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ECT Manual-NIMHANS Ed.2 Compressed-2
ECT Manual-NIMHANS Ed.2 Compressed-2
2ND EDITION
ECT ROOM
REC0VERY ROOM
ECT ADMINISTRATION
MANUAL
Copyright ©
National Institute of Mental Health &
Neuro Sciences, Bangalore - 560 029
1) Introduction 01
2) Part-I: ECT stimulus 02
3) Part II: ECT procedure 11
4) Part III: ECT in special populations 31
5) Appendices
I. ECT consent form 47
II. Pre-ECT evaluation proforma 49
III. ECT record sheet 51
IV. B4ECT-ReCoDe Questionnaire and score sheet 54
K
AN
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ECT ADMINISTRATION MANUAL 1
I NTRODUCTION
PART – I :
ECT STIMULUS
T he objective of ECT is to electrically induce a generalized seizure, which
is an essential but not sufficient ingredient for therapeutic effect. It is now
established that additional factors like electric dosage relative to the seizure
threshold; and anatomical positioning of electrode determine the efficacy of
ECT (Merkl, Heuser, & Bajbouj, 2009). It is important to understand the role of
electrical stimulus parameters, as they exert neurobiological effects that
determine the efficacy and adverse effects (Peterchevet al, 2010). The twin goals
are to maximize therapeutic effect and minimize adverse effects, especially
cognitive morbidity. Unfortunately, the procedures which enhance the former
often increase the latter too. Hence, an optimal balance between the two must be
attempted by combining appropriate choices on the following parameters:
Earlier ECT machines delivered current in the form of sine waves (Fig.1a).
The slow rising and trailing edges of the sine wave do not produce efficient
cerebral stimulation. This delivers substantial amounts of electrical stimulation
below seizure threshold and continues stimulation even while the neuronal
tissue is in post-depolarization refractory period. This may increase the cognitive
adverse effects without enhancing the benefits. Further, the slow rising current
increases the neuronal threshold. Hence, the sine wave has been modified to
ECT ADMINISTRATION MANUAL 3
eliminate the rising and trailing edges, retaining only the peaks in the form of
‘rectangular’ pulses (Fig. 1b). Stimulus is given in the form of brief pulses
(0.5ms) with no stimulus in between the pulses. Intermittent stimulation using
pulses is more efficient as it allows the tissue to recover from post-depolarization
refractory period. Brief pulse ECT is able to induce seizures with substantially
more efficient, needing less than a third of stimulus dose as compared to the
former if given to a patient with same impedance (200 Ohms, in this example).
Table-1: Comparison of waveforms
NOTE: At conventional threshold settings, SINE: PULSE = 3:1
Parameters which can be chosen by the operator are in bold face.
_______________________________________________________________
Voltage is the electromotive force between the two electrodes which drives
the flow of electrons. The unit is Volt. Over 90% of this force drops as a result
of the impedance offered by the scalp and skull. Across brain tissue less than
10% of applied voltage exists.
Current is the flow of electrons between the electrodes which more
truthfully reflects the stimulus exposure to brain tissue. The unit is Ampere.
Impedance is the resistance (Ohm) offered for the flow of electrons by the
matter between the two electrodes.
The Ohm’s law governs the flow of electrons: Current = Voltage/
Impedance.
_______________________________________________________________
While using the earlier ECT devices of voltage-constant sine-wave stimuli,
the clinicians expressed the stimulus dose in units of volts delivered for a known
duration. This however, poorly reflects the actual stimulus exposure to the
brain.Contemporary methods of stimulus dosimetry supercede older convention.
The values of current/voltage are uniform across the brief pulses and are
ECT ADMINISTRATION MANUAL 5
Frequency: Frequency refers to number of cycles per second and the unit is
Hertz (Hz). In the transformer-based sine wave stimuli, this is always the line
frequency (50Hz or 60 Hz). In brief pulse ECT, the frequency can be varied by
the operator. The term pulses per second (PPS) is preferable in this form of
stimulus. It has been seen that lower frequency of current stimulation is
associated with lower seizure threshold, but it does not have an effect on seizure
duration, ictal cardiovascular responses and therapeutic outcome (Girish et al,
2003; Kotreshet al, 2004). However there is no consensus on the optimum
frequency of stimulation (Peterchev et al., 2010). As per the current
understanding, optimizing other parameters like pulse width and stimulus
duration may be simpler for routine use.
Directionality & Polarity: The stimulus used in ECT is usually
bidirectional, where the direction of the current alternates with each successive
current, as shown in Figure 1. There has been a renewed interest in unidirectional
current, as it has been shown to decrease the seizure threshold (Spellman,
Peterchev & Lisanby, 2009). With unidirectional current, it is possible to provide
specific polarity of currents (anodal v/s cathodal) to specific brain regions.
Varying the polarity of current may lead to differential effects on the underlying
neurons as seen in other brain stimulation techniques. For example, in
transcranial direct current stimulation (tDCS), anodal current potentiates the
activity of the underlying nervous tissue whereas cathodal current has the
opposite effect (Nitsche et al., 2005). Modulation of polarity of the ECT
stimulus is currently being explored, but it is still at a nascent stage.
Pulse amplitude: The amplitude of the delivered current is an important
determinant of the volume of nervous tissue that is directly stimulated by the
ECT. Modern ECT machines usually maintain the current constant at 800 or 900
mA to ensure that adequate charges are delivered. Some machines allow some
degree of manipulation of the current delivered. Currents lower than 800 mA do
not result in optimal electric fields. Likewise, currents above 800 mA do not
increase the electric fields across brain tissue. However, it has been seen recently
ECT ADMINISTRATION MANUAL 7
that current amplitudes less than 800 mA can elicit adequate seizures (Peterchev
et al., 2010). The clinical significance of manipulating the amplitude of current
has not been demonstrated conclusively.
Charge: Charge is the total amount of electrons traversing the inter-electrode
tissue including the brain. It is the product of current and actual duration of
stimulus. Its unit is Coulomb or milli-Coulomb(mC). Stimulus estimation by
charge (coulometry) is used in contemporary ECT practice. In brief pulse ECT,
charge = current x pulse width xpulse frequency x length of train. For example ;
for a current of 0.8 A, pulse width of 1 ms, pulse frequency of 100 and a train
length of 1.5 ms, the charge provided will be 120 mC. The length of the train is
usually varied to provide the desired charge by keeping the other parameters
constant.
2. Stimulus intensity
The stimulus intensity (measured as charge in milli-Coulomb) is an important
determinant of therapeutic efficacy and cognitive adverse effects of ECT.
Treatment with stimulus intensity barely above seizure threshold may be less
effective despite production of generalized seizure. This is more apparent for
unilateral ECT. It is recommended that the stimulus intensity should be
modestly to moderately suprathreshold (1.5 to 2.5 times threshold) for bilateral
ECT. For unilateral ECT, the stimulus should be moderately to markedly
suprathreshold (2.5 to 6 times above seizure threshold)(American Psychiatric
Association, 2005; Enns et al, 2010). Unilateral ECT using lesser stimulus
intensities is less effective than bilateral ECT.
Cognitive morbidity is not as much dependent on the absolute dose per
second, as on the degree by which the dose exceeds threshold. Hence, the
stimulus intensity should be titrated carefully to maintain a balance between
efficacy and side-effects. It is recommended that the stimulus titration is carried
out from the lowest setting given in the ECT devices. Usually, this corresponds
to a dose of 30 mC of charge. Increments are made by 25-50% until the seizure
occurrence is confirmed. There is wide variation in seizure threshold across
patients; from 5 to 40 folds in different studies. Formula based titration of
8 ECT ADMINISTRATION MANUAL
the degree and rate of clinical improvement and adverse effects. A typical course
of ECT for depression consists of 6 to 12 sessions. Patients with schizophrenia
require more treatment sessions. The number of treatments required to achieve
clinical response varies widely between patients. Once the patient achieves
remission of symptoms, the ECT course can be terminated. If a patient does not
show noticeable improvement within 6 sessions, a change in technique may be
considered. These include increasing stimulus intensity, switching from
unilateral to bilateral ECT, etc. If the patient shows plateauing of clinical
response despite adequate duration (6-12 sessions) and changes in technique,
the course may be terminated. Unlike pharmacotherapy, the treatment can be
terminated abruptly (American Psychiatric Association, 2005).
Continuation ECT can be considered in rare patients for whom
pharmacotherapy prophylaxis is ineffective or intolerable and sometimes based
on patient preference. Continuation ECT begins after the index course, lasts up
to 6 months, and is designed to prevent relapse of the episode while
maintenance ECT is provided to prevent further episodes for longer periods
(Andrade & Kurinji, 2002; Petrides et al , 2011). For continuation and
maintenance ECT, the frequency of ECT is slowly tapered off to once a month.
The patient should be assessed frequently for adverse effects and the treatment
plan should be updated. Pre-anesthetic evaluation should be conducted at least
once in 6 months for maintenance ECT (American Psychiatric Association,
2005).
The above considerations are however applicable largely to depression.
Similar research in non-depressive patients is lacking. In particular, there is a
need to evolve standards of ECT parameters in mania and schizophrenia. There
is some evidence to suggest that bifrontal ECT is superior in terms of efficacy
and adverse effect profile in patients with mania and schizophrenia (Hiremani et
al, 2008; Phutane et al, 2013).
ECT ADMINISTRATION MANUAL 11
PART – II :
ECT PROCEDURE
A dministration of ECT without a muscle relaxant is known as unmodified
ECT. In modified ECT, anesthesia, muscle relaxant, and the seizure-eliciting
electrical stimulus are administered in the same order (Andrade et al., 2012). Use
of a muscle relaxant prevents musculoskeletal injuries resulting from peripheral
seizures. The anesthetic agent induces sleep and prevents anxiety associated
with the cessation of breathing due to a muscle relaxant. Other medications are
also provided as needed.
Preparation of patient:
Before each treatment, the patient should be assessed for adherence with the
pretreatment orders. The patient should avoid solid food for at least 6 hours
before treatment. Moderate amounts of clear fluids can be taken till 2 hours
before treatment. Oral medications should be taken 2 hours before treatment
with sips of water. The patient should be encouraged to pass urine to prevent
bladder rupture during ECT. Dentures, jewellery, hair clips, contact lenses and
hearing aids should be removed. Hair should be dry and clean. Damp hair and
presence of cream may lead to short-circuiting of the current over scalp.
Modification Procedures:
Short acting barbiturates are commonly used as induction agents.
Methohexitane (0.5-1 mg/kg body weight) is recommended as it has been shown
to have minimal effect on seizure threshold, while ensuring quick induction and
recovery (Mayo et al, 2010). Thiopentone (3-5 mg/kg) is also commonly used,
but may be associated with shorter seizure duration and increased hemodynamic
changes (Saito, 2005). Alternate anesthetic agents and their properties are given
in Table 2. Succinylcholine (0.5-1 mg/kg) is the preferred muscle relaxant due to
its rapid onset, short duration of action, and rapid recovery (Mirzakhani et al,
2012). Higher dose of succinylcholine (1 mg/kg) is more effective in modifying
the peripheral convulsion (Murali et al., 1999). However, the time to recovery
may be longer. It is recommended that 1 mg/kg of succinylcholine dose be used
12 ECT ADMINISTRATION MANUAL
in the first ECT session. For subsequent sessions, the dose may be altered,
depending on the response for optimal motor seizure modification (Murali et al.,
1999)(Mirzakhani et al., 2012).
Table 2 Alternate anesthetic agents
ECT ADMINISTRATION MANUAL 13
Before trolleying the patient into the ECT suite, an IV cannula is inserted
in the left forearm and is maintained till the patient recovers. Patient is
allowed to breathe 100% oxygen through face mask for 3 minutes at 15 -20
breaths per minute.Thiopentone in 2.5% dilution mixed with atropine is injected
from the same syringe. Longer periods of oxygenation may be needed in patients
with myocardial infarction and brief seizures. This is followed by
succinylcholine using a different syringe. Succinylcholine should be given only
after complete loss of consciousness. Before and after succinylcholine, the IV
cannula is flushed with saline.
After injecting the muscle relaxant, the patient is ventilated with 100%
oxygen under positive pressure until he is totally paralyzed and the fasciculations
have ended. Use of mere atmospheric air instead of 100% oxygen or fewer or
no ventilations before stimulus can result in lower oxygen saturation as
revealed by pulse oximetry. Pulse oximetry is recommended at least in medically
compromised patients, e.g. in patients with Chronic Obstructive Pulmonary
Disease (COPD), cardiovascular problems including ischemic heart disease.
Ventilating the patient prior to stimulation reduces anoxia during seizures. A bite
block is placed and the stimulus is administered. The block should be made of
flexible material. Rigid blocks like the Guedel airway are avoided due to risk of
tooth fracture. Positive pressure ventilations should be resumed after
stimulation, continued throughout the seizure and stopped only when the
patient has resumed spontaneous and regular respirations.
Some patients experience muscle aches post-ECT – usually as a result of
intense fasciculations with succinylcholine. A small dose of atracurium about 5
mg prior to succinylcholine is recommended in such cases. Non-depolarising
neuromuscular blockers like atracurium (0.3–0.5 mg/kg) and rocuronium (0.6–
0.9 mg/kg)are also preferred inpatients with actual or potential hypokalemia
(burns, prolonged immobilization), pseudocholinesterase deficiency, organo-
phosphorous poisoning (leads to inhibition of cholinesterase), concomitant
cholinesterase inhibitor use, history of malignant hyperthermia and
neuromuscular disease. However the muscle relaxation produced by these
14 ECT ADMINISTRATION MANUAL
agents is long lasting and may not be complete. They have to be reversed with a
cholinesterase inhibitor like neostigmine.
Atropine (0.6 mg) given along with intravenous anesthetic helps in preventing
vagal effects of electrical stimulation on heart. Glycopyrrolate (0.2-0.4 mg/kg
i.v.) is an alternative which has the advantage of limited CNS effects. When
given intravenously, it should be given 2-3 minutes before seizure induction.
Some advice its use 30 minutes before ECT to dry up secretions. It may not be
required in patients who continue on certain psychotropic drugs, which by their
anti-cholinergic effects would cause sufficient drying of secretions. It is a risk
that a waiting patient may drink water if atropine causes excessive dryness of
mouth. If ECG monitoring is available, use of atropine as a routine pre-
anesthetic may be unnecessary.
Electrode Application
Scalp preparation before applying the electrodes is essential. Non-greasy scalp
surface is recommended. The stimulus electrode skin contact is established by
using electrode jelly. Saline-soaked pads should not be used as conductant on
electrodes. The saline may flow down and short-circuit the two electrodes,
particularly in unilateral ECT. Jelly is preferable as it remains in the electrode site
besides having less corroding effect on the electrodes.
Both electrodes should be held firmly by the treating psychiatrist. The forceps
type of electrodes is discouraged as – (a) this cannot be used for unilateral
application and also (b) the head contour variations can lead to poor electrode-
skin contact. The treating psychiatrist should operate the stimulus release
switch, which is optimally provided on the electrode handle itself.
Seizure Monitoring
It is imperative that the response to stimulation – the seizure– is monitored
and its occurrence confirmed. Unmodified ECT is a dramatic event and the
standard tonic-clonic seizure is not missed. Modified ECT however demands
some method of seizure monitoring. Available method sinclude: Cuff method
and EEG monitoring. However; it has been seen that the length of the seizure
ECT ADMINISTRATION MANUAL 15
The EEG disconnect feature in the ECT machine de-links the EEG
electrodes from the patient electronically, while the stimulus is applied. The
voltages of ECT stimulus can saturate the EEG amplifier and adversely affect
the EEG recording quality. The seizure onset is indicated by occurrence of
spikes and poly spikes which are above 8-10 Hz in frequency. These are
gradually replaced by more rhythmic spike and slow-wave discharges. The
frequency of this slow-wave phase initially is about 4 Hz and reaches 3-2½ Hz.
for the rating of these have been developed. Automated estimation of seizure
duration using signal processing algorithms is possible.With ULECT, EEG
seizure may last longer on the stimulated hemisphere. The discharges may also
be more regular with higher amplitude on this hemisphere. BLECT produces
more symmetric seizure discharges. Methods have been developed to quantify
the seizure amplitude and asymmetry using signal processing algorithms. These
measures may become relevant in assessing the adequacy of seizures in future.
These trends in literature may mandate use of two-channel EEG. The motor
seizure duration is 30% shorter than EEG seizure.
When the stimulus intensity is subthreshold or just at threshold, abortive
seizure or very brief seizure occurs. When it is barely suprathreshold, a long
seizure with low amplitude and absent postictal suppression is seen. When it
becomes substantially suprathreshold, the seizure duration decreases but high
amplitude EEG with postictal suppression is observed (American Psychiatric
Association, 2005).
It is generally suggested that seizure duration below 15 seconds is inadequate.
However, recent evidence suggests that seizure duration is not a marker of
seizure adequacy (Mayur, 2006). Various EEG measures have been suggested to
determine seizure adequacy, but none have been validated. EEG expression may
be affected by various factors like medication status, treatment number, age etc.
Nonetheless, the presence of high amplitude synchronous seizure activity and
post-ictal suppression are associated with better clinical outcome (Thirthalli et
al, 2003; Abhishekh et al., 2013). The occurrence of a generalized seizure
observed either by EEG or cuff method signifies adequate treatment. If in
doubt, the 15 second cutoff can be used.
Other Physiological Monitoring: Vital signs such as blood pressure and
pulse should berecorded before and after ECT. ECG monitoring is considered
mandatory during ECT procedure. Particularly in centers where atropine is not
used routinely, this helps in recognizing vagal bradycardia. ECG monitoring has
distinct merits especially inelderly patients who are more likely to have pre-
existing or occult cardiac pathology. Single channel ECG monitoring of the
ECT ADMINISTRATION MANUAL 19
Psychotropics
of cognitive impairment is more for bilateral, thrice weekly, high dose ECT than
that seen in unilateral, twice weekly, low dose ECT. A recent meta-analysis
showed impairment of orientation, verbal episodic memory, autobiographical
memory, visual episodic memory, attention, psychomotor speed and executive
functions after ECT (Semkovska & McLoughlin, 2010). Most of these deficits
disappear within 15 days after ECT. However, retrograde amnesia of
autobiographical information can be persistent in some patients. This is
especially apparent for events that occur closer to the treatment course. ECT
may also improve some of the cognitive deficits that are secondary to depression
such as processing speed, verbal working memory, and executive function.
Close monitoring of cognitive deficits is recommended in all patients
receiving ECT. A baseline assessment should be conducted before commencing
the treatment and then repeated weekly throughout the course of ECT.The
assessment should be conducted at least 24 hours after ECT to prevent post-
ictal effects (American Psychiatric Association, 2005). If gross deficits are
present, a change of ECT technique or adjustment of medications should be
considered. The evaluation should include at least orientation and memory.
Global assessments like Mini Mental State Examination (MMSE) may not be
sensitive enough to pick the memory deficits. A brief battery called Battery for
ECT Related Cognitive Deficits (B4ECT-ReCoDe), has been designed
specifically for this purpose and validated (Viswanath et al., 2013). It assesses
verbal, visual, working and autobiographic memory, sustained attention,
psychomotor speed and subjective memory impairment. The battery can be
administered within 20-30 minutes.
Outpatient ECT
ECT can be safely provided on outpatient basis with a few precautions.
Outpatient ECTis generally used for continuation and maintenance ECT. For
the initial sessions, inpatient ECT is preferred unless it can be ensured that the
patient will be compliant with the preparation for ECT, including medication
dosage adjustments, avoiding oral intake, bowel and bladder preparation. A
responsible caregiver should be assigned to help the patients in this regard.
24 ECT ADMINISTRATION MANUAL
Further, postictal confusion and acute cognitive disturbance may impair driving
skills. Hence it is mandatory to assign a caregiver to accompany the patient.
Inpatient ECT is preferred in patients who are at high risk of post ECT delirium
(those with preexisting neurological illness and electrolyte disturbances) and
those with comorbid medical illness which increase the risk of ECT related
complications.
Use of unmodified ECT:
Despite the progress in modification of the ECT process, unmodified ECT is
still widely used, especially in developing countries. Around 50% of patients in
India receive unmodified ECT (Chanpattana et al, 2005). Various factors like
lack or unaffordability of anesthesiological support, urgent need for ECT, and
contraindication for anesthesia and/or muscle relaxants have been cited for this
practice(Andrade et al., 2012). In this background, the Indian Association of
Private Psychiatry, the Indian Association of Biological Psychiatry and the
Indian Psychiatric Society issued a joint position statement regarding the use of
unmodified ECT (Andrade et al., 2012). It was pointed out that unmodified
ECT increases the risk of complications like musculoskeletal complications,
pre-ECT anxiety, and post-ECT confusion. Thoracic spinal compression
fractures are the commonest fractures and may be asymptomatic. However, the
authors report risk for these complications may not as large as historically
portrayed. The authors recommended that unmodified ECT should not be used
as a routine form of treatment and should be used only under exceptional
circumstances.
If an unmodified ECT is inevitable, risk factors for musculoskeletal injuries
like muscularity and osteoporosis should be evaluated prior to treatment. A
dental examination should be conducted to look for loose teeth and dental
pathology. X-ray of the thoraco-lumbar spine (anterio-posterior and lateral)
should be done before the first ECT (for comparison) and after completion of
the course of treatment. X-rays may be repeated if the patient develops any
symptoms suggestive of spinal injury. Some authors recommend the use of
diazepam 10 mg slow i.v., 1-3 minutes before the commencement of treatment.
ECT ADMINISTRATION MANUAL 25
References
1. Abhishekh, H. A., Thirthalli, J., Manjegowda, A., Phutane, V. H.,
Muralidharan, K., & Gangadhar, B. N. (2013). Ictal EEG fractal
dimension in ECT predicts outcome at 2 weeks in schizophrenia.
Psychiatry Research, 209(2), 155–159.
2. American Psychiatric Association, & Committee on
Electroconvulsive Therapy. (2005). The Practice of
Electroconvulsive Therapy Recommendations for Treatment,
Training, and Privileging. American Psychiatric Association.
3. Andrade, C., & Kurinji, S. (2002). Continuation and maintenance
ECT: a review of recent research. The journal of ECT, 18(3), 149–
158.
4. Andrade, C., Shah, N., Tharyan, P., Reddy, M. S., Thirunavukarasu,
M., Kallivayalil, R. A., Mohandas, E. (2012). Position statement
and guidelines on unmodified electroconvulsive therapy. Indian
Journal of Psychiatry, 54(2), 119–133.
5. Chanpattana, W., Kunigiri, G., Kramer, B. A., & Gangadhar, B. N.
(2005). Survey of the practice of electroconvulsive therapy in
teaching hospitals in India. The journal of ECT, 21(2), 100–104.
6. Charlson, F., Siskind, D., Doi, S. A. R., McCallum, E., Broome,
A., & Lie, D. C. (2012). ECT efficacy and treatment course: a
systematic review and meta-analysis of twice vs thrice weekly
schedules. Journal of affective disorders, 138(1-2), 1–8.
7. Enns, M. W., Reiss, J. P., & Chan, P. (2010). Electroconvulsive
Therapy. Canadian journal of psychiatry. Revue canadienne de psychiatrie,
55(6), Insert 1–12.
8. Gangadhar, B N, Girish, K., Janakiramiah, N., Subbakrishna, D.
K., Parameshwara, G., & Prasad, K. M. (1998). Formula method
for stimulus setting in bilateral electroconvulsive therapy: relevance
ECT ADMINISTRATION MANUAL 27
17. Kotresh, S., Girish, K., Janakiramaiah, N., Rao, G. U., & Gangadhar,
B. N. (2004). Effect of ECT stimulus parameters on seizure
physiology and outcome. The journal of ECT, 20(1), 10–12.
18. Leiknes, K. A., Jarosh-von Schweder, L., &Høie, B. (2012).
Contemporary use and practice of electroconvulsive therapy
worldwide. Brain and Behavior, 2(3), 283–344.
19. Loo, C. K., Katalinic, N., Martin, D., & Schweitzer, I. (2012). A
review of ultrabrief pulse width electroconvulsive therapy.
Therapeutic Advances in Chronic Disease, 3(2), 69–85.
20. Mayo, C., Kaye, A. D., Conrad, E., Baluch, A., & Frost, E. (2010).
Update on anesthesia considerations for electroconvulsive therapy.
Middle East journal of anesthesiology, 20(4), 493–498.
21. Mayur, P. (2006). Ictal electroencephalographic characteristics
during electroconvulsive therapy: a review of determination and
clinical relevance. The journal of ECT, 22(3), 213–217.
22. Mayur, P. M., Gangadhar, B. N., Janakiramaiah, N., &
Subbakrishna, D. K. (1999). Motor seizure monitoring during
electroconvulsive therapy. The British journal of psychiatry: the journal
of mental science, 174, 270–272.
23. Merkl, A., Heuser, I., &Bajbouj, M. (2009). Antidepressant
electroconvulsive therapy: Mechanism of action, recent advances
and limitations. Experimental Neurology, 219(1), 20–26.
24. Mirzakhani, H., Welch, C. A., Eikermann, M., & Nozari, A. (2012).
Neuromuscular blocking agents for electroconvulsive therapy: a
systematic review: Neuromuscular blocking agents for
electroconvulsive therapy. ActaAnaesthesiologicaScandinavica, 56(1),
3–16.
25. Murali, N., Saravanan, E. S., Ramesh, V. J., Gangadhar, B. N.,
Jananakiramiah, N., Kumar, S. S., Subbakrishna, D. K. (1999). An
ECT ADMINISTRATION MANUAL 29
PART – III :
ECT IN SPECIAL POPULATIONS
even in normal subjects but are more often in cardiac patients. They include
peaked T’ waves, inverted T’ waves and S-T segment depression. Thiopentone
produces more ECG abnormalities than methohexital. ECG abnormalities are
rarely present beyond the acute postictal phase.
Non-convulsive stimulus produces only the vagal effect leading to
bradycardia and can potentially prolong the asystole. The chance of non-
convulsive stimulation is more in the initial titration phase. Despite the general
belief that non-convulsive stimuli are not associated with any CNS morbidity;
the cardiac risk cannot be ignored. The sympatho-adrenal outflow associated
with the convulsive response counteracts the vagal cardiac inhibition. The non-
convulsive stimulus hence, fails to overcome the vagal inhibition. Beta-blockers
increase the risk of asystole in such patients. Atropine pre-medication is used by
most practitioners to prevent bradycardia and asystole. However, it increases
ictal tachycardia and contributes to larger RPP. Glycoprrolate is sometimes used
in place of atropine and which has a lesser chance of inducing tachycardia. In
patients with normodynamic cardiac function, atropine pre-medication as a
routine may not be indicated.
Effects of psychotropic drugs
Tricyclic antidepressantsare known to produce sinus tachycardia, intra-
ventricular conduction abnormalities, and arrhythmias. However they do not
increase CVS risk during ECT. No rationale is offered for their discontinuation
during ECT on grounds of CVS risks. Likewise, lithium also poses no extra risk
to CVS morbidity in the absence of electrolyte disturbances. Benzodiazepines,
by virtue of increasing seizure threshold, contribute to sub-convulsions.
Pre-ECT medical evaluation of high-risk CVS patient
Majority of ECT complications result from cardiovascular risk. The risk is
more apparent in people with pre-existing cardiovascular diseases. The decision
to provide ECT in patient with pre-existing cardiac illness should be taken on a
case-by-case basis after a risk-benefit analysis. The dictum is to titrate pre-ECT
evaluations to each patient with the knowledge of pre-existing CVS disease. A
34 ECT ADMINISTRATION MANUAL
References
1. Abrams, R. (2002). Electroconvulsive therapy (4th ed.). Oxford;
New York: Oxford University Press.
2. American Psychiatric Association, & Committee on
Electroconvulsive Therapy. (2005). The Practice of
Electroconvulsive Therapy Recommendations for Treatment,
Training, and Privileging. American Psychiatric Association.
3. Anderson, E. L., &Reti, I. M. (2009). ECT in pregnancy: a review
of the literature from 1941 to 2007. Psychosomatic medicine, 71(2),
235–242.
4. Christopher, E. J. (2003). Electroconvulsive therapy in the
medically ill. Current psychiatry reports, 5(3), 225–230.
5. Ghaziuddin, N., Kutcher, S. P., Knapp, P., Bernet, W., Arnold, V.,
Beitchman, J., … AACAP. (2004). Practice parameter for use of
electroconvulsive therapy with adolescents. Journal of the American
Academy of Child and Adolescent Psychiatry, 43(12), 1521–1539.
6. Girish, K., Gangadhar, B. N., &Janakiramaiah, N. (2002). ECT in
neurological conditions. Indian Journal of Psychiatry, 44(3), 228–
239.
7. Pandya, M., Pozuelo, L., & Malone, D. (2007). Electroconvulsive
therapy: what the internist needs to know. Cleveland Clinic journal
of medicine, 74(9), 679–685.
8. Royal College of Psychiatrists, Special Committee on ECT, Scott,
A. I. F., & Royal College of Psychiatrists. (2005). The ECT
handbook: the third report of the Royal College of Psychiatrists’ Special
Committee of ECT. London; [Champaign, Ill.]: Royal College of
Psychiatrists/ ; Distributed in North America by Balogh
International.
44 ECT ADMINISTRATION MANUAL
PRACTICE AT NIMHANS
At NIMHANS, modified ECTs are used routinely. Psychiatry senior resident/
consultant, anesthesiologist, trainee residents, psychiatric nurses and other
para-medical staff form the ECT team. The treatment centre comprises a
waiting hall, preparation room, ECT Suite and recovery room.
The ECT suite is equipped with constant current ECT machines, Boyle’s
machines, EEG monitor, ECG monitor and pulse oximeter. Thiopentone (3mg/
kg), atropine (0.65mg) and succinylcholine (0.75mg /kg) are used for anesthesia.
Bilateral ECT is used unless otherwise specified by the referring psychiatric
team. Both bitemporal and bifrontal ECT are used as specified by the referring
psychiatric team. Threshold is estimated using titration method during the first
ECT session. For subsequent sessions, 1.5 times the threshold in bilateral ECT is
the recommended practice; for unilateral ECT 4-6 times threshold stimulus is
used. The frequency of ECT sessions is thrice weekly unless otherwise specified.
The clinical unit can however indicate alternative stimulus standards or session
frequency to be followed in selected cases.
The ECT machine has been designed in collaboration with the
NationalInstitution for Quality and Reliability (NIQR). It offers constant current
pulses of 800 mA strength and 1.5 ms width. The pulses are of alternating
polarity and recur at 125 pulses per second. Ten levels of stimulus can be chosen
by varying the total stimulus train duration from 0.2 to 3.6 seconds. The stimuli
start with a dose of 30mC followed by 60mC and subsequently increments in
steps of 60 mC. The maximum stimulus available is 540mC.
The same machine can also be computerized. In this condition the stimuli can
be chosen in either ‘Auto’ or ‘Manual’ mode. The stimulus settings in the former
are similar to those described earlier, except that the computer sets the stimuli in
doses of 19 steps between 30mC and 540mC, the first two increments are 15mC
and the rest 30mC. In the latter mode, all parameters of the stimuli can be
chosen as desired by the treating doctor. The general preference, however, is to
use the ‘Auto’ mode. The machine is connected to an independent EEG machine
46 ECT ADMINISTRATION MANUAL
APPENDIX-I
ECT CONSENT FORM
Information:
After examination and considering all aspects of your condition we opine that
you would require ECT as a form of treatment. The treatment is given under
anesthesia so that you do not experience any discomfort. You will be required to
be on empty stomach in the morning of ECT. The anesthesia is given as an
intravenous injection, after which we will administer a small and safe dose of
electricity using a well controlled electrical circuitry. This stimulates the brain
cells and produces a brief seizure which will last less than a minute. You will
recover consciousness within 30 minutes. Till such time, you will be under the
supervision of a medical team. The treatment is given on alternate days or
possibly twice a week, as decided by the treating doctor till sufficient
improvement occurs – usually fewer than 12 sessions.
The treatment causes some temporary side effects such as headache and or a
little confusion, for sometime on the day of ECT. You may notice some lapses in
memory for events occurring on the days of ECT. Rest of the memory including
all you have learnt earlier will not be affected. ECT with anesthesia has a few
serious side effects which are very rare. (If the patient is under 16 years no harm
to his / her growth or development is known to occur as a result of ECT). Over
all, the advantages of ECT are expected to outweigh the risks.
ECT will be administered to you only if you consent for the treatment. You
have a right to refuse now as well as withdraw the same during the course of the
treatment. In either case, the best available alternative treatments will be offered
without prejudice. You are also free to reconsider the matter and request ECT if
need be. Please feel free to contact us.
48 ECT ADMINISTRATION MANUAL
APPENDIX - II
PRE-ECT EVALUTION PROFOMA
51
delirium or any other complications and how it was handled. Please write in the file if you need more space to document.
# Date of cognitive assesment and scores.
WARD-NURSES’ CHECK LIST FOR THE PREPARATION OF PATIENTS FOR ECT
52
PATIENT’S NAME: AGE: SEX: WARD: WEIGHT:
1. Explanation of procedure to patient and relatives 2. Informed consent & proforma ‚
3. Check for special precautions: heart disease, epilepsy, brain tumor, pregnancy Specify if any medical problem:
APPENDIX IV:
B4ECT-ReCoDe Questionnaire
I understand that you are receiving ECT. I would like to see how this has
influenced your memory. For this, I would like to ask you some questions over
the next few minutes.
1. AVLT shorter version (Recent memory) (Score 1 point each for items
remembered in IR and DR)
1. Instruct the patient, “I will be reading out some words. Please
listen to them carefully. After I finish saying the words, you have
to say aloud as many words as you remember. You can say the
words in any order.”
2. Read out the 5 words from list A one at a time at the rate of one
word per second.
3. Instruct the patient to tell the words that he/she can remember.
Do not give any cues. Mark the words which are told correctly.
4. Repeat this 3 times and mark the correct answers each time. Inform
the patient that the list is being repeated as part of the evaluation
and not because he/she does not remember.
5. Trial number 4 – instead of list A, give words from list B and ask
patient to recall words from List B.
6. Thereafter, ask the patient to recall words from list A and mark
the correct answers (Do not read out list A again). (Immediate
recall – IR)
7. Administer tests number 2, 3, 4 and 5(this will take 15 minutes
approximately).
8. 20 minutes after immediate recall of list A, again ask patient to
recall words from list A and mark correct answers. (Delayed recall
– DR)
ECT ADMINISTRATION MANUAL 55
List A – Arm, Cat, Axe, Bed, PlaneList B – Boot, Monkey, Bowl, Cow,
Finger
1. Do you think your/ his/ her memory has been affected by ECT?
If so, how much has it decreased? How much is remaining on a
scale of 0-100? Can you give some examples?
2. How is your/ his/ her ability to search through the mind and recall
memories that you /he/ she know(s) are there?
5. How is your/ his/ her ability to make sense of what people explain
to you/ him/ her?
6. How is your/ his/ her ability to recall events that happened a few
minutes ago?
Practice is given for the first ten squares (during practice, the patient can be
stopped and corrected in case of errors).
Start timing after practice items are completed. Stop the test after 3 minutes
are over.
Now please try to remember the words which you heard repeatedly in the
beginning. Recall as many words belonging to the first list as you can (AVLT
delayed recall)… do you recall any more words from that list?
1. Visual Retention(Score 1 for correct location and 1 for correct object in
the final attempt)
1. Four objects of daily use (list given below) are shown to the patient
and placed at specific locations (list given below) in front of the
patient.
2. After all four objects have been placed, the patient has to rehearse
their locations immediately.
3. The patient can rehearse maximum thrice till he/she remembers
all 4 locations correctly. Then, hide them once more.
4. Administer test no.7 (Letter number sequencing)
5. The patient is asked to recall the locations again after 5 minutes.
List of objects – comb, coin, key, pen, folded paper
List of locations – Drawer, under the bag, under the file, give to patient’s
caregiver, your pocket
2. Letter number sequencing (working memory) (Score 1 for correct and
0 for incorrect response)
Instruct the patient that “I will be reading a list of letters and numbers. You
have to arrange them in such a way that the numbers come first followed by
58 ECT ADMINISTRATION MANUAL
letters. Letters and numbers, both, should be in correct sequence. For example, if
I say 2-B-1-A, you will repeat it as 1-2-A-B” (Give more examples if required).
Read out the following slowly – one word per sec (answers in brackets). Stop
after failure of 3 consecutive sequences.
1. L – 2 (2-L)
2. 6 – P (6-P)
3. B – 5 (5-B)
4. F – 7 – L (7-F-L)
5. R – 4 – D (4-D-R)
6. H – 1 – 8 (1-8-H)
7. T – 9 – A – 3 (3-9-A-T)
8. V – 1 – J – 5 (1-5-J-V)
9. 7 – N – 4 –L (4-7-L-N)
10. 8 – D – 6 – G – 1 (1-6-8-D-G)
11. K – 2 – C – 7 – S (2-7-C-K-S)
12. 5 - P – 3 – Y – 9 (3-5-9-P-Y)
13. M – 4 – E – 7 – Q – 2 (2-4-7-E-M-Q)
14. W – 8 – H – 5 – F – 3 (3-5-8-F-H-W)
15. 6 – G – 9 – A – 2 – S (2-6-9-A-G-S)
16. R – 3 – B – 4 – Z – 1 – C (1-3-4-B-C-R-Z)
17. 5 – T – 9 – J – 2 – X – 7 (2-5-7-9-J-T-X)
18. E – 1 – H – 8 – R – 4 – D (1-4-8-D-E-H-R)
19. 5 – H – 9 – S – 2 – N – 6 – A (2-5-6-9-A-H-N-S)
20. D – 1 – R – 9 – B – 4 – K – 3 (1-3-4-9-B-D-K-R)
21. 7 – M – 2 – T – 6 – F – 1 – Z (1-2-6-7-F-M-T-Z)
Now remember the 4 things hidden-tell me the name of the object and
the location where I kept it (Visual recall)
ECT ADMINISTRATION MANUAL 59
3. ORIENTATION
1 2 3 4 5
60 ECT ADMINISTRATION MANUAL
TOTAL SUBJECTIVE SCORE = Total score for patients + Total score for caregiver
Total number of questions answered =
TOTAL OBJECTIVE SCORE = AVLT DR List A + AVLT IR List A + HMSE +
Autobiographical + Digit symbol + Visual retention after 5 minutes + =
Letter number sequencing
ECG
EEG
(left)
EEG
(right)
“This concise volume efficiently conveys all the latest concepts regarding the optimal
administration of ECT, with an emphasis on day-to-day practice of ECT. The principles in this
Manual are entirely consistent with the best-practice of ECT as recommended in the USA, and it is
encouraging to see a global convergence of opinion on how to best deliver quality ECT. This manual
can serve as a quick reference for any physician with a question regarding the delivery of ECT”
W. Vaughn McCall
Editor-in-Chief, The Journal of ECT & Case Distinguished Chair,
The Medical College of Georgia, Georgia
“A ready reckoner of ECT. What should be the stimulus parameters & stimulus intensity for ECT?
What options do we have for electrode placement? How frequently and how many ECT may be
administered? How to actually administer ECT? How to maximize the efficacy and minimize the
adverse effects? To know about these and many more such practical questions for the day-to-
day practice of ECT, refer to this very comprehensive and informative ready reckoner of ECT.”
Nilesh Shah
Professor of Psychiatry, LTM medical College, Mumbai
“Excellent work on updating the manual which is comprehensive and reads well…..”
D. P. Devanand
Professor of Psychiatry and Neurology, ECT-TEAM, DEPARTMENT OF PSYCHIATRY
College of Physicians and Surgeons, Columbia University, New York
NATIONAL INSTITUTE OF MENTAL HEALTH & NEURO SCIENCES (NIMHANS)
BANGALORE- 560029
ISBN : 81-86442-00-X Price : 200/-