ECT

DEFINITION Electroconvulsive therapy is the introduction of grand mal(generalized) seizure through the application of electrical current to the brain. The stimulus is applied through electrodes that are placed either bilaterally in the frontotemporal region or unilaterally on the same side as the dominant hand. (American Psychiatric Association 1990). THE HISTORY OF ECT Years ago, virtually no meaningful treatment was available for mentally disturbed patients. Then, ECT was introduced.... The story began with von Meduna, a Hungarian psychiatrist, who observed that epilepsy and schizophrenia rarely coexist, and that when they do coexist, the occurrence of seizures reduced the severity of psychosis. Meduna therefore treated schizophrenic patients by inducing seizures using drugs such as intramuscular camphor or intravenous pentylenetetrazol. Meduna's patients improved dramatically, and for the first time a meaningful treatment became available in psychiatry. Seizures induced by the injection of drugs could not be controlled in number, duration, severity, and time of occurrence. Therefore, alternate means of inducing seizures were sought. Cerletti and Bini, neuropsychiatrists in Rome, had observed that electricity was being used to stun pigs in slaughterhouses; these pigs frequently convulsed when the current was passed. Cerletti and Bini therefore thought of using electricity to similarly induce seizures in humans. After two years of experimentation in animal models, they optimized electrical details such as dose, duration, and site of electrode placement. In April 1938, they were ready for the administration of the first ECT. The treatment was conducted under a veil of secrecy because they were uncertain of the outcome and were afraid of a public outcry. Fortunately for them and for psychiatry, the treatment was uneventful, and the patient showed improvement. A series of studies quickly established the usefulness of the treatment, and the practice of ECT spread rapidly across the globe. Today, despite the availability of effective drugs for the treatment of mental

illness, ECT retains an important place in psychiatry and is widely used all over the world. INDICATIONS: The main indications of ECT include: 1.Depressive illness: ECT is effective treatment in severe depressive illness especially with somatic features(i.e. sleep disturbances, loss of appetite & weight, psychomotor retardation, etc) and psychotic symptoms(delusions, feelings of guilt, suicidal tendencies, etc) Indications for ECT in Depression: • Severe depression with suicidal risks • Depressive stupor • Depression with marked retardation • Depressive illness with nihilistic or paranoid delusions • Failure to respond to an adequate course of antidepressants. • In the elderly where ECT may be safer than drugs. 2. Schizophrenia : ECT produces greater early symptomatic relief than neuroleptics but when both are combined the effect is maximum. The main indications of ECT in Schizophrenia are • Excitement • Stupor • Intolerable or resistance to drugs • Puerperal schizophrenia • Schizophrenia episode in first trimester of pregnancy • Depression in the schizophrenic patient 3. Mania: ECT may produce greater and rapid symptom relief than the mood stabilizer drugs The main indications of ECT in Mania are: • Excitement or uncooperative behavior • Bipolar mood disorder with mixed features • Bipolar mood disorder rapid cyclers • Others-mania in the first trimester of pregnancy, puerperal mania, schizophrenia.

4. Others conditions: The other conditions include: • Obsessive compulsive disorders • Anorexia nervosa • Sleep disorders • Mental retardation • Epilepsy • Organic mental disorders Mechanism of action The aim of ECT is to induce a therapeutic clonic seizure (a seizure where the person loses consciousness and has convulsions) lasting for at least 15 seconds. Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive. The main reasons for this are the difficulty of isolating the therapeutic effect from the plethora of effects that accompany the anesthetic, electric shock and seizure; the differences between the brains of humans and those of other animals; and the lack of satisfactory animal models of mental illness. Electroconvulsive Therapy (ECT) increases serum brain-derived neurotrophic factor (BDNF) in drug resistant depressed patients.

Side effects of ECT These can be: A) Early: •

Headache, bodyaches & vomiting due to temporary increase in intracranial pressure.

• Confusion: It is usually slight & temporary. Prolonged confusion can be due to underlying organic illness or when duration of current or voltage was more. It can be controlled by oxygenation or giving injection of benzodiazepines or neuroleptics. •

Amnesia: Memory impairment that occurs with ECT is highly variable. Some patients report no problems with their memory. But in some patients, the information acquired during days & weeks prior to, during, & for several weeks following ECT may be impaired. The memory loss is believed to be due to neuronal hypoxia during seizure. It can be minimized by:

 Using unilateral ECT  Oxygenation before & after seizure  Recall of major routine before ECT  Giving individualized minimal voltage & current  Giving minimal number of ECT with proper spacing. • Others : Rare complications like fractures (of thoracic spine & long bones e.g humerous, humerous are commonest), dislocations(temporomandibular joint, shoulder, wrist joint).

B) Late Side Effects: • •

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Brain damage: However, not all experts agree that ECT does not cause brain damage, and two studies have been published since 2007 finding that at least some forms of ECT may result in widespread, persisting, generalized cognitive dysfunction, which would seem to support claims that ECT causes brain damage. Mortality: studies indicate that the mortality rate from ECT is about 2 per 100,000 treatments (Marangell, Silver, &Yodofsky, 1999: kaplon &Sadock.1998). although the occurrence is rare, the major cause of death with ECT is cardiovascular complication, such as MI,acute coronary insufficiency, ventricular fibrillation, myocardial rupture ,cardiac arrest, stroke etc. assessment and management of cardiovascular disease prior to treatment is vital in the reduction of morbidity and mortality rates associated with ECT Permanent memory loss: Marangell, Silver, & Yodofsky, (1999) state’s initial confusion and cognitive deficits associated with ECT treatment are usually temporary, lasting approximately 30minuites. Whereas many patients report no problems with their memory, aside from the time immediately surrounding the ECT treatments, others report that their memory is not as good as it was before receiving ECT. To date, no reliable data have shown permanent memory loss caused by modern ECT,

CONTRAINDICATIONS: Absolute : The absolute contraindication to ECT is raised Intracranial pressure.

Relative: • • • •

Myocardial infarction in previous 2 years. History of cerebral infarction Pulmonary disease(tuberculosis, pneumonia, bronchial asthma, etc) Others- fractures, fever, dehydration, glaucoma.

TYPES OF ECT: • •

Use of other agents: Unmodified/ direct ECT (when anesthetic agents are not used) or indirect/modified ECT (when patient is made unconscious with the help of anesthesia before passing the current) Mode of its administration: Bilateral (if electrodes are placed on both side of skull & current is passes) and unilateral (current is passed to nondominant hemispheres)

PLACEMENT OF ELECTRODES & CURRENT: Bilateral electrodes are placed 1cm above the midpoint of internal angle of eye & external auditory meatus. Unilateral electrodes are placed During ECT, a special device is used to pass a small current (usually 0.5-0.8 A) through electrodes applied to the head. The current lasts for a duration that is seldom more than four seconds. The total electrical charge that the patient receives is 0.1-0.3 C, on average (one coulomb [C] is the charge delivered when one ampere [A] of current is passed for one second). Much of the electrical charge during ECT does not actually reach the brain but instead traverses scalp tissues. It is clear, therefore, that a very tiny electrical stimulus is applied. This should reassure those who believe that large bolts of electricity strike the brain during ECT! GETING THE FACTS STRAIGHT:  ECT is not given as a punishment to violent or uncooperative patients.  ECT is not given to a conscious patient.  ECT does not cause pain.

ECT does not cause brain damage. ECT does not deprive patients of their thinking and reasoning faculties. ECT does not make patients zombies. ECT is not necessarily given as a last resort. Patients who have received ECT usually consider the treatment less frightening than a visit to the dentist.  Patients who have received ECT almost always agree that they would willingly receive the treatment again, if necessary.     

ROLE OF THE NURSE IN ELECTROCONVULSIVE THERAPY: Nurses routinely assist with ECT, providing support because, during, & after the treatment to the client, family, & medical professionals who are conducting the therapy. ASSESSMENT: A complete physical examination must be completed by the appropriate medical professional prior to the initiation of ECT. This evaluation should include a thorough assessment of cardiovascular & pulmonary status as well as laboratory blood & urine studies. A skeletal history & X-ray assessment should also be considered. The nurse may be responsible for ensuring that informed consent has been obtained from the client. If the depression is severe & the client is clearly unable to consent to the procedure, permission may be obtained from family or other legally responsible person. Consent is only secure only after the client or responsible individual acknowledges understanding of the procedure. The nurse may also be required to assess the : •

Evidence of suicidal ideation.

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Level of anxiety & fears associated with receiving with receiving ECT.

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Current and past use of medications

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Client & family knowledge of indications for , side effects of, & potential risks involved with ECT.

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Baseline vital signs & history of allergies.

NURSING DIAGNOSIS: Selection of appropriate nursing diagnosis for client undergoing ECT is based on continual assessment before, during, & after treatment. •

Anxiety related to impeding therapy.

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Deficit knowledge related to necessity for & side effects or risks of ECT.

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Risk for injury related to altered level of consciousness immediately following treatment.

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Disturbed thought process related to side effects of temporary memory loss & confusion.

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Risk of activity intolerance related to post-ECT confusion & memory loss.

PLANNING/IMPLEMENTATION: ECT treatments are usually performed in the morning. The client is given nothing by mouth(NPO) for 4-8 hours before the treatments. Nursing interventions before the treatment include the following: •

Ensure that the physician has obtained informed consent & that a signed permission form is on the chart.

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Ensure that the most recent laboratory reports (complete blood count, urinalysis) & results of electrocardiogram (ECG) & Xray examination are available.

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Approximately 1 hour before treatment, vital signs are recorded. Have the client void & remove dentures, eyeglasses or contact lenses, jewellary & hairpins.

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Appropriately 30min before the treatment administer the pretest medication as prescribed by the physician. The usual order is for atropine sulfate given intramuscularly.

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Stay with the patient to help allay fears & anxiety, encourage client to verbalize the feelings.

In the treatment room the client is placed on the treatment table in a supine position. The anesthesiologist administers IV a short acting anesthesia, such as thiopental sodium(3-5mg/kg body weight). A muscle relaxant usually succinylchloride (1mg/kg body weight) is given IV to prevent severe muscle contractions during the seizure, thereby reducing the possibility of fractures & dislocations. Because succinylchloride paralyzes respiratory muscles as well, the client is oxygenated with pure oxygen during & after the treatment, except during electrical stimulation. A blood pressure cuff may be placed on the arm & inflated above systolic blood pressure before the muscle relaxant is given. This will ensure that seizure activity can be observed in that limb that is unaffected by the muscle relaxant.

An airway is placed in the clients mouth & he/she is positioned to facilitate airway patency. Electrodes are placed either unilaterally or bilaterally on the temples to deliver the electrical stimulation. Nursing interventions during the treatment include: •

Ensure patency of airway. Provide suctioning if needed.

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Assist anesthesiologist with oxygenation as required.

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Observe readouts to the clients arms & legs during the seizure.

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Observe & record the type & amount of movements induced by seizures.

How to know if the seizures has occurred  EEG monitoring: Isolate one arm by inflating a blood pressure cuff to above systolic blood pressure before the muscle relaxant is given. It will not become paralysed by the relaxant & will show twitching.  Others: The other signs such as bilateral plantar extensor, reaction of pupil(if constriction & then show dilatation). After the treatment anesthesiologist continues to oxygenate the client with pure oxygen until spontaneous respirations return. Most client awaken within 10-15 min & confused and some clients sleep for 1-2 hours following the treatment.

Nursing interventions in the post treatment period include the following: • • • • • •

Monitor vital signs every 15min for the first hour, during which time the client should remain in bed. Position the client on side to prevent aspiration. Orient the client to time & place. Provide reassurance that any memory loss the client may be experiencing is only temporary Allow the client to verbalize fears & anxieties related to receiving ECT. Stay with the client until he/she is fully awake, oriented & ble to perform self care activities without assistance.

EVALUATION: Evaluation of the effectiveness of nursing interventions is based on the achievements of projected outcomes. Reassessment is based on answers to the following: 1. Was the clients anxiety maintained at manageable level? 2. Was the client/family teaching completed satisfactorily?

3. Did the client/family verbalize understanding of the procedure? 4. Has the client maintained adequate tissue perfusion during & following the treatment? Have vital signs remained stable? 5. Is the client reoriented to time, place, situation & person? 6. Have all of the client’s self care needs been fulfilled? 7. What is the client’s level of social interaction?

BIBLIOGRAPHY

Townsend Mary C,Psychiatric Mental Health Nursing,4th edition,F.A. Davis company,Pp-602609 • Stuart and Laraia, Principles and practice of Psychiatric Nursing, 7th edition, Mosby publishers,Pp 316-320 • En.wikipedia.org th • Bhatia M.S, Essentials of Psychiatry, CBS publisher, 4 edition, 2004, Pp-30.2-30.12 • www.ect.org • www.indianpsychiatry.com/ECT.htm • Ectindia.in •

SUBMITTED TO: Prof. Amarjit Kaur Singhera

SUBMITTED BY:

Vice Principal

Manu

Dr. SLT CON, Moga

M.Sc (Psychiatry Nursing )1st year