ELECTROCONVULSIVE THERAPY ELECTROCONVULSIVE THERAPY Mental

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ELECTROCONVULSIVE THERAPY
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ELECTROCONVULSIVE THERAPY
Jon Lehrmann MDAssistant Professor of
PsychiatryMedical College of WIVAMC Milwaukee,
WI
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Mental Health Care Pre-1930s
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History of ECT

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

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Chemically induced seizures- (camphor,
pentylenetetrazol)
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Insulin Shock Therapy

• In the 1930s , Dr Sakel developed Insulin Shock
  Therapy

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Cerletti and Bini (1934) Electricity
Initially done without muscle blocker or
anesthetic
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Early ECT

• Assylums
• Few effective medications
• Many often severe side effects
• 1950s- ether, and curare extract developed
  (Abram Bennett- a psychiatrist helped develop a
  method for extracting curare).
• In 1950s antidepressant and antipsychotic meds
  introduced- significantly decreased utilization
  of ECT

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Electrophysiological Principles

• Ohms Law IE/R (Icurrent, Evoltage, and
  Rresistance)
• Dose of electricity in ECT 100-500 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.

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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.

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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

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Major Depression

• Efficacy vs antidepressants
• When is it a first line treatment consideration?
• Length of Antidepressant effect
• Maintenance ECT

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Bipolar Mania

• Efficacy vs Lithium
• Indications for First Line Treatment
• -Recent Myocardial Infarction w/ Acute Mania
• -Pregnancy w/ Acute mania
  
  
  
  
  
  
  
  

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Pre ECT Workup

• Physical Exam
• Head CT
• CXR
• CBC, Basic Chem
• EKG
• ? Spinal Films

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Contraindications?

• No Absolute Contraindications
• Relative Contraindications Recent MI, Berry
  Aneurysm, Brain Mass, Increased Intracranial
  Pressure

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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.

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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.

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Adverse Effects

• Mortality rate .002 per treatment session,
  .01 per patient.
• Sore Muscles
• Head ache
• Short term confusion/ delirium
• Memory

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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.

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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.