ECT Flashcards
How effective is ECT?
Success rates of greater than 80% - rapid relief from symptoms within 1 to 3 weeks.
Tend to stay well for longer, often require long term meds after treatment.
Small amounts report no change
1% felt worse
What are the clinical principles of ECT as a treatment?
Performed in a controlled environment usually a suite or OT - requires Anaesthetise/Psychiatrist and ECT Nursing team
Usually given 1-2 times a week
Ranges from 4-12 treatments
Patient will be reviewed weekly for improvement
What safety precautions are given to a patient before they are given ECT?
- Anaesthetic
- Muscle Relaxant - succinylchloride
- Mouth guard
- Oxygen delivery - pre-oxygenation for during seizure
What are the purpose of the electrodes in ECT?
Where are they placed?
Brain is stimulated with short electrical pulses
Causing a fit/seizure
Bilateral placement - between temples, faster and more effective results
Unilateral - between temple and topo of head, reduce risk of cognitive side effects (memory loss) but slower treatment effect.
What happens during the fit during ECT?
A series of brief electrical pulses are delivered - lasting three to eight seconds
Results in controlled fits lasting from 40 to 120 seconds -> muscle relaxant reduces the movement of the body.
Dose of electrical pulses can be adjusted for next time based on your measured response
Muscle relaxant wears off within minutes
Process takes less than 60 minutes.
What members of the team are involved in delivering ECT?
ECT Team manager
ECT coordinators
ECT Nursing team -specialist training
Lead Consultant Pyschiatrist
Lead Consultant Anaesthetise
Operating Department Practicioners/Anaesthetic nurses x2
SLA with the local acute trust
ECTAS - must be commendated by the RCP
When is ECT recommended?
If the illness is life threatening and needed urgently.
If illness causing significant distress/suffering
Has not responded to other treatments
If responded well to ECT in the past
Not all all in under 11yrs, may be considered rarely in under 18s with a second opinion
How does ECT work?
Gradually builds effects
Causes significant increase in serotonin, dopamine and Noradrenaline (BDNGF)
These NT are linked to positive effects of treatment
What mental health conditions is ECT not thought to be successful?
Anxiety Disorders
For what conditions might ECT be offered if other treatment options have not been successful?
Severe Depression
Mania (usually part of bipolar disorder)
Mixed state of bipolar (depression and mania)
Catatonia
Schizophrenia/Schizoaffective disorder
Pregnant/postpartum
Elderly
When is ECT considered a first line treatment?
1.When a rapid and definitive response if required for emergency depression with a high suicide risk.
2. Severe psychomotor retardation with low oral intake and deteriorating physical health
3. Treatment resistant depression previously responding to ECT
4.Pregnant with depression with risk of own or babies physical health
5. Patients who prefer this form of treatment
When is ECT recommended as second line treatment?
For treatment Resistant depression/severe
If experience severe side-effects with medication
When physical or psychiatric condition deteriorates to an extent that raises concern
What are some similar alternatives to ECT?
Transcranial Magentic Stimulation (rTMS) -> pulses to one region of brain to increase/decrease activity, specialist and needed more often
Transcranial direct current stimulation -> uses lower electrical currents
Vagal trigeminal nerve stimulation -> device implanted to send regular electrical impulses directly along the nerve.
When is ECT indicated in mania (bipolar)?
Rapid short term improvement in severe symptoms where other options are ineffective
Or conditions is potentially life-threatening from duration or severity.
What additional treatment alterations are required for mania bipolar presentation requiring ECT?
Reduction ins the dose of Lithium and or benzodiazepines before ECT
Allows to monitor seizure length and mental state for a manic switch.
Medication may prevent an effective seizure
What are the recommendations around ECT and the treatment of schizophrenia?
NICE does not recommend
RCPysch -> shows some response, allows exceptions in treatment-resistant states, schizoaffective, intolerant to medication.
What are the symptoms of catatona?
Must have 3 or more
Sudden or gradual onset
Sit in unusual position for hours/days
Staring into space and non-responsive
Unusual postures for lengthy period of time
Waxy flexibility
Echopraxia
Echolalia
Holding strange faces
No speaking, eating or drinking for long periods
Not doing something or resisting (negativism)
Extreme agitation or restlessness (excited catatonia)
When might ECT be used for the treatment fo catatonia?
For short term improvement in severe treament where other treatment options has been proven to be ineffective or condition is considered to be potentially life threatening
When is ECT indicated for use in pregnant women?
Antenatal and postnatal: unipolar/bipolar depression, mania, mixed affective states or catatonia
When physical health or foetal health is ar risk
Including post-natal psychosis
What are the contra-indications for ECT?
No asboluate contrainidications
Increased risk with:
Space occupying lesion
Raised ICP
Recent MI/ICH
Unstable vascular aneurysm or malformation
Pheochromocytoma
High anaesthetics risk
What are the immediate cognitive side effects of ECT?
Disorientation - transient rarely lasting beyond 60 minutes
Impaired attention
Amnesia for the immediate period of treatment and recovery -> can be antegrade/retrograde or autobiographical (risk IQ, age, overall baseline global cognitive function)
What are the immediate non-cognitive side effects of ECT?
Cardio-pulmonary
Prolonged seizures (>120seconds)
Suicide -> note often at increased risk before treatment
Mania -> is patients treatment for depression
Mortality is extremely low - same ratio as the risk of induction of brief general anaesthetic.
What are the subacute and long term side effects of ECT?
Anterograde amnesia - lasting up to a week (40%)
Verbal memory more affected than visual memory
No permanent effect in procedural memory.
Only 7% report persistant memory loss after 1yrs.
Memory gets tested between treatments and at regular intervals after treatment
Who is at a higher risk of congitive side effects long term from ECT?
Higher dose treatment
Female
Elderly
What cardio-pulmonary side effects are seen with ECT?
Autonomic nervous system activation
Paraympathetic - low HR/RR, premature ventricular contractions or sinus arrest
Sympathetic - inc HR/BP and myocardial oxygen consumption -. arrythmias, TIAs
When is prolonged seizure seen as a side effect of ECT?
Lasting more than 120 seconds
Up to 2%
Most common at first treatment - inc risk of take meds that lower the seizure threshold.
Non-convulsive state epileptics can be identified by prolonged post-ictal confusion -> EEG monitoring used
What are some general short term side effects of ECT?
Headaches 22%
Muscle aches - 10% especially in the jaw
Nausea
Tiredness - post anaesthetic
Confusion (more common in the elderly) wears off in 30-60 mins.
