Hello everyone.Hope you all are having a great time.
Today I am back with the second part of discussion on ECT.The initial introduction and history of development of ECT has already been discussed in my previous post.Let's discuss the remaining part about ECT.
ECT is a safe mode of treatment which is sometimes the only effective method of treatment in certain cases.
It is used as the first line of treatment in following cases.

1.Major severe depression

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According to NICE(National Institiute for Health and Clinical Excellence)guidelines 2009,ECT is indicated in cases of depression when

• It is life threatening(suicidal ideations are present)
• Rapid response is required
• Other treatments have failed
  Other sources indicate use of ECT in depression with
• Stupor
• Poor intake of food and drinks
• Psychotic features
• Drugs contraindicated

NICE guidelines clearly state that ECT is used in cases of moderate depression only if the depression has not responded despite multiple drug therapies and psychological treatment.
Also in people whose depression has not responded well to a previous course of ECT, it should be considered only after

• Reviewing the adequacy of previous treatment course
• Considering all other options
• Proper discussion about the risk benefit ratio with the patients or their advocates or caretakers.

2.Life threatening malignant catatonia

Catatonia refers to a state with marked changes in muscle tone or activity that may alternate between extremes of deficit of movements (catatonic stupor) or excessive movements(catatonic excitement).

3.Pregnancy

With severe depression or mixed affective states,mania or catatonia where health of the mother or fetus is at a serious risk.

4.Severe psychosis (schizophrenia or mania)

• With risks of suicide,homicide or danger of physical assault
• With unsatisfactory response to drug therapy
• Drugs are contraindicated or have serious intolerable side effects

5.Patients who prefer this mode of treatment

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Apart from these, ECT can also be used but not as a first line of treatment in cases of

• Organic mental disorders(Delirium,Organic delusional disorders,organic mood syndrome)
• Medical disorders(Parkinsonism,Neuroleptic malignant syndrome)
• Bipolar depression
• Post-natal psychosis

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SO HOW DOES ECT WORK?

ECT is now actually proved to be effective scientifically and various modes of actions are put forward

1.Neurotransmitter theory

• Like chemical antidepressants,ECT is known to modulate monoamine system in brain such as the serotonergic and nor-adrenergic pathways.It enhances the activity of dopaminergic systems that explain its effectiveness in depressive disorders as well as in Parkinson's disesase.
  It also causes increase in the the release of glutamate and GABA.

2.Neuroendocrine theory

• ECT causes activation of hypothalamic-pituitary axis and increased levels of ACTH,cortisol and prolactin in the blood.

3.Anticonvulsant theory

• ECT causes rise in the seizure threshold and shortens the duration of seizures over a course.

4.Neurotrophic theory

• In contrast to the previous assumptions regarding ECT that ECT causes damage to the brain,it has been found that it helps in neurogenesis,gliogenesis and dendritic & axonal arborization of existing neurons.Increase in the grey matter volume in the hippocampal, subgenual cortex and amygdala has been found after ECT.

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ADVERSE EFFECTS OF ECT

It should be clear that there is practically no any drug or form of treatment that doesn't have adverse effects .So the choice of treatment should always be based on the analysis of risk benefit ratio.As far as ECT is concerned,the major side effects are:-

• Memory disturbances
  Both retrograde and anterograde amnesia are common.These are usually mild and recovery occurs within 1-6 months but in some cases, patients claim to have lost their memories permanently.

• Headache,muscle ache,confusion after treatment

• Death
  ECT is a low risk procedure and according to APA(American Psychiatric Association )task force report 2001,mortality rate is around 1 per 80,000 treatments.Most of the deaths are due the general anaesthesia, cardiovascular and pulmonary complications.

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WHAT IS DONE TO THE PATIENT BEFORE ECT IS GIVEN?

Before adminstration of ECT to the patient, following things are always kept in mind.
1.Consent:-This is practically the most important aspect to be kept in mind.The patient should allow for the ECT after knowing all risks,benefits and alternative treatments without any coercion,fear or influence.If the patient is not in a state to give valid consent,consent should be taken from the guardian or carer.

2.Detailed medical history should be taken.

3.Cardiovascular,respiratory and neurological examination along with other physical examinations should also be done.

4.Vitals assesment and pregnancy test should be done(where relevant).

5.Medications and drug allergies should be noted.

6.Mental state examination,memory assesment and assesment of orientation should be done.

7.Laboratory inverstigations such as Hb level,TLC,DLC,ESR,ECG,Chest X-ray,estimation of plasma pseudocholinesterase level (for patients who use succinylcholine as muscle relaxant) should be done.

ARE THERE ANY CONTRAINDICATIONS FOR THE USE OF ECT?

There are no absolute contraindications for the use of ECT.However,there are some relative contraindications which are as follows.
1.Raised intra-cranial pressure
2.Recent myocardial nfarction
3.Cerebrovascular accidents
4.Severe hypertension
5.Severe pulmonary disease
6.Acute respiratory infections
7.Retinal detachment
8.Pheochromocytoma

HOW IS ECT GIVEN?

As we already know that ECT involves passing electric current through the brain.But this is done under great care taking all precautions not to provide un-necessary discomfort to the patient.Taking this into account,ECT has undergone great modifications in recent years where ECT can even be given in the OPD settings.
Modified ECT is used nowadays where muscle relaxant such as succinylcholine is given to relax the muscles to avoid fractures and physical insults that may occur due to excessive convulsions.Also general anaesthetics like propofol ,methohexitol etc. are given for producing unconsciousness.
After that ECT is adminstered by brief pulse,constant current machine that is able to produce wide range of electric dose.While providing the current,unilateral or bilateral ECT can be used.

Bilateral ECT

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This is the most commonly applied technique where the two electrodes are placed bitemporally about 4 cm above and perpendicular to the midpoint of line between lateral angle of eye and external auditory meatus.The bilateral ECT is more effective but the cognitive impairment is more.To give ECT,at first the seizure threshold is determined and in bilateral ECT electric dose at least 1.5 times of initial seizure threshold is given but in cases where the clinical improvement is inadequate after 4-6 treatments,dose upto 2.5 times seizure threshold can be given.

Unilateral ECT

Both the electrodes are placed on the same hemisphere most commonly on the temporoparietal or d'Elia position.One electrode is placed on the temporal region at the same site as in bilateral ECT and the other over parietal surface of scalp.The exact position on parietal arc is not crucial but the site should be chosen so as to maximise the distance between electrodes to reduce the shunting of electric current.Usually both the electrodes are placed over the non-dominant hemisphere which is the right hemisphere for most people.

WHAT IS SEEN DURING THE THERAPY?

Electroconvulsive-means "electric current to produce convulsions".So in case of ECT generalised tonic-clonic seizures can be seen.To monitor the seizures,following techniques can be used-

• Electroencephalogram(EEG)-Most direct available method of measuring seizure activity.EEG should show seizure activity of at least 25 seconds.

• Observed convulsions-Should be of at least 15 seconds.

• Cuff technique-Before giving muscle relaxant, circulation of one extremity is occluded by using BP cuff as torniquet by raising the pressure in the cuff above the systolic pressure so that seizure activity can be observed in that part while other muscles will be relaxed.

If the seizure persists for more than 2 minutes(according to ECT handbook) or more than 3 minutes(according to American Psychiatric Association 2001 guidelines),then it is called as prolonged seizure.It increases the cognitive side effects without clinical improvement.

WHAT SHOULD BE AVOIDED AFTER ECT in OPD setting?

• No vehicle driving for 24 hours.
• No alcholol consumption for 24 hours.
• No handling of machines or electrical appliances for 24 hours.
• At least one responsible adult should accompany the patient for at least 24 hours.

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This is all about ECT I wanted to share.

Finally,I would like to make a request from the core of my heart that Please treat the people with psychiatric illnesses with love and care.No treatment in psychiatry is effective if the person doesn't have support of the family and society.
So I hope you will never think again that ECT or shock therapy destroys the brain .Rather,it improves the brain functions.
ECT is sometimes the only method of treatment when all other methods have failed,so it is really a boon for psychiatric patients.

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References:-
1.http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/electroconvulsivetherapy,ect.aspx
2.http://www.gutsandgore.co.uk/wp-content/uploads/2013/03/ECT-Handbook.pdf
3.http://www.rcpsych.ac.uk/pdf/ECTAS%2013th%20Edition%20Standards.pdf
4.https://en.wikipedia.org/wiki/Electroconvulsive_therapy
5.http://www.psychiatrictimes.com/electroconvulsive-therapy/contemporary-ect-part-2-mechanism-action-and-future-research-directions
6.http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr176.aspx
7.https://www.nice.org.uk/guidance/ta59/chapter/2-Clinical-need-and-practice
8.A short textbook of Psychiatry,7th edition by Niraj Ahuja

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