Treatments Flashcards
Indications for ECT
Depression Mania SCZ Catatonia Parkinsons NMS Intractable seizure disorders
Relative CIs for ECT
v Acute respiratory infection v A history of recent myocardial infarction (within 3 months and depending on severity) v Uncontrolled cardiac failure v Cardiac arrhythmias v Recent cerebrovascular accident (within 1 month and depending on severity) v Raised intracranial pressure v Untreated Cerebral aneurysm v Intracerebral heamorrhage v Untreated Pheochromocytoma v Unstable major fracture v Deep vein thrombosis- until anticoagulated (to reduce risk of pulmonary embolism) v Acute/impending retinal detachment v High anesthetic risk
When is ECT first line for depressoin?
(1) emergency treatment of depression
where a rapid definitive response is needed
(2) treatment resistant depression and
who has responded to ECT in a previous episode of illness.
When to consider ECT in depression
a. Life threatening situation because of refusal of food and fluids
b. High suicide risk
c. Stupor
d. Marked psychomotor retardation
e. Depressive delusions and hallucinations (Psychotic depression)
f. Patients who are pregnant, if there is concern about the teratogenic effects of
antidepressants and antipsychotics.
It may be considered as second or third line treatment of depressive illness not
responding to antidepressant drugs
When is ECT considered in mania?
a. Life threatening physical exhaustion
b. Prolonged and severe mania with lack of response to all other appropriate drug
treatments
When is ECT considered in SCZ
Fourth line option for treatment resistant schizophrenia after
treatment with 2 antipsychotic drugs and then clozapine has proved ineffective,
Early SEs of ECT
Headache (48%) Temporary confusion (27%) Nausea/vomiting (9%), Muscular aches (5%).
Risk of death in ECT
No greater than for GA in minor surgery - 2:100,000.
Greatest in patients with CVD, usually due to VF or MI
Relapse following ECT
51.1% of responders relapse by 12 months
37.7% relapsing within the first 6
months, despite continued pharmacotherapy or continuation ECT.
In general, the use of antidepressants
halves the risk of relapse in the first 6 months
Frequency of ECT treatment
Twice weekly administration with 6-12 treatments in total for one course. If no clinical improvement at all is seen over the first six bilateral treatments, then it is highly
unlikely that more treatments will bring about either significant clinical improvement or eventual
recovery.
Memory should be assessed after each treatment.
Significant cognitive
impairment should lead to a reappraisal of the electrical dose and electrode placement.
Electrode placement in ECT
¬ The electrodes are applied to both temples in bilateral ECT and to the temple and to the parietal
surface in unilateral frontal ECT
¬ In bilateral ECT, the centre of the electrode should be 4 cms above and perpendicular to, the
midpoint of a line between the lateral angle of the eye and external auditory meatus
¬ In unilateral ECT, the centre of one electrode is in the same position as in bilateral ECT. The other
electrode is applied over the parietal surface of the scalp over the non dominant hemisphere, close
to the vertex of the skull
How long does seizure last in ECT
35-130 seconds.
Effective treatment defined as motor seizure lasting at least 20 seconds
When should maintenance ECT be considered?
v The index episode of illness responded well to ECT v There is an early relapse despite adequate continuation drug treatment v Inability to tolerate continuation drug treatment v The patient’s attitude and circumstances are conducive to safe administration.
What drugs raise seizure thresold?
benzodiazepines, barbiturates and
anticonvulsants
What drugs reduce seizure threshold?
antipsychotics, antidepressants and lithium
What drugs should be suspended 24 hours pre ECT?
Clozapine
Moclobemide
How does TMS work?
Application of magnetic pulses on the scalp surface, which creates an electrical
activity that stimulates neurons in cortical surface in line with Faraday’s principle of electromagnetic induction.
What type of TMS is used for depression?
Repetitive to left or right DLPFC for 30-40 mins a day for at least 4 consecutive weeks
Outcome of TMS
40% response rate for up to 6 months
SEs of TMS
Discomfort on the site of application,
Headaches that are transient and do not
persist beyond the treatment period (10%)
Facial muscular twitching during stimulation
(transient).
Theoretically, TMS can induce a seizure especially when applied to motor cortex.
Criteria for psychosurgery
¬ Severe mood disorder or obsessive compulsive disorder that has been resistant to all other
appropriately reasonable evidence-based treatments tried in adequate dose for adequate duration
¬ The patient is competent and provides informed consent for the surgery
What is DBS?
Deep brain stimulation involves the use of fine wire implants in certain brain regions that can be triggered
using a subdermal pacemaker device placed on the chest wall. High frequency electrical stimulation can
temporarily ‘arrest’ the activity of the brain region.
Indications for DBS
Treatment of movement
disorders like Parkinson’s disease, essential tremor, Tourette’s disorder and dystonia.
Where is DBS used for Parkinsons
Subthalamic nucleus and internal globus pallidus
Where is DBS used for OCD
Internal capsule
Relicensing for DVLA for those who have had an episode of psychosis
Do not drive during acute illness
Conditions for relicensing:
• The patient has remained well and stable for at least 3 months
• Is compliant with treatment
• Is free from adverse effects of medication which would impair driving
• Subject to a specialist favorable report
• Regained insight in case of bipolar mania or hypomania
Relicensing for group 2 drivers for DVLA following episode of psychosis
The
person must be well and stable for a minimum of three years with insight into their condition before
driving can be resumed.
Relicensing for group 2 drivers for DVLA following episode of severe anxiety of depression
Stable for 6 months
DVLA conditions for patients with Dementia
License in early stages is subject to annual review for group 1 drivers; but
group 2 drivers will get license revoked.
