The electroconvulsive therapy workbook: clinical applications

449 Pages·2018·10.283 MB·English

by  Weiss, Alan

The Electroconvulsive
Therapy Workbook
Electroconvulsive Therapy (ECT) remains one of the most effective forms of neurostimulation for severe
mental illness. Sound scientific research underpins contemporary practice challenging the complex
history and stigma that surround this treatment.
The Electroconvulsive Therapy Workbookintegrates the history of ECT with major advances in practice,
including ultrabrief ECT, in a hands-on workbook format. Novel forms of neurostimulation are reviewed,
highlighting the future directions of practice in this exciting area. The book is also richly illustrated
with historical and technical images and includes ‘clinical wisdom’ sections that provide the reader
with clinical insights into ECT practice. Online eResources are also available, featuring a wide range
of questions and answers related to each chapter to help test and consolidate readers’ understanding of
ECT, as well as regionally specific legislation governing ECT practice in Australia and New Zealand.
This comprehensive introduction to ECT is a must-read for doctors in training, psychiatrists who
require credentialing in this procedure, anaesthetists, nursing staff who work in ECT and other professionals
who have an interest in ECT as well as consumer and carer networks.
Alan Weiss is conjoint senior lecturer at the University of Newcastle, Australia. He is also a fellow of
the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and chair of the Colleges
Section for ECT and Neurostimulation (SEN); clinical director of the neurostimulation programme for the
Hunter New England Local Health District; chair of the expert committee to revise 2010 NSW ECT
Guidelines; and foundation director of neurostimulation at two private hospitals in Newcastle. Dr Weiss
is a member of the International Society for ECT and Neurostimulation and the American Psychiatric
Association.

The Electroconvulsive
Therapy Workbook
Clinical Applications
Alan Weiss
First published 2018
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor and Francis Group, an informa business
© 2018 Alan Weiss
The right of Alan Weiss to be identified as author of this work has been asserted by him
in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in
any form or by any electronic, mechanical, or other means, now known or hereafter
invented, including photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered
trademarks, and are used only for identification and explanation without intent to
infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
Names: Weiss, Alan, 1955 July 9– author.
Title: The electroconvulsive therapy workbook :
clinical applications / Alan Weiss.
Description: Abingdon, Oxon ; New York, NY : Routledge, 2018. |
Includes bibliographical references.
Identifiers: LCCN 2017056040| ISBN 9781138713369 (hardback) |
ISBN 9781138713376 (pbk.) | ISBN 9781315198897 (ebook)
Subjects: | MESH: Electroconvulsive Therapy – methods
Classification: LCC RC485 | NLM WM 412 | DDC 616.89/122 – dc23
LC record available at https://lccn.loc.gov/2017056040
ISBN: 978-1-138-71336-9 (hbk)
ISBN: 978-1-138-71337-6 (pbk)
ISBN: 978-1-315-19889-7 (ebk)
Typeset in Palatino and Bell Gothic
by Florence Production Ltd, Stoodleigh, Devon, UK
eResources are available at www.routledge.com/97811387133(cid:26)6/
Contents
Preface xvii
Acknowledgements xix
1. Introduction 1
1.1 Overview 3
Purpose 3
Aims 5
Objectives 5
A competency-based ECT programme 5
1.2 Definition 11
1.3 Equipment 14
History: ECT devices 14
ECT device characteristics 19
2. Knowledge 21
2.1 History: treatment of mental illness 23
Trepanning: early psychosurgery? 23
Bloodletting 24
Pharmacology 25
Phrenology 26
Early 1800s 27
Electricity 29
2.2 History: ECT 33
Mental illness and convulsions 34
Negative images emerge 36
The media fans negativity 36
Unmodified ECT 37
The changing face of the media 38
The Bolam test 39
vi CONTENTS
2.3 Major advances in ECT practice 42
Introduction of anaesthesia 43
Induction agents 43
Muscle relaxants 43
Hyperoxygenation and hyperventilation 43
Electrode placement 44
Ultrabrief ECT 45
Stimulus wave forms 45
Seizure threshold and stimulus dose titration 46
Electroencephalogram (EEG) 47
ECT: minimum standards and audit 48
The lived experience 48
2.4 Mechanism of action 53
Psychological hypothesis 54
Electrophysiological hypothesis 54
Neuroendocrine hypothesis 54
Neurochemical hypotheses 55
Anticonvulsive hypothesis 56
Neurogenesis hypothesis 56
Gene expression hypothesis 56
Cognitive effects of ECT 57
2.5 Clinical indications for ECT: adults 59
Major depressive disorder/unipolar depression 59
Clinical practice guidelines (CPGs) 61
United Kingdom (UK) 61
Scotland 62
Spain 62
World Federation of Societies of Biological Psychiatry (WFSBP) 62
USA 63
Canada 63
Australia 64
Bipolar disorder: mania, depression and mixed state 65
Clinical practice guidelines (CPGs) 66
United Kingdom (UK) 66
USA 66
World Federation of Societies of Biological Psychiatry (WFSBP) 66
Scotland 67
Canada 67
Australia 67
Schizophrenia 68
Clinical practice guidelines (CPGs) 69
Schizoaffective disorder 70
Catatonia 70
Neuroleptic malignant syndrome 71
CONTENTS vii
Perinatal disorders 71
Parkinson’s disease 72
Other diagnoses 73
2.6 Clinical indications: children and adolescents 80
History 80
Clinical concerns 81
Clinical indications 83
Major depressive disorder with melancholia and psychosis 83
Major depressive disorder with lethal suicide attempts/severe
self-injurious behaviour (SIB) 84
Treatment-resistant depression and bipolar disorder in adolescents 84
Bipolar disorder unresponsive to mood stabilisers 85
Schizophrenia spectrum disorders (SSD) 85
Catatonia in children and adolescents 87
Tolerability of ECT in adolescents 87
Special considerations 88
2.7 Clinical indications: older people 92
Clinical concerns 92
Clinical indications 93
Tolerability of ECT in old age 93
Management special considerations 95
2.8 Efficacy of ECT 97
2.9 Contraindications for ECT 100
Mortality rate 100
Complex comorbidities 101
Cardiovascular risk 101
Risk of untreated psychiatric illness 101
Chemotherapy 102
Conclusion 102
2.10Brain stimulation: new directions 104
Definition 105
Advantages of brain stimulation techniques 105
Convulsive stimulation techniques 106
Magnetic seizure therapy (MST) 106
Focal electrically assisted seizure therapy (FEAST) 107
Non-convulsive stimulation techniques 108
Repetitive transcranial magnetic stimulation (rTMS) 108
History of rTMS 109
Resting motor threshold 110
Patient set-up 111
Safety 111
rTMS stimulus parameters 112
viii CONTENTS
Factors that affect efficacy of rTMS 112
rTMS in depression 112
rTMS in schizophrenia 113
rTMS as a clinical treatment option 113
RANZCP Position Statement 79: rTMS (RANZCP, 2013) 114
Deep repetitive transcranial magnetic stimulation (dTMS) 114
dTMS safety data 115
dTMS in psychiatric conditions 115
dTMS in other conditions 116
Transcranial direct current stimulation (tDCS) 116
Patient set-up 117
Other forms of transcranial electrical stimulation 118
Evidence base for tDCS 118
Vestibular stimulation 120
Caloric vestibular stimulation (CVS) 120
Galvanic vestibular stimulation (GVS) 121
Evoked potentials (EP) 121
Sensory evoked potentials 121
Visual evoked potentials (VEPs) 121
Short-latency brainstem auditory evoked potentials (BAEPs) 122
Somatosensory evoked potentials (SEPs) 122
Motor evoked potentials 122
Transcranial electrical motor evoked potential monitoring
(TCeMEP) 122
Surgically invasive techniques 122
Deep brain stimulation (DBS) 122
DBS and Parkinson’s disease 123
DBS and depression 124
DBS and obsessive compulsive disorder (OCD) 125
Vagus nerve stimulation (VNS) 125
VNS and intractable epilepsy 126
VNS and treatment-resistant depression 126
Transcutaneous vagus nerve stimulation (t-VNS) 127
Direct cortical stimulation (DCS) 128
Navigated repetitive TMS (nTMS) 128
Pre-surgical functional magnetic resonance imaging (fMRI)
for language assessment 128
Magnetoencephalography (MEG) 129
Conclusion 129
3. Organisational/administrative skills 139
3.1 Setting up an ECT service/clinical governance 141
Approach to service delivery 142
ECT service goals 143
Communication 143
CONTENTS ix
ECT committee 143
ECT clinical guidelines 143
Database 144
ECT team 144
Team members 144
Clinical director of ECT services 144
Psychiatry registrars/trainees 144
ECT coordinator/nurse specialist 145
Other team members 145
Legislative framework 145
Consent 145
Equipment 147
Environment 148
General hospital 148
Stand-alone ECT suite 148
Initial assessment 148
ECT technique 149
Anaesthetic technique 150
Anaesthetic agents 150
Continuation and maintenance ECT 151
Audit 151
The lived experience 151
4. Clinical skills 155
4.1 The sequence of ECT 157
Referral 157
Emergency ECT 158
The ECT journey 158
Measurement during ECT 159
Memory 159
Audit 160
ECT tapering/step-down 161
ECT record 162
4.2 Adverse events of ECT 164
Adverse events during ECT 164
Cardiovascular events 164
Asystole/electrocardiac pause 165
Oral and dental trauma 167
Fractures 168
Complications secondary to medication 168
Prolonged seizures 168
Adverse events immediately post-ECT treatment 170
Transient postictal delirium 170
Headaches 170