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PRINCIPLES AND PRACTICE OF Electroconvulsive Therapy Keith G. Rasmussen, M.D. P P RINCIPLES AND RACTICE OF Electroconvulsive Therapy P P RINCIPLES AND RACTICE OF Electroconvulsive Therapy Keith G. Rasmussen, M.D. Professor, Department of Psychiatry and Psychology Mayo Clinic, Rochester, Minnesota Note: The authors have worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and prac tice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. 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Copyright © 2019 American Psychiatric Association Publishing ALL RIGHTS RESERVED First Edition Manufactured in the United States of America on acid-free paper 23 22 21 20 19 5 4 3 2 1 American Psychiatric Association Publishing 800 Maine Avenue SW Suite 900 Washington, DC 20024-2812 www.appi.org Library of Congress Cataloging-in-Publication Data Names: Rasmussen, Keith G., author. | American Psychiatric Association Publishing, issuing body. Title: Principles and practice of electroconvulsive therapy / Keith G. Rasmussen. Description: First edition. | Washington, D.C. : American Psychiatric Association Publishing, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018056193 (print) | LCCN 2018057526 (ebook) | ISBN 9781615372492 (ebook) | ISBN 9781615372416 (pbk. : alk. paper) Subjects: | MESH: Electroconvulsive Therapy—methods | Electroconvulsive Therapy—history | History, 20th Century | Mental Disorders—therapy | Patient Care Management—methods Classification: LCC RC485 (ebook) | LCC RC485 (print) | NLM WM 412 | DDC 616.89/122—dc23 LC record available at https://lccn.loc.gov/2018056193 British Library Cataloguing in Publication Data A CIP record is available from the British Library. Contents 1 Introduction to ECT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 Patient Selection for ECT . . . . . . . . . . . . . . . . . . . . . . 9 3 Patient Education and Informed Consent for ECT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 4 The Pre-ECT Medical Workup . . . . . . . . . . . . . . . . .57 5 Anesthesia for ECT . . . . . . . . . . . . . . . . . . . . . . . . . . .79 6 ECT Technique, Part I: Managing the Individual Treatment. . . . . . . . . . . . . . . . . . . . . . . . . 101 7 ECT Technique, Part II: Managing the Course of Treatments. . . . . . . . . . . . . . . . . . . . . . . 131 8 Preventing Relapse After ECT: Maintenance ECT and Pharmacotherapy . . . . . 163 9 Cognitive Effects of ECT . . . . . . . . . . . . . . . . . . . . 195 10 ECT Versus Other Neuropsychiatric Treatments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 1 Introduction to ECT Electroconvulsive therapy (ECT) is a topic of intense interest in the history of psychiatry. It has long been perhaps the most effective treatment for severe mental illness. Far from being effete or out of fashion, and definitely not supplanted by newer so-called neuropsychiatric brain stimulation methods, ECT is still used worldwide. Probably hundreds of thousands of people are treated with ECT each year, though precise data are lacking. To be competent to deliver ECT, a psychiatrist must be skilled at diagnosis as well as familiar with the techniques of treatment. The goal of this book is to teach psychiatric practitioners, whether in practice already or in training, how to be an ECT clinician. As such, the primary target audience naturally is psychiatrists or psychiatric residents. However, other mental health and medical professionals, and indeed anybody interested in men tal health treatment, will find the book readable and comprehensible. This introductory chapter is divided into four sections. The first is a capsule summary of what ECT is. This is intended for those readers who are new to this subject so that all subsequent chapters will make better sense. Next, a brief review of the history of ECT is presented. This is a very interesting topic for the history of psychiatry. This review is followed by a section outlining conceptualizations of the mechanism of action of ECT. The chapter ends with an outline of the remainder of the book. What Is ECT? ECT consists of the application of an electrical stimulus to the head to produce a seizure (convulsion) for therapeutic purposes. Thus, “electro” means use of an electrical stimulus, while “convulsive” means that a convulsion is induced, and “ther apy” means it is done to help people with mental illness. 1 2 Principles and Practice of Electroconvulsive Therapy ECT is used to treat psychiatric patients who have been diagnosed with major depression, mania, catatonia, or schizophrenia. Usually, such patients’ illnesses have been refractory to psychotropic medications or the patients are so severely ill that something quicker-acting must be used. This statement gets at the heart of why ECT is used in modern psychiatry: it works, it works very well, and it works faster than medications. ECT is administered as a series of treatments. Once a psychiatrist has deter mined that ECT is appropriate for a patient, and the patient has agreed to proceed, a medical evaluation is undertaken to ensure ECT can be done safely and without complications. Each treatment session follows a standardized process. First, the patient is anesthetized to achieve unconsciousness. Thus, the patient is not aware when the electrical stimulus is applied. Next, muscle-paralyzing medication is given so that during the seizure, there is not much shaking of the limbs. This re duces the risk of bone fractures, which were common in the era when no such par alyzing medication was used during ECT. Because the patient cannot breathe after these anesthetic medications are given, oxygen is administered through a mask with a bag for ventilation. Heart rate, blood pressure, heart rhythm, and blood oxygen lev els are all monitored throughout the procedure. Once the patient is paralyzed, which is determined by the anesthesiologist in attendance, the psychiatrist and psychiatric nurse will apply two electrodes to the head. These are usually adhesive pads about the size and shape of a credit card. The electrodes are connected via thin cables to the ECT device. The amount of electricity to be given to the patient is set on the ECT machine, and then the button is pushed, and this sends an electrical current through the two electrodes and into the patient’s brain, which causes a seizure. Small convulsive movements of the limbs can usually be appreciated, and an electroencephalogram records brain waves showing seizure activity. Usually, the seizure lasts a few seconds to a minute or so and stops on its own. A few minutes thereafter, the anesthetic medications wear off, the patient starts breathing, and a few minutes later awakening occurs. The patient is then transferred to a monitoring area known as the post-anesthesia care unit (PACU), where full return of alertness occurs over a few minutes to a half hour or so. The patient can then be taken back to the hospital unit where he or she is residing if an inpatient or go home accompanied by a responsible adult if an out patient. Of note, it is quite common to deliver ECT to outpatients. Treatments are repeated twice or thrice weekly until maximal improvement of the psychiatric condition occurs. This phase usually takes 2–4 weeks (thus, 6–12 treatments) for most patients. Once this acute-phase series of treatments is finished, patients may continue to receive treatments at spaced intervals, say once every week to once every 4 weeks, in order to prevent return of symptoms. Introduction to ECT 3 This so-called maintenance ECT phase may continue for a few months to a year or even longer depending on the chronicity of the patient’s illness. Side effects of ECT include muscle aches, headaches, nausea, and jaw ache. These are transient and easily treatable. Medical complications such as heart at tack, stroke, or death are exceedingly rare. The most common bothersome side ef fect of ECT is memory difficulties. There are three roles of the psychiatrist in ECT practice. The first is to recog nize appropriate patients for this treatment. This may occur during an outpatient evaluation or with a hospitalized patient. The second role of the psychiatrist is to deliver the treatments in the ECT treatment area (known usually as the ECT suite). The third role is to follow the patient during a course of treatments and make decisions about electrode placement, treatment frequency, concomitant psychotropic medications, and when to stop the treatment course. These roles may be filled by three separate physicians. For example, a psychiatrist may recog nize the need for ECT in an outpatient and then refer the patient for inpatient care to begin ECT if the clinical circumstances warrant inpatient admission. Then, another psychiatrist may actually follow the patient during the hospitalization, while a third actually performs the treatments. Alternatively, one or two physicians may fulfill these roles, depending on how staffing is arranged in a particular locale. It is important for these clinicians to sustain good communication with each other during a patient’s ECT course. This description of ECT is of course brief. All these topics and steps will be covered in much greater detail in the remaining chapters of this book. However, the previously ECT-naïve reader can now at least appreciate in general terms what happens during ECT. History of ECT The idea that a purposefully induced seizure could be a treatment for psychiatric disorders originated with Ladislas J. Meduna, a physician caring for mental pa tients in Budapest, Hungary, in the 1930s (Shorter and Healy 2007). Observing schizophrenic and epileptic patients clinically, as well as undertaking histological examinations of their brains at autopsy, Meduna concluded that the histological changes associated with epilepsy were not seen with schizophrenia. He hypothe sized that there was some type of biologic antagonism between seizures and schizophrenia, with the attendant implication that inducing seizures in schizophre nia patients may cure that disease. His next step was to undertake clinical studies utilizing seizure-inducing chemical agents in psychotic patients. Starting in 1934 with the first such session, he used agents such as pentylenetetrazol (Metrazol, an intravenously administered drug) and flurothyl (Indoklon, an inhalational agent)