Electroconvulsive Therapy
Brian E. Wood, D.O.
Associate Professor and Chair,
Department of Neuropsychiatry and Behavioral Sciences
Edward Via Virginia College of Osteopathic Medicine
Associate Professor of Clinical Psychiatric Medicine
University of Virginia School of Medicine
Department of Psychiatric Medicine
brwood6@vcom.vt.edu
What is Electroconvulsive
Therapy?
• The passing of electrical energy through
the brain under clinically controlled
circumstances, thus producing a controlled
seizure for therapeutic purposes.
• The oldest surviving biological treatment
in psychiatry.
• Interestingly, probably one of the most
efficacious but misunderstood treatments
in psychiatry.
History of ECT
• Use of convulsions to treat schizophrenia was proposed
in the early 1930’s by Ladislas Von Meduna (1896 –
1964) a Hungarian physician and researcher who
performed most of his work at the University of
Budapest.
• In the 1920’s several researchers had noted that
epileptic patients who developed schizophrenia had
marked decrease in frequency of seizures thus
postulating an antagonistic effect of schizophrenia on
epilepsy.
• Von Meduna was very interested in these studies but
proposed the converse hypotheesis.
History of ECT
• Historical accounts of inducing seizures by use of
camphor and therapeutic benefits in the treatment of
psychiatric disorders.
– Use of camphor was documented by early alchemists
to cure “lunacy”.
• Von Meduna ultimately achieved a 40 – 50% success
rate in treatment of patients with “Dementia Praecox”
• Insulin Coma therapy was developed around the same
time by Sackel and lobotomy was also being utilized and
studied by Walter Freeman.
History of ECT
• Other researchers hypothesized that electricity, now
becoming widely available, could be used in a more
controlled and easier way to induce seizures. Modern
use of electricity to induce seizures for therapeutic
purposes dates from 1938 when two Italian physicians
induced seizures in a 39 y/o male patient diagnosed with
Schizophrenia.
• Several aborted attempts at ECT were made and after
one subconvulsive stimulus, the team discussed whether
to administer another. The man reportedly responded
“not again its murderous!”
History of ECT
• ECT was initially administered without
anesthesia or muscular paralysis (unmodified)
• Most induction anesthetic agents were longer
acting and less predictable than today.
• Tolerability was significantly improved with the
routine use of general anesthesia and
neuromuscular blockade. Many ECTs were
performed from the 1940s until the late 1950’s
when antipsychotic and later antidepressant
drugs became available.
As ECT Develops
• In the 1950’s – the
chlorpromazine revolution.
• More availability of well
tolerated drugs initially
decreased prevalence of ECT
however, clinicians began to
differentiate response to
available therapies.
• Since the 1960’s the use of
ECT has continued to rise.
SUE CLARK's PSYCHIATRY BUSTERPAGE
This is a film-clip of
someone undergoing
electroshock therapy (ECT)
This could happen to you or
someone you know. Dr. Peter
Breggin, a New York State
psychiatrist states
contemporary ECT is more
danrous and that ECT always
causes brain damage. See his
website: (www.breggin.com)
The Republic of Slovenia is
the world's 1st Shock-Free
country. (See
www.banshock.org)
A CRIME AGAINST HUMANITY - A
recent California court decision has
banned electroshock from the Santa
Barbara Cottage Hospital (see full
story Click at the left margin "ECT
NEW
Modern ECT
• Present day ECT is a safe
effective procedure with
relatively few side effects
• Efficacy for depression is higher
than drugs and onset of action is
shorter.
• The patient is anesthesitized
with a short acting induction
agent and paralysed with
succinyl choline.
• There is usually an amnestic
period surrounding the actual
treatment but persistent memory
impairment is rare.
Modern ECT
• Pt. Is monitored throughout procedure with
EEG, EKG, EMG, Pulse oximeter, etc.
• Usual duration of seizure is 30 to 60
seconds for established efficacy.
• Patient is recovered per anesthesia
protocol.
• Most procedures are done in the hospital
in OR or recovery settings although many
are done as outpatient procedures.
The ECT Procedure
• Bilateral ECT
– Electrodes are placed bitemporally and electricity is
passed through both hemispheres of the brain
simultaneously
– Associated with greater efficacy
• Unilateral ECT
– Electrodes are placed at the vertex and near the nondominant temple (right). Electricity is passed through
the nondominant hemisphere with generalization to
both hemispheres.
– Associated with less memory disturbance.
The ECT Procedure
• Electricity is administered with several variable
parameters:
– Wave form
• Sine wave- originial studies
• Brief pulse square wave – used in all modern treatments.
– Frequency
– Stimulus duration
• Goal is to provide a threshold stimulus (to induce
seizure) without excess dose.
• Dosing is primarily dependent on patients’
individual CNS characteristics, skull thickness,
body water composition and age.
Physiology of ECT
• Known to affect multiple
neurotransmitter systems in
the brain.
• Catecholamine surge theory
• Differential recovery theory
• Distinct mechanism of action
remains unknown.
Applications of ECT
• Depression
– Severe
– With psychotic
symptoms
– With catatonia
• Primary psychotic
disorders with
catatonia
• Acute mania
Contraindications of ECT
• Almost all are relative contraindications
• Only absolute contraindication is
increased intracranial pressure.
• Usually not performed with space
occupying CNS lesions.
• Relatively contraindicated with recent MI
because of increased risk of ventricular
rupture.
Side effects of ECT
• Most important is memory loss.
– Usually only amnestic for time period around
treatment.
– Amestic period typically widens with successive
treatments and can be worse with preexisting
cognitive disorders
• Muscle soreness or tension – usually due to
incomplete neuromuscular blockade.
• Fractures or dental complications are relatively
rare but still do occur.
Potential Benefits of ECT
• Rapid response.
• Greater efficacy
(particularly in some
populations and
syndromes)
• May increase efficacy of
other treatments.
• May be used in patients
that cannot tolerate other
antidepressant
treatments.
Advantages in the Elderly?
• Patients are often more physically fragile
with higher morbidity associated with
depression.
• Increased risk of medication intolerance or
side effects.
• ? Higher rates of psychotic symptoms
associated with mood disorders in the
elderly
• ? Differential response in the elderly
The Future of ECT
• Probable continuation of focus on safety
and minimization of cognitive side effects
• Increasing focus on economics of
healthcare.
• Possible future for non-convulsive
techniques such as TMS but may be
fading.
TMS
• Magnetic impulses that
produce electrical
conductivity in the brain.
• When administered at
sub threshold nonconvulsive levels (<1 Hz)
is termed TMS.
– Equivocal findings re:
efficacy in depression
– Probably not near the
efficacy of ECT.
– Does not require
anesthesia so may be
used in patients with
general anesthesia
risks.
Summary
• Modern ECT is an effective and safe procedure
when applied to appropriate patients and has
some advantages over pharmaceutical agents.
• There are relatively few contraindications to ECT
when carefully observed and monitored.
• Alternative therapies such as TMS may prove to
be an alternative to ECT in some patients in the
future.
• ECT has remained and probably will remain an
important tool in the psychiatric armamentarium.