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Electroconvulsive therapy: An effective treatment
Lucille Ahern, RN
Electroconvulsive therapy: An effective treatment
Electroconvulsive therapy (ECT) is a safe, effective, but often misunderstood somatic treatment for mental disorders. In the past, this type of electric shock therapy conjured up images of frightened, unwilling patients held down while wires were strapped to their heads, gags forced into their mouths, and trained assistants stood by to prevent fractures during convulsions. Today, a modified ECT is administered t o patients under carefully monitored conditions in hospital operating rooms, daysurgery units, and recovery rooms. Patients are premedicated and anes-
Lucille Ahern, RN, is supervisor of somatic therapies at Carnelback Hospitals in Phoenix, Ariz. A diploma graduate of St Anthony's Hospital, Rock Island, 111, she received a BS and an MA in education from Northern Arizona University, Flagstaff. The author wishes to acknowledge Karl Voldeng, MD, William McGrath, MD, and Floyd Templeton, MD, for their assistance in writing the manuscript.
thetized t o allow electrode stimulation of their brains without the accompanying violent muscle spasms. ECT has always been a controversial topic in psychiatric circles, with its advocates claiming therapeutic benefits for depressed and schizophrenic patients and its opponents pointing out the risks of memory loss and confusion. These differences of opinion continue to hamper the use and study of ECT. Although many psychiatrists administer ECT to selected patients, misconceptions about the process, its efficacy, safety, and mode of action continue to persist. The nurse caring for the ECT patient can play an important role in helping the patient to understand the procedure and to resolve the feelings of anxiety that may accompany it. The search for modes of somatic therapy for mental disorders is by no means recent. As far back as 1785, camphor was used to induce convulsions in the treatment of mental disorders, but this method proved to be unreliable. The treatment was revived in 1933 by the Hungarian psychiatrist Ladislas Von Meduna. He observed that psychotic patients often showed a decrease in symptoms following a seizure from any cause. Camphor was gradually replaced by a more reliable drug, pentylenetetrazol (Metrazol). Von Meduna recognized that the treatment was more effective in depressions than in schizophrenia.
ocAORN Journal, September 1981, V o l 3 4 , No 3
463
In 1938two Italian psychiatrists, Ugo Cerletti and Loeio Bini, introduced the technique of passing an electric current through two electrodes placed on the forehead, thereby producing a convulsion. ECT became an effective method in the treatment of mental disorders. I n 1939, Lothar Kalinowsky, a Berlin-born psychiatrist, introduced ECT in the United States. In the past 40 years, several shock therapies have developed. Many have been discarded, but ECT remains a safe, effective, lifesaving treatment. After years of ECT treatment and research studies, why ECT alters specific psychiatric symptoms remains a mystery. It is important to emphasize that ECT does not cure the illness, but promotes the remission of symptoms. At Camelback Hospital, where I am a psychiatric nurse, the primary indication for ECT is in affective disorders. Some psychiatrists consider i t the treatment of choice for endogenous depression; it is usually considered when drug therapy has failed to bring improvement. A brief series of six to eight treatments usually relieves depression. The physician may choose to treat acute or chronic schizophrenia patients with ECT. Eight to 15treatments are usually effective. ECT is not indicated for neurotic or personality disorders. The mortality rate for ECT is less than 0.03%. Some hospitals report no fatalities after thousands of treatments given over periods of many years. In contrast, the mortality rate from suicide associated with untreated depressive illness is high, and the medical complications from antidepressants and psychotropic drugs are considerable, especially in geriatric patients. Some temporary impairment of memory occurs almost inevitably with ECT. This impairment may range from a mild tendency to forget names or dates to a severe confusion. Some patients ex-
466
perience a period of physical discomfort, such as headache, sore muscles, nausea, and psychomotor restlessness. Permanent adverse effects are extremely rare. An important part of preparing the patient for therapy is to identify and dispel1 any fears or fantasies about ECT. Patients may have fear of pain, dying from electrocution, or suffering permanent memory loss or impaired intellectual functioning. The nurse should explain to the patient that in modified ECT, he will not be alone. He will be put to sleep rapidly and will not consciously experience treatment. Before ECT treatment, the patient should have a complete evaluation of his physical condition, consisting of history and physical examination, laboratory, chest x-ray, anteroposterior projection and lateral spine films, and electrocardiogram (ECG). The hospital should provide an experienced medical team t h a t will provide constant safeguards in administering ECT therapy. The consent to treatment form should explain the nature of the treatment, the purpose of the treatment, possible alternate methods of treatment, possible side effects, and risks of complications. This form is then read and signed by the patient, physician, and a witness. Any remaining fantasies or misconceptions should be corrected by the physician. The patient should be given nothing by mouth, including oral medication, after midnight. The premedication, usually atropine sulfate, is given one hour before the scheduled therapy. It inhibits secretion and lessens vagal stimulation. ECT is usually scheduled every other day in a series of 6 to 15 treatments. The registered nurse checks all supplies and equipment, such as emergency cart, suction, oxygen, defibrillator, and equipment to deliver electricity in measured amounts.
AORN Journal, September 1981, V o l 3 4 , N o 3
ursing intervention is needed to resolve fears and uncertainty.
N
The patient is brought to the treatment room 15 minutes before a scheduled treatment. This provides the nurse enough time to complete the checklist form. This form is part of the patient’s chart. The items to be checked are history and physical examination; signed consent to treatment form; current medication order; NPO status; time premedication was given; x-rays; ECG;laboratory report; reports if patient voided, and if patient has dentures, jewelry, wig, etc. Any questions the patient may have should be answered and reassurance given. The nurse may give support to the patient by simply listening to his fears, expressing understanding of his anxiety. When the physician arrives, the nurse assists the patient onto a n adequately insulated gurney. She then positions the patient and covers him with a sheet, exposing the feet so that any fasciculation can be seen after the anesthesia is given. In some institutions, an anesthetist is on hand to administer the intravenous anesthetic. In other instances, the drugs are given by an attending psychiatrist qualified t o handle emergency complications. An alcohol or iodine swab is used to prepare the skin at the injection site. A #21 scalp vein needle is used for the infusion of the anesthesia. A short-acting anesthetic, such as thiopental sodium (Pentothal) or methohexital (Brevital), is given, followed by a muscle relaxant,
succinylcholine chloride (Anectine). These drugs are titrated according to the patient’s size, age, physical condition, and medical history. If the patient cannot tolerate barbituates, diazepam (Valium) is used instead. The nurse cleans the temporal area of the head with alcohol. Electrode contact jelly is applied to the electrodes, which are attached to a rubber headband. Treatment can be unilateral or bilateral, that is, with electrodes applied to stimulate one or both brain hemispheres. Unilateral stimulation is applied to the nondominant hemisphere. Unilateral ECT produces results similar to bilaterally induced ECT, but seems to cause less posttreatment amnesia. It requires a longer series of treatments, however. The patient is ventilated with oxygen until the maximal muscle paralysis is reached, then the nurse attaches the lead wires to the electrodes. A rubber mouth gag is placed between the teeth to prevent biting of the tongue or chipping of the teeth. The nurse then supports the chin and shoulders. The electrical stimulus is administered at 170 millivolts for one second, to produce a grand ma1 seizure. The physician or nurse ventilates the patient with oxygen immediately after the electrical stimulus. Oxygen is administered until spontaneous breathing returns. The length of the seizure varies with individuals and is usually 20 to 45 seconds. The mouth gag is kept in place until the
AORN Journal, September 1981,Vol34, No 3
467
tonic and clonic phases of the seizure have subsided. The nurse immediately removes the lead wires, the headband, and any excess jelly from the temples. When spontaneous breathing returns, the nurse turns the patient on his side. The head is supported so the neck will not be twisted. The patient’s arms should be free from the body and one leg bent to act as a brace. The chin is extended to promote a good airway. The physician determines when the patient is ready to go to the recovery room. Recovery time is determined by the amount of anesthesia given and the patient’s ability to detoxify anesthetic agents. In the recovery room, particular attention needs t o be paid t o the adequacy of ventilation after awakening, and to motor restlessness, nausea, headache, and confusion that may occur. When the patient is fully awake and stable, he is fed breakfast. Before returning the patient to his room, the nurse should answer any questions he may have related to the temporary posttreatment amnesia. The nurse plays an important role caring for the patient having ECT, Nursing intervention is needed to resolve the fears and uncertainty of the ECT process. There is a need for further nursing research on ECT. The contradictory findings and quality of reports present minimal information for nursing schools. Studies might include closer monitoring the patient’s behavior before and after ECT treatment, a followup of relapse rates, and an examination of the quality of the treated patient’s life after ECT. Most information describing ECT is antiquated and presents many doubts that may be conveyed inadvertently to the patient by the nurse. This may add to the patient’s fears and uncertainty about the ECT treatment.
470
The quality of nursing care of the ECT patient can be improved when the nurse has more insight into the efficacy 0 of ECT as a primary treatment. Suggested reading
Ashmalla, Medhat. “Electroconvulsive therapy (ECT), a moderate view.” Journal of the Florida Medical Association 66 (July 1979)688-689. Callan, John P. “Electroconvulsive therapy.” Journalof the American Medical Association 242 (Aug 10,1979) 545-546.
Gonzales, Elizabeth Rasche. ”Update on electroconvulsive therapy.” Journal of the American Medical Association 241 (April 27, 1979) 17751779.
Nardine, John. “Electricshock reconsidered,underutilized, effective and safe.” Frontiers of Psychiatry 10 (March 1, 1980). Salzman, Carl. “The use of ECT in the treatment of schizophrenia.” The American Journal of Psychiatry 137 (September 1980) 1033-1041. Soloman,Jonathan. “Electroconvulsivetherapy and overview.” Virginia Medical 106 (April 1979) 280-287.
Catheter technique rivals bypass surgery A new coronary catheter technique may
challenge bypass surgery as a treatment for narrowed coronary arteries. Percutaneous transluminal coronary angioplasty (PTCA)opens partially blocked coronary arteries by using a balloon catheter to compress obstructing plaques. When the technique is successful,the plaques remain compressed against the artery wall, blood flow to the heart is increased, and angina ceases. PTCA costs about $1,000 and requires two days’ hospitalization, compared to $15,000 and two weeks in the hospital for bypass surgery. These figures are from a Science (July 10) report on a recent PTCA workshop sponsored by the National Heart, Lung, and Blood Institute. Participants at the workshop were enthusiastic about the new technique but called for a clinical trial to prove its effectiveness. Current figures from a PTCA registry show the method has succeeded initially in about 65% of the cases, but 20% had recurrence within a few months.
AORN Journal, September 1981,V o l 3 4 , No 3
Electroconvulsive therapy: An effective treatment
Electroconvulsive therapy (ECT) is a safe, effective, but often misunderstood somatic treatment for mental disorders. In the past, this type of electric shock therapy conjured up images of frightened, unwilling patients held down while wires were strapped to their heads, gags forced into their mouths, and trained assistants stood by to prevent fractures during convulsions. Today, a modified ECT is administered t o patients under carefully monitored conditions in hospital operating rooms, daysurgery units, and recovery rooms. Patients are premedicated and anes-
Lucille Ahern, RN, is supervisor of somatic therapies at Carnelback Hospitals in Phoenix, Ariz. A diploma graduate of St Anthony's Hospital, Rock Island, 111, she received a BS and an MA in education from Northern Arizona University, Flagstaff. The author wishes to acknowledge Karl Voldeng, MD, William McGrath, MD, and Floyd Templeton, MD, for their assistance in writing the manuscript.
thetized t o allow electrode stimulation of their brains without the accompanying violent muscle spasms. ECT has always been a controversial topic in psychiatric circles, with its advocates claiming therapeutic benefits for depressed and schizophrenic patients and its opponents pointing out the risks of memory loss and confusion. These differences of opinion continue to hamper the use and study of ECT. Although many psychiatrists administer ECT to selected patients, misconceptions about the process, its efficacy, safety, and mode of action continue to persist. The nurse caring for the ECT patient can play an important role in helping the patient to understand the procedure and to resolve the feelings of anxiety that may accompany it. The search for modes of somatic therapy for mental disorders is by no means recent. As far back as 1785, camphor was used to induce convulsions in the treatment of mental disorders, but this method proved to be unreliable. The treatment was revived in 1933 by the Hungarian psychiatrist Ladislas Von Meduna. He observed that psychotic patients often showed a decrease in symptoms following a seizure from any cause. Camphor was gradually replaced by a more reliable drug, pentylenetetrazol (Metrazol). Von Meduna recognized that the treatment was more effective in depressions than in schizophrenia.
ocAORN Journal, September 1981, V o l 3 4 , No 3
463
In 1938two Italian psychiatrists, Ugo Cerletti and Loeio Bini, introduced the technique of passing an electric current through two electrodes placed on the forehead, thereby producing a convulsion. ECT became an effective method in the treatment of mental disorders. I n 1939, Lothar Kalinowsky, a Berlin-born psychiatrist, introduced ECT in the United States. In the past 40 years, several shock therapies have developed. Many have been discarded, but ECT remains a safe, effective, lifesaving treatment. After years of ECT treatment and research studies, why ECT alters specific psychiatric symptoms remains a mystery. It is important to emphasize that ECT does not cure the illness, but promotes the remission of symptoms. At Camelback Hospital, where I am a psychiatric nurse, the primary indication for ECT is in affective disorders. Some psychiatrists consider i t the treatment of choice for endogenous depression; it is usually considered when drug therapy has failed to bring improvement. A brief series of six to eight treatments usually relieves depression. The physician may choose to treat acute or chronic schizophrenia patients with ECT. Eight to 15treatments are usually effective. ECT is not indicated for neurotic or personality disorders. The mortality rate for ECT is less than 0.03%. Some hospitals report no fatalities after thousands of treatments given over periods of many years. In contrast, the mortality rate from suicide associated with untreated depressive illness is high, and the medical complications from antidepressants and psychotropic drugs are considerable, especially in geriatric patients. Some temporary impairment of memory occurs almost inevitably with ECT. This impairment may range from a mild tendency to forget names or dates to a severe confusion. Some patients ex-
466
perience a period of physical discomfort, such as headache, sore muscles, nausea, and psychomotor restlessness. Permanent adverse effects are extremely rare. An important part of preparing the patient for therapy is to identify and dispel1 any fears or fantasies about ECT. Patients may have fear of pain, dying from electrocution, or suffering permanent memory loss or impaired intellectual functioning. The nurse should explain to the patient that in modified ECT, he will not be alone. He will be put to sleep rapidly and will not consciously experience treatment. Before ECT treatment, the patient should have a complete evaluation of his physical condition, consisting of history and physical examination, laboratory, chest x-ray, anteroposterior projection and lateral spine films, and electrocardiogram (ECG). The hospital should provide an experienced medical team t h a t will provide constant safeguards in administering ECT therapy. The consent to treatment form should explain the nature of the treatment, the purpose of the treatment, possible alternate methods of treatment, possible side effects, and risks of complications. This form is then read and signed by the patient, physician, and a witness. Any remaining fantasies or misconceptions should be corrected by the physician. The patient should be given nothing by mouth, including oral medication, after midnight. The premedication, usually atropine sulfate, is given one hour before the scheduled therapy. It inhibits secretion and lessens vagal stimulation. ECT is usually scheduled every other day in a series of 6 to 15 treatments. The registered nurse checks all supplies and equipment, such as emergency cart, suction, oxygen, defibrillator, and equipment to deliver electricity in measured amounts.
AORN Journal, September 1981, V o l 3 4 , N o 3
ursing intervention is needed to resolve fears and uncertainty.
N
The patient is brought to the treatment room 15 minutes before a scheduled treatment. This provides the nurse enough time to complete the checklist form. This form is part of the patient’s chart. The items to be checked are history and physical examination; signed consent to treatment form; current medication order; NPO status; time premedication was given; x-rays; ECG;laboratory report; reports if patient voided, and if patient has dentures, jewelry, wig, etc. Any questions the patient may have should be answered and reassurance given. The nurse may give support to the patient by simply listening to his fears, expressing understanding of his anxiety. When the physician arrives, the nurse assists the patient onto a n adequately insulated gurney. She then positions the patient and covers him with a sheet, exposing the feet so that any fasciculation can be seen after the anesthesia is given. In some institutions, an anesthetist is on hand to administer the intravenous anesthetic. In other instances, the drugs are given by an attending psychiatrist qualified t o handle emergency complications. An alcohol or iodine swab is used to prepare the skin at the injection site. A #21 scalp vein needle is used for the infusion of the anesthesia. A short-acting anesthetic, such as thiopental sodium (Pentothal) or methohexital (Brevital), is given, followed by a muscle relaxant,
succinylcholine chloride (Anectine). These drugs are titrated according to the patient’s size, age, physical condition, and medical history. If the patient cannot tolerate barbituates, diazepam (Valium) is used instead. The nurse cleans the temporal area of the head with alcohol. Electrode contact jelly is applied to the electrodes, which are attached to a rubber headband. Treatment can be unilateral or bilateral, that is, with electrodes applied to stimulate one or both brain hemispheres. Unilateral stimulation is applied to the nondominant hemisphere. Unilateral ECT produces results similar to bilaterally induced ECT, but seems to cause less posttreatment amnesia. It requires a longer series of treatments, however. The patient is ventilated with oxygen until the maximal muscle paralysis is reached, then the nurse attaches the lead wires to the electrodes. A rubber mouth gag is placed between the teeth to prevent biting of the tongue or chipping of the teeth. The nurse then supports the chin and shoulders. The electrical stimulus is administered at 170 millivolts for one second, to produce a grand ma1 seizure. The physician or nurse ventilates the patient with oxygen immediately after the electrical stimulus. Oxygen is administered until spontaneous breathing returns. The length of the seizure varies with individuals and is usually 20 to 45 seconds. The mouth gag is kept in place until the
AORN Journal, September 1981,Vol34, No 3
467
tonic and clonic phases of the seizure have subsided. The nurse immediately removes the lead wires, the headband, and any excess jelly from the temples. When spontaneous breathing returns, the nurse turns the patient on his side. The head is supported so the neck will not be twisted. The patient’s arms should be free from the body and one leg bent to act as a brace. The chin is extended to promote a good airway. The physician determines when the patient is ready to go to the recovery room. Recovery time is determined by the amount of anesthesia given and the patient’s ability to detoxify anesthetic agents. In the recovery room, particular attention needs t o be paid t o the adequacy of ventilation after awakening, and to motor restlessness, nausea, headache, and confusion that may occur. When the patient is fully awake and stable, he is fed breakfast. Before returning the patient to his room, the nurse should answer any questions he may have related to the temporary posttreatment amnesia. The nurse plays an important role caring for the patient having ECT, Nursing intervention is needed to resolve the fears and uncertainty of the ECT process. There is a need for further nursing research on ECT. The contradictory findings and quality of reports present minimal information for nursing schools. Studies might include closer monitoring the patient’s behavior before and after ECT treatment, a followup of relapse rates, and an examination of the quality of the treated patient’s life after ECT. Most information describing ECT is antiquated and presents many doubts that may be conveyed inadvertently to the patient by the nurse. This may add to the patient’s fears and uncertainty about the ECT treatment.
470
The quality of nursing care of the ECT patient can be improved when the nurse has more insight into the efficacy 0 of ECT as a primary treatment. Suggested reading
Ashmalla, Medhat. “Electroconvulsive therapy (ECT), a moderate view.” Journal of the Florida Medical Association 66 (July 1979)688-689. Callan, John P. “Electroconvulsive therapy.” Journalof the American Medical Association 242 (Aug 10,1979) 545-546.
Gonzales, Elizabeth Rasche. ”Update on electroconvulsive therapy.” Journal of the American Medical Association 241 (April 27, 1979) 17751779.
Nardine, John. “Electricshock reconsidered,underutilized, effective and safe.” Frontiers of Psychiatry 10 (March 1, 1980). Salzman, Carl. “The use of ECT in the treatment of schizophrenia.” The American Journal of Psychiatry 137 (September 1980) 1033-1041. Soloman,Jonathan. “Electroconvulsivetherapy and overview.” Virginia Medical 106 (April 1979) 280-287.
Catheter technique rivals bypass surgery A new coronary catheter technique may
challenge bypass surgery as a treatment for narrowed coronary arteries. Percutaneous transluminal coronary angioplasty (PTCA)opens partially blocked coronary arteries by using a balloon catheter to compress obstructing plaques. When the technique is successful,the plaques remain compressed against the artery wall, blood flow to the heart is increased, and angina ceases. PTCA costs about $1,000 and requires two days’ hospitalization, compared to $15,000 and two weeks in the hospital for bypass surgery. These figures are from a Science (July 10) report on a recent PTCA workshop sponsored by the National Heart, Lung, and Blood Institute. Participants at the workshop were enthusiastic about the new technique but called for a clinical trial to prove its effectiveness. Current figures from a PTCA registry show the method has succeeded initially in about 65% of the cases, but 20% had recurrence within a few months.
AORN Journal, September 1981,V o l 3 4 , No 3