1. ECT & seizures: 
-Seizures necessary but not sufficient for treatment effectiveness
-Ect increases seizure threshold, has been used to treat epilepsy
-Epilepsy (endogenous) decreases seizure threshold: each seizure predicts future seizures. Epilepsy is also assoc w higher rate of depression than similarly impairing diseases.
2. ECT & Anesthesia: 
-Anesthesia plus sux, prevent fractures during seizures
-Methohexital: short acting barb. Cheap, long safety history. Fast wear off, compatible with inducing seizures since its less antiepileptic than most anesthetics. 

-Can also use thiopental, etomidate (least anticonvulsant so you can use if sb is hard to induce), propofol (most anticonvulsant, can't use in egg allergy), ketamine, remifentanil ($$$$)

-Use Sux if all possible: fast on, fast off, don't need to reverse. Only use nondepolarizing NM blockers if sux is CI (hyperK, hx of malignant hyperthermia, etc) 

3. ECT setup: 

-Bite block (since direct electrical stimulus to masseter)

-BP cuff on L leg (tourniquet) to monitor motor movements & make sure seizure is generalized.

-Also monitor with EEG. 

-Place electrodes on R unilateral side, fewer adverse effects than bitemporal placement. 

-Brief square wave is better than sine wave: reduces sx, since its believed that only the peak causes the seizure and the ramp up and down is just harmful. 0.1 to 0.4 ms pulse is enough. 

4. Perioperative adverse events

-Ect -> vagus -> bradycardia (10-15 sec). Can brady to asystole. Can use anticholinergic to protect against this. Atropine can be used but it crosses bbb (delirium) and can cause tachycardia. Glycopyrrolate doesn't cross bbb. 

-Sympathetic surge after ect for ~5 mins, most people can tolerate, can give b blocker. 

5. Indications: 
-Depression, bipolar, mania, schizophrenia/schizoaffective, catatonia (responds to benzos ESP Ativan and ECT)
-When to choose: severe or catatonic sx, hx of failure of drugs

6. Prognostic indicators:
-Predictive of good resp: severe, +psychosis, +catatonia
-Pred of poor resp: dep on dysthymia (cures acute depression not dysthymia baseline), depression due to medical condition, comorbid personality disorder or OCD
7. Contraindications: 

-space occupying lesion (ect and sux both increase ICP)

-hx recent MI-- usually wait 2 mos. 

-recent hemorrhagic stroke (rebleed risk w increased arterial pressures)

-severe heart disease like CHF with EF<30, severe valvular disease

-presence of aneurysm that may blow with increased arterial pressure 

8. Complications: 

-headache, myalgia, nausea likely due to sux and anaesthesia. 

-Postictal agitation or delirium in 10-25%. Responds to benzos. 

-Rarely: prolonged seizures >3 mins. 

-Treatment emergent mania (can give lithium, or more ect) 

-General anesthesia or seizures cause anterograde amnesia (can't make new memory) which induces a gradient retrograde deficit. Difficult to form memories during course of ect (2-4 weeks of ect 3x a week) so don't plan a wedding during this period. Anterograde memory will return to nl within a week. Retrograde deficit is days to weeks. 

9. Duration

-Will need maintenance psychotropic medications

-Most people will relapse without continued psychotropic meds

-Some people may need maintenance ECT on a weekly or monthly basis for the long-term 

10. Treatment of tic disorder in children: 

-Typical antipsychotics: pimozide, haldol 

-Clonidine

-Respiridone