1. Copyright © 2014. F.A. Davis Company Electroconvulsive Therapy Chapter 20

2. Copyright © 2014. F.A. Davis Company ECT Defined ECT is the induction of a grand mal (generalized) seizure through the application of electrical current to the brain. Stimulus is applied through electrodes placed bilaterally in the frontotemporal region or unilaterally on the same side as the dominant hand.

3. Copyright © 2014. F.A. Davis Company Dose of stimulation is based on the client’s seizure threshold, which is highly variable among individuals. The duration of the seizure should be at least 15 to 25 seconds. Usually administered every other day, for three times per week; most clients need 6 to 12 treatments. ECT Defined (cont.)

4. Copyright © 2014. F.A. Davis Company Historical Perspectives The first treatment was performed in 1938 in Rome. Other types of somatic therapies had been tried before that time: insulin coma therapy and pharmacoconvulsive therapy. With insulin coma therapy, an injection of insulin produced a hypoglycemic coma, which was believed to alleviate the symptoms of schizophrenia. A number of fatalities occurred with insulin therapy, and its use has been discontinued in the treatment of mental illness.

5. Copyright © 2014. F.A. Davis Company Pharmacoconvulsive therapy involved induction of convulsions with intramuscular injections of camphor in oil. The originator of this therapy believed this treatment also alleviated schizophrenic symptoms. He switched to the use of pentylenetetrazol when camphor was found to be unreliable. Some successes were reported in terms of reduction of psychotic symptoms, and this method was used until the advent of ECT. Historical Perspectives (cont.)

6. Copyright © 2014. F.A. Davis Company ECT was widely accepted from around 1940 to 1960. This period was followed by a 20-year span during which ECT was considered objectionable by the psychiatric profession and the lay public. A second wave of acceptance began around 1980 and has been increasing to the present. An estimated 100,000 people per year receive ECT treatments in the United States. Historical Perspectives (cont.)

7. Copyright © 2014. F.A. Davis Company Indications ECT has been shown to be effective in the treatment of severe depression. It is usually not considered the treatment of choice for depression, but may be administered after a trial of therapy with antidepressant medication.

8. Copyright © 2014. F.A. Davis Company ECT is also indicated in the treatment of acute manic episodes of bipolar disorder. It has been shown to be effective in treating manic clients who are refractory to antimanic drug therapy. ECT can induce a remission in some clients who are diagnosed with acute schizophrenia, but it seems to be of little value in the treatment of chronic schizophrenia. Indications (cont.)

9. Copyright © 2014. F.A. Davis Company Other Conditions – ECT has been used with neuroses, obsessive- compulsive disorders, and personality disorders. – Little evidence exists to support the efficacy of ECT in the treatment of these conditions. Indications (cont.)

10. Copyright © 2014. F.A. Davis Company Contraindications The only absolute contraindication for ECT is increased intracranial pressure (from brain tumor, recent CVA, or other cerebrovascular lesion).

11. Copyright © 2014. F.A. Davis Company Individuals at high risk with ECT include those with myocardial infarction or cerebrovascular accident within the preceding 3 to 6 months, aortic or cerebral aneurysm, severe underlying hypertension, and congestive heart failure. Contraindications (cont.)

12. Copyright © 2014. F.A. Davis Company Mechanism of Action The exact mechanism of action by which ECT effects a therapeutic response is unknown. Some credibility has been given to the biochemical theory that ECT results in significant increases in the circulating levels of serotonin, norepinephrine, and dopamine.

13. Copyright © 2014. F.A. Davis Company Side Effects The most common side effects are temporary memory loss and confusion.

14. Copyright © 2014. F.A. Davis Company Risks Associated with ECT Mortality Mortality from ECT is about two per 100,000 treatments. Although death is rare, when it does occur, it is usually related to cardiovascular complications.

15. Copyright © 2014. F.A. Davis Company Permanent Memory Loss – Most individuals report no problems with memory aside from the time immediately surrounding the treatments; however, some have reported retrograde amnesia extending back months. – All clients receiving ECT should be informed of the possibility for some degree of permanent memory loss, although the potential for these effects appears to be minimal. Risks Associated with ECT (cont.)

16. Copyright © 2014. F.A. Davis Company Brain Damage Critics of ECT remain adamant in their belief that the procedure always results in some amount of immediate brain damage. There are, however, no current data to substantiate that ECT produces any permanent changes in brain structure or functioning. Risks Associated with ECT (cont.)

17. Copyright © 2014. F.A. Davis Company 1.The nurse is assessing a client for side effects of electroconvulsive therapy (ECT). Which side effects are common and to be expected? A.Temporary disorientation B.Enduring memory loss C.Residual seizure disorders D.Cardiovascular complications Risks Associated with ECT (cont.)

18. Copyright © 2014. F.A. Davis Company Correct answer: A – Temporary memory loss and confusion are common side effects of ECT. Risks Associated with ECT (cont.)

19. Copyright © 2014. F.A. Davis Company Role of the Nurse The nursing process is the method of delivery of care for the client receiving ECT. The client must receive a thorough physical examination before initiation of therapy. This examination should include assessment of cardiovascular and pulmonary status as well as laboratory blood and urine studies. A skeletal history and x-ray assessment should also be considered.

20. Copyright © 2014. F.A. Davis Company The nurse must ensure that informed consent has been granted. The nurse must also assess mood, level of anxiety, thought and communication patterns, and vital signs. Appropriate nursing diagnoses are formulated based on assessment data. Role of the Nurse (cont.)

21. Copyright © 2014. F.A. Davis Company Nurses prepare the client for the treatment by having him or her void and removing dentures, eyeglasses or contact lenses, jewelry, and hairpins. Atropine sulfate or glycopyrrolate is administered according to physician’s orders approximately 30 minutes before the treatment. Role of the Nurse (cont.)

22. Copyright © 2014. F.A. Davis Company 2.A client is preparing to undergo electroconvulsive therapy (ECT). Which nursing intervention is appropriate? A.Keep the client NPO 24 hours before the procedure. B.Verify that informed consent has been granted. C.Ascertain that client has dentures securely in place. D.Place side rails down for easy access to the restroom. Role of the Nurse (cont.)

23. Copyright © 2014. F.A. Davis Company Correct answer: B – Informed consent must be obtained prior to ECT. Role of the Nurse (cont.)

24. Copyright © 2014. F.A. Davis Company In the treatment room, the anesthesiologist administers a muscle relaxant (usually succinylcholine) and a short-acting anesthetic (such as methohexital sodium). The client receives oxygen during and after the treatment. Role of the Nurse (cont.)

25. Copyright © 2014. F.A. Davis Company An airway/bite block is used to facilitate the client’s airway patency. Electrodes are placed on the temples to deliver the electrical stimulation. The nurse assists the psychiatrist and the anesthesiologist as required, and provides support to the client, both physically and emotionally. Role of the Nurse (cont.)

26. Copyright © 2014. F.A. Davis Company After the treatment, the nurse remains with the client until he or she is fully awake. Vital signs are taken every 15 minutes for the first hour. The client is oriented to time and place, and given an explanation of what has occurred. Role of the Nurse (cont.)

27. Copyright © 2014. F.A. Davis Company Evaluation of changes in client behavior is made to determine improvement and provide assistance in deciding the number of treatments that will be administered. Role of the Nurse (cont.)

28. Copyright © 2014. F.A. Davis Company 3.In the posttreatment period of electroconvulsive therapy (ECT), which is an appropriate nursing intervention? A.Monitor vital signs every 30 minutes during the first hour. B.Place client on back to facilitate comfort. C.Orient client to time and place. D.Ambulate immediately to promote adequate circulation. Role of the Nurse (cont.)

29. Copyright © 2014. F.A. Davis Company Correct answer: C – Orienting to time and place assists with overcoming the temporary confusion and disorientation that often follow the ECT treatments. Role of the Nurse (cont.)