ECT Flashcards
(19 cards)
Delivering education about ECT
- Approach
- time, learning resources sent out, use of PowerPoint, information delivered in an appropriate manner dependent on the knowledge base of those attending - Content
- historical aspects and stigma
- misrepresentation of modern ECT in the media
- electrophysiology
- indications and contraindications
- practicalities of delivering ECT-> dose, placement, prescription
- side effects and their management
- application of MHA, AHD, MHRT, voluntary patients
How to address stigma
- acknowledging the abuse of ECT in the past;
- providing an outline of the changes that have taken place in the delivery of ECT (e.g. introduction of anaesthesia);
- emphasising the safety record of ECT
- describing modern techniques that reduce cognitive impairment
- explaining the stringent legal regulations in place for the practice of ECT; and
- promoting ECT psychoeducation opportunities that focus on patients, families and community.
- Offering opportunity for family attendance at ECT to promote a better understanding
Strategies reducing negative impact and stigma associated with ECT
Since its inception 80 years ago, ECT has undergone successive changes.
ECT anaesthesia came to use in late 1960s.
Abandonment of sine wave, and use of brief pulse and ultrabrief pulse: Sine waves were earlier used to produce seizure, but they were later replaced by pulse waves that are associated with fewer cognitive deficits. This progress culminated in the use of ultrabrief pulse which has favourable outcomes on cognitive functions post ECT.
Other measures to reduce cognitive deficits (see below).
Legislative regulation has been put in place, particularly when used in people with reduced capacity to consent, and tight regulation measures ensure appropriate use of ECT.
Increased research into application, safety and outcomes of ECT to guide practice change.
Training and education of staff and patients / family / carers, credentialing processes for psychiatrists regularly include ECT. ECT education activities focus on patients / family brochures and DVDs; being available to answer specific questions; visits to the ECT suite; family attendance at ECT.
Media Education about ECT.
Indications for ECT
Major depressive disorder (severe, psychotic, reduced food/fluid intake, high-risk suicide or Catatonia)
Depressive symptoms refractory to pharmacotherapy
Manic syndrome and psychosis not responding to pharmacotherapy
Some use in BPSD, self-injurious associated w/ ASD, Parkinson’s disease and intractible epilepsy
Neuroleptic malignant syndrome
Side effects
1. Anaesthetic Death Allergic reactions Pseudocholinesterase deficiency 2. Cardiac Arrythmias Hypotension Bradycardia TachyC Sinus arrest MAIN CAUSE of mortality, reduced by pre-oxygenation 3. Other physical health complications Vasuclar headache NV Muscle aches Burns Fractures Tongue biting, dental damage 4. Psychiatric and neurocognitive Memory loss, both anterograde and retrograde amnesia (permanent in 12% with BT and sine, not reported for UL), more with BT and sine wave Subjective autobiographical memory loss can rarely be severe Delirium Mania
Contraindications and precautions
Cochlear implant is an important contraindication for ECT,
Severe cardiac failure (ejection fraction below 30%), recent myocardial infarction, raised intracranial tension, current deep vein thrombosis, arterial aneurysm, arterio-venous malformation, bone fracture, uncontrolled hypertension and lower respiratory infections are some of the relative contra-indications for ECT. Retinal detachment Phaeochromocytoma Osteopororsis
The treatment under these circumstances is given when it is determined that ECT is lifesaving, and no alternate treatment is effective or available.
Electrode placement
commonly used electrode placements: bifrontotemporal (or widely known as ‘bitemporal’), bifrontal and right unilateral (RUL) placements.
- For bitemporal ECT the anatomical location is 2.5 cm above the midpoint on a line drawn from the tragus of ear to the outer angle of eye on either side (Prudic and Duan 2017).
- The original placements for bifrontal ECT were two inches apart symmetrically on either side of the midline extending superiorly from the nasion (Abrams and Taylor 1973). This was later modified to 4–5 cm above the outer canthus of the eye along a vertical line perpendicular to a line connecting the pupils (either response from the candidate is acceptable).
- The anatomic locations for RUL ECT include right frontotemporal position as in bitemporal placement, and the other will be just to the right (1cm) of the vertex (nasion and onion) (d’Elia position).
Prevention of cognitive deficits
autobiographical memory loss is the most troublesome adverse effect of ECT.
significant cognitive impairment associated with bitemporal ECT, specifically retrograde amnesia which can be permanent in some patients
techniques to reduce cognitive side effects of ECT.
These include:
RUL electrode placement instead of bitemporal placement;
reducing the frequency of ECT from three to two times a week;
using ultra-brief pulse (mildly less efficacious) place of the brief pulse
use of cholinesterase inhibitor (donepezil) in improving cognitive function
Focal electrically administered seizure therapy (FEAST)-> relatively new approach to ECT designed to reduce adverse cognitive effects. It differs from ultrabrief pulse RUL ECT because it uses unidirectional rather than bidirectional current, and a novel nonsymmetric electrode placement (a large posterior electrode in front of the right motor cortex and a small anterior electrode above the centre of the right eyebrow, over the right orbitofrontal cortex)
Is RUL as efficacious to BT
To the best evidence, RUL is as efficacious as BT ECT at higher dose (six times threshold) with better cognitive outcomes compared with BT ECT (Kolshus, et al 2017).
Testing long-term autobiographical amnesia
As retrograde amnesia for autobiographical information is the most significant adverse effect of ECT, more recent research tends to suggest testing for long-term autobiographical amnesia.
Tools like the Columbia University Autobiographical Memory Interview (CUAMI) or the short form of this scale (CUAMI-SF) have been studied.
Calculating the dose
There are two methods to determine dose in ECT: dose titration and age-based dosing
Titration:
individualise the threshold dose.
determining threshold dose is critical in ensuring efficacy and safety particularly for right unilateral ECT.
For bitemporal ECT 1.5 times threshold is recommended, and for RUL six times (500% times above threshold) threshold is necessary for optimal outcome
Medications to cease prior
Benzo’s-ceased 2-3 days earlier
Anti-convulsants-> reduce or seize if used as mood stabilised. Continue or reduce if for epilepsy
Lithium- reduce or cease depending on risk/benefit. Consider low serum levels during acute course of ECT if essential to continue.
Pro-convulsants-> clozapine, has been shown to work synergistically
Regular antihypertensive, cardiac, anti-refluc should be administered to prevent adverse events
Role of continuation or maintenance treatment
may be required for many patients with severe and recurrent forms of mood disorders.
There is modest efficacy from these treatment modalities in preventing relapse and recurrence in patients who have responded to an index course of ECT.
Multiple relapses soon after remission from acute ECT even with adequate pharmacotherapy is a clear indication for continuation or maintenance ECT.
Continuation vs maintenance
Continuation: up to six months after remission of index episode) or
Maintenance: beyond six months with no predetermined endpoint
Would you consider switching from RUL and BT
future switch into bitemporal ECT if RUL ECT fails after 6-8 treatments
Determining an adequate seizure
The minimum requirements for a therapeutic seizure have not been universally agreed. However, current literature indicates that adequate seizures are determined by a compilation of:
- the clinical response
- an EEG seizure duration of 25 seconds or more
- a motor seizure with muscular activity noted
- good post-ictal suppression (87 per cent has been suggested)
- the quality, amplitude and left-right synchronisation of the EEG recording
Review of the stimulus dose
The dose should be reviewed after each treatment on the basis of the person’s clinical response. An increase in dose may be indicated either:
if the treatment response is poor
if generalised seizures of sufficient duration are not achieved
when a reduction in the length of the seizure occurs; seizure threshold rises by an average of 80 per cent during a course of treatment (range 25–200 per cent), thus seizure duration shortens.
Decreasing the dose?
A decrease in dose may be indicated either:
if the person is experiencing adverse cognitive side effects (in instances like this it may be beneficial to consider less frequent treatments, for example, twice weekly)
where prolonged seizures occur.
Providing information to patient about ECT- overview
- address uncertainty and anxiety in a patient preparing for ECT
- articulate accurate but hopeful language the likely efficacy and safety of ECT
- Understanding of the practical details of how ECT is administered
- Knowledge of cognitive dysfunction secondary to ECT
