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Review Article
History
Convulsive therapy, relevant to the practice of psychiatry, has its origins in the work of Ladislaus von Meduna,^
Meduna used pentylenetetrazol to induce seizures in patients
with catatonic schizophrenia,''^ This form of convulsive therapy was wide- spread in Europe in the 1930s, Electricity was
used successfully in 1938 by Ugo Cerietti and Lucio Bini for
the purpose of eliciting seizures to treat mental illness. In the
1950s, Max Fink, one of the most important figures in the
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Patient Selection
It has long been known that ECT is an appropriate treatment for medication resistant depression. Patients who have
shown no response to pharmacotherapy, or psychotherapy,
will still respond to ECT at a rate that approaches 55%,'*
Recent studies have demonstrated that ECT is highly effective for the initial treatment of depression as well. The response rate for index depression has been reported as high as
80 to 90%,' Index depressions have been defined as depressive episodes that are currently occurring, with a discemable
Key Points
Electroconvulsive therapy (ECT) has been shown to
be a highly effective, safe, and even life-saving treatment for persistent and severe depression, bipolar disorder and schizophrenia,
ECT is safe for patients with comorbid medical conditions, as modem anesthesia techniques and medications have greatly reduced the morbidity and mortality
of ECT,
Experience and emerging research have made it clear
that ECT should be offered to patients as a viable
treatment option at all stages of their illness process.
Review Article
beginning and a clear history of the patient experiencing normal mood states before the onset of depression. These data
have led the APA to recommend that the use of ECT be
considered as an initial treatment option, in certain cases, for
patients with severe depression,^
For all patients treated with ECT, it should be stressed
that ECT represents a treatment that will bring remission, not
a cure, and in many cases, maintenance ECT should be discussed with patients because the effects of ECT are transient,^
These caveats are in part due to the nature of the treatment
itself, as well as the remitting nature of the illnesses for which
ECT is effective. The APA recommends that the patient receive ECT once a week for a month following the initial
treatment. Subsequent maintenance treatments should be
scheduled according to clinical judgment, patient preference,
and with regard to the patient's history of previous illness
relapses,^
ECT has been approved for the treatment of bipolar illness in mania, depression, and mixed states, ECT has also
been shown efficacious in the treatment of schizophrenia with
pharmacotherapy as psychotic symptom relapse prevention.*
Mechanism of Action
Though ECT has proven efficacy and safety, the mechanism of action is difficult to elucidate, A full discussion of
the proposed mechanisms of action is well covered elsewhere,^ There are three mechanisms that seem to hold the
most favor among researchers: 1) Modulation of monoamines,
2) Change in neurotrophic factors, and 3) Anticonvulsant
factors,^'''
It has been shown that monoamine levels increase in
animal models treated with ECT,^'' It may also be that increases in serotonin levels have an indirect impact on levels
of endogenous opioids,' The increase in dopamine levels with
ECT may explain why ECT improves symptoms of Parkinson
disease,'**
Little is known about the intracellular impact of ECT,
though researchers have looked at neurotrophic mechanisms and
possible relation to therapeutic response. This theory of neurotrophic mechanism states that cyclic AMP (cAMP) is up regulated with ECT,^ which increases brain derived neurotrophic
factor (BDNF)," BDNF regulates neuron cell strength, growth
and survival, as well as norepinephrine and serotonin receptor
expression.
Increase in GABA transmission and receptor antagonism
has been observed in ECT,'^ This anticonvulsant action raises
the seizure threshold during ECT. Also, ECT causes an increase of endogenous opioids that may also have anti-seizure
properties.
sidered safe, with a mortality of approximately 1/10,000 patients or 1/80,000 treatments. This puts the ECT risk at the
level of childbirth or minor surgery,' There are no recommendations regarding the total number of ECT treatments.
However, some case reports have examined patients who
have had thousands of lifetime treatments with no ill effects,'^
The most commonly expressed worries and criticisms
center on memory loss, Anterograde amnesia, or the inability
to form new memories, has been reported, though it tends to
be short-lived and resolves rapidly within a few weeks of the
procedure,''' Retrograde amnesia, or loss of past memories,
tends to affect recent memories more than remote memories.
Loss of memories of the events immediately surrounding the
procedure is not uncommon and usually resolves within weeks
of the treatment,'^ Loss of remote memories is quite rare, and
for that reason, is difficult to quantify. Permanent memory
loss is extremely rare,'*
Other reported side effects include headache, nausea, and
muscle soreness. Muscle soreness is often due to the use of
succinylcholine; however, inadequate muscle blockade also
causes muscle soreness,'^ Nausea is common with ECT given
that ECT stimulates the vagus nerve. Proton pump inhibitors
can be used safely in such patients.
Missed or short seizures can occur. It is also noted that
seizure induction can be difficult, particularly in the elderly.
In addition to hyperventilation, pharmacologic methods have
been shown to be of help. Augmentation with caffeine or
switching anesthetic agents may also
"*'^
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Electrode Placement
When ECT was first used, the electrodes were placed on
either side of the head at the temples. By the mid 1950s,
practitioners began to experiment with unilateral electrode
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Medications in ECT
ECT was performed without anesthesia in the first several years of its use, but by the late 1950s, anesthesia had
become commonplace. Early use of barbiturates carried the
risk of cardiac arrhythmias, as well as decreasing seizure
duration.^'' Today, methohexital, a short-acting barbiturate,
has become the anesthetic of choice among ECT practitioners. Though barbiturates increase seizure threshold and decrease seizure duration, among barbiturates, methohexital appears to have the least impact on these factors.
The use of muscle blockers has greatly reduced the likelihood of physical injury during ECT,'^'^'* The dmg of choice
among psychiatrists and anesthesiologists is succinylcholine.
This dmg has a quick onset of action, is short-acting, and
does not need to be reversed, as is the case with many nondepolarizing blockers,
ECT causes a significant change in autonomic function.
Initially, the patient experiences a parasympathetic surge,
which can cause significant bradycardia, hypotension, and, in
some cases, brief asystole,^^ To prevent this, anticholinergic
dmgs such as glycopyrrolate are often used. Although atropine has been the dmg of choice in the past, glycopyrrolate
offers the advantage over atropine in that it does not cross the
blood-brain barrier and therefore does not cause unwanted
cognitive side effects,^"*
Review Article
late pregnancy, the patient should lie on her left side, which
will ensure adequate blood flow to the fetus. Transmission of
anesthetic agents across the matemal fetal barrier is considered to be minimal,
A careflil dental examination should be part of the patient workup. Modifications to the bite block may be necessary for chipped or broken teeth. Loose teeth may need to be
extracted before ECT to avoid injury to the oral cavity and
aspiration.
Patients with gastroesophageal reflux disease may experience worsening symptoms during ECT, as the treatment
stimulates the vagus nerve. Antacid medications can be safely
used. Patients who are on proton pump inhibitors may safely
use them before and after ECT, Some anesthesiologists argue
that intubation may be called for in rare cases in which the
patient suffers from severe reflux disease.
Discussion
ECT is a safe and effective treatment option for patients.
It has proven efficacy in treating medication resistant depression. It is also an excellent treatment option for patients with
severe suicidal ideation, ECT currently exists as an option for
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Acknowledgments
20. McCall WV, Reboussin DM, Weiner RD, et al. Titrated moderately
suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy: acute antidepressant and cognitive effects. Arch Gen Psychiatry
2000;57:438-444.
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