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A teaching guide for electroconvulsive therapy
Comprehensive Psychiatry (Official Journal of the American Psychopathological Association)
VOL. 40, NO. 5
SEPTEMBER/OCTOBER
A Teaching Guide for Electroconvulsive Therapy Barry Alan Kramer Concern has been raised regarding the erratic and sometimes less than adequate teaching of electroconvulsive therapy (ECT) to health professionals. The development of standardized curricula will ultimately improve the quality of care for patients receiving ECT and help to minimize the myths and misinformation clinicians have regarding ECT. An outline for teaching ECT is presented that covers the following areas: preconceptions, history, patient selection, conditions
of increased risk, medical and neurological side effects, memory issues, technical aspects, electrode placement, clinical problems, management of the postECT course, legal and ethical issues, mechanisms of action, and educational issues. This outline can be expanded to encompass up to a 6-hour course for psychiatric residents, or compressed to provide the basics to nursing, medical, or pharmacy students.
IXTY YEARS AFTER its introduction into psychiatric practice, training in electroconvulsive therapy (ECT) is often minimal and standards are lacking. Raskin 1 was critical of the educational activities in psychiatric training programs in 1984 based on a survey of their clinical and treatment techniques. Of the 42 programs responding, five indicated that ECT was not used in their programs at all. No attempt was made to ascertain the didactic material being taught to the trainees. An editorial by Fink e commented on the increasing technology needed to administer ECT at today's standard. He concluded that current teaching programs are often deficient in conveying up-to-date ECT skills and knowledge to residents. He recommended that the American Psychiatric Association (APA) should examine training practices in medical schools and residency programs. A 1989 survey of residents in Philadelphia 3 confirmed an inadequate level of knowledge for many of the residents and significant gaps in residency training with regard to ECT. Although most of the residents possessed a positive attitude toward ECT, only two of 29 residents surveyed reported confidence in their own ability to administer ECT. They conclude that current training in ECT often fails to meet clear educational objectives. The recent APA Task Force on ECT 4 deplored the fact that the "present training in ECT in many residency programs ranges from marginal to totally
absent" (p. 116). They recommend a minimal amount of training in ECT for medical students, psychiatric residents, anesthesiologists, and nursing students. The training recommendations consist of general and specific didactic information, as well as videotapes, observation, and "hands-on" experience. Medical students should receive at least l hour of training. Residency programs should develop adequate curricula and solicit outside practitioners if existing faculty are not sufficiently versed in ECT. A minimum of 4 hours formal didactic instruction is suggested. Videotapes may be a helpful adjunct in training but should not be relied on exclusively, because the interchange between the resident and the instructor is important. The didactic instruction should be supplemented with an intensive practical training experience supervised by a well-qualified practitioner. These are minimum requirements that should be exceeded when possible. The recommendations, however, are voluntary. Two years after these recommendations, Fink and Abrams 5 critiqued the inadequate training for ECT in the United States. It was found that few medical schools or residency training centers met
S
Copyright© 1999by W.B. Saunders Company
From the Cedars Sinai Medical Center, Los Angeles, CA. Address reprint requests to Barry Alan Kramer, M.D., Medical Director of ECT, Cedars Sinai Medical Center, 8730 Alden Dr, Thalians-W223, Los Angeles, CA 90048. Copyright © 1999 by W.B. Saunders Company 0010-440X/99/4005-000351 O.00/0
Comprehensive Psychiatry, Vol. 40, No. 5 (September/October), 1999: pp 327-331
327
328
the minimum guidelines suggested by the APA Task Force. They criticized the fact that little is asked on the American Board of Psychiatry and Neurology (ABPN) examination regarding ECT, and called upon the APA and the Accreditation Council for Graduate Medical Education (ACGME) to establish and monitor standards for ECT training for residents. Deficiencies in ECT education are not confined to the United States. Concern has been raised regarding the quality and consistency of ECT teaching to psychiatrists in training in Great Britain. Responding to severe criticism by the Royal College of Psychiatry about the wide variability in training and treatment standards in Great Britain, the editor of The Lancet 6 warned that "If ECT is ever legislated against or falls into disuse it will not be because it is an ineffective or dangerous treatment; it will be because psychiatrists have failed to supervise or monitor its use adequately." A recent audit of ECT facilities in Great Britain continued to find serious deficiencies in training, including half of the trainees' being unsupervised by an experienced psychiatrist the first time they performed ECTT,8 A Canadian survey9 of senior psychiatric residents revealed that only half of the respondents received more than 2 hours of formal didactic lecture on ECT. Only half of the respondents had observed more than 10 treatments, and 3.8% had never observed a treatment. ECT was never administered by 19.6% of the respondents. Nearly half of the respondents who had administered ECT did so without the attending psychiatrist present for direct supervision. The reasons for this teaching deficit may be quite varied. There are many different activities and learning experiences vying for the resident's attent i o n - t h e r e is so much to teach and so little time. If the existing faculty have not been adequately trained in ECT, they often will not view this as important to pass on to current residents. The faculty may have negative stereotypes and prejudices regarding ECT. There may be no available faculty to teach such a course. On the other hand, Bolwig ~°reported that as part of the training of psychiatrists in Denmark, they are required to receive training from a senior psychiatrist in charge of ECT at a university or universityaffiliated hospital. They receive a certificate after 25 such sessions. Froimson et al. u discuss the need for increased
BARRY ALAN KRAMER
ECT knowledge by nurses to effectively care for patients today. TRAINING STUDIES
Reports of the effects of training are few. Benbow 12reported a positive effect of training on ECT administration in housestaff following a training period consisting of viewing a videotape on ECT followed by discussion. Szuba et al. ~3 concluded that intensive education about ECT improves the attitudes and knowledge of residents and medical students. Attempts have been made to compensate for this deficiency on a postresidency level. Several universities have begun to offer ECT courses on a regular basis for physicians and nurses. Courses have been appearing with increased regularity in medical meetings, but these courses are aimed primarily at those already in practice--we cannot rely on medical meetings for basic education. Jackson 14 notes that industry-sponsored symposiums at psychiatric meetings extensively educate us about drug treatment. The same does not exist for ECT, which is only mentioned "parenthetically," if at all. It is the intention of this article to present a basic outline that, with the aid of selected references, faculty can use to formalize and structure an ECT teaching program. EXPLANATION OF DIDACTIC MODEL
Several books and journal articles are listed in Appendix 1 that can be used by the seminar leader as a reference source for up-to-date information on ECT to help prepare the lecture material. These are also useful reading materials for psychiatric residents interested in learning more about ECT. Appendix 2 contains a condensed sample outline to aid in its use by others. It has evolved over the past 20 years in teaching ECT to different disciplines. Usually, this is given during PGY1 or PGY2, which correspond to time on the inpatient service. The outline encompasses the areas that should be mentioned at least briefly in a didactic overview of ECT. Different areas can be emphasized for different audiences such as medical students, nursing students, pharmacy students, medical residents, or psychiatric residents. The material that a psychiatric resident should know upon graduation would require approximately 6 hours to present. The bare minimum for a psychiatric resident could be covered in 3 hours, with supplementary material in the
TEACHING GUIDE FOR ECT
clinical experience. Depending on the time available, some subjects will be reviewed cursorily and others will be covered in depth. For example, in a 3-hour course, 5 minutes would be allotted for mechanisms of action; in a 6-hour course, 20 minutes would be allotted. The brief historical overview would require about the same amount of time in a 3-hour or 6-hour presentation. More time is allocated for legal and consent issues for psychiatric residents than for pharmacy students.
329
8.
9. OVERVIEW OF COURSE
1. Introduction: This section acknowledges the "lay" (but not scientific) controversy surrounding ECT. The impact of the media and antipsychiatry organizations is discussed. Participants are encouraged to express their preconceptions of ECT. The usefulness of knowledge about ECT is discussed regardless of the attendees' discipline or goals. 2. Histo~: The origins of ECT are discussed--first dealing with the use of electricity in medicine and next focusing on seizures as therapy. The historical discussion of electricity should emphasize that electricity is not a central issue in ECT. The introduction of ECT in Europe and America is placed in the context of the availability of psychiatric treatments at that time and the chronology for the introduction of other somatic treatments into the psychiatrist's armamentarium. 3. Patient Selection: The format of the APA Task Force report 4 is followed. Primary and secondary indications for ECT are discussed. Specific diagnostic indications are enumerated. Special population groups based on age or pregnancy are discussed. The usefulness and limitations of ECT in medical disorders such as neuroleptic malignant syndrome and Parkinson's disease are covered. 4. Increased Risk: Issues that increase the risk of ECT or require special interventions are discussed. Medical problems, concurrent medications, and psychiatric diagnoses that complicate the treatment are discussed, including how to minimize these risks. 5. Side Effects: Medical, neurological, and memoryloss side effects are discussed. 6. Technical Aspects: The medical and psychiatric work-up is outlined. Preparation of the patient and anesthesia techniques are discussed. Stimulus dosing strategies are discussed. ECT equipment available in the United States is discussed. 7. Electrode Placement: The controversy between
10.
1l.
12.
unilateral and bilateral electrode placement is introduced. The pros and cons of each are discussed, as well as the current recommendations for choice of electrode placement. Clinical Problems: Management of both problems with the treatment procedure itself and medical events that complicate the treatment are discussed. Topics include missed seizures, abortive seizures, measures to influence seizure induction or duration, prolonged seizures, hypertension, tachycardia, and atypical cholinesterase. Management of Post-ECT Course: Following completion of the acute course of ECT, the risk of relapse must be minimized. Prophylactic medication, continuation ECT, and maintenance ECT are discussed as treatment options. The frequency of ECT and location (inpatient v outpatient) are discussed. Legal and Ethical Aspects: An overview of general legal requirements should be supplemented by detailed specific requirements in the state where the seminar is given. The right to refuse treatment that these laws protect is contrasted with the right to receive treatment. The status of malpractice insurance regarding ECT is discussed. The social stigma of ECT is discussed. The limited availability of ECT in the public sector compared with the private sector, including demographics, is discussed. Mechanisms of Action: The major theories as to why ECT works are presented. The disproven psychological theories are mentioned. The major theories covered include the catecholamine theories, neuroendocrine-hypothalamic theories, and antiseizure theories. Education: The availability of videotapes, books, and other patient educational materials is discussed. Material may be distributed. APA Task Force l° recommendations are discussed. External training programs that are regularly offered at several schools are discussed, as well as certification issues. APPENDIX 1: BIBLIOGRAPHY
• Abrams R. ElectroconvulsiveTherapy. New York, NY: Oxford UniversityPress, 1997. • AmericanPsychiatricAssociationTask Force on ECT. The Practice of ElectroconvulsiveTherapy: Recommendations for Treatment,Training,and Privileging.Washington,DC: AmericanPsychiatricPress, 1990. • CoffeyCE (ed). The ClinicalScienceof Electroconvulsive Therapy. Washington, DC: American Psychiatric Press, 1993.
330 • Fink M. Informed ECT for Health Professionals (video). Lake Bluff, IL: Somatics Inc, 1986. • Fink M, Sackeim HA. Convulsive therapy in schizophrenia? Schizophr Bull 1996;22:27-39. • Kellner CH, Pritchett JT, Beale MD, Coffey CE. Handbook of ECT. Washington, DC: American Psychiatric Press, 1997. • Krystal AD, Coffey CE. Neuropsychiatric considerations in the use of electroconvulsive therapy. J Neuropsychiatry 1997;9:283-292. • Rabheru K, Persad E. A review of continuation and maintenance electroconvulsive therapy. Can J Psychiatry 1997;42:476-484.
APPENDIX 2: BASIC ECT SEMINAR OUTLINE 1. Did anyone ever witness ECT? 2. Preexisting ideas of ECT (Frankenstein, Cuckoo's nest, etc.)? 3. Even if you will not do ECT, you need to know who to refer and how to evaluate medically for ECT. History 1. Torpedo fish in Ancient Greece (43 AD). 2. Fascination with electricity in medicine. 3. Electricity is peripheral to ECT development. The seizure is the central issue. 4. Laszlo Von Meduna, 1935, belief that epilepsy and schizophrenia are antagonistic to each other. 5. Chemically induced convulsive therapies. 6. First ECT in 1938 in Italy by Cerlietti and Bini. Patient selection and treatment course 1. Primary and secondary use of ECT (see APA Task Force). 2. Major depression. 3. Mania. 4. Schizophrenia. 5. Other psychotic disorders. 6. Delirium, dementia, and other cognitive disorders. 7. Medical disorders: catatonia secondary to medical illness, intractable seizure disorder, neuroleptic malignant syndrome, Parkinson's disease (especially severe "onoff" phenomenon). 8. Children and adolescents. 9. The elderly. 10. Pregnancy. Increased risk 1. No absolute contraindication. 2. Age issues. 3. Cardiac disease: differentiate status post-acute myocardial infarction v chronic cardiac disease (including pacemakers, valves, surgery, etc.). 4. Glaucoma. 5. Neurologic disease: brain tumor or other increased intracranial pressure v chronic neurologic problems. 6. Vascular aneurysms or malformations. 7. Pheochromocytoma. 8. Porphyria. 9. Patient with comorbid axis II pathology. 10. Drug problems: reserpine, monoamine oxidase inhibitors, lithium, drugs interfering with cholinesterase, and anticonvulsants including benzodiazepines.
BARRYALAN KRAMER Side effects 1. Headache. 2. Nausea and vomiting. 3. Fractures and dislocations. 4. Pulmonary: aspiration and prolonged apnea from atypical cholinesterase. 5. Cardiac arrhythmias. 6. Death--rare (0,2 deaths per 10,000 treatments). 7. Emergence delirium. 8. Spontaneous seizures: no increased incidence from ECT. 9. "Brain damage"--no evidence with current techniques. Review studies. 10. Memory loss--review issues in memory testing and other causes of memory loss including depression and psychotropic drugs. Discuss anterograde v retrograde memory issues in ECT. Technical aspects 1. Medical and laboratory work-up. 2. Nothing orally after midnight. 3. Anesthesia: anticholinergic (atropine or glycopyrrolate), methohexital, succinylcholine, hyperoxygenation. 4. Stimulus dosing strategies. 5. Outpatient ECT, 6. ECT equipment: brands and electrical and safety issues. 7. ECT equipment: EEG, ECG, and EMG monitoring capabilities and computed seizure quality measures. Unilateral v bilateral ECT 1. Efficacy and memory issues, 2. Biological issues including EEG changes and changes in prolactin. 3. Different unilateral electrode placements. Most effective is d'Elia. Clinical problems 1. Seizure issues: missed seizures, short or abortive seizures, prolonged seizures. Include pharmacological agents that may augment ECT. 2. Hypertension and/or tachycardia. 3. Atypical cholinesterase--rare (1 in 3,000 people); frightening; use of alternate muscle relaxers such as atracurium. Management of post-ECT course: 1. Drug treatment, 2. Continuation and maintenance ECT. Legal and ethical issues 1. Legal and consent requirements of the specific state where training occurs. 2. Effect of anti-ECT regulation on underutilization of ECT (California is a good example with data in the literature). 3. Public v private patients. Very limited use in the public sector. 4. Social stigma. 5. Malpractice. Theories of action 1. Psychological theories---disproven. 2. Catecholamine theory. 3. Neuroendocrine/hypothalamic theories. 4. Antiseizure theory. Education 1. Professional education: medical students, psychiatric residents, nursing students, other health workers. 2. Patient educational material. 3. Postgraduate courses and brief fellowships.
TEACHING GUIDE FOR ECT
331
REFERENCES
1. Raskin DE. A survey of electroconvulsive therapy: use and training in university hospitals in 1984. Convuls Ther 1986;2: 293-296. 2. Fink M. New technology in convulsive therapy: a challenge in training. Am J Psychiatry 1987; 144:1195-1198. 3. Jaffe R, Shoyer B, Siegel L, Roemer R, Dubin W. An assessment of psychiatric residents' knowledge and attitudes regarding ECT. Acad Psychiatry 1990; 14:204-210. 4. American Psychiatric Association Task Force on ECT. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. Washington, DC: American Psychiatric Press, 1990. 5. Fink M, Abrams R. Qualification for ECT (editorial). Convuls Ther 1992;8:1-4. 6. ECT in Britain: a shameful state of affairs (editorial). Lancet 1981 ;2:1207-1208. 7. Duffett R, Lelliott P. Auditing electroconvulsive therapy. The third cycle. Br J Psychiatry 1998; 172:401-405. 8. Duffett R, Lelliott P. Junior doctors' training in the theory
and the practice of electroconvulsive therapy. J Electroconvuls Ther 1998;14:127-130. 9. Goldbloom DS, Kussin DJ. Electroconvulsive therapy training in Canada: a survey of senior residents in psychiatry. Can J Psychiatry 1991;36:126-127. 10. Bolwig TG. Training in convulsive therapy in Denmark. Convuls Ther 1987;3:156-157. 11. Froimson L, Creed P, Mathew L. State of the art: nursing knowledge and electroconvulsive therapy. Convuls Ther 1995; 11:205-211. 12. Benbow SM. Effect of training on administration of electroconvulsive therapy by junior doctors. Convuls Ther 1986;2:19-24. 13. Szuba MP, Guze BH, Liston EH, Baxter LR, Roy-Byrne P, Psychiatry resident and medical student perspectives on ECT: influence of exposure and education. Convuls Ther 1986;8:110117. 14. Jackson J. Electroconvulsive therapy: problems and prejudices. Convuls Ther 1995; 11:179-181,
VOL. 40, NO. 5
SEPTEMBER/OCTOBER
A Teaching Guide for Electroconvulsive Therapy Barry Alan Kramer Concern has been raised regarding the erratic and sometimes less than adequate teaching of electroconvulsive therapy (ECT) to health professionals. The development of standardized curricula will ultimately improve the quality of care for patients receiving ECT and help to minimize the myths and misinformation clinicians have regarding ECT. An outline for teaching ECT is presented that covers the following areas: preconceptions, history, patient selection, conditions
of increased risk, medical and neurological side effects, memory issues, technical aspects, electrode placement, clinical problems, management of the postECT course, legal and ethical issues, mechanisms of action, and educational issues. This outline can be expanded to encompass up to a 6-hour course for psychiatric residents, or compressed to provide the basics to nursing, medical, or pharmacy students.
IXTY YEARS AFTER its introduction into psychiatric practice, training in electroconvulsive therapy (ECT) is often minimal and standards are lacking. Raskin 1 was critical of the educational activities in psychiatric training programs in 1984 based on a survey of their clinical and treatment techniques. Of the 42 programs responding, five indicated that ECT was not used in their programs at all. No attempt was made to ascertain the didactic material being taught to the trainees. An editorial by Fink e commented on the increasing technology needed to administer ECT at today's standard. He concluded that current teaching programs are often deficient in conveying up-to-date ECT skills and knowledge to residents. He recommended that the American Psychiatric Association (APA) should examine training practices in medical schools and residency programs. A 1989 survey of residents in Philadelphia 3 confirmed an inadequate level of knowledge for many of the residents and significant gaps in residency training with regard to ECT. Although most of the residents possessed a positive attitude toward ECT, only two of 29 residents surveyed reported confidence in their own ability to administer ECT. They conclude that current training in ECT often fails to meet clear educational objectives. The recent APA Task Force on ECT 4 deplored the fact that the "present training in ECT in many residency programs ranges from marginal to totally
absent" (p. 116). They recommend a minimal amount of training in ECT for medical students, psychiatric residents, anesthesiologists, and nursing students. The training recommendations consist of general and specific didactic information, as well as videotapes, observation, and "hands-on" experience. Medical students should receive at least l hour of training. Residency programs should develop adequate curricula and solicit outside practitioners if existing faculty are not sufficiently versed in ECT. A minimum of 4 hours formal didactic instruction is suggested. Videotapes may be a helpful adjunct in training but should not be relied on exclusively, because the interchange between the resident and the instructor is important. The didactic instruction should be supplemented with an intensive practical training experience supervised by a well-qualified practitioner. These are minimum requirements that should be exceeded when possible. The recommendations, however, are voluntary. Two years after these recommendations, Fink and Abrams 5 critiqued the inadequate training for ECT in the United States. It was found that few medical schools or residency training centers met
S
Copyright© 1999by W.B. Saunders Company
From the Cedars Sinai Medical Center, Los Angeles, CA. Address reprint requests to Barry Alan Kramer, M.D., Medical Director of ECT, Cedars Sinai Medical Center, 8730 Alden Dr, Thalians-W223, Los Angeles, CA 90048. Copyright © 1999 by W.B. Saunders Company 0010-440X/99/4005-000351 O.00/0
Comprehensive Psychiatry, Vol. 40, No. 5 (September/October), 1999: pp 327-331
327
328
the minimum guidelines suggested by the APA Task Force. They criticized the fact that little is asked on the American Board of Psychiatry and Neurology (ABPN) examination regarding ECT, and called upon the APA and the Accreditation Council for Graduate Medical Education (ACGME) to establish and monitor standards for ECT training for residents. Deficiencies in ECT education are not confined to the United States. Concern has been raised regarding the quality and consistency of ECT teaching to psychiatrists in training in Great Britain. Responding to severe criticism by the Royal College of Psychiatry about the wide variability in training and treatment standards in Great Britain, the editor of The Lancet 6 warned that "If ECT is ever legislated against or falls into disuse it will not be because it is an ineffective or dangerous treatment; it will be because psychiatrists have failed to supervise or monitor its use adequately." A recent audit of ECT facilities in Great Britain continued to find serious deficiencies in training, including half of the trainees' being unsupervised by an experienced psychiatrist the first time they performed ECTT,8 A Canadian survey9 of senior psychiatric residents revealed that only half of the respondents received more than 2 hours of formal didactic lecture on ECT. Only half of the respondents had observed more than 10 treatments, and 3.8% had never observed a treatment. ECT was never administered by 19.6% of the respondents. Nearly half of the respondents who had administered ECT did so without the attending psychiatrist present for direct supervision. The reasons for this teaching deficit may be quite varied. There are many different activities and learning experiences vying for the resident's attent i o n - t h e r e is so much to teach and so little time. If the existing faculty have not been adequately trained in ECT, they often will not view this as important to pass on to current residents. The faculty may have negative stereotypes and prejudices regarding ECT. There may be no available faculty to teach such a course. On the other hand, Bolwig ~°reported that as part of the training of psychiatrists in Denmark, they are required to receive training from a senior psychiatrist in charge of ECT at a university or universityaffiliated hospital. They receive a certificate after 25 such sessions. Froimson et al. u discuss the need for increased
BARRY ALAN KRAMER
ECT knowledge by nurses to effectively care for patients today. TRAINING STUDIES
Reports of the effects of training are few. Benbow 12reported a positive effect of training on ECT administration in housestaff following a training period consisting of viewing a videotape on ECT followed by discussion. Szuba et al. ~3 concluded that intensive education about ECT improves the attitudes and knowledge of residents and medical students. Attempts have been made to compensate for this deficiency on a postresidency level. Several universities have begun to offer ECT courses on a regular basis for physicians and nurses. Courses have been appearing with increased regularity in medical meetings, but these courses are aimed primarily at those already in practice--we cannot rely on medical meetings for basic education. Jackson 14 notes that industry-sponsored symposiums at psychiatric meetings extensively educate us about drug treatment. The same does not exist for ECT, which is only mentioned "parenthetically," if at all. It is the intention of this article to present a basic outline that, with the aid of selected references, faculty can use to formalize and structure an ECT teaching program. EXPLANATION OF DIDACTIC MODEL
Several books and journal articles are listed in Appendix 1 that can be used by the seminar leader as a reference source for up-to-date information on ECT to help prepare the lecture material. These are also useful reading materials for psychiatric residents interested in learning more about ECT. Appendix 2 contains a condensed sample outline to aid in its use by others. It has evolved over the past 20 years in teaching ECT to different disciplines. Usually, this is given during PGY1 or PGY2, which correspond to time on the inpatient service. The outline encompasses the areas that should be mentioned at least briefly in a didactic overview of ECT. Different areas can be emphasized for different audiences such as medical students, nursing students, pharmacy students, medical residents, or psychiatric residents. The material that a psychiatric resident should know upon graduation would require approximately 6 hours to present. The bare minimum for a psychiatric resident could be covered in 3 hours, with supplementary material in the
TEACHING GUIDE FOR ECT
clinical experience. Depending on the time available, some subjects will be reviewed cursorily and others will be covered in depth. For example, in a 3-hour course, 5 minutes would be allotted for mechanisms of action; in a 6-hour course, 20 minutes would be allotted. The brief historical overview would require about the same amount of time in a 3-hour or 6-hour presentation. More time is allocated for legal and consent issues for psychiatric residents than for pharmacy students.
329
8.
9. OVERVIEW OF COURSE
1. Introduction: This section acknowledges the "lay" (but not scientific) controversy surrounding ECT. The impact of the media and antipsychiatry organizations is discussed. Participants are encouraged to express their preconceptions of ECT. The usefulness of knowledge about ECT is discussed regardless of the attendees' discipline or goals. 2. Histo~: The origins of ECT are discussed--first dealing with the use of electricity in medicine and next focusing on seizures as therapy. The historical discussion of electricity should emphasize that electricity is not a central issue in ECT. The introduction of ECT in Europe and America is placed in the context of the availability of psychiatric treatments at that time and the chronology for the introduction of other somatic treatments into the psychiatrist's armamentarium. 3. Patient Selection: The format of the APA Task Force report 4 is followed. Primary and secondary indications for ECT are discussed. Specific diagnostic indications are enumerated. Special population groups based on age or pregnancy are discussed. The usefulness and limitations of ECT in medical disorders such as neuroleptic malignant syndrome and Parkinson's disease are covered. 4. Increased Risk: Issues that increase the risk of ECT or require special interventions are discussed. Medical problems, concurrent medications, and psychiatric diagnoses that complicate the treatment are discussed, including how to minimize these risks. 5. Side Effects: Medical, neurological, and memoryloss side effects are discussed. 6. Technical Aspects: The medical and psychiatric work-up is outlined. Preparation of the patient and anesthesia techniques are discussed. Stimulus dosing strategies are discussed. ECT equipment available in the United States is discussed. 7. Electrode Placement: The controversy between
10.
1l.
12.
unilateral and bilateral electrode placement is introduced. The pros and cons of each are discussed, as well as the current recommendations for choice of electrode placement. Clinical Problems: Management of both problems with the treatment procedure itself and medical events that complicate the treatment are discussed. Topics include missed seizures, abortive seizures, measures to influence seizure induction or duration, prolonged seizures, hypertension, tachycardia, and atypical cholinesterase. Management of Post-ECT Course: Following completion of the acute course of ECT, the risk of relapse must be minimized. Prophylactic medication, continuation ECT, and maintenance ECT are discussed as treatment options. The frequency of ECT and location (inpatient v outpatient) are discussed. Legal and Ethical Aspects: An overview of general legal requirements should be supplemented by detailed specific requirements in the state where the seminar is given. The right to refuse treatment that these laws protect is contrasted with the right to receive treatment. The status of malpractice insurance regarding ECT is discussed. The social stigma of ECT is discussed. The limited availability of ECT in the public sector compared with the private sector, including demographics, is discussed. Mechanisms of Action: The major theories as to why ECT works are presented. The disproven psychological theories are mentioned. The major theories covered include the catecholamine theories, neuroendocrine-hypothalamic theories, and antiseizure theories. Education: The availability of videotapes, books, and other patient educational materials is discussed. Material may be distributed. APA Task Force l° recommendations are discussed. External training programs that are regularly offered at several schools are discussed, as well as certification issues. APPENDIX 1: BIBLIOGRAPHY
• Abrams R. ElectroconvulsiveTherapy. New York, NY: Oxford UniversityPress, 1997. • AmericanPsychiatricAssociationTask Force on ECT. The Practice of ElectroconvulsiveTherapy: Recommendations for Treatment,Training,and Privileging.Washington,DC: AmericanPsychiatricPress, 1990. • CoffeyCE (ed). The ClinicalScienceof Electroconvulsive Therapy. Washington, DC: American Psychiatric Press, 1993.
330 • Fink M. Informed ECT for Health Professionals (video). Lake Bluff, IL: Somatics Inc, 1986. • Fink M, Sackeim HA. Convulsive therapy in schizophrenia? Schizophr Bull 1996;22:27-39. • Kellner CH, Pritchett JT, Beale MD, Coffey CE. Handbook of ECT. Washington, DC: American Psychiatric Press, 1997. • Krystal AD, Coffey CE. Neuropsychiatric considerations in the use of electroconvulsive therapy. J Neuropsychiatry 1997;9:283-292. • Rabheru K, Persad E. A review of continuation and maintenance electroconvulsive therapy. Can J Psychiatry 1997;42:476-484.
APPENDIX 2: BASIC ECT SEMINAR OUTLINE 1. Did anyone ever witness ECT? 2. Preexisting ideas of ECT (Frankenstein, Cuckoo's nest, etc.)? 3. Even if you will not do ECT, you need to know who to refer and how to evaluate medically for ECT. History 1. Torpedo fish in Ancient Greece (43 AD). 2. Fascination with electricity in medicine. 3. Electricity is peripheral to ECT development. The seizure is the central issue. 4. Laszlo Von Meduna, 1935, belief that epilepsy and schizophrenia are antagonistic to each other. 5. Chemically induced convulsive therapies. 6. First ECT in 1938 in Italy by Cerlietti and Bini. Patient selection and treatment course 1. Primary and secondary use of ECT (see APA Task Force). 2. Major depression. 3. Mania. 4. Schizophrenia. 5. Other psychotic disorders. 6. Delirium, dementia, and other cognitive disorders. 7. Medical disorders: catatonia secondary to medical illness, intractable seizure disorder, neuroleptic malignant syndrome, Parkinson's disease (especially severe "onoff" phenomenon). 8. Children and adolescents. 9. The elderly. 10. Pregnancy. Increased risk 1. No absolute contraindication. 2. Age issues. 3. Cardiac disease: differentiate status post-acute myocardial infarction v chronic cardiac disease (including pacemakers, valves, surgery, etc.). 4. Glaucoma. 5. Neurologic disease: brain tumor or other increased intracranial pressure v chronic neurologic problems. 6. Vascular aneurysms or malformations. 7. Pheochromocytoma. 8. Porphyria. 9. Patient with comorbid axis II pathology. 10. Drug problems: reserpine, monoamine oxidase inhibitors, lithium, drugs interfering with cholinesterase, and anticonvulsants including benzodiazepines.
BARRYALAN KRAMER Side effects 1. Headache. 2. Nausea and vomiting. 3. Fractures and dislocations. 4. Pulmonary: aspiration and prolonged apnea from atypical cholinesterase. 5. Cardiac arrhythmias. 6. Death--rare (0,2 deaths per 10,000 treatments). 7. Emergence delirium. 8. Spontaneous seizures: no increased incidence from ECT. 9. "Brain damage"--no evidence with current techniques. Review studies. 10. Memory loss--review issues in memory testing and other causes of memory loss including depression and psychotropic drugs. Discuss anterograde v retrograde memory issues in ECT. Technical aspects 1. Medical and laboratory work-up. 2. Nothing orally after midnight. 3. Anesthesia: anticholinergic (atropine or glycopyrrolate), methohexital, succinylcholine, hyperoxygenation. 4. Stimulus dosing strategies. 5. Outpatient ECT, 6. ECT equipment: brands and electrical and safety issues. 7. ECT equipment: EEG, ECG, and EMG monitoring capabilities and computed seizure quality measures. Unilateral v bilateral ECT 1. Efficacy and memory issues, 2. Biological issues including EEG changes and changes in prolactin. 3. Different unilateral electrode placements. Most effective is d'Elia. Clinical problems 1. Seizure issues: missed seizures, short or abortive seizures, prolonged seizures. Include pharmacological agents that may augment ECT. 2. Hypertension and/or tachycardia. 3. Atypical cholinesterase--rare (1 in 3,000 people); frightening; use of alternate muscle relaxers such as atracurium. Management of post-ECT course: 1. Drug treatment, 2. Continuation and maintenance ECT. Legal and ethical issues 1. Legal and consent requirements of the specific state where training occurs. 2. Effect of anti-ECT regulation on underutilization of ECT (California is a good example with data in the literature). 3. Public v private patients. Very limited use in the public sector. 4. Social stigma. 5. Malpractice. Theories of action 1. Psychological theories---disproven. 2. Catecholamine theory. 3. Neuroendocrine/hypothalamic theories. 4. Antiseizure theory. Education 1. Professional education: medical students, psychiatric residents, nursing students, other health workers. 2. Patient educational material. 3. Postgraduate courses and brief fellowships.
TEACHING GUIDE FOR ECT
331
REFERENCES
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