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Electroconvulsive Therapy (ECT)

Electroconvulsive Therapy (ECT) is a medical procedure effective in patients with major depression, depression with resistance to therapy, catatonia, or episodes of drug-resistant mania. The exact mechanism of ECT is not known. However, applying weak electrical currents to the brain is believed to affect the central nervous system components and exert a therapeutic effect in these patients.

Bini and Cerletti first introduced electroconvulsive therapy (ECT) in 1938. They conducted a weak electric current through electrodes attached to the temporal lobe to induce seizures as a therapy for schizophrenia.

A. Indications and Contraindications

1. Indications

Electroconvulsive therapy (ECT) is indicated in adult patients with catatonia, major depression, schizophrenia, and bipolar affective disorder (BPAD).

Electroconvulsive therapy indications include:
  • Severe depression that threatens the patient's life (with a high risk of suicide and/or inadequate intake of nutrients and fluids)
  • Depression that is resistant to therapy (does not respond to treatment of 2 antidepressant drugs with optimal doses and duration) or conditions where treatment options are limited due to severe drug side effects
  • Acute catatonia (where intramuscular administration of benzodiazepines such as injectable diazepam and antipsychotics fails to improve)
  • BPAD Manic episodes that fail to treat pharmacotherapy or are limited by severe side effects
  • Relative indication in patients who previously responded well to ECT or only responded to ECT
  • Pregnant women with depression. However, there are several things that ECT should consider in pregnancy. Obstetricians must accompany this procedure to consider the possible risks to the mother (aspiration and preterm labor) and the fetus (spontaneous abortion and death) in high-risk patients. The use of tocolytics may be necessary for patients who have a history of recurrent abortions.

2. Contraindications

What are the contraindications of ECT? Electroconvulsive therapy (ECT) has no absolute contraindications. However, some relative contraindications should be considered before performing ECT. Systemic studies show that ECT is more effective than pharmacotherapy. Electrical stimuli are given after anesthesia. The target stimulus is seizures with a duration of 15 - 120 seconds. During a seizure, do monitoring of vital signs, ECG, and EEG.

ECT can cause central nervous system complications as well as physical complications. Seizures after ECT that exceed 120 seconds are called prolonged seizures, so performing ECT requires monitoring. ECT can have physical and neurological side effects. However, the side effects are generally short term and do not require intervention. 

Some diseases or comorbidities can increase complications caused by anesthesia. One of these comorbidities, such as heart failure, increased intracranial pressure, to deep vein thrombosis. So that in this population, close monitoring is needed to avoid complications.

Relative contraindications to ECT procedure include the following:
  • Nervous system disorders: cerebrovascular events in the last three months, increased intracranial pressure, untreated cerebral aneurysms, organic brain lesions, space-occupying lesions such as brain tumors
  • Cardiovascular: unstable angina pectoris, history of myocardial infarction (last three months), heart failure, untreated heart valve disease, vascular aneurysm
  • Respiratory: asthma, COPD
  • Eyes: retinal detachment, glaucoma
  • Thrombosis: deep vein thrombosis, pulmonary embolism
  • C-spine instability and electrolyte disturbances: Unstable fracture or injury of the cervical spine, abnormal serum potassium levels


Although cardiac disorders are a relative contraindication to ECT, ECT is still safe to perform in patients who are using pacemakers.


B. Clinical Guidelines

The clinical guidelines for ECT are:
  • ECT is safe and effective as a therapy for depression with a remission rate of 60-80%. After ECT, adequate pharmacotherapy is still needed to prevent relapse.
  • There are no absolute contraindications for ECT. However, there are some relative contraindications.
  • ECT can be performed in patients with epilepsy. However, anti-epileptic treatment can increase the seizure threshold and the energy required to induce seizures.
  • ECT can be performed in patients who have had a heart implant or brain implant as well as in pregnancy
  • Side effects from ECT are usually mild and do not require intervention. In a few weeks, cognitive complications will improve.
  • Cerebrovascular and cardiovascular complications usually only occur in patients at risk.


C. Procedure

Electroconvulsive Therapy (ECT) is given serially. Most patients need 6-12 procedures. ECT measures are only performed once a day with a break of 24 hours every 2 or 3 consecutive actions. Currently, the ECT procedure is performed under anesthesia to reduce pain.

1. Preparation

Preparation for ECT includes preparation for ECT and its anesthetic measures. Patients have to fast for at least 6 hours before the ECT procedure.

Pre Anesthesia Examination
A psychiatrist can do the initial physical exam. However, for patients at high risk, a complete pre-anesthesia examination should be performed by the anesthesia team. Do an entire medical history and physical examination. Digging the history of Cardiovascular diseases (coronary heart disease, heart failure, valvular heart disease, uncontrolled hypertension), chronic obstructive pulmonary disease, gastroesophageal reflux, and previous anesthetics.

Explore a history of head trauma or surgery, seizures, focal or general neurological complaints, and musculoskeletal trauma/pathology.

Supporting Examinations
Laboratory tests that must be done are complete blood count, urea, creatinine, and electrolytes. A 12-lead EKG is recommended, especially in patients aged 60 years and over.

Medicines
Medicines that can help improve the patient's condition to make it safer when doing ECT should still be given: for example, antihypertensive drugs, steroids, anti-GERD, antianginal, and anti-arrhythmic drugs. However, it should be given at least 3 hours before ECT with a minimal amount of water to help swallow.

During ECT, Avoid use medicines that increase the risk of harm to ECT: diuretics such as furosemide, drugs with hypoglycemic effects such as glibenclamide, long-acting benzodiazepines such as diazepam and clonazepam, lithium carbonate, anticonvulsants, supplements containing magnesium, and acetylcholinesterase inhibitors.

Facilities and infrastructure
a. Room for ECT
The room to be used for ECT should be a particular room for ECT, which is comfortable and spacious enough to accommodate all ECT personnel. The ECT room should have access to an emergency trolley, oxygen cylinder, suction device, telephone, and emergency lighting.

b. Devices and Equipment
  1. All ECT rooms must be equipped with the following equipment:
  2. Modern ECT tools with the following facilities:
  • Constant current, bi-directional output brief pulse square wave
  • The ECT tool must have an electrical power of 1000 mC. On an ECT with a voltage of 450 V, this is equivalent to 104 Joules' power.
  • Capable of delivering a variety of stimulus parameters, including pulses of short duration
  • Connect with EEG monitors with at least two channels and paper printers
  • Method for measuring circuit impedance
  • The safety mechanism on the button for ECT to prevent accidental discharge
  • Routine maintenance by trained personnel for medical equipment
  • Electrodes for disposable EEG
  • Electrodes to deliver the stimulus with a minimum diameter of 5 cm to prevent burns
  • A solution or gel that can conduct electric
  • Vital sign monitoring tools and cardiovascular function, including pulse oximetry
  • Human resources who perform ECT procedures,: anesthetist, psychiatrists and support members such as nurses and nursing assistants
  • Anesthesia and resuscitation equipment


c. Position of the Patient
When going for ECT, the patient's position is lying on his back without a pillow and dresses loosely.


2. Procedure

Before Action
Before ECT, ask patients to fast for at least 6 hours to prevent regurgitation during seizures. After the patient lies down their back without a pillow, connect a monitoring device such as a cuff sphygmomanometer, ECG and EEG lead for monitoring. All metal accessories attached to the patient must be removed, including dentures. Patients shouldn't receive drugs before ECT than those needed to reduce the risk of ECT (e.g., antihypertensives). After everything is ready, do general anesthesia.

During Actions
Put bilateral electrodes over the temporal lobe. If there is a concern of post-ictal confusion, unilateral electrodes can be used in the non-dominant hemisphere. However, bilateral electrode placement is more effective than unilateral placement.

After stimulation, tonic-clonic seizures will develop within 5-10 seconds. Ideally is seizures for 15-120 seconds. If the seizure lasts for more than 120 seconds, do the intervention to stop it. During a seizure, do maneuvers to keep the patient's airway open. Use an oropharyngeal airway or a device to prevent the patient from biting during the seizure phase. Do monitoring vital signs, ECG, and EEG during seizures.

After Action
After the procedure, transfer the patient to the recovery room. Trained personnel should monitor the airway, pulse, blood pressure, signs of tardive seizures, oxygen saturation, and level of consciousness and orientation of the patient.

Follow Up
Follow up within 1x24 hours after the procedure to see any side effects in the patient. Side effects that occur in patients go away on their own and do not require intervention. Ask patients to reduce physical activity after the ECT procedure.


D. Side Effects and Complications

The complications of electroconvulsive therapy or ECT can be divided into two, namely the effects on the nervous system and the effects on the patient's physique.

ECT can cause an increase in intracranial pressure and the blood-brain barrier permeability. Patients also occasionally report side effects of dizziness, confusion, and transient amnesia. A rare severe central nervous system complication is delirium after ECT.

A serious but relatively rare physical complication is the bone dislocation or fracture. Some patients complain of nausea, myalgia after ECT. Seizures due to ECT can also damage the oral cavity, for example, on the teeth or tongue.

Several cardiovascular complications can arise, including:

  • During or immediately after the stimulus, there are responses 10-15 post ECT, such as sinus arrest, sinus bradycardia, or hypotension. These occur due to the parasympathetic response activation due to the vagus nerve stimulation.
  • During seizures, the increased sympathetic tone and catecholamine release result in tachycardia, and hypertension.
  • Immediately after a seizure - a rapid drop in pulse and blood pressure to return to pre-ECT. Generally, within a few minutes after the seizure, blood pressure and pulse will be normal. In this phase, cardiovascular complications are the most common.


Side effects

Side effects after ECT are dizziness, confusion, transient amnesia, nausea, fatigue, and myalgia. Side effects on memory and cognition appear only in the short term and are not persistent. Other side effects that occur are generally caused by the anesthetic drug used.

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