Electroconvulsive Therapy

Electroconvulsive therapy

Steps of application summarised.

Step-1: Preparing the patient

Obtain consent, pass intravenous line, perform a physical examination. Get the patient nil -by-mouth at midnight.

Before shifting the patient to the electroconvulsive therapy room, Check case notes including the medication chart for medications that affect seizure threshold or interact with anaesthesia, the outcome of earlier electroconvulsive treatments, especially seizure duration and complications. Check for the placement—whether unilateral or bilateral—agreed. Confirm there is a valid consent form. 

The nursing staff checks vital signs, have the patient void, remove dentures, jewelry, hairpins, eyeglasses, and change into a gown. 

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Step-2: Pre-procedure

When the patient enters the treatment room, introduce yourself, put the patient at the ease, and confirm their identity. Also, confirm the patient has been nil-by-mouth for at least 5-hours. Confirm the patient continues to consent. Check vital signs. 

ECT without anaesthesia

The world health organization recommends modified ECT in countries where anesthetists are deficient. If the procedure is performed without anesthesia, ensure emergency-trolley passive, pressure oxygen supply, and emergency drugs.

Step-3 The procedure

1. Give atropine sulfate or glycopyrrolate. 
2. Request the anaesthetist to induce anaesthesia. 
3. Put blood pressure cuff on the lower leg inflated to just above systolic pressure. 
4. Administer a muscle relaxant/paralytic agent. 
5. Start assisted ventilation. 
6. Apply electrical stimulus, unilaterally/bilaterally. 
7. Confirm seizure activity and note the duration of the seizure.

Step-4 Recovery

Shift to recovery and monitor until the patient recovers. 

As early as the 16th century, agents to induce seizures were used to treat psychiatric conditions. In 1785, we documented the therapeutic use of seizure induction in the London Medical and Surgical Journal.  As to its earliest antecedents, one doctor claims 1744 as the dawn of electricity's therapeutic use, as documented in the first issue of Electricity and Medicine. Treatment and cure of hysterical blindness were documented eleven years later. Benjamin Franklin wrote that an electrostatic machine cured "a woman of hysterical fits." In 1801, Giovanni Aldini used galvanism to treat patients suffering from various mental disorders. G.B.C. Duchenne, the mid-19th century "Father of Electrotherapy", said its use was integral to a neurological practice.

In the second half of the 19th century, such efforts were frequent enough in British asylums to make it notable.

They introduced convulsive therapy in 1934 by Hungarian neuropsychiatrist Ladislas Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then Metrazol (cardiazol). 

They think Meduna to be the father of convulsive therapy. 

In 1937, we held the first international meeting on schizophrenia and convulsive therapy in Switzerland by the Swiss psychiatrist Max Müller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide. Italian Professor of neuropsychiatry Ugo Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his assistant Lucio Bini at the Sapienza University of Rome developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1938, experimented for the first time on a person affected by delusions. It was believed early on that inducing convulsion aided those with severe schizophrenia but later found to be most useful with affective disorders such as depression. Cerletti had noted a shock to the head produced convulsions in dogs. The idea to use electroshock on humans came to Cerletti when he saw how pigs were given an electric shock before being butchered to put them in an anesthetized state. Cerletti and Bini practiced until they felt they had the right parameters needed to have a successful human trial. Once they started trials on patients, they found that after 10-20 treatments the results were significant. Patients had much improved. A useful side effect of the treatment was retrograde amnesia. It was because of this side effect that patients could not remember the treatments and had no ill feelings toward it. 

Electroconvulsive therapy soon replaced Metrazol therapy all over the world because it was cheaper, less frightening, and more convenient. They nominated Cerletti and Bini for a Nobel Prize but did not receive one. By 1940, they introduced the procedure to both England and the US. In Germany and Austria, Friedrich Meggendorfer promoted it. Through the 1940s and 1950s, the use of electroconvulsive therapy became widespread. At the time the electroconvulsive therapy device was patented and commercialized abroad, the two Italian inventors had competitive tensions that damaged their relationship. In the 1960s, despite a climate of condemnation, the original Cerletti-Bini electroconvulsive therapy apparatus prototype was hotly contended by scientific museums between Italy and the USA The electroconvulsive therapy apparatus prototype is now owned and displayed by the Sapienza Museum of the History of Medicine in Rome.

In the early 1940s, to reduce the memory disturbance and confusion associated with treatment, they introduced two modifications: the use of unilateral electrode placement and the replacement of sinusoidal current with a brief pulse. It took many years for brief-pulse equipment to be widely adopted. In the 1940s and early 1950s, they usually gave electroconvulsive therapy in the "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious complication of unmodified electroconvulsive therapy was the fracture or dislocation of the long bones. In the 1940s, psychiatrists experimented with curare, the muscle-paralyzing South American poison, to modify the convulsions.

Suxamethonium

Introducing suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to the more widespread use of "modified" electroconvulsive therapy. A short-acting anesthetic was usually given besides the muscle relaxant to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants.

Antidepressants

The steady growth of antidepressant uses along with negative depictions of electroconvulsive therapy in the mass media led to a marked decline in using electroconvulsive therapy during the 1950s to the 1970s. The Surgeon General stated there were problems with electroshock therapy in the initial years before they routinely gave anesthesia, and that "these now-antiquated practices contributed to the negative portrayal of electroconvulsive therapy in the popular media." 

For Big Nurse in One Flew Over the Cuckoo's Nest

The New York Times described the public's negative perception of electroconvulsive therapy as being caused mainly by one movie: "For Big Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and, in the public mind, shock therapy has kept the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".

Constant current, brief pulse device electroconvulsive therapy.

In 1976, Dr. Blatchley showed the effectiveness of his constant current, brief pulse device electroconvulsive therapy. This device eventually largely replaced earlier devices because of the reduction in cognitive side effects, although as of 2012 some electroconvulsive therapy clinics still were using sine-wave devices. The 1970s saw the publication of the first American Psychiatric Association (APA) task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001). The report endorsed the use of electroconvulsive therapy in the treatment of depression. The decade also saw criticism of electroconvulsive therapy. Specifically, critics pointed to shortcomings such as noted side effects, the procedure abuse, and uneven application of electroconvulsive therapy. Using electroconvulsive therapy declined until the 1980s, "when use increased amid growing awareness of its benefits and cost-effectiveness for treating severe depression". 

Safety Statement of the Royal College

In 1985, the National Institute of Mental Health and National Institutes of Health convened a consensus development conference on electroconvulsive therapy and concluded that, while electroconvulsive therapy was the most controversial treatment in psychiatry and had significant side-effects, studies have shown it to be effective for a narrow range of severe psychiatric disorders.

Because of the backlash noted previously, national institutions reviewed past practices and set new standards. In 1978, the American Psychiatric Association released its first task force report in which they introduced new standards for consent and they recommended the use of unilateral electrode placement. The 1985 NIMH Consensus Conference confirmed the therapeutic role of electroconvulsive therapy in certain circumstances. The American Psychiatric Association released its second task force report in 1990, where specific details on the delivery, education, and training of electroconvulsive therapy were documented. Finally, in 2001, the American Psychiatric Association released its latest task force report. This report emphasizes the importance of informed consent and the expanded role that the procedure has in modern medicine. 

By 2017, electroconvulsive therapy was routinely covered by insurance companies for providing the "biggest bang for the buck" for otherwise intractable cases of severe mental illness, was receiving favorable media coverage, and was being provided in regional medical centers.

Though electroconvulsive therapy use declined with modern antidepressants, there has been a resurgence of electroconvulsive therapy with new modern technologies and techniques. We give modern shock voltage for a shorter duration of 0.5 milliseconds, where the conventional brief pulse is 1.5 milliseconds.

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