lecture 24a: non-pharm therapies in psychiatry

electroconvulsive therapy

•the use of small electric current to produce a brief generalized cerebral seizure under general anesthesia in order to quickly reverse certain mental health symptoms

•dopamine, serotonin, and norepinephrine

ECT increases the release of monamine neurotransmitters such as

•by causing hypothalamus or pituitary gland to release hormones

•prolactin, TSH, ACTH, and endorphins

how does ECT relieve depression?

-refractory to antidepressants

-situations where rapid response is required (pregnancy, suicidal, refusal of oral intake)

-psychotic features

-Catatonia

when is ECT indicated to treat mood disorders?

catatonia

a state of unresponsiveness to one's outside environment, usually including muscle rigidity, staring, and inability to communicate

-an INDICATION FOR ECT

-mood disorders with severe features

-Parkinson's

-neuroleptic malignant syndrome

medical conditions that are indications for ECT

ECT

what treatment should we use?

pt with persistent suicidal ideation and intent and catatonia

ECT

•Most effective acute treatment for depression and is superior in symptom relief over antidepressant pharmacotherapy including Ketamine

Succinylcholine

•used for skeletal muscle relaxation and to attenuate seizure activity in pts recieiving ECT

Methohexital

-anesthesia of choice with ECT

has minimal effect on increasing seizure threshold and reduces pressor response to ECT

persons with personal or familial history of malignant hyperthermia, skeletal muscle myopathies, and known hypersensitivity to the drug

primary contraindication to succinylcholine

•space-occupying lesion causing intracranial pressure; intracerebral hemorrhage; unstable aneurysms or vascular malformations

MENINGIOMA

Still some debate on whether there is a true absolute contraindication to doing ECT. Must weigh risk vs benefits

absolute contraindications to ECT

•HR and BP. Given this, medical clearance is needed for patients with cardiac comorbidities

when ECT is given, there is a physiologic transient increase in

headaches, nausea, muscle pain n

MOST COMMON side effects of ECT

ECT

Most common "Absolute Contraindication" are increased intracranial pressure from space occupying lesions such as tumors; bleeds from cerebral hemorrhage and anatomical abnormality such as unstable aneurysms or vascular malformations.

no

are seizures/epilepsy absolute CIs to ECT? pregnnancy?

succinylcholine

muscle relaxant used to stop the tonic-clonic movements while receiving ECT

increase in CSF pressure

Space occupying lesion is not an absolute contraindication to ECT unless there is

transcranial magnetic stimulation

*this is the test question

A 46 yo woman comes to your office with moderate depression. She has tried SSRI's, but could not tolerate the sexual side effects. Tricyclic antidepressants caused excessive weight gain. Bupropion was helpful; however, it caused agitation and insomnia. She is afraid of "any more chemicals put into my body". What treatment options could be offered next?

transcranial magnetic stimulation

•the use of magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression

•Stimulation of discrete cortical regions alters pathologic activity in regions involved in mood regulation

•Increase monoamine turnover

•Unipolar major depression who have failed at least one antidepressant medication

•Map brain functions and connections

indications to transcranial magnetic stimulation

ECT

which is more effective, TMS or ECT?

•adjunctive therapy for partial-onset epilepsy in 1997 and treatment-resistant depression in 2005.

•Many other uses are being explored such as multiple sclerosis, migraine and Alzheimer's disease.

indications for vagal nerve stimulation