2Disclosures I don’t call my parents enough I actually like “Sweet Caroline” being played in the 8th inning of Red Sox GamesI occasionally enjoy a nice cigarI didn’t give up anything for Lent last yearI hated the movie “The English Patient”I have no financial disclosures or conflicts of interest related to this talk.
3Growth in Demand for McLean ECT Number of ECT Treatments
4What is ECT? ECT = Electroconvulsive Therapy Done under brief general anesthesia – asleep for whole treatment, with muscle relaxant – no significant convulsion or movement.Brief electrical stimulus administered for a couple of seconds, inducing a short (minute or so) seizure – while under anesthesia. Can be administered to one side (unilateral) or both sides (bilateral).Safe and Painless, except for occasional post-treatment headache or soreness (usually mild)Very quick – Only a few minutes and patients can go home after 2 hours
5ECT Why do we still use ECT? Superior efficacy Medication resistance No medication or other treatment ever shown to be more effective in the acute treatment of Major DepressionUp to 90% response in psychotic depression, % in catatoniaMedication resistanceMedication intoleranceSpeed of response and severity of illness
6Indications and Efficacy Psychotic depressionECT sometimes first line treatmentResponse rates as high as 95% (Petrides 2001)CatatoniaEfficacy rates around 85% (Hawkins 1995 review)Should be considered when Lorazepam fails or in cases of malignant catatonia or when rapid resolution is neededMajor DepressionNo trial has ever found any medication to be superior in efficacy to ECT (APA task force)Responses range from 50-60% in patients who are medication resistant to 80-90% in medication naive or intolerant patients (Prudic, Sackheim, APA)Bipolar DepressionCan be very effective – recent meta-analysis of 6 studies found ECT to be equally effective for both bipolar and unipolar depression (Remission rate of 53.2% in 316 bipolar depression). (Dierckx et al., Bipolar Disorders, 2012)May be a good alternative to anti-depressantsBipolar Mania or Mixed EpisodeECT associated with remission or marked improvement in approximately 80% of manic pts (Mukherjee 1994)Mixed states are difficult to treat pharmacologically and appears to respond well to ECT (Ciapparelli 2001)Schizophrenia or Schizoaffective DisorderGenerally not used first lineCombination of ECT and anti-psychotic may be more effective than ECT alone
7Case Example #1MWM in his 70’s, no history of psychiatric illness until retired in 2008, when became depressed. Progressively his mood worsened over the next several years.Trials of paroxitine, escitalopram, mirtazapine, ziprasidone, duloxetine, imipramine, and others without benefit.Last two years developed anhedonia, anergia, insomnia, poor appetite (lost 57 lbs in 5 years of episode), paranoid delusions, and difficulty caring for self – would soil himself repeatedly rather than use bathroom.
8Case Example #2Mid 30’s MWW, high functioning health care professional, with history of depression vs. bipolar 2, including a possible remote history of hypomania that lasted 9 months.Two previous episodes of depression since the birth of her daughter 4 years ago. 2 suicide attempts. Now admitted for 3rd episode, worsening over last 6 weeks and including suicidal thinking with planning, marked anxiety, guilt, poor energy, 13 lb weight loss over last month, and poor concentration and functioning. Hospitalized less than a month ago for similar symptoms. Just completed partial program. Is unable to work, and is worried about losing her job.Currently taking venlafaxine and aripiprazole, which have helped in the past, and she has been on for years. No other med trials except she thinks may have been tried on SSRI in remote past.
9Side EffectsPhysicalOne of the safest procedures done under general anesthesia – risk of death around 1 per 25,000 treatments.Extra precautions taken for patients with neurologic, cardiac or pulmonary problemsMild headache, jaw soreness, nausea are not uncommon but usually mild, and rarely cause discontinuation of treatment
10Side Effects Memory Loss Probably the biggest concern of patients and family members regarding ECTTypically memory loss is mild and usually resolves when ECT is finished, although frequently there are some gaps in memory for the period during, or just prior to acute courseCan be more significant gaps in memory with longer, more complicated courses or with bilateral ECT (more aggressive form of ECT)We have ways of delivering ECT –which minimizes memory loss significantly for most people.Unilateral – stimulus applied to only one sideUltrabrief pulse – newer type of ECT, using much smaller pulses of stimulus, and seems to cause little if any sustained memory loss for most patients.
11Side Effects Cognitive Function Disruption of Cognitive Functioning, including anterograde memory (ability to remember new things) occurs to varying degrees during ECT, but is generally a short-term effect, and resolves after ECT is stopped.Recent Meta-Analysis and Systematic Review in Biological Psychiatry (2010) – reviewed 84 studies (2981 patients) of ECT where cognition was assessed using standardized tests.Found that “cognitive abnormalities associated with ECT are mainly limited to the first 3 days post-treatment. Pretreatment functioning levels are subsequently recovered.After 15 days, processing speed, working memory, anterograde memory, and some aspects of executive function improve beyond baseline levels.”
12How Do We Keep Patients Better? Once Better – We recommend tapering ECT as patients tolerate it, staying with patients long enough to make sure they reintegrate into a non-depressed lifestyle again.We can work with outpatient psychiatrists to find the right medicines to help add stabilityWe can encourage ways to add structure and therapeutic supports/strategies.Day programExerciseWorkOther (Reiki, Tai Chi, Meditation, etc.)We can recommend resuming or starting therapy to help cope with the losses that depression may have brought and to help move forward and prevent relapse.
13What Can We as ECT Providers Do to Make ECT Better? Informed Consent as an ongoing process – “our best patient is an informed consumer”Tailoring treatment to not just patient’s condition, but to patient’s wishes and concerns.Set realistic expectationsWork as part of a treatment team to help patient’s stay better once they get betterPrivacy and ComfortBe Kind – remember our patients are suffering and often frightened by what we do
14What Questions Should I Ask at My ECT Consultation? What types of ECT do you offer?Unilateral, bilateral, bifrontalUltrabrief pulseWhich type do you recommend for me?Will you tell me if you change types?What is a realistic expectation for me in terms of improvement in my symptoms?How often will I get to meet with you during the course of treatment?What should I do after ECT to stay well?Do you offer continuation or maintenance ECT?
15Summary ECT is a powerful treatment for severe depression It is not without possible side effectsAll ECT is not the same, and not everyone will respond to ECT the same wayIf you are considering ECT, it is important to find an ECT provider who will consult with you and help you determine the potential risks and benefits of ECT for your illness.