No More Cuckoo’s Nest

1. No More Cuckoo’s Nest Exploring ECT

2. Disclosures 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.

3. Growth in Demand for McLean ECT Number of ECT Treatments

4. What 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

5. ECT • 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, 80-90% in catatonia • Medication resistance • Medication intolerance • Speed of response and severity of illness

6. Indications and Efficacy • 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 (Mukherjee1994) • 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

7. Case Example #1 • 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.

8. Case Example #2 • 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. • 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.

9. Side Effects • 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

10. 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.

11. Side 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.”

12. How 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 stability • We can encourage ways to add structure and therapeutic supports/strategies. • 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.

13. What 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 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

14. What Questions Should I Ask at My ECT Consultation? • What types of ECT do you offer? • Unilateral, bilateral, bifrontal • Ultrabrief pulse • 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?

15. Summary • 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.