Tasks for the ECT teamTasks for the ECT team

Dr Grace FergussonArgyll and Bute Hospital

Lochgilphead

Royal College of Psychiatrists ECT training day, January 2002

The ECT consultantThe ECT consultant

Advice and liasonTreatment policyTraining Supervision

Advice and LiasonAdvice and Liason

ECT suite and equipmentStaffingLiasonManagement - clinical governanceAudit

ECT machines - UKECT machines - UK

Machine output control +display EEG

(mC)

ECTONUS 5A 50-700 single yesoptional

ECTONUS 5B 50-700 single yesoptional

NTS-R 75-4455 multiple no no

NTS-C 60-720 single no no

ECT machines - MectaECT machines - Mecta

Machine output control +display EEG

(mC)

JR1 22-1152 multiple yes no

SR1 22-1152 multiple yes yes

JR2 25-1200 single yes no

SR2 25-1200 single yes yes

Spectrum

4000 Q or M 5-1152 either yes no

5000 Q or M 5-1152 either yes yes

ECT machines - SomaticsECT machines - Somatics

Machine output control +display EEG

(mC)

Thymatron

DGx 25-1008 either yesoptional

Thymatron

system IV 25-1008 either yes yes

Nursing standardsNursing standards

first level nurse responsibilityregistered nurse at each stageCPR competencyescort nurse familiar and aware of

legal issues and consent statusbackup easily available

National Audit of ECT in Scotland, 1997-2000.

Guidelines for AnaesthesiaGuidelines for Anaesthesia

consultant responsibilitytrained anaesthetiststrained assistant (ODP)

standard equipmentECT workupaccess to critical care for ASA

grades 3 or above (medical condition affecting lifestyle)

Possible mode of actionPossible mode of action

Anticonvulsant (1)

Receptor modulator (2)

Neurotrophic (BDNF) (3)

Changes in gene expression (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;14:206-19

Advice and LiasonAdvice and Liason

ECT suite and equipment Staffing Liason

Management - clinical governanceAudit

Treatment policyTreatment policy

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

2. Treatment protocols

Prescription of ECTPrescription of ECT

high dose low dose

Bilateral 80% efficacy 70% efficacy

s/e +++ s/e ++

Unilateral 70% efficacy but 30% efficacy

depends on dose

s/e + 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

Prescription of ECTPrescription of ECT

high dose low dose

Bilateral 70% efficacy

s/e ++

Unilateral 70% efficacy but 30% efficacy

depends on dose

s/e + 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

Prescription of ECTPrescription of ECT

high dose low dose

Bilateral 70% efficacy

s/e ++

Unilateral 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 ECTBilateral ECT

Sackeim et al. (series of studies 1991 - 93, USA)

low dose UECT - 28% response low dose BECT - 70% response same seizure length cognitive side-effects related to dose above seizure

threshold rather than absolute dose

conclusion: best outcome when the dose exceeds

seizure threshold (BECT) by 50 - 100% for a given individual

Unilateral ECTUnilateral ECT

Efficacy increases with dose above ST maybe up to 12 fold side effects increase with dose above ST but probably not to the extent of BECT

so maybe no need to measure ST? but technically more difficult

ref:McCall, Reboussin, Weiner,Sackeim, Titrated Moderately Suprathreshold vs fixedhigh-dose Right Unilateral ECT, 2000, Archives of Gen Psychiatry, 57,438-444.

Cognitive side-effectsCognitive 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 thresholdSeizure threshold

measure. pros: specific

theraputic, despite seizure length

decreased risk of overdose

cons: time under anaesthetic

risks of repeated stimulation?

estimate. pros: quick

cons: predictive factors for only 25%

risk of overdose in upto 25% so keep starting dose low

Stimulus dosing protocolsStimulus dosing protocols

missed seizurespartial seizuresprogressive shortening of seizure

length

prolonged seizures

EEG monitoring ?EEG monitoring ?

for: direct measure

detection of prolonged seizures

(indicator of clinical efficacy?)

against: anxiety provoking??

time taken

training implications

Other protocolsOther protocols

Consent to treatmentpre-ECT work-uprecord of treatmentmonitoring of side-effectsfeedback to clinical team

Special populationsSpecial populations

outpatients young peoplepregnancycognitively impaired

see The ECT Handbook 1995.

Training and supervisionTraining and supervision

% adequate: 1981 1991 1996 1997 1999

(scotland)

training 60 93 93 supervision 10 10 16 45 50 anaesthetist 43 66 100 100 100 nurses 35 66 ‘varied’ 94

1. Royal College of Psychiatrists, three audit cycles, 1981, 1991, 1996

2. The National Audit of ECT in Scotland , 1997-00

Tasks for the ECT teamTasks for the ECT team

Dr Grace FergussonArgyll and Bute Hospital

Lochgilphead

Royal College of Psychiatrists ECT training day, Jan 2002