Electroconvulsive therapy

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Unit-4

• Therapeutic Modalities in Psychiatry
• Electroconvulsive Therapy (ECT)

By Mrs. Sudha Anbalagan, Lecturer, Nursing
Department College of Applied Medical Sciences,
PSAU.
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Introduction

• In a psychiatric setting the treatment may not be
  so specific and most patients are given more than
  one treatment.
• The various treatment modalities in psychiatry
  are broadly divided as
• Somatic (physical) therapies
• Psychological therapies
• Other therapies included in this unit are
• Milieu therapy
• Therapeutic community
• Activity therapy

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Introduction

• SOMATICTHERAPIES
• Psychopharmacology
• Antipsychotics
• Antidepressants
• Lithium and Other Mood Stabilizing Drugs
• Anxiolytics and Hypno-sedatives
• Anti-parkinsonian Agents
• Antabuse Drugs
• Drugs Used In Child Psychiatry
• Electroconvulsive Therapy
• Psychosurgery

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Electroconvulsive Therapy
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Earliest evidences

• Swiss physician Paracelsus in 1500s, induced
  seizures with oral camphor to treat psychiatric
  illness.

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Earliest evidences

• Manfred Sakel, a Viennese physician in 1920s.
• Administered in patients to induce a
  hypoglycemic state. (Insulin Shock Therapy)

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Electrically Induced Seizures

• In 1937, Italian physicians Cerletti Bini
  applied electricity to head to induce therapeutic
  seizures.
• First patient had catatonia and he improved.
• Safer than chemically induced seizures.
• Widespread acceptance through out Europe and USA.

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Definition
Electroconvulsive therapy is the artificial
induction of a grandmal seizure through the
application of electrical current to the brain.
The stimulus is applied through electrodes.
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Parameters of Electrical Current Applied

• Standard dose according to American Psychiatric
  Association, 1978
• Voltage - 70-120 volts.
• Duration - 0.7-1.5 seconds

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Type of Seizure Produced

• Grandmal seizure-tonic phase lasting for 10-15
  seconds.
• Clonic phase lasting for 30-60 seconds.

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Mechanism of Action

• Neurotransmitter levels all ? in CSF after
  seizure, Cerebral blood flow ?.
• After seizure, blood flow and metabolism is ?
  especially in the frontal lobes.

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Frequency and Total Number of ECT

• Frequency Three times per week or as indicated.
• Total number 6to 10 upto 25 may be preferred as
  indicated.

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Application of Electrodes
Bilateral ECT Each electrode is placed 2.5-4 cm
(1-1½ inch) above the midpoint, on a line joining
the tragus of the ear and the lateral canthus of
the eye. Unilateral ECT Electrodes are placed
only on one side of head, usually non-dominant
side. Unilateral ECT is safer, with much fewer
side effects particularly those of memory
impairment.
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Indications Contraindications

• Indications

• Contra Indications

• Raised ICP (intracranial pressure)
• Cerebral aneurysm
• Cerebral hemorrhage
• Brain tumor
• Acute myocardial infarction
• Congestive heart failure
• Pneumonia or aortic aneurysm
• Retinal detachment

• Major depression
• Severe catatonia
• Severe psychosis (schizophrenia or mania)
• Organic mental disorders
• organic mood disorders.
• organic psychosis

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Side Effects of ECT

• Memory impairment.
• Drowsiness, confusion and restlessness.
• Poor concentration, anxiety.
• Headache, weakness/fatigue, backache, muscle
  aches.
• Dryness of mouth, palpitations, nausea, vomiting.
• Unsteady gait.
• Tongue bite and incontinence.

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ECT Team

• Psychiatrist, anesthesiologist, trained nurses
  and nursing aides, ECT assistants should be
  involved in the administration of ECT.

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Treatment Facilities

• There should be three rooms
• A pleasant, comfortable waiting room (pre-ECT
  room).
• ECT room, which should be equipped with
• ECT machine and accessories, an anesthetic
  appliance, suction apparatus, face masks, oxygen
  cylinders with adjustable flow valves, curved
  tongue depressors, mouth gags,
• resuscitation apparatus and emergency drugs.
  There should be immediate access to a
  defibrillator.
• A well-equipped recovery room.

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Role of the Nurse
Before ECT

• Detailed medical and psychiatric history.
• Assessment of patient's and family's knowledge of
  indications, side-effects, therapeutic effects
  and risks associated with ECT.
• An informed consent should be taken.
• Allay fears and anxieties regarding the
  procedure.
• Assess baseline vital signs.
• Patient should be on empty stomach for 4-6 hours
  prior to ECT.
• Withhold night doses of drugs.
• Withhold oral medications in the morning.
• Head shampooing in the morning.
• Any jewellery, prosthesis, dentures, contact
  lens, metallic objects and tight clothing should
  be removed from the patient's body.
• Empty bladder and bowel just before ECT.
• Administration of 0.6 mg atropine IM or SC 30
  minutes before ECT, or IV just before ECT.

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Role of the Nurse
During ECT

• Place the patient comfortably on the ECT table in
  supine position.
• Stay with the patient to allay anxiety and fear.
• Administer the anesthetic agent (thiopental
  sodium) and muscle relaxant (succynylcholine).
• Patent airway should be ensured and ventilator
  support should be started.
• Mouth gag should be inserted to prevent possible
  tongue bite.
• The place(s) of electrode placement should be
  cleaned with NS conducting gel applied.
• Monitor voltage, intensity and duration of
  electrical stimulus given.
• Monitor seizure activity using cuff method.
• 100 percent oxygen should be provided.
• During seizure monitor V/S, ECG, oxygen
  saturation, EEG, etc.
• Record the findings and medicines given in the
  patient's chart

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Role of the Nurse
After ECT

• Monitor vital signs.
• Continue oxygenation till spontaneous respiration
  starts.
• Assess for post-ictal confusion and restlessness.
• Take safety precautions to prevent injury.
• If there is severe post-ictal confusion and
  restlessness, IV diazepam may be administered.
• Reorient the patient after recovery and stay with
  him until fully oriented.
• Document any findings as relevant in the
  patient's record.

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