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

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.

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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 non- dominant 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 non- convulsive 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.