The Nurse's Role
Nurses play an integral role in the teaching, preparation and administration of ECT. In the United States, the treatments are typically given 3 times a week on alternating days and usually in a series of 6-12 treatments.1
Due to the potential risks of using general anesthesia, emergency care should be readily available. The ECT nurse assists in coordinating the pretreatment exams, including a medical exam to ensure there are no pre-existing conditions that would pose an increased risk for the patient (i.e., cardiac conditions). Musculoskeletal problems also can be a risk.
Informed consent is required prior to giving treatment, and the ECT nurse assists with the teaching. The American Psychiatric Association states patients must be informed about risks of the treatment itself, including mortality, side effects of treatment, a description of the treatment, treatment alternatives and why ECT is being recommended. Also, the fact ECT is voluntary and can be withdrawn at any time must be acknowledged.
After the administration of general anesthesia and oxygen, the nurse prepares the site and places the electrodes according to the physician order, either unilaterally (one on the back of the head and one on a temple over the non-dominant hemisphere) or bilaterally (on both temples). Glycopyrrolate (Robinul) or atropine sulfate is given prior to treatment, as well as a muscle relaxant such as succinylcholine chloride. The nurse also inserts a bite block to prevent injury to the teeth during the seizure.
The physician administers the stimulus dose. Typically, only slight bodily movements are seen due to the administration of the muscle relaxant.2,6 If the seizure is not long enough to enlist a therapeutic response as noted by wave changes on the EEG (generally 25-60 seconds), the stimulus dose will be repeated.
Monitoring and assessment by the ECT nurse are vital during the treatment and recovery phases. Anesthesia induction by itself increases baseline heart rate by about 25 percent.4 The ECT nurse must have a strong background in ECG strip interpretation because several transient cardiac abnormalities are noted.
As the patient awakes from anesthesia and vital signs stabilize, the nurse must orient the patient since confusion and short-term memory loss are common around the time of the treatment. The patient remains in the recovery area until alert and vital signs are stabilized. Usually, the patient can leave the recovery area within 30-60 minutes.10
Physicians confront a difficult challenge when it comes to determining the stimulus dose for ECT. Seizure threshold varies greatly from person to person and increases as treatments progress. It is influenced by gender, age, coexisting medical conditions (e.g., brain disease, dehydration, etc.) and use of anticonvulsants, barbiturates and benzodiazepines. To add to the challenge, over-stimulations produce greater side effects such as slowed recovery, confusion and memory changes, while under-stimulations and stimulations just above threshold are ineffective. There are several dosing formulas in use today.
Another piece of the puzzle for the physician is to determine whether unilateral or bilateral electrode placement will best benefit the patient. The literature overwhelmingly favors bilateral electrode placement, stating that it results in a more rapid and full response than unilateral electrode placement. However, unilateral nondominant treatment - treating only the side of the brain that has the lesser influence, i.e., typically the right unless the patient is left-handed - may give other but probably less subjectively injurious side effects than bilateral treatment.11 It usually can be done on an outpatient basis after three or more treatments.
Current Studies on Efficacy
According to the National Mental Health Association, ECT study results are unclear, with some studies citing 80 percent improvement in severely depressed patients and others indicating relapse is high, even for patients who take medication after ECT.12 We also must consider ECT often is reserved for medication-resistant patients. The majority of literature on ECT suggests it is an effective short-term treatment, with follow-up therapy - not necessarily medication treatment if the patient has been resistant in the past - being necessary.13
The National Institute of Mental Health continually conducts studies on treatments for depression, as the disease currently affects approximately 19 million American adults. They report that "80-90 percent of people with severe depression improve dramatically with ECT," and add that "ECT remains one of the most effective yet most stigmatized treatments for depression."14
The side effects of ECT have been reduced greatly due to modern techniques. Memory loss remains the main side effect.1,4,5 Most of the literature states it is temporary and in most cases resolves within 6 months; however, others claim it can be permanent.
Patients may experience amnesia in two forms: retrograde (loss of memory of past events) and anterograde (inability to retain new memories). A 1987 study of patients during the period immediately following ECT demonstrated disorientation for past events, which lessened during the recovery period. This is similar to that of retrograde amnesia following an injury to the head.4
Another study reports that 10 minutes post-ECT, patients achieved only 10 percent accuracy with functional area testing. By 2 hours post-ECT, patients reached 100 percent accuracy in all functional areas and responded to only five items of time orientation with less than 60 percent accuracy.4 The effect of ECT on anterograde amnesia also has been studied with similar results.4
There have been claims of brain damage from the treatment; however, recent studies refute this position. A notable 1991 study involving brain imaging before and after treatment noted no acute or delayed changes in several key areas of the brain.4 Another study, performed in 1990, of seven patients with major depression who received right unilateral ECT compared MRIs previous to treatment and 1 week following treatment. The study revealed no differences from baseline.4
The majority of studies have found a lower mortality rate for ECT-treated psychiatric patients versus psychiatric patients with other treatment modalities.13 There have been numerous studies on ECT over the past 60 years; however, many of them are plagued by problems of lack of treatment standardization. Although the treatments have become more regulated in recent years, there still are factors that vary, such as those noted throughout the sections above.
Patients' views of ECT treatments vary. One report on interviews with 72 patients who received ECT stated more than half of those interviewed considered a trip to the dentist more distressing, 83 percent said they had improved and 81 percent said they would agree to have the treatment again.4
A patient satisfaction survey at the Mayo Clinic was given to 24 patients both during and 2 weeks after treatment, and also to 24 patients who had never received ECT. Twenty-one (91 percent) of 24 patient respondents endorsed the statement: "I am glad that I received ECT."15 The positive attitudes about ECT were significantly higher in the group that had received the treatment as compared to the control group. Individually, others have claimed they would not have ECT again and it has caused them disabling memory loss.
What Does Future Hold?
According to the current studies and legislation, ECT will likely remain in practice, as it has proved to be an effective short-term treatment. Over the past 60 years, ECT has become safer, more humane and generally less frightening for patients.
With continued studies on long-term effects, standardization of treatment, improved reporting requirements and the incorporation of patient attitudes into improving practices, ECT could be better understood and accepted. As nurses, we possess the ability to greatly impact the future of ECT with our teaching and continued quest for knowledge of the latest developments in the field.