CNA741 Foundations Of Mental Health Nursing Theory 2

Question:

Nursing Care Management and Electro Convulsive Therapy

Write about ECT and its history, epidemiology, indications, and mechanism of action.

Answer:

Introduction

An electroconvulsive treatment (ECT), is the intentional induction induction of a modified generalized seizures in an anaesthetized subject under medically-controlled circumstances to produce a therapeutic result (Kavanagh & McLoughlin (2009)).

This is achieved by passing an electric charge through the brain between two electrodes placed on the scalp.

The goal of electroconvulsive treatment is to change the brain’s chemical to reverse certain mental disorders.

When other therapies fail, ECT is often recommended.

ECT has been proven to be a more effective treatment than pharmacotherapy for treating depression.

It is recommended as an effective treatment option to treat depression with psychotic symptoms. (Petrides and colleagues 2001).

ECT plays a crucial role in modern mental health care. When a patient is undergoing electroconvulsive therapy, nurses have to play a very important role.

This resource covers ECT, its history, epidemiology, indications, and the mechanism of its action.

A Brief History of ECT

On the basis of convulsions being used to treat mental illness, the history of electroconvulsive treatment can be traced back as far as the 1500s.

Inducing convulsions through the oral administration of camphor was the first practice.

Paracelsus, a Swiss psychiatrist, was able to induce seizures using oral administrations of camphor.

1785 was the first time that a report was published about the use of camphor to induce seizures to treat mania.

The Hungarian neuropathologist Ladislas Jose von Meduna demonstrated that oral camphor could be replaced with intramuscular injection in 1934 to treat catatonic schizophrenia.

Treatment of mental conditions that were induced by chemically-induced seizure was not without their distressing and long-lasting preictal effects, which helped to open the door for new ways of inducing therapeutic seizures.

Modern ECT can be traced back in 1938 when electricity was used as a method to induce seizures to treat a catatonic person by Ugo Cerletti (Kalapatapu (2015)).

In the US, ECT became available in 1939 (Pandya et. al., 2007,).

However, ECT procedures were not properly anaesthetic or used muscle relaxation techniques. Dislocations and fractures also occurred due to insufficient knowledge about the dosage parameters of electrical stimulation.

Curare was used to relax muscles during ECT procedures in order to combat these problems (Sadock & Sadock 2007).

Until the 1950s, ECT was the only option. Effective antipsychotic drugs began to be developed.

The 1950s were the first time that electroconvulsive therapy had been scientifically investigated.

Max Fink, a psychiatrist used rigorous scientific research methods to examine the efficacy of the ECT procedure (Taylor 2007).

In the same year, succinylcholine (a depolarizing muscular relaxant) was introduced. This was used along with a short-acting sedative during ECT procedures. The purpose of this combination is to prevent injuries and numb patients from experiencing the ECT procedure.

Sadock & Sadock (2007) reported that ECT’s response rates were significantly higher than those of other medications used to treat mania.

The American Psychiatric Association published in 1978 the first Task Force Report about ECT. It sought to reduce the misuse and misuse of the procedure.

Later revisions of this report were made in 1990 and 2001.

The National Institutes of Health and National Institute of Mental Health Consensus Conference on ECT further accelerated the development of ECT (Sadock & Sadock 2007, 2007).

Randomized controlled clinical trials comparing ECT to lithium were done towards the end 20th century. These results indicated that both are equally effective in the treatment for mania.

Sarah Lisanby and her colleagues at Columbia University demonstrated magnetic stimulation as a way to induce convulsive seizures in the early 21st Century. (Sadock & Sadock 2007, 2007).

There were two eras that shaped the history of ECT.

One was an era of therapeutic optimism in psychoiatry and the other was one of almost unrestricted use (Glass. 2001).

The first era of therapeutic optimism began when there was no other option to ECT.

ECT was used almost indiscriminately in the mid-20th Century. The anti-psychiatry movement that exaggerated the adverse aspects of ECT and hospital treatment, as well as negative portrayals in media like “One Flew Over The Cuckoo’s Nest”, (Swaine 2011, 2011) were consequences.

These actions cast doubt on ECT’s efficacy.

In today’s times, ECT has been surrounded by stigmatization and fear (Dowman et. al., 2005).

In two ways, this prevents effective treatment of severe mental illnesses.

The first is the refusal of treating teams or patients to accept the treatment.

Glass (2001) suggests that healthcare professionals should be informed about current ECT practices, including efficacy and indications.

Epidemiology of ECT

As early as 1941, electroconvulsive treatment was used in schizophrenia treatment.

After the introduction and widespread use of pharmaceutical treatments for severe mental disorders, the usage of the procedure decreased in the 1970s, 1980s, and 1992 (McCall, McLoughlin, et. al.).

ECT became a last-resort option for those with severe life-threatening illnesses or patients who had resistance to medication.

This was changed by the National Institutes of Health, National Institute of Mental Health Consensus Conferencing on ECT. It recommended that ECT be not used as a last resort.

After World War II, the rapid spread of ECT to Europe and other continents, including the US, was due to the displacement of psychiatrists (Shorter (2009)).

An estimated 1 million patients receive electroconvulsive treatment each year worldwide (Hermann, Hermann, and al., 1995).

Swartz (2009) claims that ECT is a widely accessible treatment for individuals with mental disorders.

Even though there are common international guidelines (Enns and al., 2011, for this practice), there are vast differences between countries and regions.

Additionally, there are differences in ECT use across various divisions.

Van Waarde et. al., 2009, a study of the ECT utilization in the US in the past decade found that ECT was used by 4.9 persons per 10,000 people in 1995 (van Waarde et. al., 2009).

According to Leiknes et. al. (2012), there are signs of low ECT utilisation on the continents of Africa and Latin America.

ECT is a popular practice in America, Asia and Europe.

Despite widespread use in Europe, America, Asia, and elsewhere, there are significant differences in utilization rates and clinical practice among countries.

Unmodified ECT, which is ECT administered without anaesthesia, is largely in use in Asia. It has a 90% prevalence in Latin America, Africa, as well as some European countries (Spain Russia and Turkey). (Leiknes et al. 2012).

ECT is mainly used by older female patients with depressive disorders in Australia, New Zealand, and the United States.

Unmodified ECT is not available in other regions of the world, such as Africa Asia, Russia, and Latin America. In these areas, patients suffering from schizophrenia are the majority (Leiknes et. al., 2012).

Baghai et.al. (2005), and Moksnes et.al. (2006) both agree with this observation. Moksnes et.al. (2006) also note that patients receiving ECT in the first tier countries are overwhelmingly elderly females with affective disorders.

Saudi Arabia and Pakistan share the same profile, but are older.

ECT treatment rates are also higher in Western Australia among Caucasian whites of Caucasian ethnicity (Teh et. al., 2005).

There are many variables in the provision of ECT within psychiatric institutions.

Asia has the highest ECT rates (59-78%), followed closely by Australia (66%), 23-51% in Europe (Leiknes, 2011), and 6% in America (Leiknes, 2012).

Chanpattana (2007) concurs with this observation. He notes that in Australia the procedure is provided only by 66% institutions, while training on ECT can be provided by 73%.

A limited number of reports regarding side effects, adverse reactions and mortality rates due to ECT have been analyzed.

Thailand is the country with the highest death rate, at 0.8% (Chanpattana & Kramer 2004; Scarano & Felthous 2000).

It is not clear if these ECT-related death are due to anaesthesia complications, comorbid somatic conditions, or lethal side effect such as cardiac arthymia.

The consent of administration of ECT is a procedure that is largely performed involuntarily or under guardian consent conditions. This applies to all regions.

Indications of ECT

ECT is a nonpharmacologic treatment for biological disorders that is highly effective, primarily in treating depression and schizophrenia.

ECT can be used to treat therapy-resistant psychiatric disorders that are the result of medication failures.

Major Depression

The treatment of severe depression can be done quickly and effectively with electroconvulsive therapy.

It is indicated for major depression cases where antidepressant treatment has failed to work or is too difficult to tolerate.

Because of its fast response, it is often preferred by patients suffering from severely psychotic or suicidal depressive symptoms.

It is impossible to wait for antidepressants in these cases.

ECT is a very safe and effective treatment in psychiatry.

Unfortunately, the treatment’s effects often do not last long and may require additional treatment.

The availability of atypical antipsychotics as well as classical neuroleptics, lithium, and other mood stabilizers with better antimanic efficacy has led to a decline in the use of ECT for mania.

However, ECT’s efficacy has been proven in controlled randomised trials and studies.

ECT has shown a high rate of remission (or improvement) (Baghai & Moller (2008).

Bipolar disorder can lead to acute depression. Acute depression is often not responsive to antidepressants or mood stabilizers.

ECT is recommended to clients with bipolar disorder who are depressed and not responsive to antidepressants or mood stabilisers.

ECT doesn’t cause switching, which is why it is preferable to antidepressants.

Contrary to common belief, ECT can be an excellent alternative for those with bipolar disorder, co-morbidities, and the elderly (Brooks (2015)).

Cerletti & Bini, in 1938, first introduced ECT to manage schizophrenia.

The effectiveness of the procedure in treating patients with schizophrenia and other schizoaffective disorders has been demonstrated (Chanpattana and colleagues, 2010).

This is despite a decrease in its use in treating schizophrenia since the introduction neuroleptics in the 1950s.

ECT is a viable option for people suffering from schizophrenia. It is recommended to those with schizophrenia and who have had a negative or minimal response to antipsychotics.

Theories on Mechanism Of Action

Studies using animal models to study the mechanism of ECT have shown that repeated administration is necessary to entrain a series molecular and structural brain changes which are relevant to the antidepressant effect. (Kavanagh & McLoughlin 2009).

These changes include the stimulation of neuronal growth factor, which increases neurones’ survival. They also increase plasticity and the adaptability of neurones to improve their connection with one another.

Notably, ECT increases hippocampus nerve cell numbers (Grover et al. 2005).

The hippocampus deals with mood regulation and memory.

Kavanagh & McLoughlin (2009) state that antidepressants produce a much lower effect than ECT.

Nursing Role

ECT has seen a shift in psychiatric nursing care from traditional supportive and adjunctive practices to the current practice of collaborative, independent nursing actions (Burns & Stuart 1992).

Current practice in ECT nursing includes a variety of nurses, including an ECT Nurse, a ward Nurse, Operating Department Assistant, Nurse Coordinator, and a Recovery nurse.

The ECT nursing role is to coordinate the service. They also have the responsibility for managing the ECT clinic, as well as caring for the patient (IECT Accreditation Service 2016, 2016).

The ECT nurse is responsible for creating protocols that conform to best practice guidelines.

The ECT nurse is responsible for ensuring that all medications, equipment and ECT environment are in accordance with best practices guidelines (Kavanagh & McLoughlin 2009.

The psychiatrist and anaesthetist are responsible for administering electroconvulsive treatment. However, the ECT nursing team plays a crucial role in addressing psychological concerns of clients undergoing the procedure.

This includes, but is not limited to, educating the patient on their condition, the reasons for the procedure, the initial and ongoing treatment process, and dealing with the family’s concerns regarding the procedure.

The nurse can educate the patient about their condition and help them to dispel any myths or negative premonitions.

As the nurse is less intrusive and more positive, this encourages the patient to continue the treatment regardless of any adverse effects.

The nurse conducts a pretreatment checklist before the patient goes under anaesthesia.

The nurse also takes care of the patient’s legal, mental and medical status (Kavanagh & McLoughlin (2009)

Post ECT

After ECT treatment, the role of the recovery nurse is crucial.

They are trained in advanced life support techniques and are conversant with all possible adverse events.

After treatment, the nurse will keep the patient’s airway open, monitor their vitals, and give prescribed medications to combat side effects.

The nurse continues to play a role in the recovery area until the patient regains their orientation and the anaesthetist gives them a clean bill. (Queensland Health 2017, 2017).

Conclusion

Electroconvulsive Therapy (ECT) is the best treatment for severe mental illnesses.

Since its inception, the procedure has experienced tremendous growth. It was originally developed for schizophrenia.

There is still a stigma associated with this process. However, there is ample evidence to support its safety and effectiveness in modern medicine.

Nurses are now playing a major role in the provision and administration of ECT.

This is in contrast with the former role of a support nurse.

Nurses are now able to play a number of roles. They can be ECT nurses, ward nurses, recovery nurses, and anaesthetist’s assistant.

It is crucial to emphasize the education of nurses about ECT to improve their central role in the enhancement of and development of the therapy.

References

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