1. Electroconvulsive Therapy in a Rural Setting

2. George R Martin, MD Staff Physician Department of Psychiatry James A Quillen VA Medical Center Mountain Home, Tennessee Associate Professor, Psychiatry James A Quillen School of Medicine East Tennessee State University Johnson City, Tennessee

3. Six Questions (1)What it is not (2) What it is (3) How it is done (4) For whom does it work (5) For whom does it not work (6) Why is it worth supporting in this region

4. What it is not

9. What it is Part 1: How it began

10. Ladislas J. Meduna

11. Ladislas J. Meduna (1896–1964) Hungary until 1938 then Loyola University & Illinois Psychiatric Institute Noted that epileptics and schizophrenics have differing ratios of glial cells at autopsy Could induced seizures heal schizophrenia? Camphor then metrazol. Five treatments 29 initial cases, 10 “cured” and 3 improved 10 of first set had catatonia

13. Ugo Cerletti 1877- 1963 Designed winter camouflage uniforms for Italian Army Designed delayed fuses for artillery shells 1935 Chair, Department of Neurological and Mental Diseases at the University of Rome Iatrogenic malaria “cured” general paresis.

14. Assigned to pick up dinner from local butcher, but butcher out of the specified cut of meat. Butcher shop to slaughter house – Shocked pigs – stunned and docile – easy to slaughter Would it work on people? Tried dogs first, lots of cardiac deaths Eventually settled on bilateral head electrodes

15. Lucio Bini (1908 – 1964) Italian psychiatrist Colleague of Cerletti Let’s try it on people with mental illness “meek and mild,” not looking for cure Several treatments led to remission lasting for many months. Initial patients: – Obsessional, – schizophrenia, – manic-depressive

16. Mortality rates Schizophrenia’s morality rate in 1930’s was 20% Mortality of Cerletti’s shocks was 10% Meta-analyses of published data from 1969 – 1996:all-cause SMRs of 1.51 and 1.57 (UK) 1997 excess mortality rates suicide (28%), accidents (12%) and natural causes (60%). Schizophrenia life expectancy UK < 10-15 years US < 15 -23 years

17. 1977-1990 Harvard University the mortality rate in subjects within 15 years after first hospital admission: major depression without psychosis 20% major depression with psychosis 41% Current US: Bipolar reduces life expectancy by 9.3 years.

18. What it is Part 2: The Preliminaries 1. Patient selection 2. Pre treatment workup

19. Patients for whom ECT should be a serious option

20. “Before you go home” Psychotic Depression Nihilistic delusions Body rotting from the inside Catatonia (Schizophrenia, catatonic type) Stuporous Excited

21. Good ECT candidates Depression: Relenting and unresponsive Usual medications contraindicated Actively suicidal malnourished/electrolyte imbalance Prolonged Manic episode (neurodegenerative)

22. Good ECT candidates Psychosis Schizophrenia, unrelenting and unresponsive Usual medications contraindicated Actively suicidal Affective component

23. Pregnancy Largest series is 339 cases (1941 – 1992) Majority treated for depression At least partial remission reported in 78% There were 20 maternal complications reported and 18 were likely related to ECT.

24. Four cases of premature labor (1.3%) In all cases, the clinician determined that the premature labor was not related to the ECT. Miscarriage rate for women receiving ECT during pregnancy (1.6%) not significantly higher than the rate of miscarriage in the general population.

25. Unusual and “desperate” situations

26. Parkinson’s Disease Depression Abnormal Movements Psychosis Dementia

27. De la Tourette’s OCD Delusional Disorder Epilepsy PTSD Neuroleptic Malignant Syndrome

28. Poor candidates Predominantly personality disorder Unstable logistics/unreliable Somatic focused Anesthesia risks Drug/alcohol addicts due to anesthesia risks Militant family member

29. Pre treatment workup No “absolute” contraindications Unstable arrhythmias with risk of asystole Recent MI and unstable cardiac function Space occupying CNS entity especially low Recent hemorrhagic CVA or unstable aneurysm Retinal detachment Pheochromocytoma

30. Pre-treatment workup Vital Sign recordings Routine pre-anesthesia labs Spine films Imaging of the head EKG

31. What it is Part 3: The treatment itself

32. The Evolution of the procedure Early 1940’s introduced to US and UK “Unmodified” sine wave (AC) current, no meds Tried curare as paralytic agent Succinyl choline 1951 Late 1950’s general anesthesia 1976 Data shows pulsed DC current superior to alternating current (Blatchley)

33. AC vs DC pulsed current

34. Variation of pulse parameters

35. Recovery room or outpatient surgery NPO IV Anesthesia monitoring Cardiac Pulmonary BP External Ventilation Driver and not home alone

36. Caffeine (IV) Romazicon (Flumazenil) Short acting anesthetic methohexital (Brevital) propofol (Diprivan) Ketamine Glycopyrrolate (Robinul) peripheral antimuscurinic Paralytic agent: Succinyl Choline

37. Pre-existing Medications during ECT

38. Anticonvulsants and barbiturates Reduce effectiveness of seizures If used for epilepsy, replace with benzos If used as a “mood stabilizer” can be eliminated during ECT Benzodiazepines Almost universal Neutralized by flumazenil (Romazicon)

39. Lithium controversial (1) thought to increase risks of delirium and/or (2) Perhaps prolongs neuromuscular effect of succinyl choline

40. Psych Meds during ECT Anti psychotics. ECT + trifluoroperazine BPRS 61 % decrease at 6 weeks An additional 15 % at 20 weeks Sham ECT and Trifluoroperazine BPRS 28% decrease at 6 weeks an additional 25% at 20 weeks

41. Antidepressants during ECT Studies are meager and not useful U of Pittsburgh: All depressed patients start Lithium and Nortriptyline for last week of Tx Lag time to effective response to anti- depressants is several weeks.

42. EEG Monitoring.

43. EEG monitoring

44. Single line tracing, not 21 Determines length and architecture of seizure Determines that it stopped Multiple monitored, not additionally effective

45. Electrode placement Non-dominant Unilateral – Recommended in 1978 – Hope to reduce memory loss – More “missed” seizures – Used at initial treatment and continue if effective Bilateral Almost universal in US and UK Some memory loss, less now with pulsed current

46. Seizure Architecture on EEG 1.Recruiting 2.Full seizure: Delta waves 3.Suppression 4.Quiet/Recovery

51. Treatment Response Treatments three times per week See initial progress after 3-6 treatments Progress should be steady, but will plateau Go two more treatments and stop Common 9-12, 24 maximum Maintenance reduces relapse

52. Controversies Memory loss Safety Effectiveness Anti-psychiatry

53. Memory Loss Retrograde Usually short term “autobiographical” Much less with newer technology Some patients claim longer, larger loss Usually resolves within weeks to months “Can’t concentrate, can’t remember” are standard complaints of severely depressed.

54. Glenda MacQueen, MD, FRCPC, PhD Professor University of Calgary (2007) demonstrated some cognitive deficits after ECT. “However, it is… unlikely that such findings, even if confirmed [by others], would significantly change the risk–benefit ratio of this notably effective treatment.”

55. Harold Sacheim, PhD, Columbia University Review of old studies Memory loss is real Significant with 50’s technology New study 347 patients (2007) Minimal loss with current type of treatments Unilateral is no protection No control group

56. Safety Denmark 25 year study, ECT patients’ death rate no different than general population UK NHS 2011 death rate published as 4 or 5 in 100,000 (not clear if patients or treatments) Sweden death rate from appendectomy on non-perforated appendicitis was 56 in 73,326 cases, or 76/100,000

57. Efficacy Daniel Pagnin, M.D., M.Sc.; Valéria de Queiroz, M.D., M.Sc.; Stefano Pini, M.D.; Giovanni Battista Cassano, M.D. Efficacy of ECT in Depression: A Meta-Analytic Review University of Pisa, Italy J ECT 2004; 20:13—20 Reviewed Randomized and non Randomized

58. Efficacy Randomized Predermined criteria of “success” Decision on medication doses and length of treatment time Non randomized Ethics of “sham” ECT and anesthesia Cannot do double blind cross over method

59. Randomized

60. The response criteria were defined as a (1)reduction of at least 50% from baseline to end point on the Hamilton Scale for Depression (HAM-D), or (2) HAM-D score of 10 or less at the end point, or (3) clinical judgment of "recovered" or "marked improved”

62. Date of download: 2/20/2012 Copyright © American Psychiatric Association. All rights reserved. From: Efficacy of ECT in Depression: A Meta-Analytic Review

63. Non Randomized

65. Lancet. 2003 Mar 8;361(9360):799-808. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. UK ECT Review Group.

66. ECT was significantly more effective than simulated ECT (six trials, 256 patients, standardized effect size [SES] -0.91, 95% CI - 1.27 to -0.54).

67. Treatment with ECT was significantly more effective than pharmacotherapy (18 trials, 1144 participants, SES -0.80, 95% CI -1.29 to - 0.29).

68. Bilateral ECT was more effective than unipolar ECT (22 trials, 1408 participants, SES -0.32, 95% CI -0.46 to -0.19).

69. Why is it worth supporting Works for some patients when nothing else does Works for some patients who cannot undergo other treatments Works in pregnancy

70. Requires special training and credentialling Requires a team: psychiatry, anesthesia, nursing and administration Team is easier to sustain than to build from scratch Need is growing and start from scratch only alternative 2009 did 50 treatments per month, 2012 have 65 slots per month still not enough

71. http://www.youtube.com/watch?v=RFxVA2qG47M http://www.youtube.com/watch?v=Y5LIVAaYNrQ

72. http://www.youtube.com/watch?v=QjpmYSo ApC0&feature=related http://www.youtube.com/watch?v=QjpmYSo ApC0&feature=related http://www.youtube.com/watch?v=ZjFF81ikQ Jc&feature=related http://www.youtube.com/watch?v=ZjFF81ikQ Jc&feature=related

73. Hope you will see it, be able to say “yes” to someone who asks about it.