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Electroconvulsive Therapy

Electroconvulsive Therapy. Jerome Greenfield M.D. Historical Background. Hippocrates 400 B.C. Melancholic “black bile” Paracelsus 1520 Psychiatric illness not demonic but natural diseases Kraeplin Illnesses divided into two major groups. Etiologies of Depression.

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Electroconvulsive Therapy

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  1. Electroconvulsive Therapy Jerome Greenfield M.D.

  2. Historical Background • Hippocrates 400 B.C. Melancholic “black bile” • Paracelsus 1520 Psychiatric illness not demonic but natural diseases • Kraeplin Illnesses divided into two major groups

  3. Etiologies of Depression • Bioamine Hypothesis Neurotransmitters • Freud Loss of the love object • Genetic Factors • Life’s Stressors • Learned Helplessness • Cognitive Theories • Organic Cause drugs, medications, illnesses, sleep abnormalities

  4. Epidemiology • 20% lifetime expectancy • 2:1 female to male ratio • 50% have onset by age 30 • More common in single/divorced • No correlation between social classes or race • 10% complete suicide 66% contemplate

  5. Treatment Options • Medications • ECT • Transcranial Magnetic Therapy • Vagal Nerve Stimulator • Various Psychotherapies • Psychoanalysis

  6. ECT History • Can a seizure be protective? • Meduva 1930’s camphor • Cerletti and Bini electrical charge • 75,000 treatments per year • Twice as effective as medication • Mortality .01% per course same as any anesthesia induction

  7. ECT INDICATIONS • Major Depression 90% effective • Mania 80% effective • Acute Schizophrenic Psychosis 50% effective • Neuroleptic Malignant Syndrome • Advanced Parkinson’s • Intractable Epilepsy • Catatonia

  8. Contraindications • No absolute contraindications • High risk with: Space occupying lesion Recent myocardial infarction Brain aneurysm

  9. ECT Procedure • Confirm Diagnosis • Medical and Psychiatric Exam • EKG • Lab tests • Head CT/Spine films if indicated • Consent forms • Anesthesia evaluation • Risks, benefits, alternatives

  10. Primary Choice • Urgent need for rapid response • Patient history • Patient preference • Elderly • Psychotic Depressions • Catatonic States

  11. Adverse Effects • General Anesthesia • Complicated seizure • Medication Interactions • Cognitive Changes • Cardiovascular Problems

  12. Risk Reduction • Oxygenation • Reduce medications • Pre treatment with Robinul • Use of Beta Blockers • Check electrolytes • BP and EEG monitoring • NPO after midnight, clean scalp, usual BP meds with sip of water • Atropine if necessary

  13. Anesthetic Agents • Diprovan Non barbituate short acting • Brevital barbituate yet less effect on seizure • Succinylcholine • Beta Blockers • Versed

  14. Misc Items • Sine wave vs. brief pulse • Seizure threshold meds, age • Number of treatments • Mostly done on out patient basis • Maintenance ECT • Lengthen Seizure Caffeine, Hyperventilation, Wellbutrin • Abort Seizure Valium

  15. Amnesia • Retrograde and Anterograde • Few weeks to month in duration • Less with non dominant unilateral treatment • Discontinue Lithium • Occurs in patients with severe Depression who do not have ECT • BDNF theory • ECT does not injure the brain

  16. Complications • Headache, muscle soreness • Jaw pain, oral injury • Spinal problems • Nausea • Confusion • Cardiovascular Problems • Death 1:10,000

  17. Special Conditions • Pregnancy Meds are non-teratogenic • Cardiovascular Illnesses K, Pacemaker • Diabetes • Asthma • Epilepsy

  18. How does it work? • Not sure!!! • Massive release of neurotransmitter? • Alteration in seizure threshold? • Akin to re-boot of a computer?

  19. Consent • Description of the procedure • Why recommended • Alternative treatment • Benefits may be transient • Behavioral restrictions • Voluntary treatment • Available to answer questions • Implies consent for emergency treatment • Risks major and minor

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