CNA411 Nursing Medication Therapeutics

Electroconvulsive Therapy (ECT)
It is a brain stimulation procedure used to reverse the symptoms of the certain mental illnesses. It is used to treat cases of major depression in cases when the patients are unable to respond to the standardized treatments. In this procedure, through the brain, small electric currents are passed that triggers a brief seizure for a certain time intentionally. It is used when there are no other options left for the treatment and they prove unsuccessful (Zilles, Wolff-Menzler and Wiltfang 2015).
It provide significant, rapid improvements in severe mental health cases to treat conditions like:
Severe depression- In this condition, a person is detached from the reality and has refusal or desire to commit suicide.
Resistant depression- It is case of severe depression that cannot be cured by any kind of medications.
Severe mania- Agitation, hyperactivity or a state of intense euphoria due to bipolar disorder. The decision making is impaired with risky or impulsive behavior, psychosis or substance abuse.

Catatonia- It is characterized by strange movements, lack of movement or speech. It may also be caused by some medical illness or schizophrenia.
It is also used in treating aggression and agitation in dementia that affect the quality of life.
Procedure And Mechanism
This procedure requires the informed consent of the patients prior to the procedure. There is placement of electrodes with duration and dose is decided prior to the stimulation of the treatment. Electrodes are placed on the side of the patient’s head categorized into unilateral, bilateral and bifrontal ECT. Unilateral ECT is used to treat side effects of memory loss and when the electrodes are placed on the both sides of the brain, it is bilateral ECT. When the electrodes are positioned in between the unilateral and bilateral, it is bifrontal ECT (Regenold et al. 2015).
However, unilateral is considered to be less effective and have few cognitive effects as compared to bilateral ECT if the administration of the dose is in close with the seizure threshold.
The electrodes provide electrical stimulus where it is above the threshold of the seizure with 12 times in unilateral ECT and by more than one and a half in case of bilateral ECT. The levels below this threshold are not effective and also the massive levels that are above the threshold also have detrimental effect on the patients. Prior to the ECT, short-acting anesthesia is given such as thiopental, etomidate or methohexital. A muscle relaxant like succinylcholine and at times, atropine is also given that inhibits salivation.
Patient’s blood oxygen levels, ECG and EEG are monitored during ECT (Fink, Kellner and McCall 2014).
Mechanism Of Action
The exact ECT mechanism is not clear; however, have anti-convulsant effects on the frontal lobes with decrease in blood flow and metabolism. It also have neurotrophic effects on the medial temporal lobe like increase in metabolism and perfusion and an increase in the hippocampus volume (Jorgensen et al. 2016).
Advantages Of ECT
It is used in cases where medication does not work or for the people who are not able to tolerate the side effects of many drugs. People prefer ECT when they are unable to take medications.
It is one of the most effective and safest treatments that are available for depression. It provides the fastest way to relieve the symptoms of severe depression or suicidal thoughts. It is also effective in cases of mania or severe mental illnesses.
It gives fast results instantly as it relives from the symptoms of mental illnesses and the seizure that prevails lasts for a minute. Medications take weeks to show its effectiveness and compared to that, ECT gives instant results and is an ideal therapy to control the episodes of suicidal thoughts or debilitating mania.
Unilateral ECT is used where it has less memory impairment and fast recovery of cognitive functions (Rasmussen 2014).
Effectiveness Of ECT
It is an effective treatment for major depression; however, it is not necessary that it will work on every kind of mental illness as there are variations in doses, duration of the electricity impulse that is delivered through the electrodes.
It is a fast and short term treatment for severe symptoms of depression that is considered to be life-threatening.
Some people have positive effects after ECT application like less invasive thoughts of self-harm and mood uplift with management of severe depression thoughts (Delmonte et al. 2015).
However, some people suffer from side effects with depressive thoughts with no positive change in well-being or mood. It is also reported that I some cases, medication and self-help worked better than ECT.
Risk Factors
ECT is highly controversial as it has dangerous side effects like memory loss, confusion, physical side effects and medical complications.
Memory loss- There are trouble regarding remembering the events that occurred before the ECT session.
Confusion may also occur that might last from few minutes to hours and are more noticeable in old people.
There are several physical side effects like headache, nausea, muscle ache or jaw pain. Dental or oral injury during clenching of the jaws in seizure attack.
Spinal or long bone fracture
As this medical procedure involves use of anesthesia, there are medical complications associated with it. During the procedure, the blood pressure and heart rate increases and in adverse cases, it leads to heart problems and this is risky.
It is used in cases when no other medication or therapies work and it has 86% of remission rates with strange feelings of numbness, hallucinations, problem thinking and disorientation (Hawton et al. 2015).
ECT Patient/Family Education
ECT is shrouded with misconceptions and myths that it generates high level of anxiety among the mental patients and their families. The intervention is a five-step plan where the patients are educated to reduce the anxiety of the patients and their families. The healthcare providers provide sensitivity towards the fears and special needs of the families to take up the decision of proceeding with the ECT treatment.
Patients and their families should be educated about the ECT procedure including the management of the illness (Hawton et al. 2016).
Pre-Teaching Interventions In ECT
Assessment And Development Of The Therapeutic Relationship

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The healthcare professionals try to promote active patient and family involvement in the assurance for the success of this treatment. Firstly, they prepare meetings with the patient’s family to discuss the background, history, functioning and the psychological or physiological condition. It helps to know about the family and develop an individualized intervention. When the information is shared between the patient’s families and healthcare professionals, a sense of caring is developed (Obbels et al. 2016).

Exploration Of The Concerns And Fears

Due to the preconceived notions about ECT, the anxiety and concerns need to be dealt in a proper manner. A supportive and safe environment is important to acknowledge so that the patient’s families are able to share their concerns and fears about the treatment. The concerns are addressed individually being an empathetic listener who is cognizant of both nonverbal and verbal language. This also promotes understanding when the specific information is shared (Salehi et al. 2016).  

Identification Of Teaching Tools

The needs of the patients differ and so there are specific teaching tools that are required for the patients and their families. The teaching tools involve the information about ECT that incorporates the common questions that are asked about the procedure. There is a booklet that encompasses the requests and responses of the former patients who have undergone ECT and their families. ECT video is also present that demonstrates the procedure and demonstration of the equipments involved in the treatment. It is said that the sensory and instructional information are required that would lower the anxiety levels (Gligorov et al. 2015).

Coping Strategies For The Anxiety Reduction

The coping methods are useful during this phase as the patients and their families are able to cope up with the anxiety like breathing and relaxation techniques (Semkovska et al. 2016).


In this phase, the basic information provided by the patient and their families are reviewed and the potential or real problems are discussed that greatly focuses on the problem-solving and active decision-making. This assessment and the planning are documented in the chart of the patient.


Lamotrigine is the anticonvulsant drug. It is used in the treatment of partial seizures in both adults and children with epilepsy and clinical depression as an adjunct treatment.  The action of the drug is to stabilise the neuronal membranes by impeding the sodium transport. The therapeutic effect of the drug includes decreasing the incidence of the seizures. The time of recurring mood episodes are delayed by the drug. It is also used as alternate treatment for atonic seizures, absence seizures, and in bipolar disorder. However, the drug seems ineffective in maintaing current rapid cycling, acute depression, and acute mania in bipolar disorder (Riaz and Matsuo 2015).

The drug is a synthetic phenyltriazine with analgesic and anti-epileptic property. The function of the drug is initiated by the enhancing the action of the GABA (gamma-aminobutyric acid) which is a neurotransmitter that reduces the transmission pain related signals along the nerve fibres. Its neuroprotective and antiglutamatergic effects are major contributors of the mood stabilising activity (Matsuo and Riaz 2009).

Reasons For Withholding The Medication

During ECT Lamotrigine may interfere with the expression of seizure. This anti-convulsant may exacerbate the cognitive side effects. There is a more frequent occurrence of the missed seizures during ECT treatment with the concurrent use Lamotrigine. In all patients this concurrent use may result in elicitation of seizure of adequate duration (Riaz and Matsuo 2015).

The drug is contraindicated in hypersensitivity. In all patient it increases the risk of suicidal behaviours. A lower maintenance dosage is required in patients with impaired cardiac function, renal dysfunction, and hepatic dysfunction. Adverse side effects of the drug include photosensitivity, rash, multi-organ hypersensitivity reactions (Wechsler et al. 2014).

The drug has various interactions. When used with carbamazepine the levels of Lamotrigine my decline and increase the level of active metabolite of  carbamazepine. The evel of Lamotrigine is also decreased by the concurrent use of phenytoin, Phenobarbital and valproic acid. The use of valproic acid decreases the level of Lamotrigine by 50% (Yamamoto et al. 2014)

Patient Education (Ting et al.2016)

Instruct the patients to take medication as directed by the medical practioner
Instruct not to take the double dose or missed dose unless time for the next dose
Educate the patient that if the medication is discontinued abruptly it may lead to increase in frequency of seizures
Educate the patient about the side effects of the drug such as fever, rash, swollen lymph glands
Instruct to notify the heath care professional in case the patient is experiencing drowsiness, dizziness and blurred vision
Instruct patient to notify the heath care professional if thoughts about committing suicide appears, or feels very agitated of experiences severe agitation, panic attack or in case of symptoms of aseptic meningitis.
Lithum Carbonate         

It is an essential medicine for the treatment of bipolar disorder. It is an effective agent to treat mania.

Lithium ions interfere with the process of ion transport which aids in the relay and in amplification of messages carried to the brain cells. Mania is characterised by irregular increase in protein kinase C activity within the brain. Lithium carbonate inhibits the activity of protein kinase C. It greatly reduces the intensity of manic episodes. The drug can alter the cation transport in nerve and muscle. It also influences the re-uptake of neurotransmitters. By altering the sodium transport in muscle an nerve cells, the drug effects a shift towards intraneuronal metabolism of catecholamines (Sadananda et al. 2013).

Reasons For Withholding The Medication

The drug has contradictions. It is  not given to the patients with significant cardiac and renal diseases. It is not given supposed to be given to the patient with severe dehydration, debilitation, or sodium depletion, and in case the patient is receiving diuretics.  The drug may be withhold during ECT due to adverse reactions such as increase in seizure response, fatigue, impaired memory, sedation, confusion, arrhythmias, hypotension, abdominal pain, weakness and rigidity (Oruch et al. 2014).

The drug has various drug- drug interactions, which may prolong the action of neuromuscular blocking agents. It increases the risk of neurologic toxicity with concurrent use of haloperidol, diuretics, probenecid, fluoxetine, methyldopa and NSAIDS. When this drug is taken concurrently with ACE inhibitors it increases the blood levels. Chlorpromazine clearly masks the signs of lithium toxicity. When the drug during ECT is taken with the ant thyroid agents, it may add to the effects of the hypothyroidism (Can et al. 2014).

Patient Education (Oruch Et Al. 2014)
Instruct the patients to take medication as directed by the medical practioner
Patient can take the missed dose as soon as remembered unless within the two hours of the next dose
Caution patient about the dizziness and drowsiness associated with the medication
Educate the patient that low sodium levels may predispose the patient to toxicity
Instruct the patient to drink 2-3 litres fluid each day and have diet with moderate sodium intake.
Advise patient to avoid excessive amount of tea, coffee, cue to diuretic effect
Instruct the patient to notify the heath care professional in case of vomiting, diarrhoea, and fever
Instruct patient to notify the heath care professional in case of experiences such as fainting, irregular pulse and difficulty breathing
Instruct and emphasise on periodic lab test and its importance to monitor the lithium toxicity
Sodium Valproate 

Sodium Valproate is an anticonvulsant. It is used an aesthetic agent for ECT. It has seizure-shortening properties. It is mood stabiliser and is thus used in the bipolar effective disorder treatment. Its mechanism of action includes increasing the level of Gamma-Amino butyric acid in the brain. This mechanism includes inhibition of the enzymes that catalyses the catabolism of GABA as a result the synaptic action of GABA is potentiated. It also acts by altering the action of the voltage dependent sodium channels. This drug also affects the potassium channels, which leads to membrane stabilising effect. It is highly effective in suppressing the seizure activity (Haghighi et al. 2013)

Reasons For Withholding The Medication

It raises the threshold of the seizure decreasing the efficacy of ECT treatment. It is also withhold due to increased risk of suicidal thoughts and severe depression (Haghighi et al. 2013). 

The contraindications of Sodium Valproate include acute or chronic liver injury, pregnancy; know hypersensitivity to drug or any of its ingredients, urea cycle disorder, mitochondrial disease, pancreatitis, and porphyria.  The drug has many interactions. Sodium Valproate is given in conjunction with other antiepileptic drugs such as  carbamazepine, lamotrigine, it leads to reduced clearance. The concentration of Sodium Valproate increases with intake of aspirin. It interacts with benzodiazepines to cause CNS depressants (Hafezian et al. 2013). It interacts with Erythromycin inhibits the valproate’s metabolism in the liver. The drug passes into breast milk and effects lactation. When used during pregnancy it leads to congenital anomalies (Doellinger et al. 2016).

Patient Education (Misra Et Al. 2017)
Instruct the patients to take medication as directed by the medical practioner. In case of multiple dose schedule, a dose is missed then it should be taken within six hours of the scheduled time
Patient should be educated that abrupt withdrawal of the drug may lead to status epilepticus
Instruct the patient to notify in case of increase in depression, suicidal thoughts and other changes in mood
Instruct the patient to notify the health professionals in case of chest pain, easy bruising, irregular heartbeat, severe allergic reactions, swollen lymph nodes, severe dizziness
Patient should be educated about weight gain, insomnia and visual disturbances that may occur due to drug intake
Patient should be made cautious that alcohol consumption should be avoided during ECT
The female patients should be instructed to notify the health care professional in case pregnancy or breastfeeding is planned  

Can, A., Schulze, T.G. and Gould, T.D., 2014. Molecular actions and clinical pharmacogenetics of lithium therapy. Pharmacology Biochemistry and Behavior, 123, pp.3-16.

Delmonte, D., De Santis, C., Verri, F.M., Rossini, D., Lucca, A., Zanardi, R., Barbini, B. and Colombo, C., 2015. Electroconvulsive Therapy (Ect) in Treatment-resistant Depression (Trd): a Naturalistic Study. European Psychiatry, 30, p.844.

Doellinger, O.V., Ribeiro, J.P., Ribeiro, Â., Freitas, C., Ribeiro, B. and Silva, J.C., 2016. Spontaneous seizures after ECT in a patient medicated with bupropion, sertraline and risperidone. Trends in psychiatry and psychotherapy, 38(2), pp.111-113.

Fink, M., Kellner, C.H. and McCall, W.V., 2014. The role of ECT in suicide prevention. The journal of ECT, 30(1), pp.5-9.

Gligorov, N., Sommer, T.M., Ballato, E.C.T., Frank, L.E. and Rhodes, R., 2015. Bridging the gap between knowledge and skill: integrating standardized patients into bioethics education. Hastings Center Report, 45(5), pp.25-30.

Hafezian, H., Roustaii, O. and Ahmadpanah, M., 2013. Comparison of Cognitive Impairment and Seizure Parameters in Manic Patients Receiving Electroconvulsive Therapy with or without Concurrent Treatment with Sodium Valproate.

Haghighi, M., Bajoghli, H., Bigdelou, G., Jahangard, L., Holsboer-Trachsler, E. and Brand, S., 2013. Assessment of cognitive impairments and seizure characteristics in electroconvulsive therapy with and without sodium valproate in manic patients. Neuropsychobiology, 67(1), pp.14-24.

Hawton, K., i Comabella, C.C., Haw, C. and Saunders, K., 2013. Risk factors for suicide in individuals with depression: a systematic review. Journal of affective disorders, 147(1), pp.17-28.

Jorgensen, A., Magnusson, P., Hanson, L.G., Kirkegaard, T., Benveniste, H., Lee, H., Svarer, C., Mikkelsen, J.D., Fink?Jensen, A., Knudsen, G.M. and Paulson, O.B., 2016. Regional brain volumes, diffusivity, and metabolite changes after electroconvulsive therapy for severe depression. Acta Psychiatrica Scandinavica, 133(2), pp.154-164.

Matsuo, F. and Riaz, A., 2009. Lamotrigine. The Treatment of Epilepsy, Third Edition, pp.535-558.

Misra, U.K., Dubey, D. and Kalita, J., 2017. A randomized controlled trial of lacosamide versus sodium valproate in status epilepticus. Epilepsia, 1, p.5.

Obbels, J., Verwijk, E., Bouckaert, F. and Sienaert, P., 2016. ECT-Related Anxiety: A Systematic Review. The Journal of ECT.

Oruch, R., Elderbi, M.A., Khattab, H.A., Pryme, I.F. and Lund, A., 2014. Lithium: a review of pharmacology, clinical uses, and toxicity. European journal of pharmacology, 740, pp.464-473.

Rasmussen, K.G., 2014. Propofol for ECT anesthesia a review of the literature. The journal of ECT, 30(3), pp.210-215.

Regenold, W.T., Noorani, R.J., Piez, D. and Patel, P., 2015. Nonconvulsive electrotherapy for treatment resistant unipolar and bipolar major depressive disorder: a proof-of-concept trial. Brain stimulation, 8(5), pp.855-861.

Riaz, A. and Matsuo, F., 2015. Lamotrigine. The Treatment of Epilepsy, 4, pp.498-515.

Sadananda, S.K., Narayanaswamy, J.C., Srinivasaraju, R. and Math, S.B., 2013. Delirium during the course of electroconvulsive therapy in a patient on lithium carbonate treatment. General hospital psychiatry, 35(6), pp.678-e1.

Salehi, I., Hosseini, S.M., Haghighi, M., Jahangard, L., Bajoghli, H., Gerber, M., Pühse, U., Holsboer-Trachsler, E. and Brand, S., 2016. Electroconvulsive therapy (ECT) and aerobic exercise training (AET) increased plasma BDNF and ameliorated depressive symptoms in patients suffering from major depressive disorder. Journal of psychiatric research, 76, pp.1-8.

Semkovska, M., Landau, S., Dunne, R., Kolshus, E., Kavanagh, A., Jelovac, A., Noone, M., Carton, M., Lambe, S., McHugh, C. and McLoughlin, D.M., 2016. Bitemporal versus high-dose unilateral twice-weekly electroconvulsive therapy for depression (EFFECT-Dep): a pragmatic, randomized, non-inferiority trial. American Journal of Psychiatry, 173(4), pp.408-417.

Ting, T., Jiang, W., Kane, M. and Polli, J., 2016. Evaluation of Reproducibility of Pharmacokinetics and Clinical Outcome Differences with Brand and Generic Lamotrigine Switching in Epilepsy Patients (BEEP FU Study)(P2. 033). Neurology, 86(16 Supplement), pp.P2-033.

Wechsler, R.T., Leroy, R., Van Cott, A., Hammer, A.E., Vuong, A., Huffman, R., VanLandingham, K. and Messenheimer, J.A., 2014. Lamotrigine extended-release as adjunctive therapy with optional conversion to monotherapy in older adults with epilepsy. Epilepsy research, 108(6), pp.1128-1136.

Yamamoto, T., Hong, S.B., Shimizu, M., Sato, K. and Numachi, Y., 2014. Lamotrigine monotherapy in newly diagnosed epilepsy or recurrent epilepsy: A multi-center, open-label study. Epilepsy & Seizure, 7(1), pp.55-65.

Zilles, D., Wolff-Menzler, C. and Wiltfang, J., 2015. Electroconvulsive therapy for the treatment of major depression. Der Nervenarzt, 86(5), pp.549-556.