Electoconvulsive Therapy (ECT) & it´s use in depressive disorders

Introduction ECT applies an electrical current to the human brain (patient is under

general anesthesia – at least nowadays)

A general seizure is induced

History Physicians observed that schizophrenic patient improved after a seizure

At first attempted to induce seizure pharmacologically

In 1938 italian physians induced the first seizure by electrical current

Bone fractures were common before the development of muscle relaxants in the 1950s

Indications Main Indication: severe depressive episode

Others: bipolar disorder, schizophrenia, schizoaffective disorder, delirium, and neuroleptic malignant syndrome.

Mechanism of Action Is in fact UNKNOWN

But biochemical changes within the brain have been observed: Increase release of monoamine neurotransmitters (i.e. dopamine, serotonine, and

norepinephrine) Increase release of hypothalamic hormones (prolactin, TSH, endorphins) Decreased metabolic activity in frontal and cingulate cortex

Contraindications (no absolute ones) ECT causes transient increases in blood pressure, pulse, and intracranial

pressure Patient should be evaluated for coronary heart disease before undergoing ECT Arterial hypertension should be well controlled As well as heart failure and valvular heart disease Pulmonary disease (with respect to general anesthesia) Neurologic disease (brain tumors, history of stroke, dementia)

Adverse Effects It is a very safe procedure (mortaliy rate of 0.004 %)

Aspiration pneumonia

Fracture – especially patients with osteoporosis

Dental and tongue injuries

Headache

Nausea

Cognitive impairments (memory loss, thought process – transient, after 15 days cognitive improvement!)

SHORT! Recapitulation Unipolar major depression:

At least one major depressive episode (5 out 9 specified symptoms/signs) NO history of mania (minor depression: 1-3 out of 9 symptoms / signs)

Bipolar disorder At least one major depressive episode PLUS one episode of mania or hypomania

ECT in unipolar severe major depressive episode If treatment with two or three antidepressants fail or patient cannot

tolerate antidepressants

Special considerations: pregnant / lactating, elderly, debilitated, patient request

Indications for first-line therapy: Severe suicidality Catatonia Severe psychosis Malnutrition with food refusal

Efficacy Superior to any other treatment in severe major depressive episode

(remission is induced in 70-90 %) Citalopram induces remission in 30 % Imipramine in 49%

Other conditions – bipolar disorder Severe major depressive episode (as in unipolar disorder)

Mania – usually responds to pharmacotherapy – but: manic delirium ECT may be life saving

Efficacy in bipolar disorder: 78 % (imipramine 59 %)

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