Electroconvulsive Therapy (ECT)

Psychiatry is the study and treatment of mental illness. Cereleti and Bini were the First to conduct electrical induction of seizures in the patient to produce a successful treatment response.

Types of Electroconvulsive Therapy (ECT)

There are two types of ECT.

• Direct ECT, Performed without anesthesia or muscle relaxants, is prohibited in India due to its higher risk of complications or side effects, such as fractures and tooth dislocation. This information is crucial for understanding why it is not commonly used nowadays.
• Modified / indirect ECT is performed after administering anesthetic agents and muscle relaxants. Anesthetic agents like Methohexital are most commonly used.

There are some Proposed hypotheses to understand the mechanism of action of the electroconvulsive therapy.

• There could be changes in neurotransmitters, like Downregulation of postsynaptic beta-adrenergic receptors
• Increase in BDNF (Brain-derived neurotrophic factor)
• ECT brings about Structural changes that cause Neurogenesis in the hippocampus
• Neurophysiological changes can also be observed after ECT- During a generalized seizure, there is an increase in cerebral blood flow, cerebral metabolism, and the brain permeability to blood. In the post-ictal period, there is a decrease in cerebral blood flow and cerebral metabolism. This usually correlates with treatment outcome.

ECT uses a mild electric shock to induce brief seizures in the patient. Understanding the various placements of electrodes is key. For this purpose, a range of configurations have been developed. These include bilateral ECT, where leads are placed on both sides of the scalp, and unilateral ECT, which is done on one side. This detailed knowledge empowers us to understand the nuances of ECT procedures.

Unilateral ECT is done on the Right side only using d'ELIA placement). This has a better cognitive side effects profile and Is used increasingly nowadays.

Electroconvulsive therapy, shock therapy, or electroshock therapy is a serious procedure, and therefore, it becomes really important for the doctor to monitor the seizures closely. One should Observe tonic-clonic movement closely. Evidence of seizure activity should be monitored using EEG or EMG. For a seizure to be effective in the course of ECT, it should last at least 25 seconds.

In case of Prolonged seizure where it is  > 180 seconds or status epilepticus, the session should be Terminated.

Also Read: Attention Deficit Hyperactivity Disorder (ADHD)

ECT should be done at most 2-3 times a week.

Certain indications have shown significant improvements with electroconvulsive therapy. These indications are very important for competitive exams like NEET-PG, nEXT, and FMGE. They are enlisted below:

1. MDD - Major Depressive Disorder
   • MDD is the most common indication for ECT.
   • Depression with suicidal risk - treatment of choice as it has the earliest onset of action
   • Depression with stupor/ severe agitation
   • Depression with psychotic symptoms
   • Failed medication trials/ intolerance to medications
   • Treatment of choice in a pregnant woman with depression and suicidal tendencies who cannot take medicines
2. Manic episodes
   • When unresponsive /intolerant to medications
   • Manic behavior has produced dangerous levels of exhaustion
   • Lithium lowers the seizure threshold. But has complications post ECT like Confusion and delirium. Lithium should be Discontinued 2 days before ECT.
3. Schizophrenia
   • Catatonic Schizophrenia
   • Schizophrenia with positive/affective/ marked symptoms for which Antipsychotics have been given initially
   • ECT not used for chronic schizophrenia
   • Used for intolerant/unresponsive patients to medications
4. Other indications
   • Obsessive-compulsive disorder (OCD)
   • Neuroleptic malignant syndrome
   • Hypopituitarism
   • Intractable seizure disorder
   • On and off phenomenon of Parkinsonism

There are no absolute Contraindications to ECT. Unlike most in-hospital procedures, Pregnancy is not a contraindication for ECT. Certain relative contraindications to ECT are:

• Presence of Space occupying CNS lesions. ECT may cause Edema and brain herniation.
• Raised intracerebral pressure as during ECT, CSF increases.
• Cerebrovascular diseases ECT may cause cerebral bleeding
• Recent Myocardial Infarctions
• Severe pulmonary disease
• Retinal detachment

Electroconvulsive therapy is also known to have certain side effects. But here, the doctor has to make a judgment regarding the paint’s condition versus the side effects of ECT. Memory impairments could occur. Though they are usually mild, they are a significant complication of ECT.

Headaches, confusion, delirium, nausea and vomiting, muscle pain, and fractures are some other side effects associated with ECT.

Also Read: Sleep Disorder : Symptoms, Causes & Treatment

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