electroconvulsive therapy in a rural setting. george r martin, md staff physician department of...

Electroconvulsive Therapy

in a Rural Setting

George R Martin, MD

Staff PhysicianDepartment of PsychiatryJames A Quillen VA Medical CenterMountain Home, Tennessee

Associate Professor, Psychiatry James A Quillen School of MedicineEast Tennessee State UniversityJohnson City, Tennessee

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

What it is not

What it is

Part 1: How it began

Ladislas J. Meduna

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

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.

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 deathsEventually settled on bilateral head electrodes

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

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

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.

What it is

Part 2: The Preliminaries

1. Patient selection2. Pre treatment workup

Patients for whom ECT should be a serious option

“Before you go home”

Psychotic Depression• Nihilistic delusions• Body rotting from the inside

Catatonia (Schizophrenia, catatonic type)• Stuporous• Excited

Good ECT candidates

Depression: • Relenting and unresponsive• Usual medications contraindicated• Actively suicidal • malnourished/electrolyte imbalance• Prolonged Manic episode (neurodegenerative)

Good ECT candidates

Psychosis• Schizophrenia, unrelenting and unresponsive• Usual medications contraindicated• Actively suicidal• Affective component

PregnancyLargest 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.

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.

Unusual and “desperate” situations

Parkinson’s Disease

• Depression• Abnormal Movements• Psychosis• Dementia

De la Tourette’s OCDDelusional Disorder Epilepsy

PTSD

Neuroleptic Malignant Syndrome

Poor candidates

Predominantly personality disorderUnstable logistics/unreliableSomatic focusedAnesthesia risksDrug/alcohol addicts due to anesthesia risksMilitant family member

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

Pre-treatment workup

Vital Sign recordingsRoutine pre-anesthesia labsSpine filmsImaging of the head EKG

What it is

Part 3: The treatment itself

The Evolution of the procedure

Early 1940’s introduced to US and UK “Unmodified” sine wave (AC) current, no medsTried curare as paralytic agentSuccinyl choline 1951Late 1950’s general anesthesia1976 Data shows pulsed DC current superior to

alternating current (Blatchley)

AC vs DC pulsed current

Variation of pulse parameters

Recovery room or outpatient surgeryNPOIVAnesthesia monitoring• Cardiac• Pulmonary• BP• External VentilationDriver and not home alone

Caffeine (IV) Romazicon (Flumazenil)Short acting anesthetic • methohexital (Brevital) • propofol (Diprivan)• KetamineGlycopyrrolate (Robinul) peripheral

antimuscurinic Paralytic agent: Succinyl Choline

Pre-existing Medications during ECT

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)

Lithium controversial

(1) thought to increase risks of delirium and/or (2) Perhaps prolongs neuromuscular effect of

succinyl choline

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

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.

• EEG Monitoring.

EEG monitoring

Single line tracing, not 21

Determines length and architecture of seizure

Determines that it stopped

Multiple monitored, not additionally effective

Electrode placement

Non-dominant Unilateral – Recommended in 1978– Hope to reduce memory loss– More “missed” seizures– Used at initial treatment and continue if effective

BilateralAlmost universal in US and UKSome memory loss, less now with pulsed current

Seizure Architecture on EEG

1. Recruiting2. Full seizure: Delta waves3. Suppression4. Quiet/Recovery

Treatment Response

Treatments three times per weekSee initial progress after 3-6 treatmentsProgress should be steady, but will plateauGo two more treatments and stopCommon 9-12, 24 maximumMaintenance reduces relapse

Controversies

Memory lossSafetyEffectivenessAnti-psychiatry

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.

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 ofthis notably effective treatment.”

Harold Sacheim, PhD, Columbia UniversityReview of old studies• Memory loss is real• Significant with 50’s technologyNew study 347 patients (2007)• Minimal loss with current type of treatments• Unilateral is no protection• No control group

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

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

Efficacy

Randomized • Predermined criteria of “success”• Decision on medication doses and length of

treatment timeNon randomizedEthics of “sham” ECT and anesthesiaCannot do double blind cross over method

Randomized

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”

Date of download: 2/20/2012

Copyright © American Psychiatric Association. All rights reserved.

From: Efficacy of ECT in Depression: A Meta-Analytic Review

Non Randomized

Lancet. 2003 Mar 8;361(9360):799-808.

Efficacy and safety of electroconvulsive therapyin depressive disorders: a systematic review and meta-analysis.

UK ECT Review Group.

• 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).

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

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

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

• 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

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

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