EXPERT ANALYSIS FROM IPS 2017
NEW ORLEANS (FRONTLINE MEDICAL NEWS) – In 2001, a patient at the Menninger Clinic, Houston, asked whether her husband could be with her during ECT treatments, so she’d feel safer.
He declined, but then she told her care team “the fact that you would allow that makes me feel entirely safe now,” recalled M. Justin Coffey, MD, medical director of Menninger’s Center for Brain Stimulation.
“She made her request partly in jest, but it was a great idea,” he said. Fast-forward 16 years, and it’s now standard practice at Menninger for patients to invite loved ones to ECT sessions. Sometimes they pick family members, other times a neighbor or even a pastor.
“One of the most powerful benefits we’ve seen is that the loved ones observing the treatment become thoroughly underwhelmed by what they see,” not much more than the patient under anesthesia. “At the same time, they are incredibly impressed by the expertise and competence of the team. They become ambassadors against stigma; I’ve got family members and patients now that join me in workshops talking about why ECT should be [used] more,” Dr. Coffey said at the American Psychiatric Association’s Institute on Psychiatric Services.
The approach is catching on, including at the New York Community Hospital, Brooklyn, where it was implemented a few years ago. “It’s a wonderful thing to decrease patient anxiety and the stigma of treatment. You ask the patient’s permission, of course, and discuss with the family members what they are going to see. It demystifies the whole thing,” said Charles H. Kellner, MD , chief of electroconvulsive therapy at the hospital and a well-known ECT researcher.
Another benefit they’ve seen at Menninger is that patients come out of their postictal confusion sooner when there’s a familiar, comforting person in the room. That’s important, because the quicker patients reorient, the less likely they are to have retrograde memory problems, Dr. Coffey said.
Memory loss is perhaps the top fear people have about ECT, and it leads to the underuse of an otherwise safe and effective treatment for severe, refractory depression. Anterograde memory problems generally clear up in a few days, but retrograde problems can linger; memories formed within 3-6 months of ECT are the most vulnerable. It’s tough to pin down exactly how great the risk is because of variations in how ECT is performed from one center to the next.
“It’s always a risk-benefit decision,” Dr. Kellner said. “The vast majority of patients do not have profound memory trouble with ECT; it’s a temporary nuisance. I’d say maybe 10% or fewer have memory problems significant enough to stop treatment, or that really bother them.”
“The most important thing” when counseling patients “is not to promise anything, because you really don’t know how an individual is going to respond to ECT,” said Adriana P. Hermida, MD , a geriatric psychiatrist and ECT practitioner at Emory University, Atlanta.
In general, cognitive problems and memory loss are less likely with unilateral treatment than with bilateral, and least likely with ultra-brief unilateral treatment. Two sessions per week are less likely to cause problems than are the usual three, but treatment response isn’t as rapid. Also, giving more than two seizures per session increases the risk of medical and cognitive side effects, and isn’t recommended.
To manage the memory risk, cognitive function should be assessed before each session, not just by objective measures and patient report, but also by asking family members what they’ve noticed. “Many times patient do not report memory issues, but family members will,” Dr. Hermida said.
If there’s a problem, patients can switch to two sessions per week, for instance, or to ultra-brief unilateral ECT.
A few studies have suggested that cholinesterase inhibitors and memantine (Namenda) might attenuate cognitive side effects, but there’s not enough evidence to recommend their use, she said.
The speakers had no relevant industry disclosures.
