1. Scottish ECT Audit Network August 2000 Treatment protocols at ECT Dr Grace Fergusson

2. Scottish ECT Audit Network August 2000 Treatment protocols u past u present u future

3. Scottish ECT Audit Network August 2000 development of protocols u 1939-69: high efficacy high side-effects u 1975-85: low efficacy low side-effects u 1985-00: search for theraputic supremacy

4. Scottish ECT Audit Network August 2000 development of protocols (2) 1939 - 69: u sine wave electricity u little attention to dose u side-effects accepted or ignored

5. Scottish ECT Audit Network August 2000 development of protocols (3) 1969 - 85: u any seizure activity accepted u re-introduction of pulsed wave forms u doses of electricity low u unilateral ECT u College statement 1977

6. Scottish ECT Audit Network August 2000 development of protocols (4) 1985 - 89: u importance of dose intensity u 25 sec seizure as a guide u College guidelines 1989

7. Scottish ECT Audit Network August 2000 intensity of electrical dose u Lambourne & Gill1978 (L & G)* cf. u Royal Edinburgh DB trial1979 (RE) u Northwick Park ECT trial1980 (NWP) u Sutton Hospital DB trial1981 (SH) u Leicestershire trial1984 (L) *see notes

8. Scottish ECT Audit Network August 2000 intensity of electrical dose (2) A double blind controlled comparison of the theraputic effects of high and low dose energy electroconvulsive therapies. Robin and deTissera. BJPsych. 1982:141 1. low dose 2. high dose with pulsed energy 3. high dose with chopped sine wave results:same seizure length 2 and 3 more efficacious; 3 more side-effects than 2

9. Scottish ECT Audit Network August 2000 development of protocols (5) 1989 - 95: u concept of seizure threshold (ST) u variability in seizure threshold u change in ST with treatment u treatment to suit the individual u College guidelines 1995

10. Scottish ECT Audit Network August 2000 millenium treatment protocols u bilateral ECT as treatment of choice u dose 50-100% above seizure threshold (ST) u measure seizure length as a guide to ST u restimulate ‘missed’ seizures, higher dose u terminate prolonged seizures

11. Scottish ECT Audit Network August 2000 efficacy data for setting dose Sackeim et al. ( series of studies 1991 - 93, USA) u low dose UECT - 28% response u low dose BECT - 70% response u same seizure length u cognitive side-effects related to dose above seizure threshold rather than absolute dose conclusion: best outcome when the dose exceeds seizure (BECT) threshold by 50 - 100% for a given individual

12. Scottish ECT Audit Network August 2000 seizure threshold - first ECT u measure.pros:specific theraputic, despite seizure length decreased risk of overdose cons: time under anaesthetic risks of repeated stimulation? u estimate. pros:quick cons:variation from the mean in 1 in 20 so need clinical feedback

13. Scottish ECT Audit Network August 2000 variations in seizure threshold raised by:incr. age male sex dehydration low oxygen propofol propranolol benzodiaz. bilateral electrodes lowered by:female sex low CO 2 some drugs caffeine unilateral electrodes

14. Scottish ECT Audit Network August 2000 subsequent treatments (seizure threshold measured) u monitor length of seizure u increase dose if fit length falls by 30-50% u re-titrate after 6th ECT

15. Scottish ECT Audit Network August 2000 subsequent treatments (seizure threshold estimated) u take account of clinical picture u reduce dose if any cognitive side-effects u increase dose if fit length falls by 30-50% u increase dose if no improvement

16. Scottish ECT Audit Network August 2000 initial seizure threshold first dose 19971999 of ECT (n=36)(n=35)% measured2226 estimated 5663 fixed2211 (Scottish Audit of ECT 1997-00)

17. Scottish ECT Audit Network August 2000 stimulus dosing protocols Scotland 1994: 77% 1997:89% 1999:94% 2000:100% (E & W in 1996: 34%)

18. Scottish ECT Audit Network August 2000 outcome in a clinical setting definite improvement (MADRS/CGI) diagnosis19971999 depressive illness72%72% schizophrenic illn.66%61% manic illness65%68%

19. Scottish ECT Audit Network August 2000 questions for 2001 u is seizure threshold measurement worthwhile in a routine clinical setting? u is high dose unilateral ECT a better option? u what can we gain from EEG monitoring?

20. Scottish ECT Audit Network August 2000 choice of electrode placement type of ECToutcomeside-effects 1. low dose UECT22% 2. high dose UECT70% (high relapse) I (2.5 x ST) 3. low dose BECT70%II 4. high dose BECT80%III Sackeim et al. New Eng J of Medicine, 1993. 328:839-846

21. Scottish ECT Audit Network August 2000 EEG monitoring u detection of prolonged seizures u indication of efficacy??

22. Scottish ECT Audit Network August 2000 conclusion ECT is a safe and effective treatment provided care is taken to fit the treatment to the patient