APM ECT Course Revised (2)

Electroconvulsive TherapyElectroconvulsive Therapy

Jay A. Yeomans, M.D.Jay A. Yeomans, M.D. Service ChiefService Chief

Electroconvulsive Therapy Electroconvulsive Therapy CMC-R, BHCCMC-R, BHCGrand RoundsGrand Rounds

Tuesday, Oct 2Tuesday, Oct 2ndnd 2007 2007

Electroconvulsive TherapyElectroconvulsive Therapy

History History ( physical therapies vs. psychotherapies)( physical therapies vs. psychotherapies)

1785 therapeutic use of seizure induction documented in the London Medical Journal

1917 (Vienna psychiatrist: Julius von Jauregg, MD)… Malarial-fever treatment of neurosyphilis

History of ECTHistory of ECT 1934 - Hungarian neuropsych Meduna believed 1934 - Hungarian neuropsych Meduna believed

that Schizophrenia & Epilepsy were antagonistic that Schizophrenia & Epilepsy were antagonistic disorders …induced seizures with IM camphor oil disorders …induced seizures with IM camphor oil then later with metrazol (cardiozol)then later with metrazol (cardiozol)

1937 – ‘therapeutic seizures’ reported in the 1937 – ‘therapeutic seizures’ reported in the AmerJourPsych & used worldwideAmerJourPsych & used worldwide

1938 - Italian neuropsych Ugo Cerletti and Lucio 1938 - Italian neuropsych Ugo Cerletti and Lucio Bini induced seizures with electrical current Bini induced seizures with electrical current (Schizophrenia)(Schizophrenia)

(Nominated for the Nobel Prize)(Nominated for the Nobel Prize)

History of ECTHistory of ECT

1940’s – 1940’s – WidespreadWidespread use throughout the world use throughout the worldMay 1940 APA (Goldman) … RULMay 1940 APA (Goldman) … RUL

1950’s – 1950’s – ModificationsModifications in ECT technique (curare in ECT technique (curare then succinylcholine)then succinylcholine)Standard treatment for hospitalized depressionStandard treatment for hospitalized depression

History of ECTHistory of ECT 1960’s – 1980s … 1960’s – 1980s … DeclineDecline in use of ECT in use of ECT Psychoanalysis marginalized ECT? Psychoanalysis marginalized ECT? Pharmaceutical industry marginalized ECT?Pharmaceutical industry marginalized ECT? 1960s counterculture hostility toward ECT1960s counterculture hostility toward ECT 1961: Erving Goffman’s 1961: Erving Goffman’s AsylumsAsylums (bore a (bore a

scanting reference to ‘shock therapy’)scanting reference to ‘shock therapy’) 1962: Ken Kesey’s anti-psychiatry novel, 1962: Ken Kesey’s anti-psychiatry novel, One One

Flew Over the Cuckoo’s NestFlew Over the Cuckoo’s Nest

History of ECTHistory of ECT

Mid 1970s – 1980s (epicenter)Mid 1970s – 1980s (epicenter) 1970: Kesey’s play1970: Kesey’s play …” ECT…a device which combines …” ECT…a device which combines

the best features of a sleeping pill, the electric chair and the best features of a sleeping pill, the electric chair and the torture rack. Zap! Punishment and therapy in one the torture rack. Zap! Punishment and therapy in one

shocking package.”shocking package.” 1974: California law against ECT1974: California law against ECT 1975:1975: Milos Forman’s version of Ken Kesey’s novel -Milos Forman’s version of Ken Kesey’s novel -

‘‘ONE FLEW OVER THE CUCKOO’SONE FLEW OVER THE CUCKOO’S NEST’NEST’ (mingled ECT & lobotomy)

History of ECTHistory of ECTMid 1970s – 1980s (epicenter)Mid 1970s – 1980s (epicenter)

1975- 1978 : APA ECT WORKGROUP report1975- 1978 : APA ECT WORKGROUP report lukewarm endorsement … written consentlukewarm endorsement … written consent 1979 NIH consensus conference on ECT (Fink)1979 NIH consensus conference on ECT (Fink)

ECT: the use of electrically-induced seizures for ECT: the use of electrically-induced seizures for therapeutic purposes therapeutic purposes

1980’s – 1980’s – ResurgenceResurgence of use of ECT of use of ECT 1985: JAMA,1985: JAMA, “not a single controlled study has “not a single controlled study has

shown another form of treatment to be superior to shown another form of treatment to be superior to ECT in the short-term management of severe ECT in the short-term management of severe depression”depression”

Primary Use of ECTPrimary Use of ECT

Consider primary use of ECT with the following:Consider primary use of ECT with the following:» Need for rapid definitive intervention Need for rapid definitive intervention » Medically illMedically ill, risk of inanition, risk of inanition» Psychotic depressionPsychotic depression, , catatoniacatatonia, manic delirium, manic delirium» ElderlyElderly» Pregnant Pregnant (succinylcholine: low ratio of placental transfer / (succinylcholine: low ratio of placental transfer /

teratogenicity a function of exposure duration)teratogenicity a function of exposure duration)

» Risk of suicideRisk of suicide, self injury, self injury» Treatment history – previous ECT response Treatment history – previous ECT response » Patient preferencePatient preference

How does ECT (therapeutic seizures) How does ECT (therapeutic seizures) modify mood?modify mood?

Brain StructureBrain Structure Neurotransmitter EnhancementNeurotransmitter Enhancement Normalization of Neuro-Endocrine AbnormalitiesNormalization of Neuro-Endocrine Abnormalities ElectrophysiologyElectrophysiology

How does ECT (therapeutic seizures) How does ECT (therapeutic seizures) modify mood?modify mood? Brain StructureBrain Structure

Low brain glia amounts in pts. w/Schizophrenia Low brain glia amounts in pts. w/Schizophrenia & high amounts in pts. w/Seizure Disorders & high amounts in pts. w/Seizure Disorders (antagonism)(antagonism)

1934 experimented in a patient with catatonic 1934 experimented in a patient with catatonic Schizophrenia was successfulSchizophrenia was successful

Hippocampal neurogenesis w/increased mossy Hippocampal neurogenesis w/increased mossy fibers following ECT – Hippocampal cell loss / fibers following ECT – Hippocampal cell loss / hypometabalism normalized & levels of BDNF hypometabalism normalized & levels of BDNF increasedincreased


Neurotransmitter EnhancementNeurotransmitter Enhancement Seizure releases a flood ofSeizure releases a flood of Catecholamines; Catecholamines; increased levels of increased levels of SerotoninSerotonin Norepinephrine Norepinephrine DopamineDopamine GABA - GABA - occipital cortex GABA conc. increase 2-fold following ECToccipital cortex GABA conc. increase 2-fold following ECT

Sanacora, et al., Am J Psych 2003; 160: 577-579Sanacora, et al., Am J Psych 2003; 160: 577-579 BDNFBDNF (brain derived neurotropic factor)(brain derived neurotropic factor)

How does ECT (therapeutic seizures) modify mood?How does ECT (therapeutic seizures) modify mood?

Normalization of Neuro-endocrine AbnormalitiesNormalization of Neuro-endocrine Abnormalities Hypothalamic & Pituitary peptides (prolactin, Hypothalamic & Pituitary peptides (prolactin,

adrenocorticotropic hormone, TRH, corticotropin-adrenocorticotropic hormone, TRH, corticotropin-releasing homone, cortisol, GH, neurophysins & releasing homone, cortisol, GH, neurophysins & endorphins) surge in the serum & CSF w/ea. seizureendorphins) surge in the serum & CSF w/ea. seizure

Serum & CSF calcium concentrations fallSerum & CSF calcium concentrations fall The integrity of the BBB is temporarily compromised The integrity of the BBB is temporarily compromised

allowing for greater transfer of substances between the allowing for greater transfer of substances between the blood & CSFblood & CSF


Normalization of Neuro-endocrine AbnormalitiesNormalization of Neuro-endocrine Abnormalities Hypercortisolemia is frequently found in Hypercortisolemia is frequently found in

Melancholia Melancholia … serum cortisol levels are elevated, … serum cortisol levels are elevated, diurnal rhythmicity is lost and the expected diurnal rhythmicity is lost and the expected feedback suppression by steroid administration is feedback suppression by steroid administration is blunted (blunted (DSTDST))

Cortisol functions normalize,TSH response to Cortisol functions normalize,TSH response to Thyrotropin & GH response to GHRF are abnl Thyrotropin & GH response to GHRF are abnl during illness and normalize with remissionduring illness and normalize with remission

How does ECT (therapeutic seizures) modify mood?How does ECT (therapeutic seizures) modify mood?

Normalization of Neuro-endocrine AbnormalitiesNormalization of Neuro-endocrine Abnormalities Periods of greatest neuro-endocrine hormonal flux Periods of greatest neuro-endocrine hormonal flux

(adolescence, involution, & aging = periods with the (adolescence, involution, & aging = periods with the greatest incidence of mood disorders)greatest incidence of mood disorders)

Restoration of Endocrine Homeostasis


ElectophysiologyElectophysiology Anticonvulsant effects (kindling)Anticonvulsant effects (kindling) Analogous to Analogous to CardioversionCardioversion: heart in a : heart in a

dysrhythmic state is restored to normal rhythm by dysrhythmic state is restored to normal rhythm by an electrical stimulus an electrical stimulus

CerebroversionCerebroversion: hyperactive hypothalamic-: hyperactive hypothalamic-pituitary system (which leads to a breakdown of pituitary system (which leads to a breakdown of the feedback mechanism in the stress response) is the feedback mechanism in the stress response) is normalized after a therapeutic seizure.normalized after a therapeutic seizure.


Ctrl-Alt-DeleteCtrl-Alt-Delete

Risk - Benefit AnalysisRisk - Benefit Analysis– No No absoluteabsolute contraindications to ECT contraindications to ECT– Risks vs. Benefits of ECTRisks vs. Benefits of ECT

» There is a potential risk to delaying treatmentThere is a potential risk to delaying treatment» Relative contraindications: pts. w/increased intracranial Relative contraindications: pts. w/increased intracranial

pressure secondary to intracerebral masses; w/markedly pressure secondary to intracerebral masses; w/markedly fragile myocardial vascular status ; w/leaky or otherwise fragile myocardial vascular status ; w/leaky or otherwise unstable aneurysmsunstable aneurysms

» There is the option of alternative or no treatment with its There is the option of alternative or no treatment with its attendant risks/benefitsattendant risks/benefits

Selection of PatientsSelection of Patients General ConsiderationsGeneral Considerations

Diagnostic categories:Diagnostic categories:– MDE, esp. psychotic depression (e.g. Geri depressed MDE, esp. psychotic depression (e.g. Geri depressed

w/nihilistic delusions)w/nihilistic delusions)– Bipolar Affective Disorder, depressed or manicBipolar Affective Disorder, depressed or manic– CatatoniaCatatonia– Depression in Pregnancy Depression in Pregnancy – OCD OCD – SchizophreniaSchizophrenia– Personality Disorders (w/depression)Personality Disorders (w/depression)

Timing of referral/treatment algorithms … Timing of referral/treatment algorithms … treatment resistant / treatment treatment resistant / treatment inadequateinadequate

Risk / Benefit analysisRisk / Benefit analysis

ECT Mortality/MorbidityECT Mortality/Morbidity

- Estimated at 1 per 10,000 patients or 0.01% - Estimated at 1 per 10,000 patients or 0.01% (higher in the severely medically ill)(higher in the severely medically ill)

- Lower mortality rates in depressed patients - Lower mortality rates in depressed patients receiving ECT than alternative treatmentreceiving ECT than alternative treatment

- Risk of tardive seizures probably not increased - Risk of tardive seizures probably not increased following ECT coursefollowing ECT course

- Treatment emergent mania- Treatment emergent mania

ECTECTPre-ECT evaluation, recommendations, patient preparation, and Pre-ECT evaluation, recommendations, patient preparation, and

written informed consentwritten informed consentPRE- ECT WORKUP PRE- ECT WORKUP Consultation from Consultation from ECT-privilegedECT-privileged psychiatrist psychiatrist (H/O head trauma / LOC / loose teeth / TMJ / HTN / (H/O head trauma / LOC / loose teeth / TMJ / HTN /

cardiac dz., handedness, etc.)cardiac dz., handedness, etc.) Physical examination, esp. cardiovascular,Physical examination, esp. cardiovascular, neurological, musculo-skeletal, and dentalneurological, musculo-skeletal, and dental Laboratory studies (CBC / electrolytes, esp. KLaboratory studies (CBC / electrolytes, esp. K++ / LFTs) / LFTs) B-HCGB-HCG CXR / EKG / CTCXR / EKG / CT Special consultations and studies as indicatedSpecial consultations and studies as indicated

ConsenConsent Issues in ECTt Issues in ECT

Explanation of procedure and rationaleExplanation of procedure and rationale Potential treatment alternativesPotential treatment alternatives Realistic view of anticipated benefitsRealistic view of anticipated benefits Risks Risks

– Relapse ratesRelapse rates– Cognition Cognition

Consent Issues ECT in (cont)Consent Issues ECT in (cont)

Consent is voluntary / revocable at any pointConsent is voluntary / revocable at any point Consent for emergency intervention (involuntary)Consent for emergency intervention (involuntary) Restrictions to behaviorRestrictions to behavior

– NPONPO– Driving (when cognitively able)Driving (when cognitively able)

ECTECTECT W/UECT W/U

Montgomery-Asburg Depression Rating Scale: Montgomery-Asburg Depression Rating Scale: (MADRS)(MADRS) 10 item / scored 0-60 and Mini-Mental State 10 item / scored 0-60 and Mini-Mental State Exam: Exam: (MMSE)(MMSE) scored 0-30 scored 0-30

D’C AED mood modulators, e.g. Depakote, Lamictal, D’C AED mood modulators, e.g. Depakote, Lamictal, Trileptal, NeurontinTrileptal, Neurontin

D’C Lithium (arryhthmogenic)D’C Lithium (arryhthmogenic) D’C Benzodiazapines (BZDs), esp. long acting e.g. D’C Benzodiazapines (BZDs), esp. long acting e.g.

ValiumValium TCA (? increase risk of post ECT delirium); TCA (? increase risk of post ECT delirium); MAOI (? interacts with anesthetic agents) MAOI (? interacts with anesthetic agents)

ECT AdministrationECT Administration ‘‘Brief-pulse current’ machine (Somatics: Tymatron & Brief-pulse current’ machine (Somatics: Tymatron &

MECTA) preferred over ‘sine wave current’ machine d/t MECTA) preferred over ‘sine wave current’ machine d/t fewer cognitive effects (Class III medical devices)fewer cognitive effects (Class III medical devices)

Seizure threshold determined by ‘dose titration’ preferred Seizure threshold determined by ‘dose titration’ preferred over ‘fixed dose’over ‘fixed dose’

MADRS, remission MADRS, remission < < 1010 Because 20% - 50% relapse after 6 months, a Because 20% - 50% relapse after 6 months, a

maintenancemaintenance treatment of antidepressants, lithium treatment of antidepressants, lithium oror ECT at 4-6 weeks might be advisable. ECT at 4-6 weeks might be advisable.

State regulations; > 15y/o for catatonia / stupor / deliriumState regulations; > 15y/o for catatonia / stupor / delirium ‘‘modified’ / Standard of care?modified’ / Standard of care?

Unilateral ECTUnilateral ECT

Seizure threshold: ‘dose titration’ vs.' fixed dose’Seizure threshold: ‘dose titration’ vs.' fixed dose’ Needs to be 250% Needs to be 250% thresholdthreshold Probably better at 600% (FDA limitations)Probably better at 600% (FDA limitations) Even at high dosing appears to have less amnesiaEven at high dosing appears to have less amnesia Ultra brief pulse width may be of valueUltra brief pulse width may be of value

Why (RUL) Right Unilateral ECT ?Why (RUL) Right Unilateral ECT ?

Right handed- left hemisphere dominantRight handed- left hemisphere dominant 70% Left handed-left hemisphere dominant70% Left handed-left hemisphere dominant Speech areas (Broca’s) in left / dominant Speech areas (Broca’s) in left / dominant

hemispherehemisphere Therefore; decrease risk of verbal aphasiaTherefore; decrease risk of verbal aphasia Switch to LUL if confusion / delirium from RULSwitch to LUL if confusion / delirium from RUL

Bilateral ECTBilateral ECT

Seizure thresholdSeizure threshold Some evidence for efficacy of bi-frontal & LART Some evidence for efficacy of bi-frontal & LART

techniquetechnique Effective at 150% thresholdEffective at 150% threshold Amnesia related to stimulus dosingAmnesia related to stimulus dosing Ultra brief pulse width may not be effectiveUltra brief pulse width may not be effective Most effective form of ECT but greater amnesiaMost effective form of ECT but greater amnesia

BITEMPORAL (BT), RIGHT UNILATERAL (RU), BITEMPORAL (BT), RIGHT UNILATERAL (RU), and BIFRONTAL (BF) POSITIONSand BIFRONTAL (BF) POSITIONS

Letemendia et al., 1993

ECT PRE-OP MEDICATIONSECT PRE-OP MEDICATIONS RanitidineRanitidine – 150 mg BID – 150 mg BID Beta-blockersBeta-blockers, e.g. Labetolol / Esmolol , e.g. Labetolol / Esmolol

when indicated d/t elevated BP &/or HRwhen indicated d/t elevated BP &/or HR Robinul Robinul (decrease secretions)(decrease secretions) Zofran Zofran (antiemetic)(antiemetic) FlumazenilFlumazenil – blocks effect of BZDs … – blocks effect of BZDs …

post treat with post treat with Versed?)Versed?) Theophylline or Theophylline or CaffeineCaffeine – for seizure – for seizure

enhancementenhancement

Induction Agent: MethohexitalInduction Agent: Methohexital

Preferred due to safety, efficacy, and costPreferred due to safety, efficacy, and cost Thiopental used also, but has slower onset and Thiopental used also, but has slower onset and

possibly increased postictal arrythmiaspossibly increased postictal arrythmias Short-acting barbiturate, so affects seizureShort-acting barbiturate, so affects seizure Given IV push prior to muscle relaxationGiven IV push prior to muscle relaxation Etomidate, Propofol, KetamineEtomidate, Propofol, Ketamine

Muscle RelaxantsMuscle Relaxants

Goal is to minimize risk of musculoskeletal injuryGoal is to minimize risk of musculoskeletal injury Nerve stimulator or loss of Babinski response Nerve stimulator or loss of Babinski response Age-related circulatory factors can affect onsetAge-related circulatory factors can affect onset Succinylcholine: preferred depolarizing agent Succinylcholine: preferred depolarizing agent

given in IV bolus, rapid onset/short duration of given in IV bolus, rapid onset/short duration of action, assure airway, fasiculations can lead to action, assure airway, fasiculations can lead to myalgiasmyalgias

Physiologic Monitoring During ECTPhysiologic Monitoring During ECT

Automated non-invasive blood pressure deviceAutomated non-invasive blood pressure device Pulse oximetry (separate from BP extremity)Pulse oximetry (separate from BP extremity) ECGECG EEGEEG Nerve stimulator (posterior tibial nerve)Nerve stimulator (posterior tibial nerve) Visual / palpable observationVisual / palpable observation

Therapeutic Seizure … > 20 second Therapeutic Seizure … > 20 second motor seizuremotor seizure

(measured in lower extremity)(measured in lower extremity)

Airway ManagementAirway Management

100% oxygen / positive pressure ventilation100% oxygen / positive pressure ventilation Prevents brain cell anoxiaPrevents brain cell anoxia Oxygenation is important if desaturation likely inOxygenation is important if desaturation likely in

– morbid obesitymorbid obesity– pulmonary diseasepulmonary disease

Useful in patients at risk for myocardial ischemiaUseful in patients at risk for myocardial ischemia Can prolong seizures/decrease seizure threshold if Can prolong seizures/decrease seizure threshold if

hyperventilatehyperventilate

Prevention of Dental ComplicationsPrevention of Dental Complications

Pterygoid, masseter, and temporalis muscles Pterygoid, masseter, and temporalis muscles directly stimulateddirectly stimulated

Not blocked by muscle relaxantNot blocked by muscle relaxant Flexible “bite block” with air passagewayFlexible “bite block” with air passageway Mandible supported during stimulationMandible supported during stimulation Gauze padding if few teeth presentGauze padding if few teeth present

Cardiovascular Effects of ECT: Cardiovascular Effects of ECT: Parasympathetic ActivityParasympathetic Activity

Initial intense vagal parasympathetic Initial intense vagal parasympathetic outflowoutflow

corresponds to tonic phase of seizure corresponds to tonic phase of seizure can result in asystole of 2 seconds or morecan result in asystole of 2 seconds or more gastric contraction gastric contraction (NPO)(NPO)

Cardiovascular Effects of ECT: Cardiovascular Effects of ECT: Sympathetic ActivitySympathetic Activity

Direct sympathetic neural outflowDirect sympathetic neural outflow Adrenal catacholamine release later in seizure and Adrenal catacholamine release later in seizure and

postictallypostictally Corresponds to clonic phase of seizureCorresponds to clonic phase of seizure Resultant tachycardia and HTNResultant tachycardia and HTN

ECTECT

Side Effects, Adverse Rxs., & long term consequences Side Effects, Adverse Rxs., & long term consequences

Side effectsSide effects Headaches Headaches Muscle pain (Myalgia)Muscle pain (Myalgia) NauseaNausea Cognitive effectsCognitive effects

Cognitive Effects of ECTCognitive Effects of ECT

Can be positive or negativeCan be positive or negative Negative effects: amnesia, confusion, deliriumNegative effects: amnesia, confusion, delirium Positive effects: ECT can have beneficial effects Positive effects: ECT can have beneficial effects

on cognitive problems associated with severe on cognitive problems associated with severe depression. MMSE scores typical improve after a depression. MMSE scores typical improve after a course of ECT.course of ECT.

Cases of permanent loss (controversial)Cases of permanent loss (controversial)

ECT AmnesiaECT Amnesiaepisodic memory: medial temporal lobeepisodic memory: medial temporal lobe

Anterograde can last days or even weeksAnterograde can last days or even weeks Retrograde can be permanent (rare)Retrograde can be permanent (rare) Self-rating not always correlated to objective Self-rating not always correlated to objective

findingsfindings Factors: # of Tx’s, electrode placement, stimulus Factors: # of Tx’s, electrode placement, stimulus

dose, medications, pre-morbid impairmentdose, medications, pre-morbid impairment

ECTECT

Side EffectsSide Effects, , Adverse Rxs.,Adverse Rxs., & & long term consequenceslong term consequences

Adverse ReactionsAdverse Reactions DeathDeath … 1 per 10,000 patients … 1 per 10,000 patients Bone fractures & other musculo-skeletal injuriesBone fractures & other musculo-skeletal injuries Status EpilepticusStatus Epilepticus Prolonged apneaProlonged apnea TransientTransient severe BP increases & disturbances in cardiac severe BP increases & disturbances in cardiac

rate and rhythmrate and rhythm

ECTECT

Side Effects, Adverse Rxs., & long term consequences Side Effects, Adverse Rxs., & long term consequences

Long term consequencesLong term consequences NONO evidence of structural or functional brain evidence of structural or functional brain

damagedamageSome patients report memory loss (other than Some patients report memory loss (other than

amnesia for the pre-treatment period)amnesia for the pre-treatment period)

ECTECT How much electricity does ECT deliver to the How much electricity does ECT deliver to the

brain?brain?

““1.21 gigawatts!!!1.21 gigawatts!!!,, Marty”Marty”

Doc BrownDoc Brown ‘ ‘Back to the Future’Back to the Future’

ECTECT How much electricity does ECT deliver to the How much electricity does ECT deliver to the

brain?brain? Maximum amount: 576 millicoulombs over a 4-Maximum amount: 576 millicoulombs over a 4-

to-8 second stimulus = amount of energy that to-8 second stimulus = amount of energy that passes through a 60-W light-bulb in just more passes through a 60-W light-bulb in just more than 1 second than 1 second (don’t do this at home)(don’t do this at home)

At 10 cents per kilowatt-hour, the cost would be At 10 cents per kilowatt-hour, the cost would be 0.0002 cents0.0002 cents

DepressionDepression

– Efficacy demonstrated through open trial, Efficacy demonstrated through open trial, ECT/pharmacotherapy trials and meta-analysis, ECT vs. ECT/pharmacotherapy trials and meta-analysis, ECT vs. sham ECT trials, variations in ECT technique (electrode sham ECT trials, variations in ECT technique (electrode placement, stimulus dosage)placement, stimulus dosage)

– Unipolar and Bipolar likely to be responsiveUnipolar and Bipolar likely to be responsive

– Increased likelihood of response with:Increased likelihood of response with:» psychotic or catatonic symptomspsychotic or catatonic symptoms» older ageolder age

Depression - (cont)Depression - (cont)

““Secondary depression” in pre-existing psychiatric or medical Secondary depression” in pre-existing psychiatric or medical illnessillness

Post-stroke depression-often ECT-responsivePost-stroke depression-often ECT-responsive

Suicide- evidence for short-term efficacy in depressed pts (not Suicide- evidence for short-term efficacy in depressed pts (not Axis II as primary dx)- APA Practice Guidelines 2003Axis II as primary dx)- APA Practice Guidelines 2003

Decreased likelihood of responsiveness with:Decreased likelihood of responsiveness with:a. Longer duration of episodea. Longer duration of episodeb. Co-morbid illness, esp. Axis IIb. Co-morbid illness, esp. Axis II

--

ManiaMania

– Efficacy of 80% reported by Mukherjee, et al 1994 Efficacy of 80% reported by Mukherjee, et al 1994 (review of 589 patients)(review of 589 patients)

– Efficacy may exceed that of lithium, establishing role Efficacy may exceed that of lithium, establishing role of ECT in medication resistant patientsof ECT in medication resistant patients

– Established as acute / emergent treatment for Bipolar, Established as acute / emergent treatment for Bipolar, manic with psychotic features (?consent)manic with psychotic features (?consent)

SchizophreniaSchizophrenia

– Remains a common diagnostic indication for Remains a common diagnostic indication for ECTECT

– Efficacy highest for acute illness (75%)Efficacy highest for acute illness (75%)– ECT with pharmacotherapy may be superior to ECT with pharmacotherapy may be superior to

use of either as monotherapy (recent safety use of either as monotherapy (recent safety studies include atypicals, including clozapine)studies include atypicals, including clozapine)

– Schizoaffective patients: affective symptoms Schizoaffective patients: affective symptoms predictive of positive outcome in predictive of positive outcome in somesome studies studies

ECT in Personality Disorder (PD)ECT in Personality Disorder (PD)

Co-morbid PD commonly associated with treatment-Co-morbid PD commonly associated with treatment-resistant depression (30%-70%)resistant depression (30%-70%)

Presumed PD may remit with successful treatment of Presumed PD may remit with successful treatment of mood disorder mood disorder DeBattista & Mueller JECT 2001DeBattista & Mueller JECT 2001

ECT in Personality DisorderECT in Personality Disorder

Borderline Personality- Dysthymia, suicidal ideation Borderline Personality- Dysthymia, suicidal ideation likely chronic, treatment resistant; patient expectations likely chronic, treatment resistant; patient expectations may be unrealisticmay be unrealistic

Prospective studies- 40-75% of MDD+PD pts had Prospective studies- 40-75% of MDD+PD pts had >50% decrease in standardized scores; presence of >50% decrease in standardized scores; presence of Axis I disorder the critical factor Axis I disorder the critical factor DeBattista & Mueller 2001 DeBattista & Mueller 2001

Other Diagnostic IndicationsOther Diagnostic Indications

OCD- no controlled studiesOCD- no controlled studies Delirium- ETOH, enteric fevers, SLE, secondary Delirium- ETOH, enteric fevers, SLE, secondary

catatoniacatatonia ““Pseudodementia”Pseudodementia” Parkinson’s Disease- presence of off-on Parkinson’s Disease- presence of off-on

phenomenon predictive of positive responsephenomenon predictive of positive response NMSNMS Intractable epilepsy, status epilepticusIntractable epilepsy, status epilepticus

SummarySummary Approximately 18.8 million adults aged 18 and older are Approximately 18.8 million adults aged 18 and older are

stricken with depression in an given year (NIMH)stricken with depression in an given year (NIMH) Suicides eclipse homicides in the US annually by one Suicides eclipse homicides in the US annually by one

third (DHHS). The elderly are particularly at risk.third (DHHS). The elderly are particularly at risk. “…“…ECT is associated with a robust reduction in suicidal ECT is associated with a robust reduction in suicidal

thinking in depressed patients…” thinking in depressed patients…” (McCall, JECT, Ed. (McCall, JECT, Ed. 2005)2005)

Antidepressants Antidepressants maymay increase suicidality in some patients increase suicidality in some patients and may not be safely used during pregnancy.and may not be safely used during pregnancy.

Medications and psychotherapy may fail to alleviate Medications and psychotherapy may fail to alleviate severe depressions, particularly those complicated by severe depressions, particularly those complicated by psychosis or catatoniapsychosis or catatonia

SummarySummary ECT is a safe & very effective treatment for ECT is a safe & very effective treatment for

depressive disorders either first-line treatment depressive disorders either first-line treatment or after medications fail.or after medications fail.**

Between 80% and 90% of patients will Between 80% and 90% of patients will respond to ECT. It is the most efficient and respond to ECT. It is the most efficient and fast-acting treatment for urgent-care, severely fast-acting treatment for urgent-care, severely depressed patients for which medications take depressed patients for which medications take 4-6 weeks to work.4-6 weeks to work.**

*Source: APA Taskforce book, *Source: APA Taskforce book, The Practice ofThe Practice of Electroconvulsive TherapyElectroconvulsive Therapy, 2001, 2001

Final IssuesFinal Issues

Continued stigma …Continued stigma … Portrayal in the media (Fox TV’s: Portrayal in the media (Fox TV’s: HouseHouse; ;

Kitty Dukakis / Larry Tye’s book, Kitty Dukakis / Larry Tye’s book, Shock: Shock: The Healing Power of Electroconvulsive The Healing Power of Electroconvulsive TherapyTherapy))

New technologies: rTMS, VNS, DBS, etc.New technologies: rTMS, VNS, DBS, etc.

Questions & Discussion Questions & Discussion

Documents

APM ECT Course Revised (2)