1. ELECTROCONVULSIVE THERAPY By:-Dr.Santosh Mishra

2. HISTORY
Von Mesuna in 1934,used 25% camphor in oil intramuscularly to produce convulsion for the first time for therapeutic purposes.
Later he used metrazol for the same purposes.
A much safer form of convulsive therapy was used by Cerletti and Bini in 1938 called it EST or electroshock therapy.
Later this method of treatment came to be known as ECT or electroconvulsive therapy.

3. INDICATION
1.Major severe depression
a.With suicidal risk(this is the first and most important indication for ECT)
b.With stupor
c.With poor intake of food and fluids.
d.With melancholia
e.With psychotic features.
f.With unsatisfactory response to drug therapy.
g.Where drugs are contraindicated or have serious side effects.
h.Where speedier recovery is needed.

4. 2. Severe catatonia a. With stupor b
2.Severe catatonia a.With stupor b.With poor intake of foods and fluids c.With unsatisfactory response to drug therapy. d.Where drugs are contraindicated or have serious side effects. e.Where speedier recovery is needed. 3.Severe psycoses(schizophrenia or mania) a.With risk of suicide,homicide or danger of physical assault. b.With unsatisfactory response to drug therapy.

5. c. Where drugs are contraindicated or have serious side effects. d
c.Where drugs are contraindicated or have serious side effects. d.With very prominent depressive features(eg;schizo-affective disorder) CONTRAINDICATIONS A.Absolute The only absolute contraindication is the presence of raised intracranial tension. B.Relative 1.Recent myocardial infarction 2.Severe hypertension 3.Cerebrovascular accident 4.Severe pulmonary disease

6. 5.Retinal detachment 6.Pheochromocytoma TECHNIQUES The techniques used for ECT administration are of two types:- a.Direct ECT:- Here ECT is given in the absence of muscular relaxation and general ansesthesia. All other step are same as modified ECT.This method of treatment is now very infrequently used.

7. b.Modified ECT:- Here ECT is modified by drug-induced muscular relaxation and general anaesthesia given by anesthetist. Pre-Treatment Evaluation The pre-treatment evaluation consists of the following steps:- 1.An informed consent. 2.Detailed medical and psychiatry history taking,which includes the current and past treatment history.

8. 3.General and systemic physical examination.
4.Routine laboatory investigation like Hb,TC,DC,ESR,urine-RME,ECG,chest X-ray, and other needful investigation.
5.Examination of fundus to rule out papilledema.

9. PROCEDURE -ECT is usually administered in the morning after an overnight fast. -If given at any other time during the day,the patient should be empty stomach for at least 4hrs. -No oral medication should be given in the morning. -The bladder and bowel should be emptied just before the treatment,as incontinence can occur during the induced seizure.

10. The usual anaesthetic precautions are taken.
The patient is placed on a hard bed which is well insulated.
A slow intravenous drip started.
Atropine(0.6mg)is given i.v. just before the treatment (given to decrease oral secretions and to prevent vagal stimulation which can cause cardiac arrest).
This is followed by administration of an anaesthetic agent like propofol or thiopentene and a muscle relaxant succinylcholine.
An oxygen mask is placed on the face and ventilation with 100% oxygen is given.

11. Then a mouth gag is inserted between the teeth,to prevent tongue bite during the convulsion.
Then the electrodes(u-shaped in most equipments)are moistened with saline or 25%bicarbonate solution and are applied on the head.
According to position of application of electrodes,ECT is of two types:-
i.Bilateral ECT:-
This is the standard form of ECT used most commonly.Each electrode is placed cm(1-1half inch)above the midpoint on a line joining the tragus of the ear and the lateral canthus of the eye.

12. ii.Unilateral ECT:- Here,the electrodes are placed only on one side of head. The therapeutic adequacy of the treatment is gauzed by the occurrence of a generalized tonic-clonic seizure lasting for not less than secs. This is made sure by:- a.Observing the seizure(in direct ECT) b.EEG recording during ECT(in modified ECT). c.Occluding the circulation of one extremity with a BP apparatus cuff,before giving succinylcholine.Thus the whole body is paralyzed but one extremity convulses and can be directly observed.

13. d.Observing plantar extension and eyelid contractions,which may be seen even despite the muscular relaxation. The usual dose for obtaining an adequate seizure response is90-150volts (average 110volts)for seconds (average0.6seconds). The usual amount of current passed in an ECT session is mA.

14. Duration of therapy The total duration and number of treatments given depends on the diagnosis,presence of side-effects and the response of treatment. Usually 6-10 treatments are sufficient,although up to 15 tretments can be given if needed. The treatment should be spaced,so that no more than 3ECTs are given per week.

15. Side-Effects 1.Side effect associated with general anesthesia: Death during ECT are due to general anesthesia, Succinylcholine and drug reactions(1:1000). 2.Memory disturbances(both anterograde and retrograde)are very common. These are mild and recovery occurs within 1-6 months after treatment. 3.Confusion may occur.

16. 4.Other side-effects include headache,prolonged apnea,prolonged seizure,cardiovascular dysfunction,emergent mania, muscle aches.