Transcript ELECTROCONVULSIVE THERAPY

ELECTROCONVULSIVE
THERAPY
ELECTROCONVULSIVE
THERAPY
Jon Lehrmann MD
Assistant Professor of
Psychiatry
Medical College of WI
VAMC Milwaukee, WI
Mental Health Care Pre-1930’s
History of ECT
• Von Meduna (1934)- Autopsies of patients
w/ Seizure disorders and of patients w/
Schizophrenia.
• Difference in Glial cell proliferation
Chemically induced seizures(camphor, pentylenetetrazol)
Insulin Shock Therapy
• In the 1930’s , Dr Sakel developed Insulin
Shock Therapy
Cerletti and Bini (1934):
Electricity
Initially done without
muscle blocker or
anesthetic
Early ECT
•
•
•
•
Assylums
Few effective medications
Many often severe side effects
1950’s- ether, and curare extract developed
(Abram Bennett- a psychiatrist helped
develop a method for extracting curare).
• In 1950’s antidepressant and antipsychotic
meds introduced- significantly decreased
utilization of ECT
Electrophysiological Principles
• Ohm’s Law: I=E/R (I=current, E=voltage,
and R=resistance)
• Dose of electricity in ECT= 100-500
milliCoulombs
• Brain has low impedance (resistance), skull
has very high impedance. Only 20% of
applied charge actually enters the brain.
• Seizure involves propagation of action
potentials in a large percentage of neurons.
Mechanism of Action
• Neurotransmitter levels all increased in CSF
after seizure. Results in down regulation of
Beta adrenergic receptors.
• During seizure- PET studies show an
increase in BBB permeability and in
cerebral blood flow and metabolism.
• After seizure, blood flow and metabolism is
decreased especially in the frontal lobes.
Research shows this correlated w/ response.
Indications
• Major Depression w/ or w/o psychotic
features
• Bipolar disorder - manic or depressed phase
• Acute or Catatonic Schizophrenia
• Some studies have shown efficacy in
treating OCD, Delirium, NMS, Chronic
pain syndromes, and intractable seizure
disorders
Major Depression
• Efficacy vs antidepressants
• When is it a first line treatment
consideration?
• Length of Antidepressant effect
• Maintenance ECT
Bipolar Mania
• Efficacy vs Lithium
• Indications for First Line Treatment:
• -Recent Myocardial Infarction w/ Acute
Mania
• -Pregnancy w/ Acute mania
Pre ECT Workup
•
•
•
•
•
•
Physical Exam
Head CT
CXR
CBC, Basic Chem
EKG
? Spinal Films
Contraindications?
• No Absolute Contraindications
• Relative Contraindications: Recent MI,
Berry Aneurysm, Brain Mass, Increased
Intracranial Pressure
Treatments
• Premedicate w/ Glycopyrrolate, consider
short acting Beta blocker
• Patient not intubated
• Bite block
• Cuff leg to monitor sz
• EEG and EMG
• Length of sz- 20 sec to 1 min.
Number and Spacing of ECT
• 2-3x/wk- efficacy vs less memory
impairment
• 5-12 sessions/ treatment (although up to 20
is possible)
• Point of maximum improvement- no more
improvement after 2 further treatments.
Adverse Effects
• Mortality rate: .002% per treatment
session, .01% per patient.
• Sore Muscles
• Head ache
• Short term confusion/ delirium
• Memory
Transcranial Magnetic
Stimulation (TMS)
• Rt Frontal lobe- TMS pulses suppress
activity and causes happiness and increased
energy
• Left Frontal lobe- TMS pulses suppress
activity and leads to sadness
• 4/250 had seizure
• 10Hz stimulation 20x/day, 11/17 patients w/
Major Depression showed significant
improvement.
TMS continued
• So far positive effects have not lasted as
long as positive effects from ECT
• Handful of case reports show efficacy w/
anxiety disorders.