ECT: an update. Grand Round 26 May Chris Gale. Local audit data: Sebastian Alverez-Grandi Paul Glue

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1 ECT: an update. Grand Round 26 May 2017 Chris Gale. Local audit data: Sebastian Alverez-Grandi Paul Glue

2 Experience with ECT. l l l l 1987: as SHO, gave ECT while on call. One session teaching. 1992: as Registar, gave ECT under supervision of consultant. Fixed dose, bitemporal. 2004: retrained in ECT (North Shore, Sydney). RUL, brief pulse, dose titration. 2017: clinical update ECT (Kogarah, Sydney). RUL, ultrabrief, Bifrontal, brief dose titration, cognitive monitoring.

3 Rate of ECT by age: Denmark. Hundrup Osler Jorgensen. Time Trends and Variations in Electroconvulsive Treatment in Denmark 2008 to 2014: A Nationwide Register-Based Study. J ECT. DOI: /YCT

4 ECT statistics MoH

5 Treated person rate per Leiknes, K. A., Schweder, L. J.-v. and HÃ ie, B. (2012), Contemporary use and practice of electroconvulsive therapy worldwide. Brain and Behavior, 2: 283â 344. doi: /brb3.37

6 Results Between 2003 and 2012, 199 pa4ents received >1 courses of ECT treatment. Most common diagnoses: Affec4ve disorders (Major Depressive Disorder (74.8%) and Bipolar Disorder (14%; 88.8% combined)) Psycho4c disorders (Schizoaffec4ve Disorder, Catatonia and Schizophrenia, 11.2% combined). Majority inpa4ents (87.8%) Majority voluntary treatment (78.1%). Treatment under MHA was higher for pa4ents with psycho4c disorders (18/32) than with affec4ve disorders (19/137; Pearson χ 2 =27.25, p<0.0001).

7 How does our yearly treatment rate compare? Mean yearly rate for ECT treatment was 1.20 pa4ents treated/year/10,000 popula4on Lower than rates at US, UK, Aust centres which appear to treat similar pa4ent popula4ons and have comparable clinical ECT prac4ce. Otago

8 Should we combine audit data from all pa4ents? Psycho'c Affec've Mean Age 51y 67y Gender (M:F) 1:1 1:3 Repeat ECT course 27% 41% ECT under MHA 56% 14% Dura4on between ECT courses No pacern Decreasing Maintenance ECT 28% 20% Response rate >90% >90%

9 Retreatment pacern Most pa4ents received 1-2 ECT courses during a 10 year period. <15% of all pa4ents had >4 courses. #number courses in older, female pts; presumably unable to tolerate/respond to oral meds Higher rates of retreatment in affec4ve disorders than for psycho4c disorders 41% required a second course of ECT treatment at average 10 months Similar to recent meta-analysis on repeat ECT treatment (51% of depressed pa4ents relapsing within 12 months) Progressively shorter 4me to retreatment for affec4ve disorders. Count 200 psychotic disorder affective disorder Time (days) Number of ECT courses N: Inter-ECT Interval (between treatment n and n+1)

10 ECT wave parameters.

11 Electrode placement

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13 Modeling of current by electrode placement

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21 Dose Titration RUL ultra brief ECT. Thymatron Stimulus level Pulse width (ms) Frequency (Hz) Duration (s) Current (ma) Charge (mc) Ga lvez, V., Hadzi-Pavlovic, D., Waite, S. et al. Eur Arch Psychiatry Clin Neurosci (2017). doi: /s y

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29 Notes on cogni4ve side effects Acute Disorienta4on (less than one hour) Loss retrograde memory Subacute (0 3 days) Loss retrograde memory Decrease execu4ve func4oning Set shiging Verbal fluency Processing Speed.

30 2 Short term (less than 15 days) Anterograde memory Retrograde memory Longer term (up to six months) Retrograde memory Autobiographical memory

31 Assessment cogni4on. Baseline Montreal Cogni4ve Assessment (not MMSE) During Recovery of orienta4on (MSE at 30 minutes) BECS (Brief ECT cogni4ve screen ager Tx 3) Post MoCA Verbal Fluency Con4nua4on Autobiographical Memory Inventory Short Form (research)

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33 Mar4n, Katalinic, and others. A new early cogni4ve screening measure to detect cogni4ve side-effects of electroconvulsive therapy?, Journal of Psychiatric Research, 2013;47(12): ,, hcps://doi.org/ / j.jpsychires

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35 CANMAT (Canadia n) summary recomme nda4ons.

36 Dose Summary Table (From Colleen Loo) Pulse width Bitemporal Bifrontal Right unilateral 0.3 ms 6 x seizure threshold. Lower cogni4ve effects 0.5 ms Anecdotal data Anecdotal data 1.0 ms ( DGX ) 1.5 x seizure threshold Marked cogni4ve effects 1.5 x seizure threshold. Lower cogni4ve effects 3 6 x seizure threshold Moderate cogni4ve effects.

37 Summary. ECT is an effec4ve and safe treatment. Indica4ons include severe depression, par4cularly melancholic or suicidal Psychosis, par4cularly catatonia. The Southern DHB adult services uses ECT at around the average rate for NZ. By interna4onal standards, that rate is low.

38 2 It is fairly easy to give effec4ve ECT Most research relates to side effects, par4cularly Return of orienta4on. Retrograde memory Autobiographical memory. Monitoring cogni4ve outcomes is now standard.

39 What next. RANZCP guideline drag in review this year. ECT prac4toners Neuros4mula4on advanced prac4ce cer4ficate? CORE group Developed to leverage of NSW ECT requirements. Now interna4onal. Allows consistent recording outcomes for audit and research.