ECT

Electroconvulsive Therapy

ECT is a form of brain stimulation used to help in recovery in severe depression, bipolar disorder and schizophrenia.

The Process

1. Consent

You doctor will explain the process to you and ask for your permission. Without this, he or she will not proceed.

2. Medical clearance

You will be referred to your primary provider or a family doctor for medical clearance. If you are in the hospital, one of the hospital providers might do this. If you have a complex medical history, they might confer with your sub-specialist such as cardiologist, pulmonologist, surgeon or oncologist. You might be required to take blood draws, and might need to provide a urine sample as well. Imaging including chest Xray and CT scans are sometimes indicated as well. Generally, this should be completed in a day or so in a hospital setting and a little longer in the outpatient clinic.

3. The Night before

You will be asked to not take anything by mouth after midnight before the procedure. This includes gum and coffee. Its better to not brush your teeth as well. Your provider will let you know how to take your medications and insulin around the treatment.

Generally, psychiatric medications may be continued with a few exceptions.

A: Lithium: Lithium is generally not used in the course of the treatments as it can lead to confusion. Your psychiatrist will advise you on how to proceed with this.

B: Benzodiazepines: Medications like alprazolam, lorazepam, clonazepam and similar compounds can increase seizure threshold and make ECT less effective. If you have been using them on a regular basis, legally or illegally, please share with your psychiatrist as suddenly stopping the medication can be very harmful and lead to adverse outcomes.

C: Anti-seizure medications and mood stabilizers like valproic acid, lamotrigine, carbamazepine are assessed on an individual basis. Your psychiatrist will advise you on this.

Please refrain from adjusting medications yourself and follow what your provider’s directions.

The Procedure

Anxiety prior to the procedure is normal. If you accidentally took a few sips or water or coffee, please let your provider know. Aspiration of stomach contents into the lungs, however small, can cause severe consequences.

Once you enter the ECT area, you will be checked in, your vitals will be checked and the nurse will start an IV. After asking for your permission to proceed, the psychiatrist will give the anesthetist a green flag to proceed. If you have changed your mind and you do not want to proceed, you can decline further interventions and leave.

Once the anesthetist starts, he will give you a general anesthetic to make you unconscious. Etomidate and methohexital are two commonly used agents. The anesthetist would then inject the muscle relaxing agent such as succinylcholine so your body does not move when the treatment is done. You will be getting oxygen through a mask at this point. Sometimes, it is necessary to intubate a patient if airway management is hard, and a tube is passed through the throat. However, this is required infrequently.

Muscle relaxants are generally short-lived so your psychiatrist will deliver the stimulus about two minutes of the injection. The anesthetist will continue to monitor your body functions including heart rate, oxygen saturation and airway and administer drugs to maintain your cardiovascular stability.

After the delivery of the stimulus, your electrical activity in the brain is monitored to study the seizure. Once the seizure is over, the anesthetist monitors the anesthesia and you will be moved to the recovery room. The recovery area will house you for about 30-45 minutes until you are alert and awake and ready to go home. Remember that you should not drive after treatment and if you are going home, you should be monitored by someone.

ECT Equipment

ECT suite generally includes anesthetic equipment needed to monitor your status during the treatment and the equipment for seizures itself.

ECT machines are FDA regulated and are designed to have parameters within the FDA guidelines. Two main manufacturers of the equipment include MECTA corporation and Thymatron. The machines are generally similar and are different in their interfaces.

Pulse Width

Pulse width (PW) can range from 0.3ms to 1ms. Lower PW generally causes less cognitive side effects.

Frequency

The number of wave cycles per second ; this perimeter is used for determining total charge delivered.

Current

Current measured in mA which will be delivered through the electrodes. Generally, it is a low number.

Duration

It can vary from a fraction of second to 8 seconds, depending on the settings. The total charge set by the machine cannot be exceeded.

Total Charge

568.3-576 mC is the total charge delivered depending on the settings.

Current (in Amperes) X Pulse width X Frequency X 2 (Since the pulses are bi-directional) = Total charge in mC

Since the total charge delivered is dependent on several variables, increase in one variable would require a decrease in another variable at a constant charge.

A common starting setting is 120mC. Some studies show that despite a therapeutic seizure duration, charge of more than 350mC results in better clinical outcome

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