Cna741 Mental Health Nursing: Electroconvulsive Assessment Answers

Electro convulsive therapy and Nursing Care Management 

Answer:

Introduction

Electroconvulsive therapy (ECT) is the deliberate inducing of a modified generalized seizure in an anaesthetized patient under medically-controlled conditions to produce a therapeutic effect (Kavanagh & McLoughlin, 2009). To achieve this, an electric charge is passed through the brain between two electrodes that are placed on the scalp of the anaesthetized patient. Electroconvulsive therapy is used to cause changes in the chemistry of the brain so as to reverse the symptoms of some mental conditions. It is often referred when other treatments are unsuccessful. When compared to pharmacotherapy, ECT has evidenced as an effective treatment for depression. It is actually preferred as an effective treatment option for the acute treatment of depression with psychotic symptoms (Petrides, et al., 2001). ECT plays a critical role in contemporary mental health care, and nurses play a very pivotal role in which they have to deliver on when a patient undergoes electroconvulsive therapy.

This resource reviews ECT and its developmental history, epidemiology, indications and its mechanism of action.

A brief history of ECT 

The history of electroconvulsive therapy can be traced back to the 1500s on the basis of the practice in which mental illness was treated with convulsions. The initial practice involved inducing convulsions by orally taking camphor. The Swiss physician Paracelsus successfully induced seizures through oral administration of camphor to treat psychiatric illness (Sadock & Sadock, 2007). The first report to published on the use of camphor to induce seizures for the treatment of mania was in 1785. Oral camphor was later replaced with intramuscular injection as demonstrated by the Hungarian neuropathologist Ladislas Joseph von Meduna in 1934 for the treatment of catatonic schizophrenia (Sadock & Sadock, 2007). Treating mental conditions with chemically-induced seizures came along with an equal share of distressing and prolonged preictal effects which served as a precursor for the exploration of new methods to induce therapeutic seizures.

Modern ECT can be traced back to 1938 when electricity was used to induce seizures for the successful treatment of a catatonic patient by the neurologist Ugo Cerletti and psychiatrist Lucio Bini (Kalapatapu, 2015). In 1939, ECT was introduced in the US (Pandya, et al., 2007). However, the lack of adequate anaesthetic procedures or muscle relaxation measures during ECT procedures led to dislocations and fractures, and also the lack of adequate knowledge pertaining to dose parameters of electrical stimulation to severe cognitive adverse effects (Pandya, et al., 2007). To counter such, curare was used as a muscle relaxant during ECT procedures (Sadock & Sadock, 2007). Insulin shock therapy and lobotomy were the only viable alternatives to ECT until the 1950s when effective antipsychotic drugs were developed.

Electroconvulsive therapy as a procedure was first scientifically researched in the 1950s. psychiatrist Max Fink applied rigorous scientific research methods to study the efficacy and the ECT procedure (Taylor, 2007). It is in the same year in which succinylcholine, a depolarizing muscle relaxant was introduced and used alongside a short-acting anaesthetic during ECT procedures so as to prevent injuries and also numb the patient from feeling the ECT procedure. According to Sadock and Sadock (2007), randomised clinical trials conducted on the efficacy of ECT compared to other medications for the treatment of mania, the response rates were significantly higher in ECT.

As a measure to reduce abuse and misuse of the procedure, in 1978, the American Psychiatric Association published the first Task Force Report on ECT which outlined standard ECT procedures which were in-line with scientific evidence. This report was later revised in 1990 and 2001. The development of ECT was further boosted by the endorsement by the National Institutes of Health and National Institute of Mental Health Consensus Conference on ECT, which also called for additional research and national standards of practice (Sadock & Sadock, 2007). Towards the end of the 20^th century, randomised controlled clinical trials of ECT versus lithium were carried out and the results indicate that both have equal efficacy in the treatment of mania. In the early 21^st century, Sarah Lisanby and colleagues from the Columbia University successfully demonstrated inducing convulsive treatment using magnetic stimulation (Sadock & Sadock, 2007).

The development of ECT was characterised by two eras. One was an era oof therapeutic optimism in psychiatry, and the other was an era of almost indiscriminate use (Glass, 2001). The initial era of therapeutic optimism occurred when there was no alternative to ECT. However, during the mid-20^th century, ECT was almost indiscriminately used and the consequences of this period were the anti-psychiatry movement which exaggerated the negative aspects of ECT and hospital care, alongside negative portrayal in media such as “One Flew Over The Cuckoo’s Nest” (Swaine, 2011). These actions cast a shadow on the efficacy of ECT. In the current times, there is some stigma and fear that accompanies contemporary ECT (Dowman, et al., 2005). This inhibits the potential of administering effective treatment on individuals suffering from severe mental illness in two forms. First, it is the reluctance of treating teams to prescribe the treatment and second are the unwillingness of patients to accept it when prescribed. To overcome such stigma, Glass (2001), recommends that healthcare professionals need to be aware of the facts surrounding the contemporary ECT practice, alongside efficacy, indications and adverse effects.

Epidemiology of ECT 

Electroconvulsive therapy was initially indicated in the treatment of schizophrenia as early as 1941. However, the utilization of the procedure declined on the 1970s and 80s following the introduction of pharmaceutical products for the treatment of severe mental disorders (McCall, et al., 1992). As a result, ECT mainly became indicated as a last-resort option for patients who exhibited resistance to medication and those who exhibited severe life-threatening illness (Eranti & McLoughlin, 2003). This notion was however rectified following the guidelines by the National Institutes of Health and National Institute of Mental Health Consensus Conference on ECT which recommended that ECT should not be used as a last resort.

The spread of ECT from Europe to other continents including the US occurred rapidly following the displacement of psychiatrists during World War II (Shorter, 2009). There are an estimated one million patients worldwide who receive electroconvulsive therapy each year (Hermann, et al., 1995). According to Swartz (2009), ECT stands out as a widely available treatment modality for persons with mental disorders across all continents. Regardless of the common international guidelines (Enns, et al., 2011) developed for the practice, there are large differences in the practice among regions and countries. In addition, there are variations in ECT utilization across the various divides. For instance, according to a 2009 study by Van Waarde and colleagues on the utilization of ECT in the previous decade, the utilisation of ECT in the US was estimated 4.9 persons per 10,000 resident population per year as of 1995 (van Waarde, et al., 2009). Further, according to a 2012 review, there are indications of sparse utilisation in the continents of Latin America and Africa (Leiknes, et al., 2012). ECT is abundantly practiced in Europe, Asia, and America.

Regardless of the wide utilisation in Europe, America, and Asia, there are variations in the utilization rates and clinical practice between the regions and countries. Notably, unmodified ECT (ECT administered without anaesthesia) is substantially in use mainly in Asia with an over 90% prevalence, in Latin America, Africa, and some countries in Europe (Spain, Russia, and Turkey) (Leiknes, et al., 2012).

In Australia, the United States, New Zealand and Europe, ECT is mainly utilised by elderly female patients exhibiting depressive disorders. In other parts of the world (Africa Asia, Russia, Latin America), where unmodified ECT is still administered, the predominant users are younger male patients presenting with schizophrenia (Leiknes, et al., 2012). Baghai, et al., (2005) and Moksnes, et al., (2006) agree with this observation, noting that the predominance of patients who receive ECT in the first tier of countries are elderly female with affective disorder. The same profile is applicable to Pakistan and Saudi Arabia except for age being younger. Western Australia also exhibits higher ECT treatment rates among Caucasian white ethnicity (Teh, et al., 2005).

Pertaining the provision of ECT by psychiatric institutions, there are significant variations. Asia demonstrates the highest (59-78%), followed by Australia at 66%, 23-51% in Europe and 6% in the United States (Leiknes, et al., 2012). Chanpattana, (2007), agrees with this observation, noting that in Australia, the procedure is provided by 66% institutions whereas training on ECT is provided by 73% of the institutions.

An analysis of reports on the side effects, adverse effects and mortality rates related to ECT reveals a sparse database. Nevertheless, Thailand reports the highest mortality rate (0.08%) followed by Texas (14 deaths per 100.000 treatments) (Chanpattana & Kramer, (2004); Scarano & Felthous, (2000). However, there are no indications of whether these ECT-related deaths are as a result of either anaesthetic complications, comorbid somatic illnesses or as a result of lethal side effects such as cardiac arthymia.

Pertaining to the consent of administration of ECT, the procedure is largely administered involuntarily or under guardian consent conditions across all regions of the world.

Indications of ECT 

ECT is an ideal nonpharmacologic biological treatment with a proven high effectiveness predominantly for depression, schizophrenia and other indications. ECT is particularly an important alternative option in the treatment of therapy-resistant psychiatric disorders which result after medication treatment failures.

Major depression 

Electroconvulsive therapy is an effective and rapid-acting option for the treatment of severe depression. It is indicated in cases of major depression when antidepressant therapy stands out to be ineffective or intolerable or in events where the symptoms are quite severe to warrant a rapid response (O'Reardon, et al., 2011). Due to its rapid response, it is often a preferred treatment modality for patients with highly severe psychotic, or suicidal depression. For these categories of patients, waiting for antidepressants is unfeasible. ECT is recognised to be quite effective and safe treatment in psychiatry. The drawback is that the effects of the treatment usually do not last and it often warrants further treatment.

Mania 

The use of ECT as the primary treatment option for mania has declined in recent times as a result of the availability of atypical antipsychotics, classical neuroleptics, lithium and other mood stabilizers which exhibit better antimanic effectiveness. Regardless, randomised controlled trials and study reviews have indicated good efficacy of ECT. ECT has indicated high remission or improvement rate (Baghai & Möller, 2008).

Bipolar Disorder

Acute depression that is characteristic of bipolar disorder often does not rapidly or adequately respond to pharmacological agents particularly antidepressants (can precipitate the switching phase of the illness) or mood stabilizers, (with the exception of lithium, quetiapine, lamotrigine). It is thus recommended that ECT should be considered for clients with bipolar disorder in the depressive state, especially if they exhibit unresponsiveness to any medication in either category of mood stabilisers or antidepressants. The preference for ECT over antidepressants is that ECT does not precipitate switching. Contrary to common misconceptions, ECT is an ideal alternative especially for the elderly, and those patients with bipolar disorder and co-morbid medical presentations (Brooks, 2015).

Schizophrenia

ECT was initially adopted in the management of schizophrenia as early as in 1938 by Cerletti and Bini. The procedure has demonstrated efficacy in the treatment of patients with schizophrenia and schizoaffective disorder (Chanpattana, et al., 2010). This is regardless of a decline in its use for this condition in the 1950s after the introduction of neuroleptics. ECT stands out as an effective option for persons suffering from schizophrenia, and it is recommended for persons with the conditions and who have shown nil or minimal response to antipsychotics, and also those having a co-morbid status which makes this alternative a safer alternative (Phutane, et al., 2011).

Theories on Mechanism of Action

Studies on the mechanism of action of ECT using animal models have revealed that there is the need for repeated administration of the procedure in order to entrain a series of molecular and structural changes in the brain which are proposed to be relevant to its antidepressant effect (Kavanagh & McLoughlin, 2009). These changes include the upregulation of neuronal growth factors which enhance the survivability of neurones and plasticity or the manner in which neurones can adapt to enhance the way they connect with each other. Notably, ECT also increases the number of new nerve cells in the hippocampus (Grover, et al., 2005). The hippocampus is concerned with memory and mood regulations. According to Kavanagh and McLoughlin (2009), the effect produced by antidepressants is much lesser compared to ECT.

Nursing Role 

Psychiatric nursing care for ECT has evolved from the traditional supportive and adjunctive practice to the existing practice of collaborative and independent nursing actions (Burns & Stuart, 1991). In the current practice, nursing in ECT encompasses a number of nurses including an ECT nurse, a ward nurse, operating department assistant, nurse coordinator and a recovery nurse.

Pre-ECT 

The ECT nurse plays the role of coordinating the service and is also tasked with the responsibility of managing the ECT clinic and caring for the patient (IECT Accreditation Service, 2016). ECT nurses are charged with developing protocols which are in line with best practice guidelines. The ECT nurse in entirety ensures that both the medications, equipment, and environment for ECT are adopted in line with the best practice guidelines (Kavanagh & McLoughlin, 2009).

Whereas the actual administration of electroconvulsive therapy is the primary responsibility of the anaesthetist and the psychiatrist, the ECT nurse plays a very critical role in addressing the psychological needs of the client undergoing the procedure. This involves but not limited to educating the patient about their condition, the reasons why the procedure has been recommended, the initial and through the treatment process, addressing the patient's or family's fears pertaining the procedure and using scientific evidence and facts to direct them (Queensland Health, 2017). With such, the patient is educated, a therapeutic relationship is also formed between the nurse and the patient, it reduces anxiety and also dispels myths and negative premonitions formed. The nurse plays a critical role in this element as (s)he makes the process less intrusive and more positive and these encourage the patients to persist through the process regardless of the adverse effects.

Before the treatment, the nurse undertakes a pre-treatment checklist and ensures the patient is ready for anaesthesia and the procedure itself. The nurse is also in charge of the patient’s prevailing mental, legal and medical status (Kavanagh & McLoughlin, 2009)

Post ECT

The recovery nurse plays an important role following the ECT treatment course. These nurses are equipped with knowledge in advanced life support and are also conversant with the ECT treatment process and all possible adverse events. Following the treatment, the nurse will maintain the integrity of the patient’s airway, monitor the vitals and also administer prescribed medications to counter the side effects. The nurse’s role in the recovery room persists until the patient regains his orientation and the anaesthetist gives a clean bill of health (Queensland Health, 2017).

Conclusion 

Electroconvulsive therapy (ECT is considered the most effective treatment for the management of severe mental illness. The process has undergone tremendous development dating back to 1938 when it was adequately developed to treat schizophrenia. Even though there is a significant amount of stigma associated with the process, there is a significant amount of evidence base that supports its efficacy and safety in modern medicine.

Nurses currently play a very important role in the provision of ECT. This is opposed to the earlier role that was just a supportive one. Currently, nurses play a multifaceted role ranging from the ECT nurse, ward nurse, recovery nurse and the anaesthetist’s assistant. It is therefore of great significance to lay emphasis on the education of nurses in ECT so as to enhance the central role they play in the enhancement and development of the therapy.

References

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