ECT Workshop - 1st day Dr Amr Kamal - Dr Shimaa Wagih 17-3-2012

1. TREATMENT COURSE

2. ADVERSE EFFECTS

3. ECT procedures carry some risk
• Risks are associated with the induction of
general anesthesia, the seizure and
convulsion, the interaction between
concomitant medications and ECT, and other
aspects of the ECT procedure
• The most common side effects involve
cognitive changes, transient cardiovascular
alterations, and general somatic complaints.

4. Contraindications
• According to the American Psychiatric
Association (2001), ECT has no absolute
contraindications. However, some conditions
pose a relatively high risk.

5. Medical conditions associated with increased risk from ECT
• Space-occupying intracerebral lesion
(tumor, hematoma, etc.)
• Other condition causing increased intracranial pressure
• Recent myocardial infarction
• Recent intracerebral hemorrhage
• Unstable vascular aneurysm or malformation
• Pheochromocytoma
• High anesthesia risk (American Society of
Anesthesiologists [ASA] class 4 or 5)
Source. American Psychiatric Association 2001.

6. Mortality Rate
• Despite what can be perceived as the invasive nature
of ECT, the overall mortality rate from ECT in a general
population of patients is extremely low, estimated at
2–10 per 100,000 patients (0.0001%) (Shiwach et al.
2001). This is roughly the same ratio as for the
induction of brief general anesthesia itself.
• Some data suggest that patients who receive ECT have
a lower mortality rate due to nonpsychiatric causes of
death than do patients with psychiatric illness who do
not receive ECT (Munk-Olsen et al. 2007).

7. Cognitive Changes
The clinician should keep in mind a couple of facts
about cognitive changes:
• First, depressive episodes themselves are often
accompanied by profound cognitive
changes, which are sometimes severe enough to
present as dementia (pseudodementia). In such
cases, a successful response to ECT may actually
be associated with at least a subjective
improvement in cognitive status.
• Second, cognitive change is not equivalent to
structural brain damage.

8. Three types of cognitive impairment may
be observed with ECT
• Postictal disorientation
• Interictal confusion
• Amnesia (anterograde and retrograde
memory disturbances).

10. Cardiovascular Complications
• Cardiovascular complications are the main cause
of mortality and serious morbidity with
ECT, although most such complications are minor
(Weiner and Coffey 1993; Zielinski et al. 1996)
• During the seizure and acute postictal
period, both the sympathetic and
parasympathetic autonomic systems are
sequentially stimulated.
• Activation of the sympathetic system increases
heart rate, blood pressure, and myocardial
oxygen consumption, placing an increased
demand on the cardiovascular system

11. Other Adverse Effects
• Headaches, generalized muscle soreness, and
jaw pain are the most common side
effects, usually lasting up to several hours, but
occasionally longer

12. Managing the ECT Seizure
• Missed Seizures
when no motor and ictal evidence of
seizure activity is seen following the
electrical stimulus

13. Causes
Insufficient stimulus intensity
Premature termination of stimulus
Poor electrode contact with the skin
Patient’s high intrinsic seizure threshold
Hypercarbia due to hypoventilation

14. Inadequate Seizures
• Seizures of “inadequate” duration

16. Seizure Augmentation
• Evidence suggests that missed or inadequate
seizures occurring at maximum stimulus intensity
decrease the likelihood that the patient will
respond to treatment.
• When these phenomena occur, efforts should be
directed at:
 Decreasing the seizure threshold
 Increasing the seizure duration
 or both
(Krystal et al. 2000).

17. Seizure Augmentation
Presently, four methods of seizure enhancement
are commonly used:
• Decreasing the anesthetic dosage (if possible and
if the agent used has anticonvulsant properties)
• Hyperventilation (inducing hypocarbia)
• Caffeine (and other adenosine receptor
antagonists)
• Ketamin anesthesia
(Weiner et al. 1991).

18. Prolonged seizure
Seizure activity lasting longer than 3 minutes
(American Psychiatric Association 2001).

19. :Causes
1) At the first treatment
2) During benzodiazepine withdrawal
3) In patients in whom proconvulsant
medications
(e.g., caffeine, theophylline) and lithium
4) In patients who have epilepsy or
preexisting paroxysmal EEG activity

21. Index ECT
• In addition to making the decisions of ECT, the
practitioner must also make a determination
of:
How frequently the seizures should be induced
(i.e., the interval between treatments)
How many treatments should be administered in
the treatment course.

22. Frequency of Treatments
 Most ECT treatments are given three
times a week whereas in other countries
they may be administered twice weekly.
 Increased frequency is associated with
a more rapid response, it may also be
associated with increased cognitive side
effects
 A three-times-weekly schedule appears
to be an acceptable

23. Number of Treatments
• A total number of treatments averaging
between six and twelve but no exact number
• The number of treatments will vary according
to the individual and severity of medical
condition.

24. Maintenance ECT
After the conclusion of a course of ECT, three
options are available for continued treatment:
1. Administration of applicable psychotropic
medications
(e.g., antidepressant, antimanic, and/or
antipsychotic agent)
2. Administration of continuation ECT
3. Psychotherapy combined with either
medication or continuation ECT.

25. • A fourth option, involving the use of both
continuation medication and ECT, may be
necessary for patients with a history of failure
of prophylaxis with either treatment alone.

26. Maintenance ECT
Multiple psychiatric disorders respond to
maintenance ECT including:
 major depressive disorder
 psychotic depression
 bipolar disorder
 and schizoaffective disorder
(Birkenhager et al. 2005).

27. • Use of maintenance ECT in the geriatric
population is also well documented
(Thienhaus et al. 1990).

28. • Particular forms of schizophrenia
(catatonia, refractory positive symptoms) may also
be responsive to the combination of ECT and
antipsychotic medication
(Shimizu et al. 2007; Suzuki et al. 2006)

30. • A typical arrangement would involve weekly
ECT for 4 weeks, then incremental increases in
the interval between ECT treatments to once a
month over the next few months
(Clarke et al. 1989).