Are they still doing that?

Transcription

1 Are they still doing that? Why we still give ECT and when to refer Nicol Ferrier BSc (Hons), MD, FRCP(Ed), FRCPsych Emeritus Professor of Psychiatry Newcastle University

2 Rates of prescribing ECT in the UK F:M 2.3:1 47% > 65 yrs 73% voluntary patients 81% affective disorders 6% schizophrenia etc 6% unspecified

3 ECTAS dataset report Sep ,148 acute courses of ECT were given to 1,969 people 65% patients were female mean age of patients was 61 major depression - 84% patients mean number of treatments per course was % patients were informal and had capacity to consent 52% were rated severely ill at the start of treatment 92% showed clinical improvement by the end of treatment

4 Efficacy in depression 49 RCTs RCTs Large multisite RCTs Remission rates of 60 80% have been reported when it is used as first line treatment in a severe depressive episode (Petrides et al, 2001). Remission rates are also high in the elderly who also show a more rapid response (Spaans et al, 2016). Emerging literature which demonstrates the importance of ECT in restoring function and quality of life in depressed patients (Rosenquist et al, 2006 ; Lin et al,2017)

5 Efficacy in depression Comparison with antidepressants 1965 MRC trial of ECT vs. Imipramine vs. phenelzine vs. placebo found ECT associated with the best and most rapid response UK ECT review group (Lancet 2003): Efficacy & safety of ECT in depressive disorders: a systematic review & meta-analysis. ECT is effective, more so than pharmacotherapy NCCMH review 2010: 18 RCTs: ECT more effective than ADs

6 ECT vs Pharmacotherapy UK ECT Review Group 2003

7 Effect of concomitant antidepressant treatment with ECT. Sackeim et al, Arch Gen Psych 2009 Treatment with nortriptyline enhanced the efficacy & reduced cognitive side effects vs placebo Conclusions: The efficacy of ECT is substantially increased by the addition of an antidepressant medication

8 Efficacy in treatment resistant depression and in depression with suicidal features Remission rates after ECT were 48% for patients with previous pharmacotherapy failure and 65% for patients without previous pharmacotherapy failure (Heijnen et al, 2010). Suicidal thoughts /acts at baseline decreased to 0 after 1/52 in 40%, after 2/52 in 60% and at end of ECT course in 80% (n=444) (Kellner et al,2005) ECT is an effective treatment for severely depressed patients including patients with previous pharmacotherapy failure and for patients with marked suicidality. If patients are at risk do not leave ECT to the last resort

9 Efficacy in psychotic depression Petrides et al, J ECT, depressives Overall remission rate with ECT = 87% Remission rates higher & earlier in psychotic depression Birkenhager et al Journal of Affective Disorders, 2003

10 ECT in pregnancy Electroconvulsive therapy Consider ECT for pregnant women with severe depression whose physical health or that of the foetus is at serious risk. Antenatal and postnatal mental health: clinical management and service guidance NICE clinical guideline 192, 2014

11 +ve Predictors of response to ECT Delusions & retardation (Buchan et al, 1992) The above plus high suicidality (Chen et al, 2017) and possibly vegetative symptoms (Okazaki et al, 2009) All effects more marked in the elderly and female. Early improvement strongly predicts high response and remission rates (Lin et al, 2015)

12 -ve Predictors of response to ECT Treatment resistance and longer duration of episode (Haq et al, 2017) Higher levels of pain (Chen et al, 2017) No effect of seizure threshold or the magnitude of its increase during a course. (Duthie et al, 2015)

13 Bilateral vs unilateral Bilateral ECT is moderately more rapid in effect than unilateral (UK ECT review group, 2003) Overall efficacy in depression > 80% for bilateral ECT (1.5 x ST) AND for high dose (6 x ST) unilateral ECT (Kellner & Fink, 2002, McLoughlin et al, 2016, Kolshus et al, 2016) High-dosage right unilateral ECT resulted in less severe amnesia (Sackeim et al, 2009) and superior immediate verbal recall (McLoughlin et al, 2016)

14 ECT: adverse cognitive effects Semkovsa & McLoughlin 2010 review 84 studies of ~ 3000pts 70% tests showed decreased cognitive performance at 0-3 days post ECT Improvement in test results by 4-15 days post ECT By 15 days post last treatment no negative effects on cognitive function were measurable 60% of tests at 15 days showed improvement over pre ECT baseline after 15 days, processing speed, working memory, anterograde memory, executive function improved beyond baseline

15 ECT & Autobiographical memory Fraser et al 2008 Autobiographical memory impairment can occur Predominantly personal events near the treatment (6 months before) Objective measures found in 6/12 after treatment, subjective for much longer Less with brief pulse vs. sine wave and Unilateral vs. Bilateral

16 12-months follow-up, 51.1% relapsed

17 Continuation and maintenance ECT Continuation ECT (cect): additional ECTs within the first 6 months after remission Maintenance ECT (mect): ECT beyond the 6 month point to prevent recurrence of illness

18 Continuation ECT is equal to Nortryptiline + Lithium in preventing relapse (CORE study). 89 Cont-ECT, 37.1% relapsed 95 Cont-Pharm, 31.6% relapsed Kellner, C. H. et al. Arch Gen Psychiatry 2006;63: Copyright restrictions may apply.

19 2013, Journal of ECT 28 c-ect+medication: 32% relapsed 28 medication: 61% relapsed C-ECT for 1 year (every 2 weeks, RUL, 292mC average) 5 years, 4 hospitals in Sweden 116 refused to take part

20 Continuation ECT in geriatric and psychotic depression Strong RCT data in geriatric depression that additional ECT after remission (in the study operationalized as four continuation ECT treatments followed by further ECT only as needed) was beneficial in sustaining mood improvement for most patients and better than the venlafaxine plus lithium arm (Kellner et al, Am J Psychiat, 173, , 2016). Another RCT showed that continuation ECT combined with antidepressant prolonged survival time in elderly patients with psychotic unipolar depression who had remitted with ECT compared to the antidepressant alone. (Navarro et al, Am J Geriatr Psychiatry 16, ,2008)

21 Maintenance ECT Gagne et al 2000, Am J Psychiatry

22 Maintenance Electroconvulsive Therapy A systematic review of 3 databases included 11 studies of Continuation/Maintenance (c/m) ECT found consistent evidence that both cect and mect were efficacious (Brown et al, 2014). This review suggests that c/m ECT is efficacious for the prevention of relapse/recurrence of major depression and that efficacy is increased when c/m ECT is provided in combination with antidepressant medication and at flexible treatment intervals, responsive to early signs of recurrence. The efficacy of mect may extend over several years while cognitive functions remain largely unaffected (Elias et al, 2014) Kirov et al (2016) reported that repeated courses of mect did not lead to cumulative cognitive deficits.

23 Treatment-Resistant Bipolar Depression: A Randomized Controlled Trial of Electroconvulsive Therapy Versus Algorithm-Based Pharmacological Treatment Schoeyen et al, American Journal of Psychiatry, 2015,172:41-51 Linear mixed-effects analysis showed that the mean score at 6 weeks was 6.6 points lower in the ECT Linear mixed-effects analysis showed that the mean score at 6 weeks was 6.6 points lower in the ECT group (SE=2.05, 95% CI= , p=0.002).e=2.05, 95% CI= , p=0.002).

24 Efficacy in Schizophrenia Friedel 1986: ECT augmentation of thiothixene resulted in significant improvement in schizophrenic patients Klapheke 1993: ECT augmentation of clozapine decreased BPRS score by 40% Cochrane review 2005: Pooled data from 26 studies, 798 pts. Courses of ECT with antipsychotic medication can, in the shortterm, result in global improvement

25 ECT in Treatment Resistant Schizophrenia Randomized single-blind 8-week study, patients with clozapineresistant schizophrenia. 39 participants assigned to treatment as usual or a course of bilateral ECT plus clozapine (Petrides et al, 2014) 50% of the ECT plus clozapine patients met the response criterion but none of the patients in the clozapine alone group did. There were no discernible differences between the groups on global cognition. Augmentation of clozapine with electroconvulsive therapy in treatment resistant schizophrenia: A systematic review and metaanalysis (Lally J, et al. 2016). The augmentation of clozapine with ECT is a safe and effective treatment option but further research is required to determine the persistence of the improvement. May need more ECT treatments in this situation.

26 Catatonia and ECT (RCPsych ECT Handbook, 2013) Catatonia: rigidity, mutism, negativism, staring, stereotypy, posturing The treatment of choice is a benzodiazepine drug; most experience is with lorazepam ECT may be indicated when treatment with lorazepam has been ineffective

27 RCPsych s Position statement on ECT (2017) Available on College website:- sofcouncil/ectandrelatedtreatments.aspx

28 Royal College of Psychiatrists' Position Statement on ECT (2017) ECT is a first-line treatment for patients (including the elderly): Where a rapid definitive response for the emergency treatment of depression is needed With high suicidal risk With severe psychomotor retardation and associated problems of compromised eating and drinking and/or physical deterioration Who suffer from treatment-resistant depression that has responded to ECT in a previous episode of illness Who are pregnant with severe depression, or severe mixed affective states, mania or catatonia and whose physical health or that of the foetus is at serious risk. Who prefer this form of treatment With life threatening malignant catatonia

29 Royal College of Psychiatrists' Position Statement on ECT (2017) ECT is a second-line treatment for patients (including the elderly): with treatment-resistant depression who experience severe side-effects from medication whose medical or psychiatric condition, in spite of other treatments, has deteriorated to an extent that raises concern with persistent or life-threatening symptoms in severe or prolonged mania

30 Royal College of Psychiatrists' Position Statement on ECT (2017) ECT in some circumstances for patients: with bipolar depression with post-natal psychosis with treatment resistant schizophrenia with treatment resistant catatonia with frequent relapses and recurrences of depression (maintenance)

31 Conclusions ECT is an effective treatment in severe depression particularly those with psychotic features or retardation It is effective in TRD, BP depression and those with suicidality It is a safe treatment and can be used safely in elderly, perinatal and most medically ill patients. It can and probably should be combined with antidepressant treatment. Care should be taken to minimise cognitive effects. R high dose unilateral should be probably be the default except where speed of response is the key issue. Treatment is needed to prevent relapse post ECT : ADs, lithium and continuation ECT all have evidence, alone and in combination.