al-Azhar University ECT workshop

The electroconvulsive therapy

ELECTROCONVULSIVE THERAPY (ECT)Ahmed Eid el-AghouryBoard-certified, MScMed, MBChBECT Fellowship, Emory University School of Medicine, USAClinical instructor & trainer at ATPAbbassia Hospital for Mental Health, MOHCairo, Egypt

1Abbassia Training Program, ATPEmail: [email protected] ECT Workshop

ECT: history and state-of-artMore than 70 years of continuous practice.Epilepsy & Dementia PraecoxMeduna: Camphor oil, 1934Cerletti & Bini: ECT, 1938Still a controversial practice!Anti-ECT movements On the other hand: Ia level of evidence in treatment of depression! Specialized ECT centers, certifications and medical journals.Not the only electrical therapy in medicine: Cardiac defibrillation. Convulsive therapy: now magnetic and NO gas

[email protected] University, May 20122


[email protected] University, May 20123Efficacy has not, and has never been, the problem with ECT. ECT remains, indisputably, the single most efficacious treatment for serious depression. The problem with ECT has been, and remains, the need to diminish adverse cognitive effects.Kellner CH. (2000): High-dose right unilateral ECT [editorial]. J ECT 76:209-210

There is no evidence to suggest that the mortality associated with ECT is greater than that associated with minor procedures involving general anesthetics, There is no evidence to suggest that ECT causes brain damage al-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

ECT amnestic syndromeTransient / permanent ?Objective / subjective?Electrode placement / electrical dosage :No significant evidence-base that their predictive value regarding cognitive outcome following brief-pulse ECT after the subacute period.

[email protected] University, May 20124M. Semkovska, O. Babalola, D. Keane, D.M. McLoughlin, P.1.g.008 Cognitive effects of electrode placement and stimulus dose in brief-pulse electroconvulsive therapy for depression, European Neuropsychopharmacology, Volume 20, Supplement 3, August 2010, Pages S312-S313,

Immediately post-ECT: acute effects within 24 hours of ECT seizure termination, Subacute effects: greater than 24 hours to less than two weeks after receiving a course of ECT, Medium-term effects: two weeks to less than three months after receiving a course of ECT, Longer-term effects: three months to less than six months after receiving a course ECT, Long term effects: six months or greater after ECT.al-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

FDA executive summary, 2011Disorientation: acute NOT long term, BL > ULExecutive function: no effect, may improveAnterograde memory: improvesRetrograde memory: decline in subacute phase EXCEPT with ultrabrief wavesAutobiographical memory: decline in subacute phase EXCEPT with ultrabrief waves and BF [email protected] University, May 20125FDA executive summary: Prepared for the January 27-28, 2011 meeting of the Neurological Devices Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices (ECT)

Limited evidence from controlled clinical trials suggests that the effects on memory and cognitive function may not last beyond 6 months Subjective reports of memory loss may be more persistent (> 6 months post-ECT) than findings examining objective measures (up to 6 months)al-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

Factors may increase cognitive side effects


Mankad WV, et al (eds): Clinical manual of electroconvulsive therapy. American Psychiatric Publishing, VA 22209-3901. 2010

al-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

Tools of neurostimulation

[email protected] University, May 20127Swartz CM (editor): Electroconvulsive and Neuromodulation Therapies. Cambridge University Press. 2009


ECT helps brain to work: few seconds with long effects !

[email protected] University, May 20128Swartz CM (editor): Electroconvulsive and Neuromodulation Therapies. Cambridge University Press. 2009

Little evidence exists supporting the long-term effectiveness of ECTal-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

Hypotheses of mechanisms of [email protected] University, May 20129

Abbassia Training Program, ATPCairo, April [email protected]

ECT works at multiple levels of brain [email protected] University, May 201210


ECT induces neuronal [email protected] University, May 201211


ECT and neuronal [email protected] University, May 201212


The centrencephalic theory of seizure generalizationRegional cerebral blood flow (rCBF): increases extensively, particularly in the centrencephalic structures in generalized [email protected] University, May 201213Differences in cerebral blood flow between missed and generalized seizures with electroconvulsive therapy: A positron emission tomographic study Harumasa Takano, Nobutaka Motohashi, Takeshi Uema, Kenichi Ogawa, Takashi Ohnishi, Masami Nishikawa, Hiroshi Matsuda Epilepsy research 1 November 2011 (volume 97 issue 1 Pages 225-228

ECT: a neurologic perspectiveAbbassia Training Program, ATPCairo, Jan 201213





EEGRelative alpha activity (8.5 12.0 Hz) increased in occipital lobe after a course (qEEG analysis)[email protected] University, May 201216Y. Kitaura, K. Nishida, R. Hama, Y. Takekita, M. Yoshimura, A. Tajika, T. Kinoshita, P27-6 Quantitative EEG analysis of electroconvulsive therapy response for senile depression: a case report, Clinical Neurophysiology, Volume 121, Supplement 1, October 2010, Page S264


Vagal system stimulationECT increases vagal activity which might be associated with the beneficial effect seen following [email protected] University, May 201217Br KJ, Ebert A, Boettger MK, Merz S, Kiehntopf M, Jochum T, Juckel G, Agelink MW. Is successful electroconvulsive therapy related to stimulation of the vagal system? J Affect Disord. 2010 Sep;125(1-3):323-9.


ECT and BRAIN DAMAGE: fiction of antipsychiatrists [email protected] University, May 201218


ECT - responsive syndromesThere are no diagnoses that should automatically lead to treatment with ECT. APA Task Force 2001Syndromic view offers more homogeneous pts, eg; acute psychosis Vs acute mood disorders.Primary (1st line) Vs Secondary ( last resort) use of ECT. [email protected] University, May 201219*Fink M: Electroconvulsive therapy. In: Gelder M, Andreasen N, Lopez-Ibor J, and Geddes J (Editors). New Oxford Textbook of Psychiatry. 2nd ed. 2009. Oxford University Press


Primary Use ECT (APA 2001)A need for RAPID, DEFINITIVE RESPONSE because of the severity of a psychiatric or medical condition (e.g., when illness is characterized by stupor, marked psychomotor retardation, depressive delusions or hallucinations, or life threatening physical exhaustion associated with mania)When the risks of other treatments OUTWEIGH the risks of ECTA history of POOR MEDICATION RESPONSE or GOOD ECT RESPONSE in one or more previous episodes of illness The patients [email protected] University, May 201220


ECT - responsive syndromes*DEPRESSIVE MOOD DISORDERS: Melancholia, Delusional, Post-partum, Pseudodementia, Catatonia, Suicide & Intractable.MANIC MOOD DISORDERS: excited, delirious, catatonic & mixed.PSYCHOSES: acute, abrupt episode mood, OC Schiz, atypical psychosis, post-partum, catatonic & Intractable.CATATONIA: retarded, excited, malignant, NMS, medical, CNS [email protected] University, May 201221*Fink M: Electroconvulsive therapy. In: Gelder M, Andreasen N, Lopez-Ibor J, and Geddes J (Editors). New Oxford Textbook of Psychiatry. 2nd ed. 2009. Oxford University Press


Last resort ECT, FDA 2011Treatment resistance:For depression, after one or more antidepressant trialsFor mania, after one or more mood stabilizer trials with adjunctive atypical antipsychotic treatmentFor clozapine resistant schizophreniaFor lorazepam resistant catatoniaIntolerance to or adverse effects with pharmacotherapy that are deemed less likely or less severe with ECTDeterioration of the patients psychiatric or medical condition creating a need for a rapid, definitive [email protected] University, May 201222FDA executive summary: Prepared for the January 27-28, 2011 meeting of the Neurological Devices Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices (ECT)


PseudodementiaCognitive disorders resulting from functional disordersCommon: depression, Ganser syndromeSuspect when: dementia syndrome appears suddenly in an adult, especially an elderly adult.Remarkable response to ECT

Fink M. Electroconvulsive therapy: a guide for professionals and their patients. Oxford, [email protected] University, May 201223


Unresponsive ptStupor vs ComaStupor: varying degrees of unresponsiveness due to an apparent decreased level of consciousnessStupor / notCatatonic signs / notPsychiatric / Neurologic dsBZD then [email protected] University, May 201224Hurwitz TA. Psychogenic unresponsiveness. Neurol Clin. 2011 Nov;29(4):995-1006.


Super-refractory status epilepticusSE that continues or recurs 24 h or more after the onset of anesthetic therapy, including those cases where SE recurs on the reduction or withdrawal of anaesthesia.ECT as an option was used since 1943After pharmacologic coma fails

[email protected] University, May 201225Shorvon S, Ferlisi M. The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol. Brain. 2011 Oct;134(Pt 10):2802-18.


Parkinsons Disease (PD)Psychotic symptoms in Parkinson's disease (PDP) are relatively commonIn a recent Japanese case series of 8 quetiapine-resistant PDP pts:significant in rCBF in the right middle frontal gyrus after ECTnotable improvements not only in PDP but also in the severity of [email protected] University, May 201226Usui C, Hatta K, Doi N, Kubo S, Kamigaichi R, Nakanishi A, Nakamura H, Hattori N, Arai H. Improvements in both psychosis and motor signs in Parkinson's disease, and changes in regional cerebral blood flow after electroconvulsive therapy. Prog Neuropsychopharmacol Biol Psychiatry. 2011 Aug 15;35(7):1704-8.


Dementia with Lewy bodiesPsychiatric Sx:Psychosis is an intrinsic part of DLB: 75% have hallucinations and >50% have delusionsDepression: 20 65 %Neuroleptic sensitivity phenomenonECT has antidepressant, antipsychotic, and dopamine-enhancing effects

[email protected] University, May 201227Burgut FT, Kellner CH. Electroconvulsive therapy (ECT) for dementia with Lewy bodies. Med Hypotheses. 2010 Aug;75(2):139-40.


Multiple sclerosisDepression: up to 25 %, may be delusionalMania: up to 14 %Suicide: 5 x other populationRecurrent catatonia / psychosis: rare

Pontikes TK, Dinwiddie SH. Electroconvulsive therapy in a patient with multiple sclerosis and recurrent catatonia. J ECT. 2010 Dec;26(4):[email protected] University, May 201228


Other movement disordersSuccessful case reports:NMSTDHDTS

Scott A. The ECT Handbook. 2nd Ed. The Third Report of the Royal College of Psychiatrists Special Committee on ECT. 2005


These results suggest that ECT is an effective and safe treatment for agitation and aggression in dementia. http://www.ncbi.nlm.nih.gov/pubmed/22143072.1ECT: a neurologic perspectiveAbbassia Training Program, ATPCairo, Jan 201229

ECT as a drug: 10 actions at the same timeAntipsychoticAntidepressantAntimanicMood stabilizerAntisuicidalAnticatatonicAlerting (anti-stupor): activity in EEGVegetative: eating after sessionAntiepileptic: STDopaminergic: Dyskinesiaal-Azhar University, May [email protected]

ECT UpdatesAin Shams Congress of [email protected]

ECT Non-responsive syndromes*Poor previous response to ECT courseNeuroses.Personality disorders.Drug dependence & related disorders.Maladjustment problems: dissociation / conversionLifelong intellectual & emotional dysfunction.Dementia.Impulse disorders.Sexual dysfunctions.Sleep disorders.Factitious / Somatoform [email protected] University, May 201231*Fink M: Electroconvulsive therapy. In: Gelder M, Andreasen N, Lopez-Ibor J, and Geddes J (Editors). New Oxford Textbook of Psychiatry. 2nd ed. 2009. Oxford University Press


Sine Vs Pulse squared wave

[email protected] University, May 201232Mankad WV, et al (eds): Clinical manual of electroconvulsive therapy. American Psychiatric Publishing, VA 22209-3901. 2010


Electrical waveforms of ECTWaveform: the shape of the stimulus as a function of time.Sine wave ECT: 1930s Cerletti and Bini, wall outlets, continuous, neurotoxic!Brief pulse ECT: 0.5 2 ms, late 1970sUltra-brief pulse ECT: < 0.5 ms, late 1990s



Related Electricity principlesV = I R Ohms LawV: voltage in volts, I: current intensity in milliamperes, R: resistance (impedance) in ohmsU = Q I RU: energy in joules, Q: charge in millicoulombs, I: current intensity in milliamperes, R: resistance (impedance) in ohmsQ = I PW 2F DQ: charge in millicoulombs, I: current intensity in milliamperes, PW: pulse width, F: frequency in hertz (cycles pairs per second), D: duration of stimulus train in seconds1 mC = 1 mA / 1 secConstant current devices: safeSummary metric: J / mC?Energy (J): unpredictable


Ohms law triangle


Specs of common ECT [email protected] University, May 201235

Seizure Threshold (ST)The total amount of electricity necessary to induce a seizure ie CONVULSIVE THRESHOLD.ST variance: up to 50 folds, a lot of factors, strong evidence for age, gender and electrode placement, so NOT a constant measureTherapeutic stimulus is NOT equal to the ST stimulus



Factors influencing [email protected] University, May 201237Mankad WV, et al (eds): Clinical manual of electroconvulsive therapy. American Psychiatric Publishing, VA 22209-3901. 2010


ImpedanceIMPEDANCE: static (200 3000 ) and dynamic (120 350 ). Electrodes, scalp and skull.IMPEDANCE: automatic self-test in MECTA devicesFemales > MalesRUL > BT > BFScalp SHUNTING of current: a lower proportion of current entering the brain. It is a short-circuitSo, INVERSE RELATION for constant-current devices between ST and dynamic impedance


Cause of variations in impedance



Is seizure duration enough?


Effects of increasing treatment number on the relationship between stimulus intensity and seizure duration:As shown in Figure 51, when the stimulus is barely suprathreshold, increasing stimulus intensity will be associated with a longer seizure duration.However, when the stimulus greatly exceeds seizure threshold, seizure duration can be expected to fall rather than increase. In addition, as the numberof index ECT treatments increases, seizure threshold rises and seizure duration falls, resulting in a shift to the right and downward of the curve depictingthe relationship between stimulus intensity and seizure duration. What this means is that some seizures that appear very brief may actually be associatedwith a higher relative stimulus intensity than longer seizures, particularly toward the end of an index ECT course. In practical terms, if increasing stimulusintensity is seen to lead to a decrease in seizure duration, that effect is evidence that the stimulus was well above seizure threshold.al-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

STIMULUS DOSINGWhy? Cerebral generalization: more effectiveBarely suprathreshold (just above ST): ineffectiveMarkedly suprathreshold (far beyond ST): hazardousST is increasing along index ECT course: fixed dosing is inappropriateEMPERICAL TITRATION: most precisePRE SELECTED (FORMULA-BASED) METHOD: pts do not tolerate titration, eg cardiac, severely suicidal. etcFIXED DOSING: may be a malpractice, esp if randomly assigned.



Where to start dosing?RULBT / BF1- Female2- Female2- Male3- Male



STIMULUS DOSING RULESStimulus 1: RUL, FemaleStimulus 2: BT/BF Female, RUL MaleStimulus 3: BT/BF MaleAfter 3rd failed stimulus (uncommon): jump 2 levels for 4th onePreselected stimulus: calculated doseStimulus 3: RUL, FemaleStimulus 4: All othersDial the device knob: 1 / 2 1 pt age (poor method with no evidence)


The half-age (HA) method estimates the stimulating dose according to the patient's chronological age, using half this age in percent of charge for the Thymatron device or the equivalent in milicoulombs for the MECTA device as starting point at the first session.Our data indicates that in most patients the HA method can be used as a starting point of treatment without concerns of over-stimulation. For the few patients who would not seize at their HA method level, treatment could be performed with restimulation at a higher point. Petrides, 2009 PubMed PMID: 19972637al-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

Example: Dose titration technique for Somatics Thymatron System IV [email protected] University, May 201244


The final rulesTitration session : up to 4-5 restimualtions with 20 seconds apart THERAPEUTIC STIMULUS INTENSITY is moderately suprathreshold for next sessions:1.5 2.5 ST in BT/BF, 2.5 6 ST in RULRestimulate increasing 50 100 % of the previous stimulus when needed


In CORE study: Subsequent treatments were performed at a dose level 50% higher than the ST estimated at treatment 1al-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

Electrode placement

[email protected] University, May 201246BTRUL dEliaBF Letemendia


SEIZURE ADEQUACYPattern & Duration: motor & EEGPattern: generalization both motor & EEGDuration: 20 60 sec motor, 30 120 sec EEG (CORE studies)MISSED: no activity both motor & EEGBRIEF (ABORTIVE): < 20 sec motor, < 30 sec EEGPROLONGED: > 60 sec motor, > 120 EEGPost-ictal suppression: a valid parameterAlthough: seizure adequacy parameters are still unclear, and lacking good [email protected] University, May 201247

CORE: Seizure threshold was defined as the lowest stimulation level required to elicit an adequate seizure, defined as at least 25 seconds of EEG duration and at least 20 seconds of motor duration.al-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

Seizure duration



How to manage inadequate seizure?MISSED / ABORTIVE: Check device and connectionsRestimulate: 20 sec apart, up to 5 times ( very rare), vary the duration and frequency, then pulse widthHyperventilate: 15 20 / minIV Flumazenil: if pt is on BZDDC / Taper drugs interfering: eg AEDsDecrease IV anesthetic dose / switch to less anticonvulsant one. Consider xanthines: Caffeine, theophylline, aminophylline.Space the scheduleCheck recent stimulus increase: paradoxical area of [email protected] University, May 201249


PROLONGED / TARDIVE seizuresMore than 60 sec motor / 120 sec EEG (APA Task Report 2001: 180 sec both !) Abort with IV anesthetic (thiopental) / BZD (midazolam). If no response (rare): intubate, IV loading phenytoin and refer to ICU.Good ventilationAdditional dose of muscle relaxantDecrease stimulusCheck pt drugs: eg [email protected] University, May 201250


ECT seizure vs Epileptic seizure



ECT PrescribingThree items: electrode placement, schedule and number2 / wk Vs 3 / wk: same at long term ie ( after 1 wk 6 m) [More than 6 SR studies]It is not possible to predict reliably how many treatments will be required in a course of ECT. A set course of treatments SHOULD THEREFORE NOT BE PRESCRIBED. RCPsych, 2004No sign of response: stop after BL 6 sessionsSlight or temporary response: continue to BL 12 sessions



Anesthesia for ECTIt is just a type of moderate sedation, NOT a full anesthesia. Adjusted per session.Suitable anesthetic drug: Ultra-brief not long duration, light not deep, weak antiepileptic & painless on injection. Typically: barbiturates. Thiopental is common in Egypt. Anticholinergics / Hyperventilation: are NOT routine.



Anesthesia for ECTMuscle relaxant: Short-acting to protect airway & decrease / minimize ictal motor activity. Full paralysis is not required in most cases. HYPERKALEMIA is a concern: Pts with catatonia / renal impairment / stroke / burn.Typically: succinylcholine (Suxamethonium): 9 13 min for recovery at dose 1 mg / Kg.The elimination half-life of succinylcholine is estimated to be 47 seconds -blockers: PRN, very restricted use.


The optimal dose of muscle relaxant for ECT reduces muscle contractions without inducing complete paralysis. http://www.ncbi.nlm.nih.gov/pubmed/22092267.1al-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

Muscle relaxants: 2 types



PChE deficiencyEnzyme produced by mainly the LIVER: hydrolyzes choline estersAlso known: plasma ChE, and BChEDibucaine number ( 70 90 %): NOT a routine testInherited / acquired (age / ds / drugs)Very UNCOMMON, more rare in AfricansNext session: use Nondepolarizing ms relaxant eg atracurium

[email protected] University, May 201256Williams J, Rosenquist P, Arias L, McCall WV. Pseudocholinesterase deficiency and electroconvulsive therapy. J ECT. 2007 Sep;23(3):198-200. PubMed PMID: 17805000. Miller: Miller's Anesthesia,7th ed, 2009

Factors that have been described as lowering butyrylcholinesterase activity are liver disease, advanced age, malnutrition, pregnancy, burns, oral contraceptives, monoamine oxidase inhibitors, echothiophate, cytotoxic drugs, neoplastic disease, anticholinesterase drugs, tetrahydroaminacrine, hexafluorenium, and metoclopramide. The histamine type 2 receptor antagonists have no effect on butyrylcholinesterase activity or the duration of succinylcholine's effect. Bambuterol, a prodrug of terbutaline, produces marked inhibition of butyrylcholinesterase activity and causes prolongation of succinylcholine-induced blockade. The -blocker esmolol inhibits butyrylcholinesterase but causes only minor prolongation of succinylcholine blockade.

Despite all the publications and efforts to identify situations in which normal butyrylcholinesterase enzyme activity may be low, this has not been a major concern in clinical practice because even large decreases in butyrylcholinesterase activity result in only moderate increases in the duration of action of succinylcholine. When butyrylcholinesterase activity is reduced to 20% of normal by severe liver disease, the duration of apnea after the administration of succinylcholine increases from a normal duration of 3 minutes to just 9 minutes. Even when treatment of glaucoma with echothiophate decreased butyrylcholinesterase activity from 49% of control to no activity, the increase in duration of neuromuscular blockade varied from 2 to 14 minutes. In no patient did the total duration of neuromuscular blockade exceed 23 minutes. Millers, 2009al-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

Drugs before ECTSymptomatic improvement of patients who are ON AEDs during ECT is comparable to those who are NOTAEDs + ECT (Vs ECT alone):Higher chargeMore sessions, esp titrationsDelayed recoveryPost ECT delirium

[email protected] University, May 201257Comparison of electroconvulsive therapy (ECT) with or without anti-epileptic drugs in bipolar disorder . Harve Shanmugam Virupaksha, Barki Shashidhara, Jagadisha Thirthalli, Channaveerachari Naveen Kumar, Bangalore N. Gangadhar Journal of affective disorders 1 December 2010 (volume 127 issue 1 Pages 66-70

continuing administration of the anticonvulsant sodium valproate does neither adversely affect nor enhance the efficacy of ECT inpatients with manic episodes. Jahangard et al Journal of ECT & Volume 00, Number 00, Month 2012 (PAP): Iranal-Azhar ECT WorkshopAbbassia Training Program, ATPEmail: [email protected]

Herbal drugs: must be stoppedSt Johns wort (Hypericum)Ginkgo extractsGinsengKavaASA recommends stopping 2 wks before



Drugs delay recovery / prolong post ECT deliriumAnti-ChTCALiAEDsAnti ChE: esp rivastigmine



Egyptian MHA, 2009Mandates: general anesthesia & muscle relaxation.Informed consent / agreement of 2 assessments from 2 registered specialists.National Accreditation Policy for ECT units and clinics was set in NMHC.

MHA: mental health actNMHC: national mental health commission



: ( ) : , , , , ... : : : [email protected] University, May 201261



Post-ictal suppression: the only biological marker for good response & prognosis of the session. Note cerebral seizure (72 sec) lags behind the peripheral motor seizure ( around 30 sec).



Example for a titration session: High ST in a young man: 184.5 mC! So, next session therapeutic dose was 2.5 x IST = 461 mC


Medical clearanceThere are no absolute medical contraindications for ECT. APA Task Force 2001No routine Pre-ECT workup / evaluation, but tailored on individual base.Risk / Benefit analysis: ECT psychiatrist & Anesthetist. Medical consultation on demand.Increased risk: ASA level 4 / 5.*Special patients groups: Elderly, Pregnant women, Puerperium, Children and Adolescents.Medical comorbidities esp. cardiovascular.

[email protected] University, May 2012*ASA: American Society of Anesthesiology



Abbassia Training Program, ATPElectroconvulsive therapyCairo, June 201165

Medical illness & ECTECT is often administered to patients with severe medical illnessRisk/benefit analysis:Severity of psychiatric illnessTherapeutic success with ECTMedical risksAlternative treatments or no tttMedical consultation: optimize medical status / modification to ECT [email protected] University, May 201266


Pre ECT workup is tailored: an example



CVS conditionsCan be safely managed during ECT. APA Task Force 2001Parasympathetic stim --- > Symapthetic stimHTN, IHD, VHD, CHD and arrhythmiasBefore ECT: ECG, CXR, electrolytes echo blockers: consider by case Antihypertensives: morning of [email protected] University, May 201268


CNS conditionsIncreased ICP: SOLs, may pre use steroids, diuretics, anti HTN & HVCVA: recent / not? Type?Dementia: esp DLBEpilepsy: refractoryParkinson ds: PDPTrauma: recent?Others: MS, Muscle ds,[email protected] University, May 201269


Other medical conditionsPulmonary: COPDDMHyperkalemia / HypokalemiaHyponatremia / DehydrationGERD: aspiration. Treat by: metoclopramide, Ranitidine OR consider intubationBoneTeethUrinary [email protected] University, May 201270


ECT in ElderlyThe largest age group receiving ECTWhy? Relative low risk, rapid, drug resistance, medical comorbidityPeople should not be denied access to ECT solely on the grounds of age. (RCPsych, 2005)Aging effect: improves therapeutic outcomeCase report: A 100-year-old woman with severe aortic stenosis received ECT safely for 5 years. [O'Reardon JP, Cristancho MA, Ryley B, Patel KR, Haber HL. Electroconvulsive therapy for treatment of major depression in a 100-year-old patient with severe aortic stenosis: a 5-year follow-up report. J ECT. 2011 Sep;27(3):227-30.]Increased: STIncreased: cognitive SE



ECT during pregnancyRisks of mental illness during pregnancy:Poor self-care, Poor prenatal care, Inadequate weight gain,Premature delivery, Substance abuse, Disengaged parenting behaviors,Neonaticide and [email protected] University, May 201272O'Reardon JP, Cristancho MA, von Andreae CV, Cristancho P, Weiss D. Acute and maintenance electroconvulsive therapy for treatment of severe major depression during the second and third trimesters of pregnancy with infant follow-up to 18 months: case report and review of the literature. J ECT. 2011 Mar;27(1):e23-6. Review. PubMed PMID: 20562638.


ECT in pregnancyMay be used in all 3 trimestersAPA guidelines: Depression & BADRelatively safeObstetric consultation is a mustIV Saline / RingerGood pre oxygenation NOT hyperventilationElevate Rt hip: separate uterus from IVC & aortaASPIRATION: [email protected] University, May 201273


ECT during pregnancyA total of 300 case reports of ECT duringpregnancydrawn from the literature from 1942 through 1991 were reviewedTwenty-eight (28) of the 300 cases reported complications: transient, benign fetal arrhythmias; mild VAGINAL BLEEDING; abdominal pain; and self-limited uterine contractions. Without proper preparation, there was also increased likelihood of ASPIRATION, aortocaval compression, and respiratory alkalosis.ECTis a relatively safe and effective treatment duringpregnancyif steps are taken to decrease potential risks.

[email protected] University, May 201274Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry. 1994 May;45(5):444-50. Review. PubMed PMID: 8045538.


ECT during pregnancyAmong the 339 cases reviewed:25 fetal or neonatal complications, but only 11 of these, which included two deaths, were likely related to ECT. 20 maternal complications reported and 18 were likely related to ECT.Although there are limited available data in the literature, it seems that ECT is an effective treatment for severe mental illness during pregnancy and that the risks to fetus and mother are [email protected] University, May 201275Anderson EL, Reti IM. ECT in pregnancy: a review of the literature from 1941 to 2007. Psychosom Med. 2009 Feb; 71(2):235-42. Review. PubMed PMID: 19073751.






ECT in PuerperiumDO NOT stop breastfeedingHow to decrease infantile exposure to anesthetic drugs? Delay / Bottle



Child and adolescentRARE indicationsLow ST: slow EMPERICAL titrationCatatonia: CP, ID and [email protected] University, May 201279



Ideal ECT suite(Typical at Abbassia with lesser beds capacity)After Swartz Textbook, 2009


Assessment after an index courseFrom start: target symptoms list & criteria of remission. Eg: Double depression & SchizoaffectiveContinuation treatment has become the rule in contemporary psychiatric practice. APA 1993Abruptly stopping ECT after improving is associated with high relapse rates ( 50%) C-Pharm, esp in the first 6 ms after an index ECT course.Prophylactic (Preventive) ECT: Continuation / Maintenance ECT.A controversial practice, no guidelines, few controlled studies and vague [email protected] University, May 201281*C-Pharm: Continuation pharmacotherapy


Assessment after an index courseAlthough psychotropic continuation therapy is the prevailing practice, few studies document the efficacy of such treatment after a course of ECT. APA Task Force 2001Recurrent illness / Relapse on psychotropics / Intolerance to them: a viable optionC-ECT: up to 6 ms, aiming at relapse prevention.M-ECT: more than 6 ms, aiming at recurrence prevention.



Key termsAfter Index ECT (2 4 wks)Short -Taper ECTLong - Taper ECTC-ECTM-ECTAbruptly Stopping ECT: continuation pharmacotherapy.

Ambulatory ECT (Outpatient) Vs Inpatient ECT?Procedure of prophylactic ECT: Same as Index / modified? [email protected] University, May 201283

Abbreviated C-ECT

Prophylactic ECT


C-ECTClassically: up to 6 m.Abbreviated C-ECT (Tapering): short (1 m), long (2 ms). Try tapering before C-ECT.Most studied in depression: likened to antidepressants. Pt has a disorder known to be an acutely responsive to an index ECT: drug resistance.Relapse on drugs = partial resistance.Previously / Currently intolerant to drugs: AE / Medical comorbidities / Poor compliance.Poor response to an index ECT: re evaluate after 10 12 sessions.



C-ECT2nd time relapse / ECT in 3 ms.Pt is severely ill: Taper / C ECT, you cannot stop or depend on drugs alone.C-ECT Vs C-Pharmacotherapy: controversial esp in depression.CORE 2010: After improvement of a depressive episode: C-Pharm after Index ECT (TCA Lithium), nearly equal to C-ECT. (one of the strongest RCTs)Nortriptyline: the most studied C-Pharm, enhancing ECT response & tolerable in old age. [email protected] University, May 201285


C-ECTRecommendations according to EMORY UNIVERSITY ECT Facility, USA*:Short- Taper:1/wk 1, 1/10 ds 1, 1/ 2 wks 1 Long-Taper: ( 2 Short-Taper) ie1/wk 2, 1/10 ds 2, 1/ 2 wks 2C-ECT:RUL: 1/wk 4, 1/10 ds 3, 1/ 2 wks 4 msBT/BF: 1/wk 2, 1/10 ds 2, 1/ 2 wks 4 msInter treatment intervals may be decreased if pt relapses during spacing / tapering.Drugs: Last 2 wks of tapering [email protected] University, May 201286*Hands-on training and personal communication in Nov, 2010


M-ECTMore than 6 ms, against recurrence.Controversial practice: NICE report 2003 questioned its empirical evidence ! While it is stated by the APA & RCPsych as a viable option in treatment of selected pts. Almost same indications like C-ECT, or if C-ECT cannot be tapered, convulsive dependence. Long practice in: Elderly & Medically ill pts who are intolerable to psychotropics.Best studied in: Depression & Schizophrenia.Again: no guidelines, and few RCTs.



M-ECT1 / 3-4 wk for 1 y, then re assess. RUL is preferred at 6 7 ST.Ambulatory: Outpatient.



Suggested readings & referencesTEXTBOOKS:The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A. Washington, DC: American Psychiatric Association; 2001. Task Force Report of the American Psychiatric AssociationMankad WV, et al (eds): Clinical manual of electroconvulsive therapy. American Psychiatric Publishing, VA 22209-3901. 2010Swartz CM (editor): Electroconvulsive and Neuromodulation Therapies. Cambridge University Press. 2009Abrams R: Electroconvulsive Therapy, 4th ed, 2002. Oxford University Press.McDonald WM, et al: Electroconvulsive therapy. In: Schatzberg AF & Nemeroff CB (editors): The American Psychiatric Publishing textbook of psychopharmacology. 3rd ed. 2004Fink M. Electroconvulsive therapy: a guide for professionals and their patients. Oxford, 2009Scott A. The ECT Handbook. 2nd Ed. The Third Report of the Royal College of Psychiatrists Special Committee on ECT. 2005SELECTED JOURNAL ARTICLES: Trevino K, McClintock SM, Husain MM. A review of continuation electroconvulsive therapy: application, safety, and efficacy. J ECT. 2010 Sep;26(3):186-95.Electroconvulsive therapy stimulus parameters: rethinking dosage. Peterchev AV, Rosa MA, Deng ZD, Prudic J, Lisanby SH. J ECT. 2010 Sep;26(3):159-74. Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Sackeim HA, Prudic J, Nobler MS,et al. Brain Stimul. 2008 Apr;1(2):71-83.Navarro V, Gast C, Torres X, Masana G, Penads R, Guarch J, Vzquez M, Serra M, Pujol N, Pintor L, Cataln R. Continuation/maintenance treatment with nortriptyline versus combined nortriptyline and ECT in late-life psychotic depression: a two-year randomized study. Am J Geriatr Psychiatry. 2008 Jun;16(6):498-505.Sienaert P, Vansteelandt K, Demyttenaere K, Peuskens J. Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: clinical efficacy. J Affect Disord. 2009 Jul;116(1-2):106-12.



[email protected] University, May 201290Smith GE, Rasmussen KG Jr, Cullum CM, Felmlee-Devine MD, Petrides G, Rummans TA, Husain MM, Mueller M, Bernstein HJ, Knapp RG, O'Connor MK, Fink M, Sampson S,Bailine SH , Kellner CH; CORE Investigators. A randomized controlled trial comparing the memory effects of continuation electroconvulsive therapy versus continuation pharmacotherapy: results from the Consortium for Research in ECT (CORE) study. J Clin Psychiatry. 2010 Feb;71(2):185-93.Rasmussen KG, Mueller M, Rummans TA, Husain MM, Petrides G, Knapp RG, Fink M, Sampson SM, Bailine SH, Kellner CH. Is baseline medication resistance associated with potential for relapse after successful remission of a depressive episode with ECT? Data from the Consortium for Research on Electroconvulsive Therapy (CORE). J Clin Psychiatry. 2009 Feb;70(2):232-7.Kellner CH, Knapp RG, Petrides G, Rummans TA, Husain MM, Rasmussen K, Mueller M, Bernstein HJ, O'Connor K, Smith G, Biggs M, Bailine SH, Malur C, Yim E, McClintock S, Sampson S, Fink M. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry. 2006 Dec;63(12):1337-44.Kellner CH, Tobias KG, Wiegand J. Electrode placement in electroconvulsive therapy (ECT): A review of the literature. J ECT. 2010Kellner CH, Knapp R, Husain MM, Rasmussen K, Sampson S, Cullum M, McClintock SM, Tobias KG, Martino C, Mueller M, Bailine SH, Fink M, Petrides G. Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial. Br J Psychiatry. 2010McDonald WM. Is ECT cost-effective? A critique of the National Institute of Health and Clinical Excellence's report on the economic analysis of ECT. J ECT. 2006 Mar;22(1):25-9.Kellner CH, Fink M, Knapp R, Petrides G, Husain M, Rummans T, Mueller M, Bernstein H, Rasmussen K, O'connor K, Smith G, Rush AJ, Biggs M, McClintock S, Bailine S, Malur C. Relief of expressed suicidal intent by ECT: a consortium for research in ECT study. Am J Psychiatry. 2005 May;162(5):977-82.Tharyan P, Adams CE. Electroconvulsive therapy for schizophrenia. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD000076.Van der Wurff FB, Stek ML, Hoogendijk WL, Beekman AT. Electroconvulsive therapy for the depressed elderly. Cochrane Database Syst Rev. 2003;(2):CD003593.


Anti [email protected] University, May 201291Burstow B. Electroshock as a form of violence against women. Violence Against Women. 2006 Apr;12(4):372-92. [ECT functions and is experienced as a form of assault and social control, not unlike wife battery. Emergent themes include electroshock as life destroying, a sign of contempt for women, punishment, a means of enforcing sex roles, a way to silence women about other abuse, an assault, traumatizing for those who undergo it and those forced to witness it]. CanadaRead J, Bentall R. The effectiveness of electroconvulsive therapy: a literature review. Epidemiol Psichiatr Soc. 2010 Oct-Dec;19(4):333-47.[The cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified]. New ZelandMcDonald A, Walter G. Hollywood and ECT. Int Rev Psychiatry. 2009 Jun;21(3):200-6.[Film depictions continue to exert a powerful and predominantly negative effect on public attitudes towards the treatment. From review of the 22 currently available films that directly refer to ECT the main themes identified are described. While initially portrayed as a dramatic but effective psychiatric intervention, ECT on film has come to stand for something quite different, representing the brutal and generally futile attempts of society to control and suppress the individual, gathering along the way a hackneyed cinematic grammar that emphasizes its inhumane and punitive nature.] UK



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