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Demystifying Electroconvulsive Therapy (ECT)

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Demystifying Electroconvulsive Therapy (ECT)

  1. 1. Demystifying Electroconvulsive Therapy (ECT) Lisa McMurray, MD, FRCPC Domenica Palermo, RN Tanya McLendon, RN DA BA Gregory McLeod, MHA
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  3. 3. Access to treatment that works 3 Insert photo of elderly woman here
  4. 4. WHAT IS ECT? Electroconvulsive therapy 4
  5. 5. ECT Device R (resistance in Ohms) Ohm’s Law: I (current) = V (voltage) R (resistance) I (current in Amperes) V (voltage in Volts)
  6. 6. 6
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  8. 8. Peterchev A et al, 2010
  9. 9. WHY ON EARTH WOULD WE DO THIS? 10
  10. 10. Convulsive Therapies • Insulin-induced coma and convulsions, to treat schizophrenia, discovered in Berlin by Manfred J. Sakel, in 1927; • Metrazol-induced convulsions, to treat schizophrenia and affective psychoses, discovered in Budapest by Ladislaus J. von Meduna, in 1934 (camphor, then pentylenetetrazol (Metrazol), and • Electroconvulsive shock therapy, discovered by Ugo Cerletti and Lucio Bini in Rome, in 1937.
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  12. 12. Med Hist. 2011 July; 55(3): 407–412.
  13. 13. Electroconvulsive Therapy
  14. 14. HOW DOES ECT WORK? 15
  15. 15. Neurotransmitters and receptors 16
  16. 16. Brain areas with significantly higher relative regional cerebral blood flow values during ECT Takano H et al, British Journal of Psychiatry, Jan 1, 2007, vol 190 no. 1 63-68 17
  17. 17. Fig. 3. Essential role of Gadd45b in activity-induced dendritic development of newborn neurons in the adult brain. D K Ma et al. Science 2009;323:1074-1077 Published by AAAS
  18. 18. Changing functional connectivity in the brain with ECT Beall et al, 2012 19
  19. 19. Patterns of use • 1950’s to 1980: decline – Pharmacotherapy – Negative portrayals in media • Stabilizing and even increasing (modestly) since then in some jurisdictions – Modified ECT – Intolerance to pharmacotherapy – Speed of action
  20. 20. One Flew Over the Cuckoo’s Nest
  21. 21. Toronto Star, 23 December 2012
  22. 22. 23
  23. 23. Declining Use of ECT in US General Hospitals
  24. 24. Contemporary use and practice of electroconvulsive therapy worldwide (2012) • In Western countries (Europe, USA, Australia, and New Zealand), ECT is at large administered to elderly female patients with depressive disorders. In those areas of the world (Asia, Africa, Latin America, Russia), where ECT is still often administered unmodified, it is predominantly prescribed to younger patients (often more male) with schizophrenia • New trends are revealed. ECT is used as first-line acute treatment and not only last resort for medication resistant conditions in many countries. Other professions than psychiatrists (geriatricians and nurses) are administering ECT. ECT use among outpatients (ambulatory setting) is increasing.
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  27. 27. INDICATIONS FOR USE
  28. 28. ECT works for: • Major Depressive Episode • Manic Episode • Schizoaffective disorder • Treatment-resistant Schizophenia • Some medical conditions, e.g. Parkinson’s
  29. 29. ECT does not work for: • Dysthymic disorder • Anxiety disorders • Substance abuse disorders • Eating disorders • Personality disorders – But may treat depression that often comes with these disorders
  30. 30. ECT in Major Depression • 80-90% remission rate (vs 60-70% with medications • Catatonic features and delusions are associated with good response • Dysthymia/Persistent depressive disorder and medication resistance are associated with non-remission – INFORMED CONSENT is important • Relapse rates are high
  31. 31. When to use ECT Primary • Urgent need for rapid response • Less risky than alternatives • History of good response • Patient preference Secondary • Poor response to alternatives • Intolerant to alternatives • Deterioration requiring rapid response
  32. 32. ECT with Elderly • May be more effective than with younger patients (van der Wurff, 2003) • Efficacy and safety in patients with comorbidity (e.g. dementia, cerebrovascular disease, Parkinson’s) is under investigation • Increased complications but safer than medications
  33. 33. SIDE EFFECTS 34
  34. 34. Consent for ECT should cover: • Risks and benefits of ECT – Including cognitive adverse effects – Including death (1/10 000 per series of ECT) • Possibility of non-response and relapse • Behavioural restrictions – E.g. NPO for several hours prior to treatment – E.g. no driving during and acute course of ECT • Alternatives to treatment – Including no treatment • Individual indication and rationale for ECT • Who can answer questions
  35. 35. Informed Consent and Cognition • Memory loss is a common side effect of ECT • Memory loss with ECT has a characteristic pattern – More treatments produce more memory loss – Worse shortly after a treatment – Gradual improvement after ECT is discontinued – Patchy memory loss extending for several months prior to ECT; some may return with time • May be left with some permanent gaps in memory • Difficulty in forming new memories – Temporary – Usually disappears within a few weeks after discontinuation of ECT • Most patients state that benefits of ECT outweigh problems with memory • Most patients report that memory is IMPROVED after ECT • A minority of patients report problems in memory that remain for months or years • There is great variability between patients • Some stimulus parameters and electrode placements are associated with more cognitive side effects than others
  36. 36. Summary of ECT • The best treatment we have for depression • Works quickly • Very safe • Not a last resort! 37
  37. 37. 38 Lipsman, N et al, CMAJ, January 7, 2014, 186(1)
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  44. 44. Objective information on ECT • https://www.isen-ect.org/websites-about- ect • http://www.canects.org/patients.php 45

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    May. 10, 2017

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