EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
Las Vegas (FRONTLINE MEDICAL NEWS) – Electroconvulsive therapy is useful for many patients, particularly those with more severe depressive symptoms and more treatment resistance, according to Dr. Bruce J. Cohen.
However, a survey of 116 psychiatrists in Virginia shows that clinician experience with electroconvulsive therapy (ECT) varies widely. In fact, 8% of respondents reported having no experience with ECT, 41% observed it in residency, 38% performed it while supervised in residency, 35% had performed ECT but are not currently using it, and only 11% indicated that they currently perform ECT ( J ECT. 2011;27[3]:232-5 ). “While most psychiatrists had a basic understanding of ECT and favorable attitude, a lesser fund of knowledge about ECT was associated with both a less favorable attitude toward ECT and fewer referrals,” Dr. Cohen, one of the study authors, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “Those who viewed ECT as a treatment of last resort made fewer referrals.”
Dr. Cohen of the department of psychiatry and neurobehavioral sciences at the University of Virginia, Charlottesville, said the most common indications for ECT are major depressive episodes both in unipolar and bipolar disorders, including medication-resistant depression; manic or mixed states; inability to tolerate medication side effects; and the need for more rapid and/or certain response.
“You might have a situation with an inpatient where the acuity of the depression is so high that you move to ECT almost immediately,” he said. Other indications include a previous good response to ECT, catatonia, refractory schizophrenia, more severe mood disorder in pregnancy, and neuroleptic malignant syndrome.
Before he meets with patients to discuss ECT, Dr. Cohen said he determines whether the focus will be on prescreening for ECT or a broader consultation about treatment-resistant depression in which he and the patient explore other treatment options besides ECT. “That’s the approach that I favor, because a patient might decide after talking to me that they don’t want ECT, or they might say, ‘I’m glad I talked to you, but I’m not quite ready for ECT at this point,’ ” he said.
Other factors could be contributing to the patient’s current depressive state, he said, perhaps someone “who’s on a very high dose of lithium that’s causing fatigue and apathy or cognitive disturbance. Or maybe the patient has had treatment-resistant psychosis, and the more you talk to them, the more you realize it may be obsessive-compulsive disorder, and not psychotic depression at all, and they’ve tried treatment with various antipsychotic agents but never with a higher dose of [a selective serotonin reuptake inhibitor].”
During the consultation, he said he emphasizes that ECT is not effective for all patients. “This is important, because some patients will come in and say, ‘ECT is my last hope,’ he said. “They might have already decided that if they don’t respond to ECT, they’re going to kill themselves. I share anecdotes and let them know that even if they end up not responding to ECT, there are other treatments out there, and not all treatments have been exhausted.” He also discusses options should ECT be successful for the patient, including the potential for maintenance therapy with ECT or a medication regimen.
Having a family member or a friend accompany the patient to the consultation is helpful. “These are the people who may bring them back and forth to treatments,” he said. “These are also the people who could sabotage treatment. If they don’t know what to expect in terms of transient confusion or memory problems or even coming out of the treatment room looking flushed, you could see where a family member or friend might be frightened. So the family member can be your best ally.”
There are no absolute medical contraindications to ECT, Dr. Cohen said, but medical conditions to be stabilized include cardiac pacemakers, hypertension, pulmonary disease, cardiovascular disease, liver disease, diabetes, skull defects, pregnancy, and CNS conditions that increase the risk of delirium, including dementia, stroke, head injury, Parkinson’s disease, and multiple sclerosis. “Sometimes we’re asking for clearance on a person who has a brain aneurysm,” he said. “I want to get a detailed medical history. At our facility, usually anesthesia will consult with the patient shortly before the treatment rather than as a whole separate outpatient visit.”
Labs to consider prior to performing ECT will include an EKG, blood count, chemistry panel, chest X-ray, spine films, and neuroimaging, “but those things aren’t obligatory or required,” he said. “But just like in any case of refractory depression, you’d want to order those things as appropriate.”
Prior to ECT, Dr. Cohen said he considers discontinuing or minimizing medications that have anticonvulsant effects, such as carbamazepine and lamotrigine and benzodiazepines. “On the other hand, you don’t want the patient relapsing right as you’re starting your treatment, so it might be that you can’t get them off benzodiazepines completely,” he said.
According to a recent meta-analysis of 32 studies, the most robust predictors of poor response to ECT were longer depressive episode duration and medication resistance, while age, psychosis, and melancholic features were not found to be as clinically useful ( J Clin Psychiatry. 2015;76[10]:1374-84 ). Dr. Cohen noted that a major consideration during a pre-ECT consultation is working out any potential logistical difficulties in advance. For example, during an acute course of ECT, he said he advises patients not to drive, even on nontreatment days.
“If you live in a city with good public transportation, it may not be a big deal, but it can be difficult in more rural areas,” he said. “It’s not that ECT makes you lose the memory of how to drive a car, but could give you subtle cognitive slowing or decreased reaction times. Therefore, arranging to have an adequate support system throughout the course of ECT is essential.”
Dr. Cohen reported having no relevant financial conflicts.
