Electroconvulsive therapy has been a treatment of choice for various psychiatric illness for decades. Over time due to improvements in the technical parameters, administration technique and advent of newer drugs, electroconvulsive therapy has transformed into a safer, tolerable and effective form of treatment.
Newer form of therapy utilizes narrower pulses of stimulation, under anesthesia to produce the desired effect. This form of treatment is known as Brief Pulse Therapy (BPT).
Brief Pulse Therapy is considered as the “GOLD STANDARD” of care in many conditions in Psychiatry.
- Major Depressive Disorder
- Suicidal tendencies arising from mental disorders
- Violent/Aggressive Behavior resulting from mental disorders
- Bipolar Mood Disorder
- Schizophrenia and allied psychotic conditions e.g. delusional disorders, first episode psychosis.
- Mania
- Catatonia
- Neuroleptic Malignant Syndrome
- Reducing hospital stay
For years now, the cinematic portrayal of ECT has vilified a necessary medical procedure.
A power packed performance where the person is AWAKE and shown tied up while being electrocuted, the scene is further dramatized by painful screaming and uncontrollable jerking followed by froth coming out of the mouth and at the end of the procedure the “actor” is shown to be completely disoriented. This exaggerated depiction has resulted in people equating ECT as a last ditch effort that is truly a punishment.
The visual medium and popularity of movies has been responsible for widespread misinformation across the globe, influencing the way millions of people perceive ECT. The only appropriate depiction came in the Hollywood Crime Drama “Homeland”, where Carrie Mathison, a CIA agent, would undergo this procedure for her Bipolar Mood Disorder.
In fact, many clinicians have covered these aspects in scientific papers to appeal to the television community to alter this depiction, in hope to de-stigmatize the procedure so that those in need, feel no fear in seeking out for help.1
ECT works in a number of ways. The exact mechanism is not entirely clear.
ECT’s most significant effect is on the neuro-endocrine balance in the brain. By increasing/decreasing the production of certain neurotransmitters, ECT enables the maintenance the homeostasis, which reduces illness severity and enhances resilience.
KNOW THE PROCEDURE
TYPE: OUT-PATIENT AND INDOOR-PATIENT PROCEDURE
When done as an OPD procedure, the patient does not require admission (after a prior consultation) and can come at the time of BPT, and is free to go after a few hours of the procedure.
Oral (NPO/NBM):
Required
Ideally before giving BPT, the patient needs to undergo a pre BPT workup. The tests required include:
- CBC
- S. Electrolytes
- S. Creatinine
- SGPT
- ECG
- X-Ray (if underlying respiratory condition is suspected)
- CT-Scan/ MRI Brian (If Required)
DURING THE PROCEDURE
- The patient is expected to come empty stomach for the procedure. No solid or liquid foods, including water, should be consumed for up to 3-4 hours prior to the procedure.
- Before starting the stimulation in BPT, the patient is anaesthetized by a trained anesthesiologist using a suitable anesthetic agent (Short acting anesthetic agents are used, with a typical duration of action of about 10-12 minutes).
- This is followed by a dose of a muscle relaxant, which relaxes the entire body.
- Then the electrical stimulation is delivered. It is usually given for 1-3 seconds.
- Application of the stimulation, elicits a therapeutic seizure, which is monitored for its duration.
- At the end of the procedure, the patient comes out of the effect of anesthesia and regains consciousness. After the patient is stable, he/she is discharged.
During the entire procedure the patient’s airway and ventilation is maintained and vital signs are continuously monitored.
NOTE : Emergency drugs are always kept handy to effectively deal with any complication, if they arise.
SIDE EFFECTS
- Side effects with BPT could be due to anesthesia or due to the BPT procedure.
- Most common side effects post BPT include:
- Body ache
- Jaw pain and
- Headache
- BPT can induce some amount of memory disturbances in the form of forgetfulness and confusion. This usually occurs for a few hours. Some patients may experience memory disturbances for up to 21 days. This is usually self-limiting and does not require any additional medications.
- A thorough pre-BPT checkup is done to minimize any anesthesia related complications.
| Myths | Facts |
|---|---|
| BPT is given to an AWAKE patient | Patient is under anesthesia for the entire procedure. BPT is given after anesthesia has been given. |
| “Electrical Shock” is given for a long time. | Controlled electrical stimulation is given using a specialized machine. The average duration of the stimulus is for a few seconds (1-3 seconds). |
| BPT causes permanent memory loss | BPT is not associated with any permanent damages to memory or to other brain structure. |
| BPT resets/factory resets the brain | BPT causes a complex chain of changes in the chemical balance of the brain, which leads to recovery from illness. It does not alter the brain structure in any way. |
| A person goes crazy after receiving a course of BPT | BPT is the cure to an illness, and does not cause the illness. |
| After a course of BPT, the patient becomes dependent on BPT. | No form of dependence occurs after a course of BPT. |
| BPT is given to patients who have serious mental illnesses. | BPT can be given to any patient with mental illnesses, irrespective of the severity of the illness. |
WHEN TO CHOOSE ECT?
Most frequently asked questions, is at what stage of the illness is ECT required for me. The answer depends on a number of clinical factors, but to give a brief idea.
| CONDITIONS REQUIRING ECT | |
|---|---|
| Melancholic Depression (Severe Depression) | Bipolar Mood Disorder (Mania/Depression) |
| Depression with Psychotic Features (Paranoia) | Increasing the time period between two episodes of Bipolarity |
| Aggression/Severe Irritability | Previous History Of Good Response To ECT |
| Schizophrenia (Positive Symptoms) | Improving residual symptoms |
| SUICIDAL THOUGHT/ACTIONS/ATTEMPTS | |
REDUCTION IN DISEASE BURDEN:
Administration of ECT causes a reduction in overall magnitude of illness.
This allows the existing medications to act in a more effective manner, thereby reducing the need to increase or change medication regimen.
If I am suffering from Depression, which form of Neurostimulation is better for me?
The newer form of neurostimulation is Repetitive Transcranial Magnetic Stimulation (rTMS). This technique employs magnetic strength to alter brain activity.
It is noninvasive and associated with minimal side effects. However, efficacy wise it is inferior to ECT in all parameters. Also, other than in depression, its role in other psychiatric illness is very limited.
The table below will describe in detail the difference in effectiveness between ECT and rTMS in a patient of depression.
|
COMPARISON OF ECT AND rTMS FOR DEPRESSION
Meta-Analysis Conducted by Berlim Et. Al.2, summarized findings are as follows:
|
||
|---|---|---|
| Parameters | ECT | rTMS |
| No. Of Patient | 102 | 113 |
| Number of sessions | 8 | 15 |
| Baseline Severity of Symptoms | High | High |
| Previous Medication History | Present | Present |
| Level of Treatment Resistant | High | High |
| Baseline (Pre-Treatment Scores) Hamilton Depression Rating Scale (HDRS) |
27.8 | 26.1 |
| Number of patients whose symptoms reduced by >50% |
52% (5/10) |
33% (3/10) |
| Number Needed to Treat | 6 | 10 |
PARTH HOSPITAL – SPECIALISTS FOR BRIEF PULSE THERAPY
The Brief Pulse Therapy (BPT) Program at Parth Hospital aims to successfully treat cases of severe depression with the latest and safest techniques in electroconvulsive therapy. Our program is among the oldest, most experienced and most active in the Gujarat.
Discuss your medical conditions and any concerns with Psychiatrists at Parth Hospital when deciding whether ECT is right for you.
REFERENCES
- 1)Sienaert P. Based on a True Story? The Portrayal of ECT in International Movies and Television Programs. Brain Stimul. 2016;9(6):882–891. doi:10.1016/j.brs.2016.07.005
- 2)Berlim, M.T., Van Den Eynde, F. And Daskalakis, Z.J. (2013), efficacy and acceptability of high frequency repetitive transcranial magnetic stimulation (rtms) versus electroconvulsive therapy (ect) for major depression: a systematic review and meta‐analysis of randomized trials. Depress Anxiety, 30: 614-623. Doi:10.1002/Da.22060