharmacology +atients who are una%le to tolerate side effects of drug treatments +re'ious history of good response to ECT A prolonged or se'ere manic episode o Schiophrenia o Catatonia +ost-schiophrenic +ost-schiophrenic depression Also ad'ocated as a treatment for neuroleptic malignant syndrome (NS" and intracta%le o seiure disorders (acts to raise seiure threshold" Contraindications No absolute contraindications .hen possi%le, use of ECT should %e limited for patients with) / in the last 0 months Cardiac arrhythmias /ntracere%ral /ntracere%ral haemorrhage or cere%ral aneurysm $rain tumour Acuteimpending retinal detachment +haeochromocytoma igh anaesthetic risk malformation 1nsta%le 'ascular aneurysm or malformation Potential benefits 234 of patients show impro'ement* impro'ement* ood impro'es within -3 weeks Side effects Early o Short-term memory loss (retrograde amnesia 6 usually resol'es completely, 784" o eadache (894" o Slight and temporary confusion (324" Nausea'omiting (:4" (:4" o Clumsiness (54" o ;arely) fractures, dislocation and fat em%olism* ania in %ipolar su%>,>>>" 6 usually due to cardiac o complications in patients with known cardiac disease Administration Before o ?ull physical e@amination ;outine %lood tests, C;, EC# o Application
Dr Diane Mullins, RCSI Tutor in Psychiatry, St Ita’s Hospital, Portrane /nduction 6 methohe@itone (most commonly" or t hiopentone Atropine 6 reduces secretions, counters cholinergic effects of muscle rela@ants o uscle rela@ant 6 su@amethonium o B@ygenate o Electrical stimulation o oltage stimulation needs to %e greater than seiure threshold to achie'e effect/f no con'ulsion, repeat stimulation up to a ma@imum of 0 Bilateral electrode placement (most common most co!nitive impairment): o frontotemporal position prefera%le 6 electrodes positioned on same point at %oth sides Unilateral electrode placement (on the non"dominant hemisphere i#e# $%&'ri!ht o unilateral): $etween frontotemporal and mastoid region =ancaster position 6 %etween frontotemporal position and 'ertically to 'erte@ o
Post-ictal B@ygenate o Nurse in a prone position with airway in situ o Continue applications twice weekly until significant reco'ery, up to ma@ of >-3 Transient ele'ation of mood on reco'ery after the first -3 treatments predicts good response* /f no response whatsoe'er %y 7th treatment then prognosis is poor
Psychiatric medications ECT Medications that raise the seizure threshold: Benzodiazepines/barbiturates: %est a'oided during ECT, or reduce to lowest dose o possi%le Anticonulsants: continue during ECT, %ut higher ECT stimulus will usually %e needed o Medications that lo!er the seizure threshold: Antipsychotics: continue if clinically indicated* Cloapine should %e suspended for 38 o hours %efore ECT Antidepressants: TCAs, SS;/s, AB/s 6 continue if clinically indicated* oclo%emide o should %e suspended for 38 hours %efore ECT Lithium: %est a'oided as may increase cogniti'e side effects and increase likelihood of o neuroto@ic effects of lithium Su!!ested startin! doses for ECT A!e Males emales D05 years 3>> mc >> mc 05-75 years 0>> mc 3>> mc 75 years 8>> mc 0>> mc
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Dr Diane Mullins, RCSI Tutor in Psychiatry, St Ita’s Hospital, Portrane /f no fit or D 5 second seiure ↑ %y 35 mc increments at lower end of scale and 5> mc increments if 8>> mc
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