The New Clinical Science of ECT - Amazon S3FINALs+100918.pdf · The Practice of Electroconvulsive...
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The New Clinical Science of ECT
C. Edward Coffey, MDProfessor of Psychiatry & Behavioral Sciences, and of NeurologyBaylor College of MedicineHouston, Texas
Fellow and Past President, International Society of ECT and Neurostimulation (ISEN)
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Disclosure• The faculty have been informed of their responsibility to disclose to the
audience if they will be discussing off-label or investigational use(s) of drugs, products, and/or devices (any use not approved by the US Food and Drug Administration).
• Applicable CME staff have no relationships to disclose relating to the subject matter of this activity.
• This activity has been independently reviewed for balance.
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Outline• How effective is ECT?
– Indications– Efficacy– Theories of mechanism of action
• How safe is ECT?• How is ECT best administered?
– ECT Team and Facility– Contemporary technique of ECT– Family-Centered ECT care
• Q & A
ECT = electroconvulsive therapy.
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How Effective is ECT?Diagnostic Indications for ECT• Major Depression, Bipolar Depression, Dysthymia(?)• Mania• Schizophrenia and Other Psychotic Disorders• Other Neuropsychiatric Conditions
– Catatonia– Delirium– Parkinsonism– Status epilepticus
American Psychiatric Association. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. Second Edition. American Psychiatric Association Publishing; 2001. American Psychiatric Association Workgroup on Major Depressive Disorder. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. Third Edition. October 2010. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Accessed June 5, 2018.
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The Expanding World of Brain Stimulation Therapies
Electroconvulsive therapy (ECT)Transcranial magnetic stimulation (TMS)
Vagus nerve stimulation (VNS)
Deep brain stimulation (DBS)
Magnetic seizure therapy (MST)Focal electrically-administered seizure therapy (FEAST)
Cranial electrotherapy stimulation (CES)
Transcranial direct current stimulation (tDCS)
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Case Presentation (with permission)
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ECT is the Most Effective Treatment Optionfor Major Depression
Fink M. Electroshock Works. Why? Psychiatric Times. 2017;24(7). Murrough JW, et al. Am J Psychiatry. 2013;170(10):1134-1142. Perera T, et al. Brain Stimul. 2016;9(3):336-346.
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ECTn=531
ECT/Psychotic Depn=77
Citalopramn=4,041
Ketaminen=47
rTMS (Open label)n=100
rTMS (Sham RCT) n=92 dTMSn=233
Rem
itted
(%)
Treatment Modality
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ECT Resolves Suicidal Behavior
Slide shows # of ECT needed to resolve suicidal ideation (≥ 3 out of 4, HAM-D-24, n=131) over course of ECT. Fink M, et al. J ECT. 2014;30(1):5-9.
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How Effective is ECT?Diagnostic Indications for ECT• Major Depression, Bipolar Depression, Dysthymia(?)• Mania• Schizophrenia and Other Psychotic Disorders• Other Neuropsychiatric Conditions
– Catatonia– Delirium– Parkinsonism– Status epilepticus
American Psychiatric Association. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. Second Edition. American Psychiatric Association Publishing; 2001. American Psychiatric Association Workgroup on Major Depressive Disorder. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. Third Edition. October 2010. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Accessed June 5, 2018.
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ECT is an Effective Continuation Treatment
C-ECT = continuation ECT; C-Pharm = combination of lithium carbonate plus nortriptyline hydrochloride.Kellner CH, et al. Arch Gen Psychiatry. 2006;63(12):1337-1344.
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Mechanism(s) of Action of ECT• A cascade of effects related to molecules, cells, and circuits
– Causal vs epiphenomena• Necessary Condition – a seizure of proper intensity and location
– Amnesia is neither a necessary nor sufficient condition• Main Theories
– Neurotransmitter (amplified and accelerated by ECT vs medications)– Neuroendocrine– Anticonvulsant– Neurotrophic/Neurogenesis (hippocampus)– Neural connectivity
Kellner CH, et al. Contemporary ECT, Part 2: Mechanism of Action and Future Research Directions. Psychiatric Times. 2015 August 26;32(8).
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How Safe is ECT?• Mortality
– ≤ 2 per 100,000 treatments– Rate declining recently
• General Medical Side Effects– Nausea, vomiting, headache, muscle soreness
• Cardiovascular Side Effects– Activation of autonomic nervous system; Transient arrhythmias and
increase in cardiac workload• Cerebral Side Effects
– Generalized seizure, but No “brain damage”• Cognitive Side Effects
– Brief, postictal disorientation– Brief anterograde amnesia– Transient retrograde amnesia
Tørring N, et al. Acta Psychiatr Scand. 2017;135(5):388-397. Ingram A, et al. J ECT. 2008;24(1):3-9. Dennis NM, et al. J ECT. 2017;33(1):22-25.
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How is ECT Best Administered?• Pretreatment Evaluation
– Optimize the patient’s general medical health; begin consent process• Treatment Team and Facility• ECT Procedure
– Anesthesia management (O2, methohexital, succinylcholine; monitor vital signs)
– ECT stimulus (parameters, dosage, and location)– Seizure monitoring– Treatment number and frequency– Outcome assessment
• Concurrent Psychosocial Therapies• Continuation and Maintenance Treatment
– Medication and/or ECTCoffey CE, et al. Electroconvulsive therapy and related treatments. In: Coffey CE et al (Eds). Textbook of Geriatric Neuropsychiatry. Third Edition. American Psychiatric Association Publishing; 2011:Chapter 10.
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ECT Stimulus Parameters and Dosage
Coffey CE, et al. Electroconvulsive therapy and related treatments. In: Coffey CE et al (Eds). Textbook of Geriatric Neuropsychiatry. Third Edition. American Psychiatric Association Publishing; 2011:Chapter 10.
Brief Pulse(0.5–1 ms)
Ultrabrief Pulse (≤ 0.3 ms)
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ECT Stimulus Electrode Placement
Lisanby SH. N Engl J Med. 2007;357(19):1939-1945.
Bitemporal Right Unilateral Bifrontal
BT = BF > RUL
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How is ECT Best Administered?• Pretreatment Evaluation
– Optimize the patient’s general medical health; begin consent process• Treatment Team and Facility• ECT Procedure
– Anesthesia management (O2, methohexital, succinylcholine; monitor vital signs)
– ECT stimulus (parameters, dosage, and location)– Seizure monitoring– Treatment number and frequency– Outcome assessment
• Concurrent Psychosocial Therapies• Continuation and Maintenance Treatment
– Medication and/or ECTCoffey CE, et al. Electroconvulsive therapy and related treatments. In: Coffey CE et al (Eds). Textbook of Geriatric Neuropsychiatry. Third Edition. American Psychiatric Association Publishing; 2011:Chapter 10.
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The Essential Role of Patient and Family Experience
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press; 2001. Coffey CE. J ECT. 2003;19(1):1-3.
The patient and family’s experience of the care is a defining component of the quality of that care.
• Safe• Effective• Patient-centered• Timely• Efficient • Equitable
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The Essential Role of Patient and Family ExperienceToday’s Delivery Room
Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79.
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The Essential Role of Patient and Family ExperienceToday’s Pediatric Trauma Bay
Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79.
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Perfect ECT Care in Real Time
Coffey CE. J ECT. 2003;19(1):1-3.
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ECT Family Focus Group (with permission)
Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79.