scholarly journals Audit of a recently introduced stimulus dosing policy in an electroconvulsive therapy clinic

1999 ◽  
Vol 23 (9) ◽  
pp. 541-543 ◽  
Author(s):  
G. Shaikh ◽  
R. Ireland ◽  
M. McBreen ◽  
R. Ramana
Keyword(s):  
Clinical Practice ◽  
Electroconvulsive Therapy ◽  
Initial Dose ◽  
Dose Adjustment ◽  
Seizure Threshold ◽  
Dose Titration ◽  
Clinical Implications ◽  
Threshold Estimation ◽  
And Training ◽  
Therapy Clinic

Aims and methodTo audit the clinical practice of seizure threshold estimation and subsequent stimulus dose adjustment in the electroconvulsive therapy (ECT) clinic. Case notes of patients who had ECT over a six-month period were audited. Results were discussed at an audit meeting and guidelines and training modified appropriately prior to the second cycle of the audit.ResultsInitial dose titration was poor in the first period, but improved in the second. The majority of patients were insufficiently stimulated after missed seizures in both periods and stimulus doses were not being reduced following prolonged seizures.Clinical implicationsThe audit identified the need for continuing supervision of trainees in addition to clear training and guidelines.

scholarly journals A re-audit of ECT training and practice

1999 ◽  
Vol 23 (7) ◽  
pp. 419-421 ◽  
Author(s):  
Farida Yousaf ◽  
Martin Lee ◽  
Jose King
Keyword(s):  
Clinical Practice ◽  
Electroconvulsive Therapy ◽  
Royal College ◽  
Current Practice ◽  
Dose Titration ◽  
Clinical Implications ◽  
Junior Doctors ◽  
Information Recording ◽  
Training And Supervision ◽  
New Guidelines

Aims and methodsA re-audit of the current practice of electroconvulsive therapy (ECT) was carried out over a period of five months using the new guidelines produced by the Royal College of Psychiatrists. The areas audited included obtaining consent from the patients, information recording, training and supervision of the junior doctors and the practical aspects of ECT administration, including dose titration.ResultsAn improvement in the training and supervision of junior doctors was seen since the last audit but shortcomings were identified in areas of pre- and post-ECT preparation, information recording and correct use of stimulus-dosing policy.Clinical implicationsRecommendations include the need to improve clinical practice and recording of information.

Electroconvulsive Therapy and the Seizure Threshold*

1983 ◽  
Vol 28 (6) ◽  
pp. 445-448 ◽  
Author(s):  
B.A. Martin ◽  
S. Strigler ◽  
K. Bezchlibnyk ◽  
G.E. Harris-Brandts
Keyword(s):  
Clinical Practice ◽  
Electroconvulsive Therapy ◽  
Electrical Energy ◽  
Sine Wave ◽  
Routine Clinical Practice ◽  
Large Series ◽  
Seizure Threshold ◽  
Square Wave ◽  
Rate Of Failure

The use of a pulsatile square wave stimulus for a large series of electroconvulsive treatments under conditions of routine clinical practice is compared to the equivalent experience with a sine wave stimulus. The literature indicates that both waveforms are equally effective convulsants. However, in this series, the induction of a convulsion was found to be much more difficult with the pulsatile square wave such that the rate of failure to convulse was four times that compared to sine wave stimulation. A number of variables that may affect the seizure threshold during ECT were examined. It is concluded that the benefit obtained by reducing the electrical energy transmitted to the patient with the pulsatile stimulus offsets the difficulty encountered in reaching the seizure threshold.

scholarly journals Induction agents in electroconvulsive therapy: a comparison of methohexitone and propofol

2002 ◽  
Vol 26 (12) ◽  
pp. 455-457 ◽  
Author(s):  
Allan Scott ◽  
Harold Boddy
Keyword(s):  
Electroconvulsive Therapy ◽  
Therapeutic Efficacy ◽  
Seizure Threshold ◽  
Clinical Implications ◽  
Seizure Duration ◽  
Efficacy Of Treatment ◽  
Induction Agents ◽  
Subject Comparison

Aims and MethodTo compare methohexitone and propofol in electroconvulsive therapy (ECT). A retrospective within-subject comparison was made of the use of these drugs in separate courses of bilateral ECT in one clinic over 10 years. Patients taking mood stabilising or anti-epileptic drugs were excluded. The initial seizure threshold and seizure duration were of particular interest.ResultsThe median initial seizure thresholds were identical (75 mC). The median initial seizure duration with threshold stimulation was 25% shorter with propofol (21v.28 s). The median total numbers of treatments in the courses were identical (eight treatments).Clinical ImplicationsThe shorter seizure duration observed with propofol was not associated with a commensurate rise in the initial seizure threshold. The shorter seizure duration may therefore have no effect on the therapeutic efficacy of treatment.

scholarly journals Alfentanil anesthetic augmentation lengthens seizure duration in electroconvulsive therapy with older people

2016 ◽  
Vol 28 (6) ◽  
pp. 1051-1052
Author(s):  
Craig D'Cunha ◽  
Christos Plakiotis ◽  
Daniel W. O'Connor
Keyword(s):  
Side Effects ◽  
Older People ◽  
Electroconvulsive Therapy ◽  
Electrode Placement ◽  
Seizure Threshold ◽  
Dose Titration ◽  
Seizure Duration ◽  
New Learning ◽  
Prescription Rates ◽  
Cognitive Side Effects

Electroconvulsive therapy (ECT) prescription rates rise with age, making it important that treatments be made as effective and safe as possible (Plakiotis et al., 2012). Older people are vulnerable to post-treatment confusion and to subsequent deficits in attention, new learning, and autobiographical memory (Gardner and O'Connor, 2008). Strategies to minimize cognitive side-effects include unilateral electrode placement and stimulus dose titration whereby electrical charge is individually calibrated to seizure threshold (Sackeim et al., 2000). It remains the case, however, that threshold levels typically rise over the treatment course, leading to an increase both in delivered charge and the risk of adverse sequelae.

Seizure Threshold Determination for Electroconvulsive Therapy: Stimulus dose Titration Versus Age-Based Estimations

2006 ◽  
Vol 40 (2) ◽  
pp. 188-192 ◽  
Author(s):  
John W.G. Tiller ◽  
Nicholas Ingram
Keyword(s):  
Major Depressive Disorder ◽  
Electroconvulsive Therapy ◽  
Significant Positive Correlation ◽  
Psychiatric Patients ◽  
Seizure Threshold ◽  
Dose Titration ◽  
High Dose ◽  
Major Depressive ◽  
Males And Females ◽  
Age Determinations

Objective: This study compared electroconvulsive therapy (ECT) seizure threshold determined by stimulus dose titration with age-based estimations. Method: Patients with major depressive disorder had their initial seizure thresholds determined by stimulus dose titration and the results compared with age-based estimations. There are no significant differences in thresholds determined by these methods. Results: Two hundred and three psychiatric patients (149 females, 54 males) had their seizure thresholds determined by stimulus dose titration. There was a significant positive correlation between seizure thresholds and age for males and females with male thresholds greater than female thresholds. Age determinations of seizure threshold would have resulted in excessive initial treatment stimuli for 30% of females and 8% of males. Ineffective stimulus doses would have been given to 2% of females and 7% of males on a full age basis and 64% using a half age strategy. Conclusions: For effective high-dose right unilateral ECT, initial seizure threshold should be determined by stimulus dose titration.

scholarly journals Electroconvulsive therapy – attitudes and practice in New Zealand

2001 ◽  
Vol 25 (12) ◽  
pp. 467-470 ◽  
Author(s):  
John A. Strachan
Keyword(s):  
Clinical Practice ◽  
New Zealand ◽  
Great Britain ◽  
Electroconvulsive Therapy ◽  
Royal College ◽  
Clinical Implications ◽  
Medical Conditions ◽  
Therapy Attitudes ◽  
Zealand College ◽  
Source Of Information

Aims and MethodThe clinical practice of electroconvulsive therapy (ECT) by New Zealand psychiatrists was surveyed by questionnaire. This paper compares the findings with national and regional surveys conducted in Great Britain, and considers the influence on clinical practice in New Zealand of the Royal College of Psychiatrists' ECT Handbook.ResultsECT has the same level of support from psychiatrists in New Zealand as in Britain, but is less frequently used. Modern brief pulse machines are used by 16 of 19 (84%) services from which data were received. The ECT Handbook was the most nominated source of information on ECT. Most (87%) respondents were aware of at least one set of ECT guidelines. However, these have apparently failed to influence some important aspects of practice. In particular, many medical conditions are still perceived as absolute contraindications.Clinical ImplicationsThe Royal College of Psychiatrists and the Royal Australian and New Zealand College of Psychiatrists need to place even greater emphasis on the importance of training in ECT for both trainees and qualified psychiatrists, and on the promotion of approved guidelines.

scholarly journals Capacity, compliance and electroconvulsive therapy (ECT): the practice of ECT among consultant psychiatrists

2006 ◽  
Vol 30 (1) ◽  
pp. 13-15 ◽  
Author(s):  
Richard Law-Min ◽  
John Patrick Stephens
Keyword(s):  
Mental Health ◽  
Clinical Practice ◽  
Electroconvulsive Therapy ◽  
Best Practice ◽  
Response Rate ◽  
Common Law ◽  
Good Practice ◽  
Legal Framework ◽  
Clinical Implications ◽  
Clinical Vignettes

Aims and MethodThe aim of this study was to seek the views of consultant psychiatrists on the legal framework they would use when considering treatment with electroconvulsive therapy (ECT). A questionnaire, consisting of three clinical vignettes, was sent to 70 consultants in the Wessex rotation (East Dorset/Hampshire region).ResultsA total of 56 questionnaires were returned; a response rate of 80%. Most consultant psychiatrists agree when giving ECT to capacitated and non-consenting patients. However, there was a lack of consensus when dealing with seemingly incapacitated but compliant patients.Clinical ImplicationsMore clarification in this area is needed. Trusts can assist clinicians by devising their own policies based on nationally agreed standards of best practice. The treatment of mentally incapacitated but compliant patients is an area of practice where uncertainty exists. If proceeding under common law in such cases, it is good practice to discuss with relatives/carers and obtain a second opinion from a consultant colleague. The most recent Bournewood judgement and the new Mental Health Bill will have further implications for clinical practice.

scholarly journals The cardiovascular safety of the empirical measurement of the seizure threshold in electroconvulsive therapy

2015 ◽  
Vol 39 (1) ◽  
pp. 14-18 ◽  
Author(s):  
Lindsay Mizen ◽  
Charles Morton ◽  
Allan Scott
Keyword(s):  
Electrical Stimulation ◽  
Cardiovascular Risk ◽  
Electroconvulsive Therapy ◽  
Heart Beat ◽  
Adverse Outcomes ◽  
Seizure Threshold ◽  
Clinical Implications ◽  
Anticholinergic Drugs ◽  
Cardiovascular Safety ◽  
Empirical Measurement

Aims and methodThe Royal College of Psychiatrists' Committee on Electroconvulsive Therapy (ECT) and Related Treatments advises the measurement of initial seizure threshold in all patients undergoing ECT if possible. The subconvulsive electrical stimulation inherent in this process is thought to increase the risk of bradycardia and therefore asystole. Our aim was to establish the prevalence of asystole (no heart beat for 5 or more seconds) during empirical measurement of seizure threshold in patients who had not received anticholinergic drugs, as we were unable to find any published reports of bradycardia or asystole prevalence under these conditions. The electrocardiogram traces of 50 such consecutive patients were analysed later.ResultsAsystole occurred in 5% of stimulations. Each episode of asystole resolved spontaneously with no adverse outcomes. Contrary to expectations, asystole was no more prevalent in subconvulsive stimulations than in convulsive stimulations.Clinical implicationsThere was no evidence that the empirical measurement of the seizure threshold added to the cardiovascular risk of ECT.

Value of the initial stimulus dose in right unilateral and bifrontal electroconvulsive therapy

1999 ◽  
Vol 29 (6) ◽  
pp. 1417-1423 ◽  
Author(s):  
P. HEIKMAN ◽  
A. TUUNAINEN ◽  
K. KUOPPASALMI
Keyword(s):  
Electroconvulsive Therapy ◽  
Threshold Level ◽  
Seizure Threshold ◽  
Dose Titration ◽  
High Dose ◽  
Titration Method ◽  
Initial Stimulus ◽  
Dose Method ◽  
High Stimulus ◽  
The Individual

Background. The outcome of electroconvulsive therapy (ECT) is affected by the placement and dose of the stimulus. In general, the ECT dose can be selected either by the dose-titration method (on which the measured seizure threshold level is based), or the method of predetermined dose (e.g. the age-based dosing and the fixed high dose method).Methods. Seizure thresholds were measured in 50 patients with right unilateral (RUL) and in 30 patients with experimental bifrontal (BF) ECT stimulus. The ECT dose (mC) of the age-based dosing was calculated by multiplying the age (years) by 5·0 (age method) or 2·5 (half-age method). The fixed high dose was set to 378 mC.Results. The seizure thresholds had only a moderate correlation with the age of the patients. The methods based on the predetermined dose would have led us to give patients with the lowest seizure thresholds in the RUL ECT group very high stimulus doses, up to 12 (age method) or 15 (fixed high dose method) times the individual seizure threshold. In contrast, the RUL ECT patients with the highest seizure thresholds would have received low stimulus doses down to 1·5 times (half-age method) the initial seizure threshold. In the BF ECT group the-age based dose would have been similarly dependent on the initial seizure threshold level.Conclusion. The use of the dose-titration method is recommended, because it is the only method that allows for the individual selection of ECT stimulus dose relative to the seizure threshold.

scholarly journals Electroconvulsive therapy stimulus titration: Not all it seems

2017 ◽  
Vol 52 (5) ◽  
pp. 410-414 ◽  
Author(s):  
Stephen J Rosenman
Keyword(s):  
Electroconvulsive Therapy ◽  
Seizure Threshold ◽  
Threshold Estimation ◽  
Short Term ◽  
Dose Threshold ◽  
Therapeutic Outcomes ◽  
Dose Optimisation ◽  
Dose Effects ◽  
Virtual Standard

Objective: To examine the provenance and implications of seizure threshold titration in electroconvulsive therapy. Background: Titration of seizure threshold has become a virtual standard for electroconvulsive therapy. It is justified as individualisation and optimisation of the balance between efficacy and unwanted effects. Result: Present day threshold estimation is significantly different from the 1960 studies of Cronholm and Ottosson that are its usual justification. The present form of threshold estimation is unstable and too uncertain for valid optimisation or individualisation of dose. Threshold stimulation (lowest dose that produces a seizure) has proven therapeutically ineffective, and the multiples applied to threshold to attain efficacy have never been properly investigated or standardised. The therapeutic outcomes of threshold estimation (or its multiples) have not been separated from simple dose effects. Threshold estimation does not optimise dose due to its own uncertainties and the different short-term and long-term cognitive and memory effects. Potential harms of titration have not been examined. Conclusion: Seizure threshold titration in electroconvulsive therapy is not a proven technique of dose optimisation. It is widely held and practiced; its benefit and harmlessness assumed but unproven. It is a prematurely settled answer to an unsettled question that discourages further enquiry. It is an example of how practices, assumed scientific, enter medicine by obscure paths.

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