The New Clinical Science of ECT

Transcription

1 The New Clinical Science of ECT C. Edward Coffey, MD Professor of Psychiatry & Behavioral Sciences, and of Neurology Baylor College of Medicine Houston, Texas Fellow and Past President, International Society of ECT and Neurostimulation (ISEN)

2 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.

3 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.

4 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; American Psychiatric Association Workgroup on Major Depressive Disorder. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. Third Edition. October Accessed June 5, 2018.

5 The Expanding World of Brain Stimulation Therapies Electroconvulsive therapy (ECT) Focal electrically-administered seizure therapy (FEAST) Transcranial magnetic stimulation (TMS) Magnetic seizure therapy (MST) Cranial electrotherapy stimulation (CES) Transcranial direct current stimulation (tdcs) Vagus nerve stimulation (VNS) Deep brain stimulation (DBS)

6 Case Presentation (with permission)

7 ECT is the Most Effective Treatment Option for Major Depression Remitted (%) ECT n=531 ECT/Psychotic Dep n=77 Citalopram n=4,041 Ketamine n=47 Treatment Modality rtms (Open label) n=100 rtms (Sham RCT) n=92 dtms n=233 Fink M. Electroshock Works. Why? Psychiatric Times. 2017;24(7). Murrough JW, et al. Am J Psychiatry. 2013;170(10): Perera T, et al. Brain Stimul. 2016;9(3):

8 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.

9 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; American Psychiatric Association Workgroup on Major Depressive Disorder. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. Third Edition. October Accessed June 5, 2018.

10 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):

11 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 August 26;32(8).

12 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): Ingram A, et al. J ECT. 2008;24(1):3-9. Dennis NM, et al. J ECT. 2017;33(1):22-25.

13 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 (O 2, 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 ECT 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.

14 ECT Stimulus Parameters and Dosage Brief Pulse (0.5 1 ms) Ultrabrief Pulse ( 0.3 ms) 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.

15 ECT Stimulus Electrode Placement Bitemporal Right Unilateral Bifrontal Lisanby SH. N Engl J Med. 2007;357(19): BT = BF > RUL

16 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 (O 2, 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 ECT 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.

17 The Essential Role of Patient and Family Experience 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 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press; Coffey CE. J ECT. 2003;19(1):1-3.

18 The Essential Role of Patient and Family Experience Today s Delivery Room Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79.

19 The Essential Role of Patient and Family Experience Today s Pediatric Trauma Bay Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79.

20 Coffey CE. J ECT. 2003;19(1):1-3. Perfect ECT Care in Real Time

21 ECT Family Focus Group (with permission) Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79.