This document provides an overview of electroconvulsive therapy (ECT), including its definition, brief history, indications and contraindications, types and techniques, pre, intra, and post-procedure roles of nursing, proposed mechanisms of action, complications and side effects, physical setup requirements, and treatment team members. ECT involves applying electric currents to the brain via electrodes on the temples to induce a seizure as a somatic treatment for various mental health conditions.

1. Electroconvulsive therapy
By
Kiranmayi Koni
Associate Professor
Apollo college of nursing
AIMSR

2. Specific objectives
• definition of ECT
• understand brief history of ECT evolution
• discuss indications & contraindications of ECT
• explain types and technique of ECT
• discuss pre, intra and post ECT procedure and role of
nursing officer
• understand mechanism of ECT
• enlist complications and side effects of ECT
• understand ECT physical set up and team members.

3. Definition
ECT therapy is a type of somatic
treatment in which electric current is applied to
the brain through electrodes placed on the
temples of the patient. The passage of the
electrical stimulus of 70-150 volts to the brain
for 0.1 to 0.5 second to produce a grandmal
seizure.

4. Father of Electroconvulsive therapy
‘Lucio Carletti’ used First ECT machine

5. Nobel Laureate Paul Greengard suggested the
term “Electro cortical therapy”

6. Milestones in the history of
convulsive therapy
1500s: Paracelsus induces seizures by oral administration of
camphor.
1785- First published report of use of seizure induction to
treat mania by using camphor
1934-Ladislaus meduna began new era by IM injection of
25% camphor oil
1938- Lucio Cerletti & Ugo Bini conducted first electrical
induction of seizures in catatonic and was successful
Termed as EST-Electo shock therapy

7. Contd...
1940- Curare developed for muscle relaxation
1951 - introduction of succinylcholine
1960- seizure activity is necessary for ECT
1970- Right unilateral electrode positioning
1978- APA first task force report on ECT
1988- RCT on ECT Vs Lithium found both are equally effective in
mania
1990- APA task force redefined the indications, gave guidelines for consent &
standards for training, treatment & privileging of ECT.
2000- Found Rt unilateral ECT is found with fewer cognitive effects
and Convulsion is induced with magnetic stimulation by H.S. Lisanby
2001 - Found post ECT pharmacotherapy ↓ relapse

8. Strychnos toxifera; curare

9. Technique
There are two types:
1. Direct ECT: ECT is given in the absence of
muscular relaxation & general anesthesia
2. Modified ECT: ECT is modified by drug
induced muscular relaxation and general
anesthesia

10. Types based on position of electrodes
1. Bilateral ECT: the standard form and most
commonly used.
• One stimulating electrode is placed several
centimeters apart over each hemisphere.
• Each electrode is placed fronto-temporally 2.5-4
cm above the mid- point, on a line joining tragus
of the ear and lateral canthus of the eye.

11. 2. Unilateral: electrodes are placed only on one side of
the head usually non-dominant side
• Both electrodes are placed several centimeters apart
over the nondominant hemisphere.
• One stimulus electrode is placed over
nondominant frontotemporal area & the other on
non dominant centro-parietal scalp just lateral to
the midline vertex.

13. • The most common approach is unilateral (more
favorable adverse effect profile)
• If not effective even after 4-6 unilateral
treatment, bilateral placement is used.
Immediate bilateral is indicated in
• severe depression, marked agitation, suicide risk,
manic symptoms, catatonic stupor, Px resistant
schiz and risk of anaesthetic adverse effects.

14. Indications
ECT as a first-line treatment
- febrile catatonia*
- malignant neuroleptic syndrome*
- severe depressive episode**
- schizoaffective psychosis**
- schizophrenia**, ***
- in case of life-threatening or intolerable side effects
of psychopharmacological treatments

15. ECT as a second-line treatment
Medication treatment failures in:
- depression
- schizoaffective psychosis
- schizophrenia
- mania
- depression or psychotic symptoms in case of
organic diseases

16. ECT as last-resort treatment
- treatment-resistant obsessive compulsive disorder
(OCD)
- treatment-resistant dyskinesias
- treatment-resistant Gilles de la Tourette syndrome
- treatment resistant epilepsy
- Parkinson's disease (treatment-resistant)

17. General indications
1. Major severe depression:
• With suicidal risk (first & foremost
indication)
• With stupor
• With Poor intake of food & fluids
• With melancholia
• With psychotic features
• With Unsatisfactory response to drug
therapy
• Where drugs are contraindicated / have
serious side effects

18. General indications (Contd..)
2. Severe catatonia:
• With stupor
• With poor intake of food & fluids
• With unsatisfactory response to drug
therapy
• Where drugs are contraindicated / have
serious side effects
• Where speedier recovery is needed

19. General indications (Contd..)
3. severe psychoses (schizophrenia or
mania)
• With risk of suicide/ homicide or danger
of physical assault
• With unsatisfactory response to drug
therapy
• Where drugs are contraindicated / have
serious side effects
• With very prominent depressive
features

20. The 1990 APA Task force suggestions
• Organic mental disorders (organic mood
syndrome, organic hallucinations, organic
delusional disorders, and delirium)
• Medical disorders (organic catatonia,
hypopituitarism, intractable seizure disorder,
neuroleptic malignant syndrome and
parkinsonism)

21. contraindications

22. Category Clinical condition
Enhanced intracerebral pressure* at present
Cerebral infarction not older than 3 months
Myocardial infarction* not older than 3 months
Intracerebral tumor* including intra cerebral edema
Any life-threatening anesthesia risk* at present
Cardiovascular disorders: Cardiac arrhythmias, CAD,
Unstable angina, MI (older than 3 months), hyper-or
hypotonia, aortic aneurysm.
Medical disorders: Disturbance of blood coagulation, severe
liver diseases, severe pulmonary diseases, pheochromocytoma

23. Contraindications (Contd..)
Neurological disorders:
intracerebral neoplasias/ bleeding/ vascular malformations,
cerebral ischemia / inflammations, hydrocephalus, dementias,
diseases of the basal ganglia, craniotomies, severe cerebral traumas
Orthopedic disorders: osteoporosis
Esophageal hernia: increased aspiration risk, intubation
recommended
Concomitant pharmacological treatment: if enhancing the
ECT risks or reducing ECT efficacy

24. PROCEDURE OF ECT

25. Pre treatment evaluation
Nurse’s role
It consists of the following steps:
• An informed consent taken from the patient or the guardian
• Detailed medical and psychiatric history taking, which
includes the current and past treatment history
• General and systemic physical examination
• Routine laboratory investigations like TC,DC,ESR , Urine
routine & microscopic examination, EKG, X-ray chest &
skull.
• Optimal investigations are EEG, estimation of plasma
cholinesterase activity for patients who would receive
succinylcholine for general anesthesia

26. Pre treatment evaluation: Nurse’s role
(Contd..)
• ECT is usually administered in the morning after an overnight fast.
(empty stomach for at least 4 hrs)
• Medications like benzodiazepines, lithium, clozapine, bupropion,
lidocaine which interferes with ECT should be withdrawn before.
• The bladder (and bowel) should be emptied just before procedure
• Dentures if present, should be removed and loose teeth should be
ruled out
• Tight clothing, & metallic & sharp objects should be removed
• Usual aesthetic precautions are taken
• Patient is placed on a hard bed which is well insulated
• A slow intravenous drip is started if needed

27. Pre treatment evaluation: Nurse’s role
(Contd..)
• A mouth gag is inserted to prevent tongue bite
• The place of electrode placement has to be cleaned
with NS or 25% bicarbonate solution or a
conducting gel is applied.
https://www.youtube.com/watch?v=9L2-B-aluCE

28. PRE ECT MEDICATIONS

29. • Anticholinergic: 0.6 mg of atropine IV is given just before or
it is given IM or SC 30 minutes before treatment to decrease
oral secretions and vagal stimulation which can cause cardiac
arrest
• Anesthetic agent: like thiopentone 150-250 mg or
Methohexital (0.75 to 1.0 mg/kg IV bolus)
• Muscle relaxant: like succinylcholine 0.5 – 1.5 mg / kg as an
IV bolus or drip.
• An anesthetic mask is placed on the face and ventilation with
100% oxygen is given.

31. Care during procedure-Role of
nurse
• ECT administration is followed by muscular
fasciculations which move from above
downwards.
• When fine twitching movements disappear
from the lower extremities, it is the time of
complete muscular relaxation.
• Pressure is applied on the mandible to
approximate upper and lower teeth till the
convulsions stops.

32. Positioning the client for ECT

33. Therapeutic adequacy:
• Therapeutic adequacy of the treatment is measured by a
generalized tonic clonic seizures lasting for not less than
25-30 secs.
This is made sure by:
1. Observing the seizure (in direct ECT)
2. EEG recording during ECT(in modified ECT)
3. Occluding the circulation of one extremity with a B.P
apparatus cuff, before giving succinylcholine. Thus the
whole body is paralyzed but one extremity convulses and
can be observed
4. Observing plantar extension and eyelid contractions,
which may be seen despite muscular relaxation (not a very
reliable method)

34. Plantar extension

35. Understanding EEG

36. Normal EEG

37. EEG Changes outof ECT

38. After care-Role of nurse
• Mouth gag is removed, secretions are sucked
from oral cavity and O2 mask is applied
• Till consciousness is regained, patient is turned to
one side to prevent aspiration
• Vital parameters are constantly monitored till
recovery
• Patient is made to rest, for about 30 minutes to 1
hr on bed.

39. Dose
• Usual dose for obtaining an adequate seizure
response is 90-150 volts for 0.1-1.0 seconds
average 0.6 secs.
• The usual amount of current passed is 200-
1600mA.

40. Duration of therapy
• Duration and total number of treatments depends
on the diagnosis, presence of side effects
• Usually 6-10 treatments can be given
• MDD - 6 to 12 treatments (although up to 20 are
possible)
• Manic episodes - can take 8 to 20
• Schizophrenia - 15 treatments
• Catatonia and delirium - as few as 1 to 4 treatments

41. Mechanism of action
• Although exact mechanism is unclear, one
hypothesis states that ECT possibly affects the
catecholamine pathways
• PET studies reveal that the degree of decrease in
cerebral metabolism (blood flow & glucose use)
after ECT is correlated with therapeutic response.

42. ❖ ECT itself acts as an anticonvulsant because its
administration is associated with an increase in the seizure
threshold.
❖ ECT changes neurotransmitter receptors activity
(recently, changes in second-messenger systems) resulting
downregulation of postsynaptic β-adrenergic receptors
❖ Some have reported an increase in postsynaptic serotonin
receptors, no change in serotonin receptors, and a change
in the presynaptic regulation of serotonin release.
❖ ECT has also been reported to effect changes in the
muscarinic, cholinergic, and dopaminergic neuronal
systems.

43. Side effects
• Deaths during ECT are due to general anesthesia.
• Mortality rate is 0.002% per treatment and 0.01%
for each patient.
• Memory disturbances both anterograde and
retrograde & recovery occurs within 1-6 months
• Confusion in post-ictal phase
• Other side effects include headache, prolonged
apnea, prolonged seizures, CV dysfunction,
emergent mania, muscle aches, apprehension

44. Complications
• Life threatening complications are rare
• ECT does not cause brain damage
• Fractures can occur in elderly clients
• Respiratory arrest in clients with h/o heart
disease, dysarythmias

45. Treatment facilities
There should be a suit of three room:
1.A pleasant waiting room (pre ECT room)
2.ECT room equipped with ect machine,
suction apparatus, face mask, oxygen
cylinder, tongue depressor, mouth gags,
resuscitation apparatus, emergency drugs.
• Immediate access to defibrillator
3.A well equipped recovery room

46. ECT team
• Psychiatrist
• Anesthesiologist
• Trained nurse
• Aides

47. Multiple-Monitored Electroconvulsive
Therapy (MMECT)
➔ Giving multiple ECT stimuli during a single
session, most commonly two bilateral stimuli
within 2 minutes.
➔ This approach may be warranted in severely
ill patients and in those at especially high
risk from the anesthetic procedures.

48. Other brain stimulation methods
• Repeated transcranial magnetic stimulation
(rTMS)
• Vagal nerve stimulation
• Deep brain stimulation