Transcript No More Cuckoo’s Nest

NO MORE CUCKOO’S NEST
Exploring ECT
Disclosures
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I don’t call my parents enough
I actually like “Sweet Caroline” being played in the
8th inning of Red Sox Games
I occasionally enjoy a nice cigar
I didn’t give up anything for Lent last year
I hated the movie “The English Patient”
I have no financial disclosures or conflicts of interest
related to this talk.
Growth in Demand for McLean ECT
Number of ECT Treatments
8000
7000
6000
5000
4000
3000
2000
1000
0
Jan-Dec Jan-Dec Jan-Dec Jan-Dec
1999
2004
2009
2012
What is ECT?
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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
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ECT
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Why do we still use ECT?
 Superior
efficacy
 No
medication or other treatment ever shown to
be more effective in the acute treatment of
Major Depression
 Up to 90% response in psychotic depression, 8090% in catatonia
 Medication
resistance
 Medication intolerance
 Speed of response and severity of illness
Indications and Efficacy
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Psychotic depression
 ECT sometimes first line treatment
 Response rates as high as 95% (Petrides 2001)
Catatonia
 Efficacy rates around 85% (Hawkins 1995 review)
 Should be considered when Lorazepam fails or in cases of malignant catatonia or when rapid resolution is
needed
Major Depression
 No 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 Depression
 Can 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-depressants
Bipolar Mania or Mixed Episode
 ECT 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 Disorder
 Generally not used first line
 Combination of ECT and anti-psychotic may be more effective than ECT alone
Case Example #1
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MWM 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.
Case Example #2
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Mid 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.
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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.
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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.
Side Effects
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Physical
 One
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 problems
 Mild headache, jaw soreness, nausea are not
uncommon but usually mild, and rarely cause
discontinuation of treatment
Side Effects
Memory Loss
 Probably
the biggest concern of patients and family
members regarding ECT
 Typically 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 course
 Can 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 side
 Ultrabrief pulse – newer type of ECT, using much
smaller
pulses of stimulus, and seems to cause little if any sustained
memory loss for most patients.
Side Effects
Cognitive Function
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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.
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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.”
How Do We Keep Patients Better?
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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 stability
We can encourage ways to add structure and therapeutic
supports/strategies.
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Day program
Exercise
Work
Other (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.
What Can We as ECT Providers Do to
Make ECT Better?
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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 expectations
Work as part of a treatment team to help patient’s stay
better once they get better
Privacy and Comfort
Be Kind – remember our patients are suffering and
often frightened by what we do
What Questions Should I Ask at My
ECT Consultation?
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What types of ECT do you offer?
Unilateral, bilateral, bifrontal
 Ultrabrief pulse
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Which 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?
Summary
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ECT is a powerful treatment for severe depression
It is not without possible side effects
All ECT is not the same, and not everyone will
respond to ECT the same way
If 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.