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Here is an essay on ‘Electroconvulsive Therapy (ECT)’ for class 11 and 12. Find paragraphs, long and short essays on ‘Electroconvulsive Therapy (ECT)’ especially written for school and college students.
Essay on Electroconvulsive Therapy (ECT)
Essay Contents:
- Essay on the Indications of ECT
- Essay on the Side Effects of ECT
- Essay on the Mode of Action of ECT
- Essay on the Types of ECT
- Essay on the Common Myths of ECT
1. Essay on the Indications of ECT:
(ECT, Also Called Electroshock Or Shock Therapy Or Electroplexy Therapy). ECT was introduced in Schizophrenia by Cerletti and Bini in 1937 and in depression by Jarvie in 1954.
The main indications of ECT include:
i. Depressive illness:
ECT is not a treatment of unhappiness or just sad mood. It cannot mend marriages or restore to the bereaved their relatives. It cannot control the impulsive suicides (without any underlying major psychiatric disorders).
ECT is effective treatment in severe depressive illness especially with somatic features (i.e., sleep disturbance, loss of appetite and weight, psychomotor retardation etc.) and psychotic symptoms (e.g., delusions, feeling of guilt, suicidal tendencies etc.). The main indications of ECT in a patient with depression are given in Table 33.1.
In different studies, Electroconvulsive therapy has been found to be equally or more effective than tricyclic antidepressants or MAO inhibitors. The combination of ECT and antidepressants has been found to produce fewer relapses at follow up.
ii. Schizophrenia:
ECT produces greater early symptomatic relief than the neuroleptics but when both are combined, the benefit is maximum.
The main indications of ECT in schizophrenia are:
a) Excitement (secondary to catatonia or delusions).
b) Stupor (catatonic).
c) Acute schizophrenic episode.
d) Intolerable or resistant to drugs.
e) Puerperal schizophrenia.
f) Schizophrenic episode in first trimester of pregnancy.
g) Schizophrenia in the presence of chronic physical illness when drugs are contraindicated.
h) Depression in the schizophrenia patients with acute onset, catatonic features and absence of Schneiderian first rank symptoms and negative symptoms respond favourable to ECT. ECT is not effective in chronic schizophrenia, unless there is marked depressive symptoms.
iii. Mania:
Butyrophenones (e.g., haloperidol, droperidol), phenothiazines, lithium and other mood stabilizers represent the mainstay of treatment for manic illness. ECT may produce greater and rapid symptoms relief.
The main indications of ECT in manic illness are:
a) Excited or uncooperative behaviour.
b) Bipolar mood disorder with mixed features.
c) Bipolar mood disorder-rapid cyclers.
d) Others-mania in first trimester of pregnancy, puerperal mania, schizophrenia.
iv. Postpartum Psychosis:
Some reports indicate that ECT is the treatment of choice in Puerperal psychosis (especially depressive or bipolar type or mixed type). ECT can be safely given to mothers who are breast-feeding their children.
v. Schizo Affective Disorders:
ECT is an effective mode of treatment in patients with schizodepression, where neuroleptics precipitate depression and antidepressants may worsen schizophrenic symptoms.
vi. Other Conditions:
There is no evidence that ECT is an effective treatment in obsessive compulsive disorders, anorexia nervosa, confusional states, sleep disorders or as an aid to narcotic drug withdrawal. Some patients with atypical pain disorder or hyponchodriacal neurosis may have an underlying depression and respond to ECT.
It is also useful in psychotic patients who have underlying mental retardation, epilepsy, organic mental disorders and delirium tremens. ECT has also been tried in anorexia nervosa, neurodermatitis, phantom limb and trigeminal neuralgia. Parkinson’s disease, depression with dementia, NMS, refractory epilepsy or status, post stroke depression, catatonia etc.
2. Essay on the Side Effects of ECT:
These can be:
(a) Early:
i. Headache, Body aches and Vomiting:
Headache, Body aches and Vomiting (due to temporary increase in intracranial pressure and myalgias).
ii. Confusion:
It is usually slight and temporary. Prolonged confusion can be due to underlying organic illness or when duration of current or voltage was more. It can be controlled by oxygenation or giving injection of benzodiazepines or neuroleptics. The threshold for seizure varies from person to person and the voltage of current should be individualized.
iii. Amnesia (both retrograde and anterograde):
Memory impairment that occurs with ECT is highly variable. A majority of patients report no problems with their memory. But in some patients, the information acquired during days and weeks prior to, during and for several weeks following ECT may be impaired. The memory loss is short term and may last from a few days to few months (from 9 days to 9 months). The memory loss is believed to be due to neuronal hypoxia during seizure.
It can be minimized by:
a) Using unilateral ECT.
b) Oxygenation before and after seizure.
c) Recall of major events or routines before ECT.
d) Giving individualized minimal voltage and current.
e) Giving minimum number of ECT’s with proper spacing.
f) Avoiding in elderly if hypertensive or diabetic.
g) Use of brief pulse stimulation than sine- wave stimulation.
iv. Other:
Other rare complications like fractures (of thoracic spine and long bones e.g., femur, humerus are commonest), dislocations (of temporomandibular joint, shoulder, wrist joint are common) and fat embolism. Mania has been rarely reported. ECT may occasionally precipitate excitement in schizophrenic patients and neurotoxicity of lithium. Tuberculosis may spread from cavity.
(b) Late side effects:
I. At 6 to 9 months after course, no impairment of memory on objective testing, subjective impairment is rated more often in patients who have received bilateral ECT.
II. (?) Brain damage: There are reports of diffuse petechial haemorrhage and neuronal degeneration in ECT facilities. However nearly all studies refer to pre-1950s when unmodified convulsions used.
Mortality:
The deaths are rare after ECT. It has been estimated as 1 to 10 per lac ECT treatments. The main reasons are due to wrong selection of patients (where a latent heart disease or neuroleptic or antidepressants induced arrhythmias have been overlooked) or giving direct, unmodified ECT in parents who are not fasting.
Reasons of Death:
i. 50% of deaths are due to adverse effect of ECT on cardiovascular system. Coronary thrombosis and cardiac arrest occurs due to vagal inhibition.
ii. Sometimes aspiration of gastric contents and respirator)’ depression may cause death.
Recent studies have shown that the mortality rates are lower in patients treated with ECT than those receiving neither ECT nor drugs.
Contraindications:
(a) Absolute:
The only absolute contraindication to ECT is raised intracranial pressure (Remember the space occupying lesions in the frontal cortex, front parietal region or small diffused lesions may not produce raised intracranial pressure).
(b) Relative:
i. Contraindications to ECT:
They are:
a) Myocardial infarct in previous 2 years.
b) Other cardiac disease including arrhythmias.
c) History of cerebral infarction.
d) Pulmonary disease (cavitating tuberculosis, pneumonia, bronchial asthma etc.).
e) Others e.g., fractures, myopathies, fever, dehydration, glaucoma, etc.
ii. Contraindications to Anaesthesia and Other Agents:
The contraindications consist to those to atropine (glaucoma, arrhythmias, prostatic hypertrophy etc.), succinylcholine (myasthenia gravis, myopathies, those with family history of pseudocholineesterase deficiency etc.) and barbiturates (porphyria, hepatic disorders, respiratory dysfunctions etc.). ECT can be safely given in women during any stage of pregnancy, patients with cardiac pacemakers and to epileptics.
iii. Psychological Contraindications:
Some reports indicate that the following are the relative psychological contraindications to ECT and may show either a deterioration or no response.
a) Phobic neurosis
b) Depersonalization syndrome
c) Obsessive compulsive disorder
d) Hysterical neurosis
e) Primary hypochondriacal neurosis
3. Essay on the Mode of Action of ECT:
The exact mode of action is unknown.
The various hypotheses are:
i. The repeated rapid induction of unconsciousness.
ii. The passage of electricity across the brain.
iii. The induction of a bilateral grand mal epileptic seizure.
iv. The administration of an anaesthetic drug, a muscle relaxant and sometimes atropine.
v. Considerable medical and nursing attention.
vi. A varied set of attitudes and expectations on the part of the patient and the family. It appears that the electricity and / or epileptic fit are necessary for ECT to exert its full effect but that in non-deluded depressed patients other factors such as 1, 5 or 6 above may play a part. Studies carried out on unmodified ECT indicate that the anaesthetic agent and muscle relaxant drugs are not essential. The electric stimulus without producing fit is not effective.
There is sensitive evidence that the cumulative duration of convulsive activity through the course of treatment was positively correlated with clinical outcome. Supraliminal stimulation does not enhance the therapeutic effect.
Low dosage bilateral ECT with the amount of current titrated to just produce a seizure appears to be highly effective. The amount of energy is however important for unilateral ECT and one needs more than the minimal required to just produce a seizure.
There is no evidence that ECT works by inducing memory impairment, fear, by punishing the patient (in accordance with his depressive view of himself).
Repeated ECT (or electroconvulsive shocks, ECS) may alter the affinity of noradrenergic, dopaminergic and serotinergic receptors for pharmacological agents.
4. Essay on the Types of ECT:
The types of ECT depend on:
(a) Mode of its Administration:
Bilateral (if electrodes are placed on both sides of skull and current is passed) or unilateral (current is passed to non-dominant hemisphere).
Administration of ECT:
(a) Before:
i. Explanation to the patient (and relatives):
As full an explanation as possible should be given.
It is aimed at:
a) Fears and fantasies about the treatment are often allayed by the facts and rarely made worse.
b) Description of the purpose of the treatment and procedure involved.
c) Reassuring the patient that the treatment takes only a few minutes, is not painful, that there is no need to undress and that sleep in induced by an injection before the treatment.
d) Repeat the explanation at the end of treatment as the patient may forget due to memory impairment.
ii. Consent:
i. Informed or real consent requires an understanding of the nature, purpose and likely consequences of a treatment. The benefits and dangers of ECT should be clearly written on a consent form. Consent is usually given to a course of treatment and it may be withdrawn by the patient at any stage.
In all cases (e.g., catatonic or depressive stupor) informed consent may also be taken from a close relative. In rare cases, a group of psychiatrists (usually 2) may decide about the treatment weighing benefits against dangers, if the patient is unable to make a rational decision but relatives, consent should be taken.
iii. Full Physical Examination:
It should also include:
a) Full discussion about any significant organic pathology with anaesthetist.
b) Ensure empty stomach (at least 6 hours); full resuscitory equipment.
c) Requisite investigations (like blood and urine examination, ECG, X-ray of chest and skull, Fundus Oculi).
d) Baseline monitoring of pulse rate, blood pressure, ECG and EEG (if possible).
e) The artificial dentures, hairpins, jewellery etc. should be removed.
f) The patient should ideally wear a loose gown and is made to lie on a hard bed.
iv. Testing for Cerebral Dominance:
This should be carried out routinely on all patients who are to receive unilateral ECT.
a) Right handed patients nearly all have left hemisphere dominant for language. .
b) Left-handed population is heterogeneous for lateralization, a substantial proportion of left handers being the left hemisphere dominant for language.
c) In case of doubt, give first ECT to one hemisphere and second to the opposite. Treatment should then continue on the side on which orientation recovered most rapidly.
(b) Application:
i. Premedication and Anaesthetic:
The following agents are used:
i. Anaeshetic Agent:
Methohexitone sodium (0.2% solution in 5% dextrose) is the drug of choice for ECT anaesthesia. It gives quicker induction and recovery and produces fewer postictal ECG abnormalities particularly atrial and ventricular ectopic. The only advantage of thiopentone is that recovery is slower and postictal confusion is masked by sleep. In India, thiopentone is commonly used (0.25 gm in 10C.C.) i.e. 5-10 c.c. of 2.5% solution and not 5.0% solution given over 20 to 25 seconds. Its main indication is to produce anaesthesia (but it increases seizure threshold, it decreases threshold to pain and is a poor muscle relaxant).
At some centres, an inhaling agent (flurothyl) is used (as it does not alter the seizure threshold and so minimal current has to be given to produce seizure).
a. Muscle Relaxant:
A muscle relaxant like succinylcholine is used. It can be given through the same needle as the anaesthetic agent but from a different syringe (thiopentone is strongly alkaline while succinylcholine is acidic and both precipitates if given in the same syringe). Its dose is about 30mg intravenously (more dose may be required in patients with rheumatoid arthritis i.e. 50mg). The dose should be adjusted as not to abolish all signs of convulsion.
b. Atropine:
Atropine should not be given routinely by subcutaneous or intramuscular route as a premeditation unless there has been a previous problem with excess salivation, bronchial secretion. The main reason to give atropine is to block the vagus nerve and so protect the heart from bradycardia and arrhythmias.
Vagal blockade can be achieved by giving atropine sulphate 0.6 to 1 mg intravenous at the same time as an anaesthetic agent (or 1 mg atropine sulphate subcutaneously 30 minutes before the procedure). Bradycardia is a rare complication and so it is not necessary to give atropine at all during ECT. There is also doubt whether a dose (as given) achieves adequate blockade.
c. Sequence of injection:
First, give the anaesthetic agent and then the muscle relaxant (if muscle relaxant is given before anaesthetic, it will produce an embarrasing respiratory embarrassment).
d. Oxygenation:
Oxygen should be given before and after the period of succinylcholine-induced apnoea. If this is done adequately cerebral hypoxia does not occur during ECT. It also reduces the seizure threshold.
ii. Use of other Agents:
Direct or unmodified (when anaesthetic agents are not used) or indirect or modified (when the patient is made unconscious with the help of anaesthesia before passing the current). Bilateral modified ECT is most commonly used.
iii. Unilateral/Bilateral ECT:
The conventional belief that bilateral ECT (B/ECT) and unilateral right sided ECT (U/ECT) are equal in therapeutic properties is no longer tenable. The general impression is that B/ECT is more effective while U/ECT produces less cognitive impairment. Both types of treatment are effective but B/ECT is more potent. It is however associated with greater memory impairment and persistent amnesia.
How to Know if a Fit has Occurred:
i. The most reliable is EEG monitoring.
ii. Isolate one arm by inflating a blood pressure cuff to above systolic blood pressure before the muscle relaxant is given. It will not become paralyzed by the relaxant and will show twitchings. When unilateral ECT is used, apply cuff to the ipsilateral forearm.
Others:
The other signs such as bilateral plantar extensor, reaction of pupil (if constriction and then slow dilatation) are not reliable (especially if unilateral ECT is used).
What to do if no convulsion:
A psychiatrist has to decide within a few seconds;
a) Check with all members of the ECT team that no signs of a fit occurred. It is more important when unilateral ECT is used and also, if fit has occurred, it will increase the seizure threshold.
b) Ask the anaesthetist to ventilate the patient with pure O2. This lowers the seizure threshold.
c) Check that the electrode sites are well-pressed, especially if patient’s scalp is hairy or oily.
d) Check that interelectrode space is dry and that the electrodes were spaced sufficiently apart.
e) Apply a second stimulus using very firm pressure on electrodes.
f) If there is still no fit, do not repeat the stimulus, make a clear note in the ECT record that no fit has occurred.
g) Check the patient’s medication, particularly benzodiazepines. They need to be topped. Also give minimum dose of anaesthetic.
h) At the next session, make sure that patient is well oxygenated. Use a higher setting and use the tourniquet to check if fit has occurred.
i) Occasional patients will not have a fit during ECT unless, a large or prolonged stimulus is given. In these cases-do lateral X-ray skull and use the thinnest area for electrode placement or give a small dose of phenothiazine several hours before ECT in an attempt to lower the threshold.
Number and Frequency of Treatments:
A set number of treatments should not be prescribed. Assess the patient after each ECT (better on the next day or the spacing day).
Most patients need 4 to 12 ECT’s:
a) There is some evidence that elderly require more treatments.
b) There is no value of giving extra ECTs after symptomatic improvement in the hope to prevent relapse (Most relapses e.g. 70% occur within 2 weeks).
c) If there is no improvement in patient’s symptoms after 6 to 8 ECTs, stop the course.
d) Treatment should be given 2 to 3 times a week (Daily ECT is not more efficacious, it rather produces more memory impairment).
e) Once a week treatment may be indicated in patients with marked post-treatment confusion or brief hypomanic episodes during treatment.
Unmodified ECT:
When anesthetist is not available or when anaesthesia cannot be given (e.g. severe liver damage) or when it is an emergency (patient is too aggressive that anaesthetist has refused ECT) unmodified ECT can be given with proper precautions (4 to 5 trained attendants to avoid complications e.g. fractures etc.).
Multiple ECT (MECT):
In this treatment, a patient is given a number of ECT in the same treatment session, the patient is anaesthesized for 60 to 90 minutes and 4 to 6 ECT’s are given. There is little evidence that it is more rapidly effective or its effects are enduring. It rather produces post-ECT confusion and is best avoided.
Regressive Electroshock Therapy (REST):
This treatment’s acronym could hardly be more appropriate. The term regressive was coined to describe the syndrome of confusion, incontinence and inability to feed patients, developed after treatment. It was introduced for schizophrenia. It is not used.
Maintenance ECT:
This involves giving treatments at regular intervals to chronically relapsing depressed patients. Shocks are given once every 2 weeks or sometimes monthly. Its efficacy has not been scientifically evaluated.
Misconceptions:
Much of the criticism of ECT is ill informed. ECT has become the ‘stepchild’, of psychiatry with regard to therapy, with no one to support it in comparison to drug therapy which has the backing of drug companies financing so called “drug research”.
The most extreme critics reject the notion that it has any therapeutic benefits. Others believe that whatever small benefits it might have are far overweighed by the attendant hazards. Yet other claim that little or nothing is known about how it works. In fact, there has been a great deal of research into ECT.
5. Essay on the Common Myths about ECT:
The common myths held by people and even doctors about ECT are:
i. Shock Therapy Causes Permanent Brain Damage:
Except for transient memory defect (only in 30 to 60 percent patients), the evidence of permanent brain damage is lacking, despite extensive study in its physiology and pathology. Lipman et al. (1985) reported a patient who received 1250 treatments and his brain postmortem findings were normal.
ii. Memory Loss is Permanent:
The memory impairment (only in few patients) remains for about 9 days to 9 months (only in 18 to 67 percent of cases), which is due to effect of current rather than convulsion. Other anaesthetic agents like flurothyl etc., with no electric currents, can also be used to induce convulsions. Moreover, the advent of unipolar ECT, oxygen therapy and voltage regulating machines (current should be used in minimum voltage and duration), the memory impairment can be avoided.
iii. Shock and Convulsion are Essential:
Shock is defined as the perception of the electric currents used to induce a convulsion or as the evocation of fear, panic and anxiety that may accompany any stressful experience. Neither type of shock is essential to the ECT process. Today, with the advent of anaesthesia, patient experiences neither panic nor pain. Seizures may also be induced by an anaesthetic inhalant flurothyl, with no electrical currents and these are as effective as ECT.
iv. ECT is not as effective as Other Therapies:
ECT is the treatment of choice in suicidal, excited, stuporous, pregnant or breast feeding females, elderly and those patients, who are intolerable or resistant to drugs. ECT also improves the efficacy of drugs used in treatment of schizophrenia and depression.
v. The Mode of Action of ECT is Unknown:
Hence, it should not be used. If lack of understanding of the mode of action were a sufficient basis for the withdrawal of a medical therapy, we would have to discard not only ECT but all therapies used in neuropsychiatry, including the drug, therapies, psychotherapy and behaviour therapy.
vi. ECT Can Cause Death:
If a patient is properly prepared and investigated, the risk of death is one in 10,000 (which is equal to that of complication of anaesthesia or less than normal mortality rate in a population). Oxygenation, sedation and muscle relaxants reduce the complications of ECT without altering its efficacy. Moreover, the voltage and duration of current is also much less and it does not pass through whole of the body (but only through brain).
vii. ECT Makes the Patient Resistant to Drugs And it is the Last Treatment Available:
This is not true because ECT not only increases the efficacy of drugs but it is the first line treatment for many types of psychiatric illnesses (suicidal depression, acute psychosis, postpartum psychosis, excitement or stupor etc.).
Relinquishing the myths and changing the faulty attitudes toward ECT can only remove our ignorance. ECT remains one of the most effective, cheap (especially in India, where patients cannot afford long term therapy with costly drugs) and safe mode of therapy for many psychological problems.