Tasks for the ECT team Dr Grace Fergusson

Tasks for the ECT team Dr Grace Fergusson Argyll and Bute Hospital Lochgilphead Royal College of Psychiatrists ECT training day, January 2002

The ECT consultant l Advice and liason l Treatment policy l Training l Supervision

Advice and Liason l ECT suite and equipment l Staffing l Liason l Management - clinical governance l Audit

ECT machines - UK Machine output (m. C) control +display EEG ECTONUS 5 A 50 -700 ECTONUS 5 B 50 -700 single yes optional NTS-R NTS-C multiple single no no 75 -4455 60 -720

ECT machines - Mecta Machine output (m. C) control +display EEG JR 1 SR 1 JR 2 Spectrum 4000 Q or M 5000 Q or M 22 -1152 25 -1200 multiple single yes yes no yes 5 -1152 either yes no yes

ECT machines - Somatics Machine output (m. C) control +display EEG Thymatron DGx 25 -1008 either yes optional Thymatron system IV 25 -1008 either yes

Nursing standards l first level nurse responsibility l registered nurse at each stage l CPR competency l escort nurse familiar and aware of legal issues and consent status l backup easily available National Audit of ECT in Scotland, 1997 -2000.

Guidelines for Anaesthesia l consultant responsibility l trained anaesthetists l trained assistant (ODP) l standard equipment l ECT workup l access to critical care for ASA grades 3 or above (medical condition affecting lifestyle)

Possible mode of action Anticonvulsant l Receptor modulator l Neurotrophic (BDNF) l Changes in gene expression l (1) (2) (3) (4) 1. Sackeim, The Anticonvulsant Hypothesis of the Mechanisms of Action of ECT: Current Status 2. Sattin A, The Role of TRH and Related Peptides in the Mechanism of Action of ECT 3. Krystal A & Weiner R, EEG Correlates of the Response to ECT all in The Journal of ECT vol 15 1999 4. Fochtmann LJ, Genetic approaches to the neurobiology of ECT. J of ECT 1998; 14: 20619

Advice and Liason l ECT suite and equipment l Staffing l Liason l Management l Audit - clinical governance

Treatment policy 1. Role and interface between – psychiatrists, clinical and ECT teams – nurses – anaesthetist(s) 2. Treatment protocols

Prescription of ECT high dose low dose Bilateral 80% efficacy s/e +++ 70% efficacy s/e ++ Unilateral 70% efficacy but 30% efficacy depends on dose s/e + ref: Sackeim et al. New England J of Medicicne, 1993, 328: 839 -846 Sackeim et al. Archives of Gen Psychiatry. 2000, 57: 425 -434 s/e +/-

Prescription of ECT high dose Bilateral Unilateral low dose 70% efficacy s/e ++ 70% efficacy but 30% efficacy depends on dose s/e + ref: Sackeim et al. New England J of Medicicne, 1993, 328: 839 -846 Sackeim et al. Archives of Gen Psychiatry. 2000, 57: 425 -434 s/e +/-

Prescription of ECT high dose Bilateral Unilateral low dose 70% efficacy s/e ++ 70% efficacy but depends on dose s/e + ref: Sackeim et al. New England J of Medicicne, 1993, 328: 839 -846 Sackeim et al. Archives of Gen Psychiatry. 2000, 57: 425 -434

Bilateral ECT Sackeim et al. (series of studies 1991 - 93, USA) low dose UECT - 28% response l low dose BECT - 70% response l same seizure length l cognitive side-effects related to dose above seizure threshold rather than absolute dose l conclusion: best outcome when the dose exceeds seizure threshold (BECT) by 50 - 100% for a given individual

Unilateral ECT Efficacy increases with dose above ST l maybe up to 12 fold l side effects increase with dose above ST l but probably not to the extent of BECT so l maybe no need to measure ST? l but technically more difficult l ref: Mc. Call, Reboussin, Weiner, Sackeim, Titrated Moderately Suprathreshold vs fixedhighdose Right Unilateral ECT, 2000, Archives of Gen Psychiatry, 57, 438 -444.

Cognitive side-effects Time to re-orientation (minutes): study 1 study 2 low dose uni- (ST x 1. 5) 11 18. 7 high dose uni- (ST x 5) 19 30. 7 low dose bi- (ST x 1. 5) 37 high dose bi- (ST x 3) 40 45. 5 1. Sobin 1995, American J of Psychiatry 2. Sackeim et al. Archives, 2000, 57, 425 -434 3. Journal of ECT vol 16 June /00

Seizure threshold l measure. pros: specific theraputic, despite seizure length decreased risk of overdose cons: time under anaesthetic risks of repeated stimulation? l estimate. pros: quick cons: predictive factors for only 25% risk of overdose in upto 25% so keep starting dose low

Stimulus dosing protocols l missed seizures l partial seizures l progressive shortening of seizure length l prolonged seizures

EEG monitoring ? for: direct measure detection of prolonged seizures (indicator of clinical efficacy? ) against: anxiety provoking? ? time taken training implications

Other protocols l Consent to treatment l pre-ECT work-up l record of treatment l monitoring of side-effects l feedback to clinical team

Special populations l outpatients l young people l pregnancy l cognitively impaired see The ECT Handbook 1995.

Training and supervision % adequate: training l supervision l anaesthetist l nurses 1981 1996 1997 1999 (scotland) l 10 43 35 10 66 66 60 93 16 45 100 ‘varied’ 1. Royal College of Psychiatrists, three audit cycles, 1981, 1996 2. The National Audit of ECT in Scotland , 1997 -00 93 50 100 94

Tasks for the ECT team Dr Grace Fergusson Argyll and Bute Hospital Lochgilphead Royal College of Psychiatrists ECT training day, Jan 2002