“ELECTRO-CONVULSIVE

THERAPY (ECT)”

DEFINITION:-
Electroconvulsive therapy (ECT), also known as electroshock, is a controversial psychiatric
treatment in which seizures are electrically induced in anesthetized patients for therapeutic
effect.

HISTORICAL PERSPECTIVES

• Electroconvulsive therapy, commonly called ECT, was developed in 1938.

• ECT gained widespread use as a form of treatment in the 1940s and 50s; today, an
estimated 1 million people worldwide receive ECT every year, usually in a course of
6-12 treatments administered 2 or 3 times a week.
• During the period following its introduction, ECT was found effective for treating
multiple psychiatric illnesses, especially depression.
• With the development of psychiatric medications and stigma associated with ECT in
the 1960's, the use of ECT treatment declined.
• Today, ECT is most often used as a treatment for severe major depression which has
not responded to other treatment, and is also used in the treatment of mania (often in
bipolar disorder), catatonia, schizophrenia and other disorders.

• The use of ECT has increased since the 1970's because of following reasons:-
1. Improved treatment delivery methods
2. Increased safety and comfort measures
3. Enhanced anesthesia management.

• ECT is most commonly used to treat patients with severe depression who fail to
respond to medications or who are unable to tolerate the side effects associated with
the medications.
• ECT may also be the treatment of choice for patients who need a more rapid response
than medications can provide. This would include those who are severely agitated,
delusional, suicidal, not eating or drinking, as well as those who suffer from catatonia
(a potentially life threatening trance-like state).
• ECT can be used to halt psychotic episodes associated with schizophrenia. Once these
individuals are stabilized, medications are started or resumed.

• Electroconvulsive therapy can differ in its application in three ways;

1. Electrode placement
2. Length of time that the stimulus is given
3. The property of the stimulus.
 The variance of these three forms of application has significant differences in both
adverse side effects and positive outcomes.

INDICATIONS OF ECT

• ECT is used predominantly as a treatment for severe depression.

• It is generally reserved for use as a second-line treatment for patients who have not
responded to drugs.
• The first-line use of treatment is for situations where immediate clinical intervention is
needed or alternative treatments are not advisable. About seventy percent of ECT
patients are women.
• psychotic state
• Mania. especially in bipolar disorder
• catatonia
• Schizophrenia
• A survey of New York psychiatrists found that they thought that 85 percent of their
patients benefited from ECT.
• Its effectiveness had not been demonstrated in dysthymia, substance abuse, anxiety, or
personality disorder

MECHANISMS OF ACTION
• Electroconvulsive therapy involves applying a brief electrical pulse to the scalp while
the patient is under anesthesia. This pulse excites the brain cells causing them to fire in
unison and produces a seizure.
• One theory suggests that the seizure activity itself causes an alteration of the chemical
messengers in the brain known as neurotransmitters.
• Another theory proposes that ECT treatments adjust the stress hormone regulation in
the brain, which may affect energy, sleep, appetite, and mood.

THE NUMBER OF TREATMENTS NEEDED

• Treatments are normally administered three times a week on Monday, Wednesday,

and Friday.
• A course of ECT normally ranges from 6 to 12 treatments. The average number of
treatments is 9.
• The number of treatments that you need will be determined by the severity of your
symptoms and how rapidly you respond.

• Family members, friends, and caregivers may begin to see mild improvements
following the first 3 to 6 treatments.

• The improvements include an increase in your activity level, improved sleeping

patterns, and a mild increase in your appetite.
RIGHT UNILATERAL TREATMENT versus BILATERAL ECT TREATMENTS

There are primarily two types of electrode placements used for the delivery
of ECT. Differences between these two techniques include
 The area of the brain stimulated.
 Timing of response and potential side effects.

Right unilateral treatment: - one electrode is placed on the crown of the head and the other on
the right temple. Those receiving the right unilateral treatments may respond somewhat more
slowly than those who receive bilateral treatments. This difference is usually no greater than 1
to 2 treatments. Right unilateral treatment is typically associated with less memory side
effects. Patients who do not respond to right unilateral treatments may require a switch to
bilateral placement.
Bilateral ECT treatment involves placing the electrodes on both temples. This treatment may
be associated with more acute memory side effects than right unilateral treatments. Bilateral
ECT is indicated for severe mental illnesses including depression with psychosis, manic
episodes of bipolar disorder, psychosis related to schizophrenia and catatonia.

The patient & doctor will work together to determine which treatment option is best. Specific
recommendations will be made after carefully evaluating patient’s concerns,
medical/psychiatric history, and the severity of your symptoms.

ECT Treatment

THE TREATMENT TEAM AND THEIR ROLES

Typically, ECT is performed by a team of medical professionals specifically trained in the

delivery of ECT. This team consists of:-

1. Psychiatrist
2. Anesthesiologist

3. Nursing staff.

The psychiatrist commonly delivers the ECT stimulation. The anesthesia team administers
medications and monitors your medical status throughout the procedure. After the treatment,
nursing staff will continue to monitor progress until patient returns to the inpatient or
outpatient unit.

THE TREATMENT

Pre ECT Nursing care:

  The night before a treatment patient will not have anything to eat or drink after
midnight.
 No oil should be there in hair, so patients are asked to wash hair.

 Thorough physical examination including cardio vascular, pulmonary, laboratory

blood & urine test.

 A skeletal history and X-ray assessment.

 Ensure about legal consent.

 Assess for allergy, dentures, loose tooth or remove any metallic object jewelry,
eyeglasses or hairpins.

 Medications in the morning can be given with a sip of water for headache, high blood
pressure, stomach reflux, or other significant medical conditions.

Nursing care During ECT:

 Shortly after patient arrives in the ECT treatment area, an ECT team member inserts a
catheter into vein, often referred to as an IV.
 The IV is used to administer medications necessary for the ECT.

 Pads with monitoring wires are placed on head and upper body to monitor the brain
waves (EEG) and heart during the procedure.

 A blood pressure cuff is placed on both arms. The cuff on one arm will be used to
monitor blood pressure. The cuff on your leg is used to prevent the muscle relaxant
medication from traveling to hand, allowing monitoring motor seizure.

 Mask is placed over nose and mouth to provide oxygen.

 A muscle relaxant is administered to prevent muscles from twitching.

 Two electrodes are placed on scalp and a pulse of electricity is administered.

 Seizures vary, but are generally in the 25 to 45 second range.

 Close monitoring during and immediately after this treatment is done.

 After the patient is conscious, vital signs are stable; patient is transferred to the
recovery area.

 The ECT treatment generally lasts only 10 to 20 minutes.

  In the recovery area, the nurse will closely monitor your blood pressure and level of
consciousness for another 20 to 30 minutes.

 After that patient is shifted on the bed.

Nursing care After ECT:

 Vital signs and level of consciousness are checked again.

 Food and beverages are provided and assisted with dressing as needed.

 If ECT is done on outpatient basis, patient is send along with relatives.

 If patients are admitted in ward, he is encouraged to participate in unit activities, or

continued to rest if feeling tired.

COMMON SIDE EFFECTS AFTER TREATMENT

 Occasionally, a patient may have a headache, muscle aches, or nausea after the
treatment. These side effects can be treated with medications before or after the ECT.
 Additionally, some people may exhibit mental confusion resulting from the
combination of anesthesia and/or ECT treatment.

 Acute confusion, if it occurs, typically lasts for 30 minutes to 1 hour.

POSSIBLE MEMORY SIDE EFFECTS

Memory loss is one of the greatest concerns of people who receive ECT. Two different kinds
of memory loss may occur during the course of ECT treatments.

1. The first is the loss of short-term memory loss during the period of time that you are
having ECT treatments. Examples: - forgetting what patient had for lunch or not
remembering talking to someone earlier in the day. The ability to remember new
information will generally return to normal level within a few weeks to a few months
after the treatments are finished.
2. The second type of memory loss that may occur involves memory loss for past events.
Recent past events (2 to 6 weeks before treatment) are more sensitive to ECT.
However, some patients may describe "spotty" memory loss for events that occurred
as far back as 6 months before beginning ECT. This memory impairment is potentially
permanent.

THE SAFETY OF ECT

 The potential risks include cardiac or respiratory arrest. The risk of respiratory or
cardiac arrest resulting in death during ECT is negligible (less than 1 in 10,000 cases).
MAINTENANCE ECT

Patients may experience repeated episodes of depression even if they respond very well to
ECT. Patients often have failed numerous medications prior to ECT, and their illness may be
significantly resistant medications. When repeated episodes of depression occur, your doctors
may recommend a taper of ECT over a course of several weeks to months. Maintenance ECT
is often very effective in keeping patients well. A common taper of ECT is treatments once a
week for a month, once every 2 weeks for two months, once every 3 weeks for two months,
and once every month for two-four months. Although there is a considerable commitment by
patients and families to undergo Maintenance ECT, the avoidance of lengthy re-
hospitalizations and undergoing more medication trials is often worth any inconveniences.

WHAT TO EXPECT AFTER ECT

ECT is an extremely effective treatment, but ECT treatment is only one component of a
complete treatment regimen. Medication, psychotherapy may be recommended.

REFERENCES:-

 Merry C. Townsend, psychiatry mental health nursing, 5th edition, jaypee

publications, page no 76-88.
 [Link]
 Steuart [Link]; Laraia T Michele, principles of psychiatry nursing, 8th edition, Mosby
publication, page no 140-168

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