A research review of

Electroconvulsive Therapy and its effects on depression and other psychological disorders relevant to Acute In-patient physical therapy

Steve Chmielewski, SPT

History 3,8

ECT was first introduced as a treatment for psychiatric disorders in 1938 by a neurologist named Urgo Cerletti.

Performed ECT on dogs and other animals to induce epileptic attacks

Thought of concept while watch pigs being killed via electric shock

First used on schizophrenic patients Began injecting CSF from electrically shocked pig

brains showing positive results Later replaced with the drug Metrazol

Widespread by 40’s and 50’s with fine tuning of procedure

Decline in popularity in 60’s due to pharmacological treatments and the negative media image

Primary Indications for ECT1

Patients with moderate to severe depression

Lack of a response to or intolerance of antidepressant medications

A good response to previous ECT The need for a rapid and definitive

response (e.g., because of psychosis or a risk of suicide).

ECT can be used safely in elderly patients and in persons with cardiac pacemakers or implantable cardioverter–defibrillators.

ECT can also be used safely during pregnancy, with proper precautions.

Patient Populations 8

Specific Clinical Disorders 1,5,6,7,9

Severe mania (too much talking, insomnia)

Depression Schizophrenia (that doesn’t respond to meds)

Suicidal drive conditions Impulsive behaviors Neuroleptic Malignant Syndrome Continuous screaming Fibromyalgia (fatigue, anxiety, depression)

Vegetative dysregulation Unipolar and bipolar disorders (catatonic)

Psychosis

14 million adults in the United States each year

1 to 2% in the general population of elderly persons 1 to 3% among those living in the community 10 to 12% among those in outpatient

primary care and inpatient settings

Depression: Clinical Facts8

Symptoms of Depression 4

Pain Muscle/joint aches Inactivity Poor physical condition Disturbed body appearance Tension Anxiety Restlessness Slowness Postural issues

Restricted breathing

Depression: Pathophysiology8

Genetic, developmental, and environmental factors.

Brain changes in depression in the elderly Abnormalities in frontostriatal limbic circuits,

can reduce the response to medications Dysregulation in corticolimbic circuits

affecting Regional brain structure and function Neurotransmitter function Neuroendocrine regulation

Depression: Pathophysiology8

Depression: Pathophysiology8

Abnormalities in the hippocampus atrophy is correlated with the duration of

depression in days Abnormalities in prefrontal cortex

atrophy is associated with familial depression

Hyperintensities notably in depression in the elderly

vascular lesions in white matter disrupt key pathways, leading to a “disconnection syndrome”

Depression: Pathophysiology8

Neurotransmitter Function Presynaptic and postsynaptic

abnormalities serotonin-receptor expression deficiencies in GABA

Effects of ECT on Depression Mechanism8

Increases cortical GABA concentrations

Enhances serotonergic function Affects the hypothalamic–pituitary–

adrenal interactions

ECT Theories 8

Neurophysiological theory Electrical shock causes seizure Stimulates a long term release of

neurotransmitters Improve brain cells functioning and

increases chemical messengers Punishment Theory (Weak)

Patients see treatment as punishment for behavior

Improve to avoid further punishment

ECT: Preparation 2,8

Consent form Physical exam Heart and Lung exam

Anesthesia Blood test Electrocardiogram Anticonvulsants and antidepressant

drugs are often discontinued

ECT Procedure/Dosage1

In-patient or Out-patient procedure Anesthetic (IV) Muscle relaxer (IV)- prevent injury HR, BP, breathing are closely monitored Medicines/ restraints to secure the body during

seizure 1-2 second shock- just enough to induce seizure Seizure typically lasts 40 seconds Total duration 5-10 minutes 3-4 times per week Typically 6-12 treatments relieve depression

symptoms

ECT Electrode Placement

Bifrontaltemporal (bilateral) Right Unilateral Bifrontal

Which is more effective?2,8

Bilateral electrode placement was moderately more effective than right unilateral placement Greater cholinergic surge

Efficacy of right unilateral ECT is dose-sensitive …(studies may be affected by this to few?)

No difference long term

Right unilateral and bifrontal placement reduce the burden of side effects bilateral placement may be selected if

the right unilateral or bifrontal positions are unlikely to be effective 8

Which is more effective?2,8

ECT: Post Procedure1

Antidepressant Medications are continued to prevent relapse

Predicting ECT Efficacy 9

Short Term 60-80% success rate

50% relapse rate if antidepressants are not used correctly

Adverse Effects 8

Initial anterograde amnesia Short term disorientation or delirium (1hr) Long term retrograde amnesia Sleep disturbances Death Memory gaps mostly of interpersonal events Physical effects

Headaches muscle aches Acute BP/HR changes- immediately treated nausea Fatigue Anatomical damage

Anatomical Damage 8

Thalamic hemorrhages

ECT Uncertainties 8

How to prevent relapse after a remission

Reduction of cognitive side effects Shorter pulse of electricity? Placement of Electrodes ?

ECT: APA Guidelines 8

Administered by properly qualified psychiatrists

Recommend ECT only for difficult-to-treat depression (5-6 unsuccessful attempts)

Use of ECT for relapse prevention Not recommend ECT as maintenance therapy Detailed criteria for patient selection, medical

screening, ECT procedures, and training in ECT

Must be credentialed by their local hospital or or board certification for ECT practice in the US

ECT Contraindications 8

Ischemia arrhythmias cerebrovascular disease

cerebral hemorrhage or stroke Increased intracranial pressure

Application to Practice6

Physical therapy interventions for depression are important but will not be affective if neurological deficits limit the patient mobility

ECT is ALWAYS secondary treatment to pharmaceutical interventions

Is the individual’s consent valid if they require ECT?

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References

1). Frederikse M, Petrides G, Kellner C. Continuation and maintenance electroconvulsive therapy for the treatment of depressive illness: a response to the National Institute for Clinical Excellence report. J ECT. 2006;22:13-17.

2). Asystole during electroconvulsive therapy: a case report. Australian and New Zealand Journal of Psychiatry [serial online]. June 2001;35(3):382-385. Available from: E-Journals, Ipswich, MA. Accessed June 10, 2009.

3). http://www.informatics.susx.ac.uk/research/groups/nlp/gazdar/teach/atc/1999/web/seans

4). Nyboe Jacobsen L, Smith Lassen I, Friis P, Videbech P, Wentzer Licht R. Bodily symptoms in moderate and severe depression. Nordic Journal of Psychiatry [serial online]. August 2006;60(4):294

5). A, Oktayoglu P, Current Pharmaceutical Design [Curr Pharm Des], ISSN: 1873-4286, 2008; Vol. 14 (13), pp. 1274-94; PMID: 18537652

6). Susman, Virginia L.. Psychiatric Quarterly, Dec2001, Vol. 72 Issue 4, p325, 12p; (AN 11303889)

7). Snowdon, John; Meehan, Tom; Halpin, Rhonda. International Journal of Geriatric Psychiatry, Nov94, Vol. 9 Issue 11, p929-932, 4p; (AN 12114218)

8). Lisanby, SH, New England Journal of Medicine (USA), Feb 2007, vol. 357, pp. 1939-1945

9). Kato N, Asakura Y, Mizutani M, Kandatsu N, Fujiwara Y, Komatsu T. Anesthetic management of electroconvulsive therapy in a patient with a known history of neuroleptic malignant syndrome. Journal of Anesthesia [serial online]. November 2007;21(4):527-528. Available from: Academic Search Premier, Ipswich, MA. Accessed June 10, 2009.

10). http://www.informatics.susx.ac.uk/research/groups/nlp/gazdar/teach/atc/1999/web/seans