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)

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.

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.

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.

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)

Case Presentation (with permission)

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

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.

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.

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.

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).

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.

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.

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)

ECT Stimulus Electrode Placement

Lisanby SH. N Engl J Med. 2007;357(19):1939-1945.

Bitemporal Right Unilateral Bifrontal

BT = BF > RUL

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.

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

The Essential Role of Patient and Family ExperienceToday’s Delivery Room

Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79.

The Essential Role of Patient and Family ExperienceToday’s Pediatric Trauma Bay

Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79.

Perfect ECT Care in Real Time

Coffey CE. J ECT. 2003;19(1):1-3.

ECT Family Focus Group (with permission)

Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79.