Electroconvulsive therapy (ECT) can be a highly effective treatment for depression and bipolar disorder, though it is shrouded in suspicion as one of the most stigmatized therapies currently in use. In truth, ECT has shown to have profound effects on depression treatment with some studies suggesting it should be considered as first-line therapy, rather than third-line after psychopharmacology and therapy have failed. Though mainly used to treat depression, ECT has been shown to have efficacy in other conditions such as schizophrenia, bipolar disorder and catatonia.

Despite its proven efficacy, ECT is a stigmatized treatment, thanks to the methods employed during its early use. These early modalities involved high doses of electricity given without anesthesia, which resulted in substantial memory loss, bone fractures and other detrimental side effects. Today, ECT has shown to produce significant improvement in depressive symptoms in approximately 80 percent of patients. 

What is ECT?

Electroconvulsive therapy is a medical procedure that involves the stimulation of electrodes applied to the patient’s skull. This stimulation produces a medically-induced generalized seizure and is conducted under anesthesia with muscle relaxation to prevent injury. While its exact mechanism of action remains unclear, we do know that ECT increases the release of neurotransmitters (namely dopamine, serotonin and norepinephrine). It is also thought that ECT causes the release of endorphins, prolactin and other hormones that are imbalanced in cases of depression.

Are there medication considerations with ECT?

Prior to the procedure, the psychiatrist and anesthesiologist will assess for the use of medications and herbal remedies that could interfere with the therapy. Ginseng, St. John’s Wort, kava, valerian and Ginkgo biloba can all interfere with the induction of the seizure. Additionally, theophylline, used to treat asthma, can place the patient at risk for status epilepticus. If the patient is taking cardiac medications such as antihypertensives, aspirin and antianginal medications, these are generally continued the day of the procedure. 

What happens during ECT?

ETC treatment is administered by a psychiatrist with an anesthesiologist providing sedation and managing the airway. A registered nurse or physician assistant will also be present to provide additional patient monitoring and assist as needed. 

Preparation for ECT is the same as for any other minor surgical procedure. The patient will need to be NPO for the prescribed amount of time and have an IV inserted for the administration of medications. Electrodes are placed either unilaterally or bilaterally, depending on the goal of treatment, with each patch being about the size of a silver dollar. Medications are administered for anesthesia and to relax the muscles and prevent injury during the seizure. 

Safety equipment at the bedside includes supplemental oxygen, a bag-valve mask and suction. If the patient has an implanted defibrillator in place, the detection mode on the device is turned off, with an external defibrillator ready at the bedside. Additionally, a bite block is placed to protect the patient’s teeth and tongue from injury because muscle relaxant medications will not block contraction of the masseter muscle during electrical stimulation.

The anesthesiologist will administer a medication to render the patient unconscious, followed by a muscle relaxant such as succinylcholine. He or she will then administer oxygen via BVM at 100% FiO2 during the duration of the procedure. 

The psychiatrist then triggers a brief electrical impulse which should induce a generalized seizure which can be observed via EEG tracings, EMG or movement in the right foot (we’ll talk about monitoring in the next section). The seizure duration is typically less than one minute, after which patients are then taken to the recovery room where they wake up from the anesthetic and are monitored for complications.

Most therapies are conducted in a series, but will vary based on the severity of symptoms. A typical course of treatment is two to three times per week for a duration of three to four weeks. Once the initial series is complete, the patient may need maintenance therapy which could be once a week or once a month and will be determined by symptom severity. A newer therapeutic approach, unilateral ultrabrief pulse electroconvulsive therapy, is administered more frequently and for a shorter duration with each electrical pulsation. Ongoing studies suggest this unilateral approach can have greater efficacy with fewer adverse effects than the standard bilateral ECT.

Patient assessment during ECT

Inducing a seizure doesn’t just affect the brain, it’s also going to cause a brief increase in intracranial pressure, changes in blood pressure and heart rate, and increased oxygen demands and cardiac workload. Therefore, careful monitoring of vital signs is necessary throughout the procedure, especially in those patients who have cardiovascular or pulmonary disease. 

During the tonic phase of the seizure, there is a brief parasympathetic response that can produce significant bradycardia as well as PVC and PACs, heart blocks, and even asystole. Then, during the clonic phase of the seizure, a catecholamine surge causes the tachycardia and hypertension that typically resolve within 20 minutes of seizure cessation. In fact some patients may be given a short-acting beta blocker if the tachycardia and hypertension could cause detrimental effects, though these medications can shorten seizure duration and decrease efficacy of the ECT.

Seizure activity itself is monitored in a few different ways. The least invasive approach involves a BP cuff inflated around the right lower leg to prevent the muscle relaxant from entering the foot, allowing it to maintain noticeable motor activity during the seizure. Similarly, electromyography (EMG), which measures electrical activity in the muscle, can be used to measure motor movement during the seizure. Additionally, EEG monitoring may be used to observe for seizure activity directly in the brain.

Pregnant patients will require fetal monitoring and careful avoidance of hyperventilation as this can decrease placental blood flow and lead to fetal hypoxia.

What happens after ECT?

After ECT therapy, the patient can expect to have a brief period of confusion and memory loss that could last for several hours. Most patients are able to return to normal day-to-day activities a few hours after the procedure, though they are advised not to drive, make significant decisions or return to work for a period of time as determined by the psychiatrist.

Because ECT does transiently increase intracranial pressure, any patient with a prior history of neurological injury or tumor, stroke or AVM should be monitored carefully for any deterioration in neurological status after the procedure. 

Additionally, serum glucose can be increased due to ECT, so you’ll want to monitor for hyperglycemia as well. 

Throughout the recovery period, the patient should be on continuous monitoring for heart rate, SpO2, respiratory rate and, possibly ETCO2 as well. Blood pressure measurements should be taken according to facility protocol, with measurements every 5 minutes not uncommon. Though it is more likely for a patient to have hypertension due to the catecholamine release, ECT has been shown to cause a decrease in ejection fraction in some patients. Therefore, the RN should monitor for decreased cardiac output in the form of hypotension as well. 

Most patients will complain of a headache that can last up to 8-24 hours after the procedure. As for sustained memory loss, studies indicate standard ECT may not cause more memory loss than standard pharmaceutical treatments. However, it is important to note that studies do show the unilateral ultrabrief modality causes less cognitive impairment than does standard ECT, so this is definitely a therapy to watch as it gains more widespread use.

TL;DR

  • ECT has been shown to be significantly effective in treating severe depression, but can also be used in schizophrenia, bipolar disorder and catatonia
  • The procedure involves the use of anesthesia and a muscle relaxant
  • A BP cuff on the right lower leg prevents the muscle relaxant from entering the foot, giving the practitioner a way to monitor for seizure activity by observing foot movement
  • A bite block will be used for patient safety
  • Seizures can cause arrhythmias and hypertension
  • Most patients will complaint of memory loss, confusion and a headache immediately following the procedure

 

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References:

American Psychiatric Association. (2019). What is Electroconvulsive therapy (ECT)? American Psychiatric Association. https://www.psychiatry.org/patients-families/ect

Johns Hopkins Medicine. (2018). How ECT relieves depression. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/news/articles/how-ect-relieves-depression

Kellner, C., Keck, P., & Solomon, D. (2020). Bipolar disorder in adults: Indications for and efficacy of electroconvulsive therapy (ECT). https://www.uptodate.com/contents/bipolar-disorder-in-adults-indications-for-and-efficacy-of-electroconvulsive-therapy-ect?search=Electroconvulsive%20therapy&source=search_result&selectedTitle=6~131&usage_type=default&display_rank=6

Kellner, C., Roy-Byrne, P. P., & Solomon, D. (2020). Overview of electroconvulsive therapy (ECT) for adults. https://www.uptodate.com/contents/overview-of-electroconvulsive-therapy-ect-for-adults?search=Electroconvulsive%20therapy&source=search_result&selectedTitle=1~131&usage_type=default&display_rank=1

Salik, I., & Marwaha, R. (2020). Electroconvulsive therapy. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK538266/