Biological treatments: Electroconvulsive Therapy, Transcranial Magnetic Stimulation, Light therapy
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1 Biological treatments: Electroconvulsive Therapy, Transcranial Magnetic Stimulation, Light therapy Basic trainee talk 23 May 2007
2 ECT
3 When is ECT used. Depression. Severe, melancholic. Resistant to treatment. Treatment options not tolerated, or higher risk Patient preference. Mania Acute relapse schizophrenia, esp. catatonia. Neurological disorders, esp. Parkinson's & status epilepticus.
4 Evidence for ECT Depression. Six meta-analyses Mania ECT > sham ECT ECT > medications (TCA, MAOI, paroxetine) ECT > rtms Open trials Schizophrenia Open trials ECT < antipsychotics.
5
6 Cognitive effects Acute Confusion. Disorientation Up to four weeks Measured as Time to reorientation or time to talking. Decreased learning of new material Longer term? Loss of autobiographical material.
7 Reduction of side effects and effect. Placement Right Unilateral (RUL) Bilateral Bifrontal Dosage 2-3x threshold 6-8x threshold Fixed Type current Sine Square Sine worse than square. Low dose less effective, less side effects Bilateral more effective, more side effects 6x as effective as 2x but less side effects.
8 Long term effects. Naturalistic trial 375 patients, 9 centres. 2 using sine wave machine has more cog. side effects (also fixed dosing) Site mattered more than type. Bilateral lead to more autobiographical memory losses. Some memory loss persisted for six months.
9 What ECT now involves A brief anaesthetic (including paralysis) EEG (brainwave) monitoring. ECG (heartbeat) monitoring. Use of minimal dose of electricity to cause an effective seizure. Monitoring clinical outcome.
10 ECT in Australia & New Zealand. RANZCP guidelines ECT mandate: Levels of equipment. Supervision by consultant psychiatrist and consultant anaesthetist All trainees must. be aware of the nature of ECT Seriousness of ECT Experience of patients undergoing ECT. Treat 10 patients under supervision, using a stimulus titration method.
11 Rate of ECT use. per population. New Zealand 8 Scotland 19.7 Wales 22 Victoria (Australia) 44 Queensland (Australia) 34 Western Australia 14 From Melding, NZMJ 2006
12 Consent for ECT. Consent Must include giving information in writing. If unable to consent. If is not mentally disordered (in terms mental health act), cannot treat. If is mentally disordered, cannot treat without second opinion that in patients' best interests. This opinion can only be given by those approved by the (National) MHA review tribunal.
13 Research. Most recent meta-analysis ( J ECT, 1995) Efficacy when compared to: Placebo Sham ECT. Cognition testing improves with ECT (AREAN data, unpublished. There are at times loss of declarative memory. 85% of psychiatrists would receive ECT if depressed (Scot Med J, 2007)
14 ECT and BDNF
15 Patient's attitudes to ECT (Mayo Clinic Proc 1999)
16 ECT v rtms Am J Psychiatry 164:73-81, January 2007
17 ECT vs rtms Biol Psychiatry Apr 15;51(8):
18 ECT vs rtms The International Journal of Neuropsychopharmacology, Volume 9, Issue 06, December 2006, pp This paper found no significant difference between rtms and ECT in HAM-D scores However, more people who had ECT (white boxes) remitted.
19 Cognitive side effects ECT and rtms
20 ECT and death Br J Psychiatry April 2007
21 ECT and suicide
22 Suggestions. ECT remains useful as a treatment. Like all psychiatric treatments, it has side effects. The safeguards within the current system are not perfect, but good enough We are probably too cautious in using ECT. Removal of ECT as an option is highly likely to be life threatening for profoundly depressed and catatonic patients.
23 rtms
24 Repetitive transcranial magnetic stimulation. Newer technique. Recurrent stimulation over a period of time. Multiple sessions.
25 Depression: rtms vs sham rtms Am J Psychiatry Jan;163(1):88-94.
26 Treatment resistant depression: sham rtms vs TMS Biol Psychiatry Jan 15;59(2):187-94
27 Response and remission in treatment resistant depression: rtms vs TMS
28 Bipolar depression rtms vs sham Bipolar disorder (1) 40-47
29 Meta analysis The International Journal of Neuropsychopharmacology, Volume 9, Issue 06, December 2006, pp
30 Predictors response to rtms
31 Response and remission rate rtms
32 Light box
33 Light therapy Bright natural light, full spectrum ie lumens, about 40 cm away from face, for 30 minutes a day. Generally used seasonal affective disorder. Common use at high latitudes: Canada, Minnesota, New York etc Scotland Scandinavia
34 Light therapy vs fluoxetine Am J Psychiatry May;163(5):
35 Use light therapy Uncertain in Dunedin (45 S). Common in Canada (55 N) and Scandinavia (50 N). In winter, it is light 9am 3 pm. In winter, light 11 am 1 pm. Is advising people to walk outside at lunchtime cheaper and as effective? Issue of quality of light? Would data vary geographically? No known data NZ.
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