al-Azhar University ECT workshop

ELECTROCONVULSIVE THERAPY
(ECT)
Ahmed Eid el-Aghoury
Board-certified, MScMed, MBChB
ECT Fellowship, Emory University School of Medicine, USA
Clinical instructor & trainer at ATP
Abbassia Hospital for Mental Health, MOH
Cairo, Egypt

ECT: history and state-of-art
 More than 70 years of continuous practice.
 Epilepsy & Dementia Praecox
 Meduna: Camphor oil, 1934
 Cerletti & Bini: ECT, 1938
 Still a controversial practice!
 Anti-ECT movements
 On the other hand: Ia level of evidence in
treatment of depression! Specialized ECT
centers, certifications and medical journals.
 Not the only electrical therapy in medicine:
Cardiac defibrillation.
 Convulsive therapy: now magnetic and NO
gas
ajhuri@gmail.com al-Azhar University, May 2012 2

“Efficacy has not, and has never been, the
problem with ECT. ECT remains, indisputably, the
single most efficacious treatment for serious
depression. The problem with ECT has been, and
remains, the need to diminish adverse cognitive
effects.”
Kellner CH. (2000): High-dose right unilateral ECT [editorial]. J ECT 76:209-210


ECT amnestic syndrome
 Transient / permanent ?
 Objective / subjective?
 Electrode placement / electrical
dosage :No significant evidence-base
that their predictive value regarding
cognitive outcome following brief-
pulse ECT after the subacute period.
M. Semkovska, O. Babalola, D. Keane, D.M. McLoughlin, P.1.g.008 Cognitive effects of
electrode placement and stimulus dose in brief-pulse electroconvulsive therapy for
depression, European Neuropsychopharmacology, Volume 20, Supplement 3, August 2010,
Pages S312-S313,


FDA executive summary,
2011
 Disorientation: acute NOT long term,
BL > UL
 Executive function: no effect, may
improve
 Anterograde memory: improves
 Retrograde memory: decline in
subacute phase EXCEPT with
ultrabrief waves
 Autobiographical memory: decline in
FDA executive summary: Prepared for the January 27-28, 2011 meeting of the Neurological
Devices subacute phase EXCEPT with
Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices
(ECT) ajhuri@gmail.com al-Azhar University, May 2012 5

Factors may increase cognitive
side effects

Mankad WV, et al (eds): Clinical manual of electroconvulsive therapy. American
Psychiatric Publishing, VA 22209-3901. 2010

Tools of neurostimulation

Swartz CM (editor): Electroconvulsive and Neuromodulation Therapies. Cambridge University Press.
2009

ECT helps brain to work: few
seconds with long effects !

Swartz CM (editor): Electroconvulsive and Neuromodulation Therapies. Cambridge University Press.
2009


Hypotheses of mechanisms of
action


ECT works at multiple levels of
brain function


ECT induces neuronal
reorganization


ECT and neuronal circuits


The centrencephalic theory of
seizure generalization
 Regional cerebral blood flow (rCBF):
increases extensively, particularly in
the centrencephalic structures in
generalized seizures.

Differences in cerebral blood flow between missed and generalized seizures with
electroconvulsive therapy: A positron emission tomographic study Harumasa Takano,
Nobutaka Motohashi, Takeshi Uema, Ken‟ichi Ogawa, Takashi Ohnishi, Masami Nishikawa,
Hiroshi Matsuda Epilepsy research 1 November 2011 (volume 97 issue 1 Pages 225-228


EEG
 Relative alpha activity (8.5 12.0 Hz)
increased in occipital lobe after a
course (qEEG analysis)

Y. Kitaura, K. Nishida, R. Hama, Y. Takekita, M. Yoshimura, A. Tajika, T. Kinoshita,
P27-6 Quantitative EEG analysis of electroconvulsive therapy response for senile depression: a
case report, Clinical Neurophysiology, Volume 121, Supplement 1, October 2010, Page S264


Vagal system stimulation
 ECT increases vagal activity which
might be associated with the beneficial
effect seen following ECT

Bär KJ, Ebert A, Boettger MK, Merz S, Kiehntopf M, Jochum T, Juckel G, Agelink MW.
Is successful electroconvulsive therapy related to stimulation of the vagal system?
J Affect Disord. 2010 Sep;125(1-3):323-9.


ECT and BRAIN DAMAGE:
fiction of antipsychiatrists !


ECT - responsive syndromes
 There are no diagnoses that should
automatically lead to treatment with
ECT. APA Task Force 2001
 Syndromic view offers more
homogeneous pts, eg; acute
psychosis Vs acute mood disorders.
 Primary (1st line) Vs Secondary ( last
resort) use of ECT.
*Fink M: Electroconvulsive therapy. In: Gelder M, Andreasen N, Lopez-Ibor J, and Geddes J
(Editors). New Oxford Textbook of Psychiatry. 2nd ed. 2009. Oxford University Press


Primary Use ECT (APA 2001)
1. A need for RAPID, DEFINITIVE RESPONSE
because of the severity of a psychiatric or
medical condition (e.g., when illness is
characterized by stupor, marked psychomotor
retardation, depressive delusions or
hallucinations, or life– threatening physical
exhaustion associated with mania)
2. When the risks of other treatments OUTWEIGH
the risks of ECT
3. A history of POOR MEDICATION RESPONSE or
GOOD ECT RESPONSE in one or more previous
episodes of illness
4. The patient‟s PREFERENCE

ECT - responsive syndromes*
 DEPRESSIVE MOOD DISORDERS:
Melancholia, Delusional, Post-partum,
Pseudodementia, Catatonia, Suicide &
Intractable.
 MANIC MOOD DISORDERS: excited,
delirious, catatonic & mixed.
 PSYCHOSES: acute, abrupt episode ±
mood, OC Schiz, atypical psychosis, post-
partum, catatonic & Intractable.
 CATATONIA: retarded, excited, malignant,
NMS, medical, CNS etc.
 SUICIDE.
 NEUROLOGICAL
*Fink M: Electroconvulsive therapy. In: Gelder M, Andreasen N, Lopez-Ibor J, and Geddes J (Editors). New Oxford
Textbook of Psychiatry. 2nd ed. 2009. Oxford University Press

Last resort ECT, FDA 2011
 Treatment resistance:
◦ For depression, after one or more antidepressant trials
◦ For mania, after one or more mood stabilizer trials with
adjunctive atypical antipsychotic treatment
◦ For clozapine resistant schizophrenia
◦ For lorazepam resistant catatonia
 Intolerance to or adverse effects with
pharmacotherapy that are deemed less likely or
less severe with ECT
 Deterioration of the patient‟s psychiatric or medical
condition creating a need for a rapid, definitive
response.
FDA executive summary: Prepared for the January 27-28, 2011 meeting of the Neurological
Devices Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices
(ECT) ajhuri@gmail.com al-Azhar University, May 2012 22

Pseudodementia
 Cognitive disorders resulting from
functional disorders
 Common: depression, Ganser
syndrome
 Suspect when: dementia syndrome
appears suddenly in an adult,
especially an elderly adult.
 Remarkable response to ECT

 Fink M. Electroconvulsive therapy: a guide for professionals
and their patients. Oxford, 2009


Unresponsive pt
 Stupor vs Coma
 Stupor: varying degrees of
unresponsiveness due to an apparent
decreased level of consciousness
 Stupor / not
 Catatonic signs / not
 Psychiatric / Neurologic ds
 BZD then ECT
Hurwitz TA. Psychogenic unresponsiveness. Neurol Clin. 2011 Nov;29(4):995-1006.


Super-refractory status
epilepticus
 SE that continues or recurs 24 h or
more after the onset of anesthetic
therapy, including those cases where
SE recurs on the reduction or
withdrawal of anaesthesia.
 ECT as an option was used since
1943
 After pharmacologic coma fails
Shorvon S, Ferlisi M. The treatment of super-refractory status epilepticus: a critical review of
available therapies and a clinical treatment protocol. Brain. Oct; (Pt -


Parkinson‟s Disease (PD)
 Psychotic symptoms in Parkinson's
disease (PDP) are relatively common
 In a recent Japanese case series of 8
quetiapine-resistant PDP pts:
◦ significant ↑ in rCBF in the right middle
frontal gyrus after ECT
◦ notable improvements not only in PDP but
also in the severity of PD
Usui C, Hatta K, Doi N, Kubo S, Kamigaichi R, Nakanishi A, Nakamura H, Hattori N, Arai H.
Improvements in both psychosis and motor signs in Parkinson's disease, and changes
in regional cerebral blood flow after electroconvulsive therapy. Prog Neuropsychopharmacol Biol
Psychiatry. 2011 Aug 15;35(7):1704-8.


Dementia with Lewy bodies
 Psychiatric Sx:
◦ Psychosis is an intrinsic part of DLB: 75%
have hallucinations and >50% have
delusions
◦ Depression: 20 – 65 %
 „Neuroleptic sensitivity‟ phenomenon
 ECT has antidepressant,
antipsychotic, and dopamine-
enhancing effects
Burgut FT, Kellner CH. Electroconvulsive therapy (ECT) for dementia with Lewy bodies.
Med Hypotheses. 2010 Aug;75(2):139-40.

Multiple sclerosis
 Depression: up to 25 %, may be
delusional
 Mania: up to 14 %
 Suicide: 5 x other population
 Recurrent catatonia / psychosis: rare

Pontikes TK, Dinwiddie SH. Electroconvulsive therapy in a patient with multiple sclerosis
and recurrent catatonia. J ECT. 2010 Dec;26(4):270-1. University, May 2012
ajhuri@gmail.com al-Azhar 28

Other movement disorders
 Successful case reports:
◦ NMS
◦ TD
◦ HD
◦ TS

Scott A. The ECT Handbook. 2nd Ed. The Third Report of the Royal College of
Psychiatrists‟ Special Committee on ECT. 2005


ECT as a drug: 10 actions at the
same time
1. Antipsychotic
2. Antidepressant
3. Antimanic
4. Mood stabilizer
5. Antisuicidal
6. Anticatatonic
7. Alerting (anti-stupor): ↑ α activity in EEG
8. Vegetative: eating after session
9. Antiepileptic: ↑ ST
10. Dopaminergic: ↓ Dyskinesia


ECT Non-responsive
syndromes*
 Poor previous response to ECT course
 Neuroses.
 Personality disorders.
 Drug dependence & related disorders.
 Maladjustment problems: dissociation /
conversion
 Lifelong intellectual & emotional dysfunction.
 Dementia.
 Impulse disorders.
 Sexual dysfunctions.
 Sleep disorders.
 Factitious / Somatoform disorders.
*Fink M: Electroconvulsive therapy. In: Gelder M, Andreasen N, Lopez-Ibor J, and Geddes J (Editors). New
Oxford Textbook of Psychiatry. 2nd ed. 2009. Oxford University Press


Sine Vs Pulse squared wave


Electrical waveforms of ECT
 Waveform: the “shape” of the stimulus
as a function of time.
 Sine wave ECT: 1930s Cerletti and
Bini, wall outlets, continuous,
neurotoxic!
 Brief pulse ECT: 0.5 – 2 ms, late
1970s
 Ultra-brief pulse ECT: < 0.5 ms, late
1990s

Related Electricity principles
 V=I×R “Ohm‟s Law”
V: voltage in volts, I: current intensity in milliamperes, R: resistance (impedance) in ohms

 U=Q×I×R
U: energy in joules, Q: charge in millicoulombs, I: current intensity in milliamperes, R: resistance
(impedance) in ohms

 Q = I × PW × 2F × D
Q: charge in millicoulombs, I: current intensity in milliamperes, PW: pulse width, F: frequency
in hertz (cycles pairs per second), D: duration of stimulus train in seconds

• 1 mC = 1 mA / 1 sec
• Constant current devices: safe
• Summary metric: J / mC?
• Energy (J): unpredictable
Ohm‟s law triangle


Specs of common ECT
devices


Seizure Threshold (ST)
 The total amount of electricity
necessary to induce a seizure ie
CONVULSIVE THRESHOLD.
 ST variance: up to 50 folds, a lot of
factors, strong evidence for age,
gender and electrode placement, so
NOT a constant measure
 Therapeutic stimulus is NOT equal to
the ST stimulus

Factors influencing ST


Impedance
 IMPEDANCE: static (200 – 3000 Ω) and
dynamic (120 – 350 Ω). Electrodes,
scalp and skull.
 IMPEDANCE: automatic self-test in MECTA
devices
◦ Females > Males
◦ RUL > BT > BF
 Scalp SHUNTING of current: a lower
proportion of current entering the brain. It
is a short-circuit
 So, INVERSE RELATION for constant-
current devices between ST and
dynamic impedance

Cause of variations in
impedance


Is seizure duration enough?

Mankad WV, et al (eds): Clinical manual of electroconvulsive therapy. American Psychiatric
Publishing, VA 22209-3901. 2010


STIMULUS DOSING
 Why?
◦ Cerebral generalization: more effective
◦ Barely suprathreshold (just above ST): ineffective
◦ Markedly suprathreshold (far beyond ST):
hazardous
◦ ST is increasing along index ECT course: fixed
dosing is inappropriate
 EMPERICAL TITRATION: most precise
 PRE SELECTED (FORMULA-BASED)
METHOD: pts do not tolerate titration, eg
cardiac, severely suicidal. etc
 FIXED DOSING: may be a malpractice, esp if
randomly assigned.


Where to start dosing?

RUL BT / BF
1- Female 2- Female
2- Male 3- Male


STIMULUS DOSING RULES
 Stimulus 1: RUL, Female
 Stimulus 2: BT/BF Female, RUL Male
 Stimulus 3: BT/BF Male
 After 3rd failed stimulus (uncommon):
jump 2 levels for 4th one
 Preselected stimulus: calculated dose
◦ Stimulus 3: RUL, Female
◦ Stimulus 4: All others
 Dial the device knob: 1 / 2 – 1 × pt age
(poor method with no evidence)

Example: Dose titration technique for
Somatics Thymatron System IV model


The final rules
 Titration session : up to 4-5
restimualtions with 20 seconds apart
 THERAPEUTIC STIMULUS
INTENSITY is moderately
suprathreshold for next sessions:
◦ 1.5 – 2.5 × ST in BT/BF,
◦ 2.5 – 6 × ST in RUL
 Restimulate increasing 50 – 100 % of
the previous stimulus when needed

Electrode placement

BT RUL BF
d‟Elia Letemendia


SEIZURE ADEQUACY
 Pattern & Duration: motor & EEG
 Pattern: generalization both motor &
EEG
 Duration: 20 – 60 sec motor, 30 – 120
sec EEG (CORE studies)
 MISSED: no activity both motor & EEG
 BRIEF (ABORTIVE): < 20 sec motor, <
30 sec EEG
 PROLONGED: > 60 sec motor, > 120
EEG
 Post-ictal suppression: a valid parameter
 Although: seizure adequacy parameters
are still unclear, and lacking good

Seizure duration


How to manage inadequate
seizure?
 MISSED / ABORTIVE:
◦ Check device and connections
◦ Restimulate: 20 sec apart, up to 5 times ( very
rare), vary the duration and frequency, then pulse
width
◦ Hyperventilate: 15 – 20 / min
◦ IV Flumazenil: if pt is on BZD
◦ DC / Taper drugs interfering: eg AEDs
◦ Decrease IV anesthetic dose / switch to less
anticonvulsant one. Consider xanthines:
Caffeine, theophylline, aminophylline.
◦ Space the schedule
◦ Check recent stimulus increase: paradoxical area
of curve

PROLONGED / TARDIVE
seizures
 More than 60 sec motor / 120 sec
EEG (APA Task Report 2001: 180 sec
both !)
◦ Abort with IV anesthetic (thiopental) / BZD
(midazolam). If no response (rare):
intubate, IV loading phenytoin and refer to
ICU.
◦ Good ventilation
◦ Additional dose of muscle relaxant
◦ Decrease stimulus
◦ Check pt drugs: eg xanthines May 2012
ajhuri@gmail.com al-Azhar University, 50

ECT seizure vs Epileptic
seizure


ECT Prescribing
 Three items: electrode placement,
schedule and number
 2 / wk Vs 3 / wk: same at long term ie
( after 1 wk – 6 m) [More than 6 SR studies]
 It is not possible to predict reliably how
many treatments will be required in a
course of ECT. A set course of
treatments SHOULD THEREFORE NOT
BE PRESCRIBED. RCPsych, 2004
 No sign of response: stop after BL 6
sessions
 Slight or temporary response: continue
to BL 12 sessions

Anesthesia for ECT
 It is just a type of moderate sedation,
NOT a full anesthesia. Adjusted per
session.
 Suitable anesthetic drug: Ultra-brief
not long duration, light not deep, weak
antiepileptic & painless on injection.
 Typically: barbiturates. Thiopental is
common in Egypt.
 Anticholinergics / Hyperventilation: are
NOT routine. ajhuri@gmail.com al-Azhar University, May 2012 53

Anesthesia for ECT
 Muscle relaxant: Short-acting to protect
airway & decrease / minimize ictal motor
activity.
 Full paralysis is not required in most
cases.
 HYPERKALEMIA is a concern: Pts with
catatonia / renal impairment / stroke /
burn.
 Typically: succinylcholine
(Suxamethonium): 9 – 13 min for
recovery at dose 1 mg / Kg.
 The elimination half-life of
succinylcholine is estimated to be 47
seconds ajhuri@gmail.com al-Azhar University, May 2012 54

Muscle relaxants: 2 types


PChE deficiency
• Enzyme produced by mainly the LIVER:
hydrolyzes choline esters
• Also known: plasma ChE, and BChE
• Dibucaine number ( 70 – 90 %): NOT a
routine test
• Inherited / acquired (age / ds / drugs)
• Very UNCOMMON, more rare in Africans
• Next session: use Nondepolarizing ms
relaxant eg atracurium
Williams J, Rosenquist P, Arias L, McCall WV. Pseudocholinesterase deficiency and electroconvulsive therapy.
J ECT. 2007 Sep;23(3):198-200. PubMed PMID: 17805000.
Miller: Miller's Anesthesia, 7th ed, 2009 ajhuri@gmail.com al-Azhar University, May 2012 56

Drugs before ECT
 Symptomatic improvement of patients
who are ON AEDs during ECT is
comparable to those who are NOT
 AEDs + ECT (Vs ECT alone):
◦ Higher charge
◦ More sessions, esp titrations
◦ Delayed recovery
◦ Post ECT delirium
Comparison of electroconvulsive therapy (ECT) with or without anti-epileptic drugs in bipolar disorder
. Harve Shanmugam Virupaksha, Barki Shashidhara, Jagadisha Thirthalli, Channaveerachari
Naveen Kumar, Bangalore N. Gangadhar Journal of affective disorders 1 December 2010
(volume 127 issue 1 Pages 66-70

Herbal drugs: must be
stopped
 St John‟s wort (Hypericum)
 Ginkgo extracts
 Ginseng
 Kava
 ASA recommends stopping 2 wks
before


Drugs delay recovery / prolong
post ECT delirium
 Anti-Ch
 TCA
 Li
 AEDs
 Anti ChE: esp rivastigmine


Egyptian MHA, 2009
 Mandates: general anesthesia &
muscle relaxation.
 Informed consent / agreement of 2
assessments from 2 registered
specialists.
 National Accreditation Policy for ECT
units and clinics was set in NMHC.
MHA: mental health act
NMHC: national mental health commission






◦
◦

(1
(2
(3



Post-ictal suppression: the only biological marker for good response &
prognosis of the session. Note cerebral seizure (72 sec) lags behind
the peripheral motor seizure ( around 30 sec).


Example for a titration session: High ST in a young man: 184.5
mC! So, next session therapeutic dose was 2.5 x IST = 461 mC


Medical clearance
 There are no “absolute” medical contraindications for
ECT. APA Task Force 2001
 No routine Pre-ECT workup / evaluation, but tailored on
individual base.
 Risk / Benefit analysis: ECT psychiatrist & Anesthetist.
Medical consultation on demand.
 Increased risk: ASA level 4 / 5.*
 Special patients groups: Elderly, Pregnant women,
Puerperium, Children and Adolescents.
 Medical comorbidities esp. cardiovascular.

*ASA: American Society of Anesthesiology


Medical illness & ECT
 ECT is often administered to patients
with severe medical illness
 Risk/benefit analysis:
◦ Severity of psychiatric illness
◦ Therapeutic success with ECT
◦ Medical risks
◦ Alternative treatments or no ttt
Medical consultation: optimize medical
status / modification to ECT procedure


Pre ECT workup is tailored: an
example


CVS conditions
 Can be safely managed during ECT.
APA Task Force 2001
 Parasympathetic stim --- > Symapthetic stim
 HTN, IHD, VHD, CHD and arrhythmias
 Before ECT: ECG, CXR, electrolytes ± echo
 β –blockers: consider by case
 Antihypertensives: morning of session


CNS conditions
 Increased ICP: SOLs, may pre use
steroids, diuretics, anti HTN & HV
 CVA: recent / not? Type?
 Dementia: esp DLB
 Epilepsy: refractory
 Parkinson ds: PDP
 Trauma: recent?
 Others: MS, Muscle ds,


Other medical conditions
 Pulmonary: COPD
 DM
 Hyperkalemia / Hypokalemia
 Hyponatremia / Dehydration
 GERD: aspiration. Treat by:
metoclopramide, Ranitidine OR consider
intubation
 Bone
 Teeth
 Urinary retention

ECT in Elderly
 The largest age group receiving ECT
 Why?
◦ Relative low risk, rapid, drug resistance, medical
comorbidity
 People should not be denied access to ECT
solely on the grounds of age. (RCPsych, 2005)
 Aging effect: improves therapeutic outcome
 Case report: A 100-year-old woman with severe
aortic stenosis received ECT safely for 5 years.
[O'Reardon JP, Cristancho MA, Ryley B, Patel KR, Haber HL. Electroconvulsive therapy for treatment of major
depression in a 100-year-old patient with severe aortic stenosis: a 5-year follow-up report. J ECT. 2011
Sep;27(3):227-30.]

 Increased: ST
 Increased: cognitive SE


ECT during pregnancy
 Risks of mental illness during pregnancy:
◦ Poor self-care,
◦ Poor prenatal care,
◦ Inadequate weight gain,
◦ Premature delivery,
◦ Substance abuse,
◦ Disengaged parenting behaviors,
◦ Neonaticide and suicide
O'Reardon JP, Cristancho MA, von Andreae CV, Cristancho P, Weiss D.
Acute and maintenance electroconvulsive therapy for treatment of severe major depression during the
second and third trimesters of pregnancy with infant follow-up to 18 months: case report and review of the
literature. J ECT. 2011 Mar;27(1):e23-6. Review. PubMed PMID: 20562638.


ECT in pregnancy
 May be used in all 3 trimesters
 APA guidelines: Depression & BAD
 Relatively safe
 Obstetric consultation is a must
 IV Saline / Ringer
 Good pre oxygenation NOT
hyperventilation
 Elevate Rt hip: separate uterus from IVC
& aorta
 ASPIRATION: ……?
 Monitoring


 A total of 300 case reports of ECT
during pregnancy drawn from the literature from 1942
through 1991 were reviewed
 Twenty-eight (28) of the 300 cases reported
complications: transient, benign fetal arrhythmias; mild
VAGINAL BLEEDING; abdominal pain; and self-limited
uterine contractions.
 Without proper preparation, there was also increased
likelihood of ASPIRATION, aortocaval compression,
and respiratory alkalosis.
 ECT is a relatively safe and effective treatment
during pregnancy if steps are taken to decrease
Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry. 1994 May;45(5):444-50.
potential risks.
Review. PubMed PMID: 8045538.


 Among the 339 cases reviewed:
◦ 25 fetal or neonatal complications, but only 11 of these,
which included two deaths, were likely related to ECT.
◦ 20 maternal complications reported and 18 were likely
related to ECT.
 Although there are limited available data in the
literature, it seems that ECT is an effective
treatment for severe mental illness during
pregnancy and that the risks to fetus and mother
are LOW.

Anderson EL, Reti IM. ECT in pregnancy: a review of the literature from 1941 to 2007. Psychosom Med. 2009 Feb;
71(2):235-42. Review. PubMed PMID: 19073751.


ECT in Puerperium
 DO NOT stop breastfeeding
 How to decrease infantile exposure to
anesthetic drugs? Delay / Bottle


Child and adolescent
 RARE indications
 Low ST: slow EMPERICAL titration
 Catatonia: CP, ID and autism
 Consent


Ideal ECT
suite
(Typical at
Abbassia with
lesser beds
capacity)

After Swartz
Textbook, 2009


Assessment after an index
course
 From start: target symptoms list & criteria of
remission. Eg: Double depression &
Schizoaffective
 “Continuation treatment has become the rule
in contemporary psychiatric practice”. APA
1993
 Abruptly stopping ECT after improving is
associated with high relapse rates (≥ 50%) ±
C-Pharm, esp in the first 6 ms after an index
ECT course.
 Prophylactic (Preventive) ECT: Continuation /
Maintenance ECT.
 A controversial practice, no guidelines, few
controlled studies and vague differences.
*C-Pharm: Continuation pharmacotherapy


Assessment after an index
course
 Although psychotropic continuation
therapy is the prevailing practice, few
studies document the efficacy of such
treatment after a course of ECT. APA
Task Force 2001
 Recurrent illness / Relapse on
psychotropics / Intolerance to them: a
viable option
 C-ECT: up to 6 ms, aiming at relapse
prevention.
 M-ECT: more than 6 ms, aiming at
recurrence prevention.

Key terms
 After Index ECT (2 – 4 wks)
1. Short -Taper ECT Abbreviated
2. Long - Taper ECT C-ECT Prophylactic
ECT
3. C-ECT
4. M-ECT
5. Abruptly Stopping ECT: ± continuation
pharmacotherapy.

Ambulatory ECT (Outpatient) Vs Inpatient
ECT?
Procedure of prophylactic ECT: Same as
Index / modified?


C-ECT
 Classically: up to 6 m.
 Abbreviated C-ECT (Tapering): short (1 m),
long (2 ms). Try tapering before C-ECT.
 Most studied in depression: likened to
antidepressants.
 Pt has a disorder known to be an acutely
responsive to an index ECT: ± drug
resistance.
 Relapse on drugs = partial resistance.
 Previously / Currently intolerant to drugs: AE /
Medical comorbidities / Poor compliance.
 Poor response to an index ECT: re evaluate
after 10 – 12 sessions.

C-ECT
 2nd time relapse / ECT in 3 ms.
 Pt is severely ill: Taper / C – ECT, you
cannot stop or depend on drugs alone.
 C-ECT Vs C-Pharmacotherapy:
controversial esp in depression.
 CORE 2010: After improvement of a
depressive episode: C-Pharm after Index
ECT (TCA ± Lithium), nearly equal to C-
ECT. (one of the strongest RCTs)
 Nortriptyline: the most studied C-Pharm,
enhancing ECT response & tolerable in
old age.

C-ECT
 Recommendations according to EMORY
UNIVERSITY ECT Facility, USA*:
 Short- Taper:
◦ 1/wk × 1, 1/10 ds × 1, 1/ 2 wks × 1
Long-Taper: ( 2 × Short-Taper) ie
1/wk × 2, 1/10 ds × 2, 1/ 2 wks × 2
C-ECT:
RUL: 1/wk × 4, 1/10 ds × 3, 1/ 2 wks × 4 ms
BT/BF: 1/wk × 2, 1/10 ds × 2, 1/ 2 wks × 4 ms
Inter treatment intervals may be decreased if pt
relapses during spacing / tapering.
Drugs: Last 2 wks of tapering

*Hands-on training and personal communication in Nov, 2010

M-ECT
 More than 6 ms, against recurrence.
 Controversial practice: NICE report 2003
questioned its empirical evidence ! While it is
stated by the APA & RCPsych as a “viable
option” in treatment of selected pts.
 Almost same indications like C-ECT, or if C-
ECT cannot be tapered, “convulsive
dependence”.
 Long practice in: Elderly & Medically ill pts
who are intolerable to psychotropics.
 Best studied in: Depression & Schizophrenia.
 Again: no guidelines, and few RCTs.

M-ECT
 1 / 3-4 wk for 1 y, then re assess.
 RUL is preferred at 6 – 7 × ST.
 Ambulatory: Outpatient.


Suggested readings &
references
 TEXTBOOKS:
1. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A.
Washington, DC: American Psychiatric Association; 2001. Task Force Report of the American Psychiatric
Association
2. Mankad WV, et al (eds): Clinical manual of electroconvulsive therapy. American Psychiatric Publishing, VA
22209-3901. 2010
3. Swartz CM (editor): Electroconvulsive and Neuromodulation Therapies. Cambridge University Press. 2009
4. Abrams R: Electroconvulsive Therapy, 4th ed, 2002. Oxford University Press.
5. McDonald WM, et al: Electroconvulsive therapy. In: Schatzberg AF & Nemeroff CB (editors): The American
Psychiatric Publishing textbook of psychopharmacology. 3rd ed. 2004
6. Fink M. Electroconvulsive therapy: a guide for professionals and their patients. Oxford, 2009
7. Scott A. The ECT Handbook. 2nd Ed. The Third Report of the Royal College of Psychiatrists‟ Special Committee
on ECT. 2005
SELECTED JOURNAL ARTICLES:
Trevino K, McClintock SM, Husain MM. A review of continuation electroconvulsive therapy: application, safety,
and efficacy. J ECT. 2010 Sep;26(3):186-95.
Electroconvulsive therapy stimulus parameters: rethinking dosage. Peterchev AV, Rosa MA, Deng ZD, Prudic J,
Lisanby SH. J ECT. 2010 Sep;26(3):159-74.
Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy.
Sackeim HA, Prudic J, Nobler MS,et al. Brain Stimul. 2008 Apr;1(2):71-83.
Navarro V, Gastó C, Torres X, Masana G, Penadés R, Guarch J, Vázquez M, Serra M, Pujol N, Pintor L, Catalán
R. Continuation/maintenance treatment with nortriptyline versus combined nortriptyline and ECT in late-life
psychotic depression: a two-year randomized study. Am J Geriatr Psychiatry. 2008 Jun;16(6):498-505.
Sienaert P, Vansteelandt K, Demyttenaere K, Peuskens J. Randomized comparison of ultra-brief bifrontal and
unilateral electroconvulsive therapy for major depression: clinical efficacy. J Affect Disord. 2009 Jul;116(1-
2):106-12.


 Smith GE, Rasmussen KG Jr, Cullum CM, Felmlee-Devine MD, Petrides G, Rummans TA, Husain MM,
Mueller M, Bernstein HJ, Knapp RG, O'Connor MK, Fink M, Sampson S,Bailine SH , Kellner CH; CORE
Investigators. A randomized controlled trial comparing the memory effects of continuation electroconvulsive
therapy versus continuation pharmacotherapy: results from the Consortium for Research in ECT (CORE) study. J
Clin Psychiatry. 2010 Feb;71(2):185-93.
 Rasmussen KG, Mueller M, Rummans TA, Husain MM, Petrides G, Knapp RG, Fink M, Sampson SM,
Bailine SH, Kellner CH. Is baseline medication resistance associated with potential for relapse after successful
remission of a depressive episode with ECT? Data from the Consortium for Research on Electroconvulsive
Therapy (CORE). J Clin Psychiatry. 2009 Feb;70(2):232-7.
 Kellner CH, Knapp RG, Petrides G, Rummans TA, Husain MM, Rasmussen K, Mueller M, Bernstein HJ,
O'Connor K, Smith G, Biggs M, Bailine SH, Malur C, Yim E, McClintock S, Sampson S, Fink M. Continuation
electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from
the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry. 2006 Dec;63(12):1337-
44.
 Kellner CH, Tobias KG, Wiegand J. Electrode placement in electroconvulsive therapy (ECT): A review of the
literature. J ECT. 2010
 Kellner CH, Knapp R, Husain MM, Rasmussen K, Sampson S, Cullum M, McClintock SM, Tobias KG,
Martino C, Mueller M, Bailine SH, Fink M, Petrides G. Bifrontal, bitemporal and right unilateral electrode
placement in ECT: randomised trial. Br J Psychiatry. 2010
 McDonald WM. Is ECT cost-effective? A critique of the National Institute of Health and Clinical Excellence's
report on the economic analysis of ECT. J ECT. 2006 Mar;22(1):25-9.
 Kellner CH, Fink M, Knapp R, Petrides G, Husain M, Rummans T, Mueller M, Bernstein H, Rasmussen K,
O'connor K, Smith G, Rush AJ, Biggs M, McClintock S, Bailine S, Malur C. Relief of expressed suicidal intent by
ECT: a consortium for research in ECT study. Am J Psychiatry. 2005 May;162(5):977-82.
 Tharyan P, Adams CE. Electroconvulsive therapy for schizophrenia. Cochrane Database Syst Rev. 2005 Apr
18;(2):CD000076.
 Van der Wurff FB, Stek ML, Hoogendijk WL, Beekman AT. Electroconvulsive therapy for the depressed
elderly. Cochrane Database Syst Rev. 2003;(2):CD003593.


Anti ECT
 Burstow B. Electroshock as a form of violence against women. Violence Against Women.
2006 Apr;12(4):372-92.
[ECT functions and is experienced as a form of assault and social control, not unlike wife battery. Emergent themes
include electroshock as life destroying, a sign of contempt for women, punishment, a means of enforcing sex roles, a way to
silence women about other abuse, an assault, traumatizing for those who undergo it and those forced to witness it]. Canada

 Read J, Bentall R. The effectiveness of electroconvulsive therapy: a literature review.
Epidemiol Psichiatr Soc. 2010 Oct-Dec;19(4):333-47.
[The cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified]. New
Zeland
 McDonald A, Walter G. Hollywood and ECT. Int Rev Psychiatry. 2009 Jun;21(3):200-6.
[Film depictions continue to exert a powerful and predominantly negative effect on public
attitudes towards the treatment. From review of the 22 currently available films that directly refer to
ECT the main themes identified are described. While initially portrayed as a dramatic but effective
psychiatric intervention, ECT on film has come to stand for something quite different, representing the
brutal and generally futile attempts of society to control and suppress the individual, gathering along
the way a hackneyed cinematic grammar that emphasizes its inhumane and punitive nature.] UK


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