Nursing Care Management and Electro Convulsive Therapy
Write about ECT, its development history, epidemiology and indications, and the mechanism of its action.
Electroconvulsive Therapy (ECT) refers to the intentional induction of a modified generalized seizure by an anaesthetized person under medically controlled conditions in order to produce a therapeutic effect. (Kavanagh & McLoughlin 2009).
An electric charge is applied to the scalp of an anesthetized patient and passes through the brain.
To reverse some symptoms, electroconvulsive therapy can be used to alter the brain’s chemistry.
This is often recommended when other treatments fail.
ECT has been shown to be an effective treatment for depression when compared with pharmacotherapy.
It is preferred for the treatment of acute depression with psychotic symptoms (Petrides et al. 2001).
ECT is a vital part of modern mental health care. Nurses play a pivotal role in delivering ECT to patients.
This resource provides information on ECT, its development history, epidemiology and indications, as well as its mechanism of action.
A Brief History of ECT
Electroconvulsive therapy dates back to 1500s, when mental illness was treated using convulsions.
Camphor was used to induce convulsions.
Paracelsus, a Swiss physician, successfully inducing seizures by oral administration of camphor for the treatment of psychiatric illnesses (Sadock and Sadock 2007).
In 1785, the first published report on the induction of seizures by camphor for the treatment of manic episodes was published.
Injectable camphor was eventually replaced by oral camphor, as Ladislas Joseph von Maduna, a Hungarian neuropathologist, demonstrated in 1934 to treat catatonic schizophrenia. (Sadock & Sadock 2007).
The treatment of mental disorders with chemically-induced seizures was not without its distressing side effects. This predicted the development of new ways to induce therapeutic seizures.
The origins of modern ECT can be traced back as far as 1938, when electricity was used for seizures to treat a catatonic patient. This was done by Ugo Cerletti and Lucio Bini (Kalapatapu 2015).
In the United States, ECT was first introduced in 1939 (Pandya et al. 2007).
However, ECT was not performed with adequate anaesthesia procedures or muscle relaxation measures. This led to fractures and dislocations. Also, there was insufficient knowledge regarding the dose parameters for electrical stimulation that could cause severe cognitive adverse effects (Pandya et al. 2007).
Curare was used during ECT procedures to counter this.
Until the 1950s, when antipsychotic drugs became available, the only options to ECT were lobotomy and insulin shock therapy.
In the 1950s, electroconvulsive therapy was first scientifically studied.
To determine the effectiveness of the ECT procedure, Max Fink, a psychiatrist, used rigorous scientific research methods (Taylor 2007, Taylor).
This is the year succinylcholine was introduced, which is a depolarizing and muscle relaxant. It is used in conjunction with a short-acting pain reliever during ECT procedures to prevent injury and numb the patient.
Sadock and Sadock (2007) found that ECT had significantly higher response rates than other medications for the treatment mania.
In 1978, the American Psychiatric Association published a Task Force Report on ECT. This report outlined standard ECT procedures that were consistent with scientific evidence. It was intended to reduce misuse and abuse of the procedure.
The report was revised several times in 1990 and 2001.
Further support for ECT was provided by the National Institutes of Health, National Institute of Mental Health Consensus Conference on ECT. This conference called for additional research and national standards of care (Sadock & Sadock 2007).
Randomised controlled clinical trials comparing ECT and lithium were conducted towards the end of 20th century. The results showed that both treatments are equally effective in treating mania.
Sarah Lisanby, a Columbia University researcher, and others demonstrated the effectiveness of magnetic stimulation to induce convulsive episodes (Sadock & Sadock 2007).
Two eras characterized the development of ECT.
The first was a time of therapeutic optimism in psychiatry. The second was a time of almost random use (Glass 2001).
When ECT was the only option, therapeutic optimism was born.
ECT became almost ubiquitously used in the middle of the 20th century. This led to the anti-psychiatry movement, which exaggerated both the positive aspects of ECT, and hospital care.
These actions have cast doubt on the effectiveness of ECT.
Contemporary ECT is accompanied by fear and stigma (Dowman et al. 2005).
Two forms of this hinder the ability to provide effective treatment for individuals with severe mental illness.
It is twofold: the unwillingness of the treating teams to prescribe treatment, and the second, the refusal of the patients to accept it when it is prescribed.
Glass (2001) recommends that healthcare professionals be educated about the current ECT practice. This includes the efficacy, indications, and adverse effects.
Epidemiology of ECT
In 1941, electroconvulsive therapy was first used to treat schizophrenia.
The use of the procedure fell after the introduction of medications for severe mental disorders (McCall et al. 1992).
ECT was therefore primarily used as a last resort for patients with severe life-threatening illnesses and patients who were resistant to medications.
However, this notion was corrected by the National Institutes of Health & National Institute of Mental Health Consensus conference on ECT. They recommended that ECT not be used as a last-resort option.
After the World War II displacement of psychiatrists, ECT spread quickly from Europe to other continents, including the US (Shorter 2009).
One million people worldwide receive electroconvulsive therapy every year, according to Hermann et al. 1995.
Swartz (2009) states that ECT is a widely-available treatment option for people with mental disorders on all continents.
There are many variations in practice between countries and regions, regardless of the international guidelines (Enns et al. 2011, 2011).
There are also differences in ECT usage across different divides.
Van Waarde and his colleagues conducted a 2009 study on the ECT usage in the US. It was found that ECT was used by 4.9 people per 10,000 residents per year in 1995 (van Waarde et al. 2009).
A 2012 review also found that there is little ECT usage in Africa and Latin America (Leiknes et al. 2012).
ECT is widely used in America, Asia, Europe.
Despite the widespread utilisation of ECT in Europe, America and Asia, there are differences in the rates of utilization and clinical practice among the countries.
Unmodified ECT (ECT given without anaesthesia) is largely used in Asia, with a prevalence of over 90% in Latin America, Africa and in some European countries (Spain and Russia, Leiknes, 2012).
ECT is mainly used in Australia, New Zealand, the United States and Europe by depressed elderly women.
Other parts of the globe (Africa Asia, Russia and Latin America) where unmodified ECT can still be administered are dominated by younger patients with schizophrenia (Leiknes et al. 2012).
Baghai et.al. (2005) and Moksnes et.al. (2006) agree with this observation. They note that elderly females with affective disorder are the predominant patients who receive ECT at the first tier.
Saudi Arabia and Pakistan have the same characteristics, except that their patients are younger.
ECT rates in Western Australia are higher among Caucasian whites (Teh et al. 2005).
There are many variations in the availability of ECT in psychiatric hospitals.
The highest number of ECT providers in Asia is 59-78%, followed by Australia (66%), 23-51% in Europe, and 6% in the United States (Leiknes et al. 2012).
Chanpattana (2007) agrees with this observation. She notes that 66% of Australian institutions provide the procedure, while 73% of institutions offer training in ECT.
A review of reports about side effects, adverse effects, and mortality rates associated with ECT revealed a small database.
However, Thailand has the highest mortality rate at 0.08%, followed by Texas with 14 deaths per 100.000 treatments (Chanpattana & Kramer (2004); Scarano & Felthous (2000).
There are no data to indicate whether these ECT-related deaths were caused by anaesthesia complications, comorbidities somatic diseases, or lethal side effects like cardiac arthymia.
Concerning consent to administration of ECT the procedure is largely administered under guardian consent conditions in all regions.
Indications of ECT
ECT is a non-pharmacologic, biological treatment that has a high success rate. It can be used for schizophrenia, depression, and other conditions.
ECT is a valuable alternative treatment for therapy-resistant psychiatric conditions that develop after treatment failures.
For severe depression, electroconvulsive therapy can be an effective and quick-acting treatment.
This treatment is recommended in severe cases of major depression where antidepressant therapy has proven ineffective or too intolerant.
It is preferred for patients suffering from severe, suicidal, or psychotic depressions due to its quick response.
These patients cannot wait for antidepressants.
ECT is a safe and effective treatment for psychiatry.
However, the side effect is that the treatment often does not last long and may require further treatment.
The availability of atypical antipsychotics and classical neuroleptics has led to a decline in the use of ECT for mania treatment.
However, ECT has been shown to be effective in reducing mania symptoms.
ECT has shown high rates of remission and improvement (Baghai & Moller 2008).
Bipolar disorder is characterized by acute depression. This condition can be caused by a slow or insufficient response to antidepressants. It can also trigger the switching phase.
ECT is recommended for clients suffering from bipolar disorder. This is especially true if the client’s response to antidepressants or mood stabilizers is not satisfactory.
ECT is preferred over antidepressants because it does not cause switching.
Contrary to popular belief, ECT is a good alternative, especially for patients with bipolar disorder or co-morbid medical conditions (Brooks 2015).
Cerletti and Bini first used ECT in schizophrenia management in 1938.
It has been proven effective in treating schizophrenia and schizoaffective disorders (Chanpattana et al. 2010, 2010).
This is despite the fact that ECT was less commonly used for schizophrenia treatment in the 1950s due to the introduction of neuroleptics.
ECT is a safe and effective treatment for schizophrenia patients. It is recommended for those with schizophrenia who have not shown a response to antipsychotics or for those with co-morbidities.
Theories of Mechanism Of Action
The mechanism of ECT’s antidepressant effects has been studied using animal models.
These include neuronal growth factors being upregulated, which can increase neurones’ survival and plasticity. This also affects the ability of neurones to adapt to each other.
Notably, ECT increases the number of nerve cells in the hippocampus. (Grover, et. al., 2005).
The hippocampus regulates mood regulation and memory.
Kavanagh & McLoughlin (2009) found that antidepressants have a lower effect than ECT.
ECT nursing has changed from a traditional supportive and adjunctive approach to a collaborative and independent practice (Burns & Stuart 1991).
The current practice of nursing in ECT includes a number nurses, including an ECT nurse and an operating department assistant, nurse coordinator, and a recovery nurse.
The ECT nurse is responsible for coordinating the service. She also has the responsibility of caring for patients and managing the ECT clinic (IECT Accreditation Service 2016).
The ECT nurses are responsible for developing protocols that are consistent with best practices guidelines.
The ECT nurse ensures that the environment, medications and equipment are all in compliance with best practice guidelines (Kavanagh & McLoughlin 2009).
While the psychiatrist and anaesthetist are responsible for administering electroconvulsive therapy, the ECT nurse is responsible for addressing the psychological needs.
It includes educating the patient about their condition and the reasons for the procedure, as well as explaining the treatment process and addressing any fears or concerns the patient may have.
This helps to educate the patient and establishes a therapeutic relationship between nurse and patient. It reduces anxiety as well as dispelling any premonitions or myths.
This element is crucial because the nurse makes the process less intrusive, more positive, and encourages patients to persevere despite adverse effects.
The nurse completes a pre-treatment checklist to ensure that the patient is prepared for the procedure.
The patient’s mental, legal, and medical status is also managed by the nurse (Kavanagh & McLoughlin 2009).
Following the ECT treatment course, the recovery nurse is an integral part of the team.
These nurses have advanced knowledge in life support, and they are familiar with all aspects of ECT treatment.
The nurse will monitor the patient’s vitals, maintain their airway integrity, and administer the prescribed medication to treat side effects.
The nurse will continue to be involved in the recovery room until the patient is able to regain his orientation and the anaesthetist gives him a clean bill (Queensland Health 2017).
The most effective treatment for severe mental illness is electroconvulsive therapy (ECT).
Since 1938, when the process was first developed for schizophrenia treatment, it has seen tremendous progress.
Although there is some stigma attached to the process, there are substantial evidence bases that support its safety and efficacy in modern medicine.
The provision of ECT is currently a major responsibility for nurses.
This is in contrast to the previous role which was a support one.
Nurses play a variety of roles, including ECT nurse, ward nurse or recovery nurse, as well as the role of anaesthetist’s aid.
Therefore, it is important to place emphasis on education of nurses in ECT in order to increase their central role in the enhancement and development therapy.
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