Electroconvulsive Therapy ECT and other procedures 1 Objectives

Electroconvulsive Therapy (ECT) and other procedures 1

Objectives Gain an understanding of the origins of ECT as an EBP for psychiatric symptoms/d/o’s Analyze the use, indications, mechanism of action, and adverse effects of ◦ ◦ Electroconvulsive therapy (ECT), Phototherapy, Deep brain stimulation, and Vagal Nerve Stimulation as treatment for psychiatric illness 2

History of ECT Intervention Seizures were known to produce improvement of psychiatric symptoms for hundreds of years. Camphor-induced seizures were used in the 16 th Century to reduce psychosis & mania. ECT was formally introduced in Italy in 1938 by Cerletti & Bini. 3

Mechanism of Action ECT produces rapid improvement in affective symptoms. Exact mechanism of action is unknown. Theories ◦ improves dopaminergic, serotonergic, and adrenergic neurotransmission ◦ Increases in brain-derived neurotrophic factor (BDNF) (regulates neuro cell growth and involved with NE and serotonin) ◦ Anticonvulsant effect r/t antidepressant effect 4

Main Indications Major Depressive Disorder ◦ 80% response rate is better than antidepressant meds. Acute mania or affective disorders with psychosis Schizophrenia ◦ Abrupt onset ◦ Catatonia 5

Factors to consider ◦ Need for rapid, definitive response ◦ ◦ Acute SI ruminations & behavior Risks of other tx’s Previous positive results from ECT Pregnancy; elderly Lower morbidity/mortality than with antidepressant mediations Medication trials failed 6

Side Effects Brief episodes of hypo- or hypertension, brady-or tachycardia & minor arrhythmias may occur. Common short term SE: headache, N/V, & muscle pain Lengthy seizures may contribute to more disorientation and confusion Increased falls risk following the procedure Memory loss is a troublesome long-term effect in some. Mostly, confusion and memory loss is short-term during tx 7

Contraindication for ECT Patients with increased: Intracranial pressure Aortic and cerebral aneurysms Recent CVA Caution with cardiac conduction problems Retinal detachment Caution with certain brain tumors Pt’s with high risk for complications from anesthesia. ◦ High-risk pregnancy ◦ ◦ ◦ ◦ 8

Nurse’s Role Maintain NPO status Obtain Informed Consent Emotional support and education Knowledge of available RX options, risks & consequences of procedure Monitoring Medication administration 9

ECT Procedure 10

The Procedure Done in OR theater During ECT ◦ Emergency supplies (e. g. , crash cart) ◦ IV access; monitor vitals; bite guard ◦ (EEG is monitored by physician) ◦ IM atropine approx 30 min prior ◦ Give short acting anesthesia (i. e. , methohexital) & muscle relaxant (i. e. , succinylcholine). 100% O 2 is given by ambu-bag/airway ◦ Oxygen is given throughout the procedure. A brief electrical current is passed through the brain to produce a generalized seizure lasting 15 -20 seconds Procedure is done 2 -3 x wk, for 9 to 12. 11

Post ECT Recovery Room Care Oxygen Suction Monitor vital signs Pulse oximeter Emergency equipment Orientation & reassurance MSE returned to acceptable level 12

Post ECT Unit Care Observation of Mental status q 15 min Vital signs q 15 min Level of orientation q 30 min until mental status returns to baseline Assess gag reflex, if present medications may be given and a meal Remove IV Allow to rest in room 13

Other procedures Repetitive magnetic stimulation ◦ Approved for major depression that has not responded to at least one antidepressant drug ◦ More specific areas of the brain less SE’s ◦ No anesthesia ◦ 30 -60 minutes ◦ SE’s: HA, lightheaded, scalp discomfort, rare seizures 14

Other procedures Vagus nerve stimulation (VNS) ◦ Implanted device under the skin ◦ Sends pulses via the vagus nerve every 5 minutes for duration of 30 seconds ◦ Appear to alter NT’s that affect mood such as 5 HT, NE, GABA, glutamate ◦ Approved for treating major depression that has lasted at least 2 years, 4 other treatments were unsuccessful ◦ SE’s: voice changes/hoarseness, cough, sore through, neck pain breathing problems, difficulty swallowing 15

VNS 16

Other procedures Deep Brain Stimulation ◦ Electrodes surgically implanted into abnormally functioning areas of the brain ◦ Pulse generators implanted below the collarbone ◦ Thought to interrupt obsessions, distressing moods, and anxieties ◦ Approved for tremors and Parkinson disease ◦ Under study for depression and OCD ◦ SE’s: seizures, bleeding, muscle contractions, adverse effect on mood, memory, and cognition 17

Other procedures Phototherapy Broad-spectrum fluorescent lamps used daily Seasonal Affective Disorder (SAD) Based on biological rhythms SE’s: eye strain, headaches, irritability, insomnia, fatigue, nausea, dye eyes and mucus membranes ◦ Caution is advised with ophthalmic conditions ◦ ◦ 18