Thursday, November 16, 2006

APM 2006: Day 1 - ECT



I thought I'd follow in Clink's footsteps and blog about things I've learned at the conference I am attending. This is the annual meeting for the Academy of Psychosomatic Medicine (APM), which is the organization for C-L (Consultation-Liaison) Psychiatry. (What is that? It essentially involves taking care of folks with other medical problems who also have something going on in the psychiatric area. If you look at this year's program, you get a sense of what we are about.)

Yesterday, I attended a 4-hour seminar on ECT. I don't do ECT, but it is done at my hospital. As Chairman of the department, I thought it was time for a refresher. Donald Malone and Leo Pozuelo presented (both from Cleveland Clinic). So here are some bullet points... (not to be used as medical advice...not warranted to be accurate)

[Ed: Most of us psychiatrists know that memory problems with ECT is a concern and that there is a need for better data, but these folks here focused more on the nuts & bolts of ECT, so I won't get into the memory issues here. There are a couple links in the comments, as well. The above Wikipedia link also has some discussion about this. Thanks, Alison.]

  • Schizophrenia is the 2nd most common diagnostic indication for ECT in the US (Major Depression is #1)
  • 86% response rate for initial treatment (50% after adequate med trials have failed)
  • there are no absolute contraindications for ECT
  • mortality risk ~1:10,000 (similar to that of any anesthesia)
  • does not increase risk of spontaneous seizures
  • common side effects: headache, muscle pain, nausea, same-day amnesia, same-day diminished cognition
  • pre-tx with Toradol and 5HT-3 antagonist reduces SFX

Consent issues

  • get separate consent for maintenance ECT, as reason is different (prevent relapse, not treatment)
  • with maintenance, re-do consent every 6 months or so (some do it every time)

Procedure

  • monitor BP, pulse, O2 sat, ECG, EEG, nerve stimulator
  • pre-oxygenate w/100% O2, esp w/morbid obesity, respiratory dz
  • continue oxygen after stimulus for a bit
  • BEWARE dental complications... most common adverse event... use bite block

Cardiac effects

  • initial parasympathetic vagal discharge, with stimulus... can get asystole
  • followed by increased sympathetic activity during clonic phase of sz
  • then recovery phase, which can include both symp and parasymp
  • can pre-tx with anticholinergic, like glycopyrolate or atropine

Pre-ECT workup

  • check for dental issues
  • H&P current
  • assess by anesthesiologist & ECT provider
  • routine brain and spine imaging not necessary
  • CBC, CMP, EKG, HCG

Medical comorbidity

  • Post-MI: most do okay; 4-6 wks after MI generally okay; beta-blockade
  • CHF: optimize cardiac status before ECT; give all rx in AM w/sips H2O; monitor for incr CHF between tx's; esmolol
  • AFib: usually okay; may convert to sinus; ?incr risk if not on AC
  • Pacemaker: no need to turn off; do turn off VNS
  • Epilepsy: may use flumazenil to decrease sz threshold in pts on chronic benzodiazepines; keep AEDs on board; stack the deck by hyperventilation, etomidate, caffeine
  • Parkinson's: ECT may improve motor fn; halve the antiparkinsonian dose (eg, Sinemet); might decr ECT to 2x/wk
  • Dementia: 2/3 improved mood; 1/2 improved cognition; electrode placement; 2x/wk; ?hold Aricept vs keep and adjust succinylcholine; may reduce agitation... occ used to treat severe agitation in dementia
  • NMS: last line
  • MS: no problem
  • Pulmonary: may need to intubate w/COPD; take inhalers in AM
  • Osteoporosis: use good muscle relaxation; use neurostimulator to assure good relaxation; ?check spine XR
  • DM: give half of usual insulin in AM, 2nd half after breakfast; check BS; hold AM insulin if prone to hypoglycemia; usually hold AM oral hypoglycemics
  • GERD: pre-tx with H2-blockers
  • Glaucoma: use drops in AM; ECT can briefly incr IOP
  • Pregnancy: does not typically affect FHT/uterine tone; monitor fetus in high-risk preg; get OB consult

Increased risk

  • increased ICP
  • aneurysm/AVM
  • bad cardiac dz
  • recent stroke
  • severe pulmonary disease

Relapse after ECT: Sackeim (JAMA 2001)... relapse after ECT = 84% on placebo, 60% on nortriptyline, 39% on nortrip+lithium


* * *

Coming up ... Day 2 ... suicidality ... psychosomatic medicine ... alcohol withdrawal

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25 comments:

Sarebear said...

Interesting! Altho it still sounds scary to me.

NeoNurseChic said...

Oooh....the only article that my psychiatrist has his name on is in the Journal Psychosomatics and refers to day 2...Zonisimide-Induced Suicidal Ideation I think? I believe that's the name anyhow! Will post more later, but thanks for sharing this!

Alison Cummins said...

Nothing about memory loss? Some people lose staggering amounts of memory to ECT, which is why I would not accept it except as a very last resort. If I am down to a fundamental choice between my memory/self and my life, I don't know which I would choose.

I'm really not worried about the cardiac effects and so on. Those are medical and can be handled medically by doctors. But it's the patient who has to go home and live with a spouse they have no recollection of ever having met. Doctors aren't involved in that part.

I know that most people lose less memory than that, but in order to accept ECT I would have to accept this possible outcome. Not sure I would.

Roy said...

Most memory loss is periprocedure... you may not recall much about the hours to days before and after the procedure. This is less actual "memory loss" than it is never laying down the long-term memories in the first place.

Less often is significant anterograde memory loss... impaired memory going forwards, typically for days or weeks, up to a couple months (occ longer).

Less often still is retrograde memory loss... losing memories laid down prior to the procedure. This can go back 6 months (occ longer), and tends to be more loss of impersonal events rather than personal ones. It is also more a function of recall rather than loss. One long-term follow-up study showed that 7 months later, ability to recall was nearly completely restored.

Still, it is a scary thing to much with one's memory like this, so ECT is not to be taken lightly. There are also newer machines which deliver the 1-2 second electrical pulse in a manner which produces less cognitive and memory side effects. Note also that there is some controversy over how much of the memory impairment is due to the severe depression versus the treatment.

Of course, benzodiazepines cause more consistent evidence of memory impairment.

dinah said...

Interesting. I have to say, I read it this and also thought What About Memory Loss. It does seem so inconsistant. I had an inpatient (back in my resident days) who was reading a novel during ECT and had no trouble remembering the plot line from day to day, even though she'd read right after ECT. I've seen others with significant memory problems. I haven't had any outpatients have ECT in years-- it takes enough to get patients to consider Lithium (which everyone thinks sounds scary at first) that I've hesitated to even suggest ECT and the "You think I'm that Sick?!" response. One patient who would consider it, severely depressed without response to many many meds, did consider it but refused because he'd have to get someone to drive him home which would mean mentioning to his family that he was in treatment...also taking time off work and worrying about memory loss.

How's the weather there? Torrential rains and flooding yesterday here, gorgeous today.

Roy said...

BTW, I took this sunset picture at the meeting... actually pictures, as it is a composite using HDR techniques (I use Photomatix, which you can get for about $30 under academic licensing or if you have a .edu email address).

Alison Cummins said...

Roy, I understand that memory loss might not be as bad as people worry, but it’s what I would worry about in that situation.

The presentation you reported on somehow seemed to have a tone of “ECT Isn’t So Bad, mortality is no worse than general anesthesia and most of the side effects can be managed with bite block, so anyone who is hesitant is just being silly.”

Aside from the fact that general anesthesia is very scary and not to be taken lightly — so not a reassuring comparison — the fact that memory loss was simply omitted as a concern... concerns me.

I’m not against ECT per se, but this sort of disingenuous failure to mention something that is a very real and legitimate concern to the patient makes me hesitant to trust anything at all from this source.

Disclosure: the only person I know who had ECT (that I know of) didn’t complain of memory loss. It’s just that I would want it addressed fully, compassionately and respectfully by someone discussing it with me. Someone who would freely acknowledge that taking a package of a 50% chance of symptom relief and a 2% chance of severe memory loss — some people lose much more than you mentioned — is not a clear choice.

Saying that benzos are just as bad as ECT isn’t very encouraging either. Taking one benzodiazepene tablet just once is not going to damage memory (recall or storage) going back four years. If you don’t like the way they make you woozy, you stop taking them. Taking several a day for years is a different story — and is not recommended, period. If someone wanted me to go on long-term benzodiazepenes I would seek out a second opinion before considering this option.

Again, it’s not about being against ECT. It’s about wanting to be taken seriously About not wanting to be lied to (even by omission) by the people I trust to help care for me.

foreva said...

Question: what percentage (roughly) of patients suffering from depression gets ECT administered in your work places? Are they only inpatients or outpatients as well? What are the conditions under which they get it prescribed (not responding to pharmacotherapy, severeness of the ilness...)?

Thanks in advance.

Roy said...

Whoa, slow down there, Alison. I don't feel the presenter lied by omission, nor that they were saying "this is no biggie."

I did mention same-day amnesia is a common side effect. These were my notes of what I learned, so I didn't write down things I know. I think all psychiatrists know that this is an issue with ECT, but your first comment motivated me to do a bit more digging, thus the additional links in my comment above.

Looking at yours and Dinah's comments, I realize I should have said something like, "This is an issue and we need better data, but these folks focused more on the nuts & bolts of ECT, so I won't get into the memory issue." Hmm, in fact, I'll add that right now to the post. Thanks for pointing this out.

Roy said...

Foreva- I'd guess it's about a fraction of a percent at our hospital (now even less, as the guy who used to do them here left). Generally reserved for folks who have not responded to multiple adequate med trials and are at risk of dying from poor nutrition or from suicide due to strong suicidal intent or persistent psychosis, and are voluntary and able to consent. We are not now doing outpt, but in many places the outpt treatments may outnumber the inpt ones.

[also, in prior comment, it should read "muck with one's memory like that."]

Dinah said...

In defense of Roy re: failure to mention memory loss:

This is blog post. We post about what we feel like-- it's our forum to rant a bit. This isn't either a comprehensive (or even accurate) depiction of anything other than the mental life of the bloggers, and it absolutely isn't Informed Consent. Hmmm, "If you have concerns, speak with your doctor" ?? Not to be dismissive, but this is just a place to toss around ideas, not a patient resource.

NeoNurseChic said...

I think it's interesting - this morning when I read this, I had forgotten about the ECT memory side effect until I started reading the comments just now. And I was aware of the memory side effect, so it's not like I had never known that - I have it written in notes from nursing school and a couple of other things. But I simply forgot. I talk about my shoddy memory all the time - wonder if, just theoretically speaking since I'm not considering ECT and don't plan on ever needing to, I would be at a higher risk for the memory side effects because I already have problems with memory.

I've also said before that my memory was amazing....photographic even....like a steel trap...until I took topamax. And now that I've been off it for nearly 3 years now, my memory has not improved. I sometimes wonder if the chronic pain and migraine are altering my brain. I mean - repeated hits of severe pain that never lets up has got to do some sort of damage...altering chemicals, what have you. I do have at least 9 white matter lesions (haven't had a brain MRI in awhile now actually) in my brain which perhaps show evidence of migraine as a progressive disease. And sometimes I wonder if those affect my memory...like a plaque variant. Sometimes I think my memory is going bad at a young age and this is a warning sign of other memory problems in the future - although I hope not.

Sometimes I get home at night and I cannot remember a lot of things that happened during the day - and that scares me. If I can't remember them now, then is it a problem at work? But it's not. I remember things like a steel trap when at work - it is not hard for me to remember medical things. It's just hard for me to remember a lot of my day once I get home. It's also weird because when I'm at work, I can remember all kinds of details about the babies - I can remember when they had certain procedures done, and I usually have the whole history of whatever room I'm in down so well that I could give report off to the docs - but I dunno if it's a short term memory thing - a recall issue where I can't get to mmy short term memory very well but once it dumps into long term memory, then I have it. That seems the most logical.

In my psychiatry appts, recently my memory issues have been bugging me more. I have had to stop whatever I'm talking about a few times lately because I can't remember what point I was getting at or I can't even remember what I was talking about. Then usually I just ask him to give me a minute and then it either comes to me or it doesn't, but this happens a lot. I often run out of concerta and then don't have it for a few days because I'll think every morning that I need to ask for a prescription but then forget for 3 appts straight. I called him on Wednesday night to leave a message about what I want to discuss on Monday because if I don't tell him, then I won't remember - I'll probably forget the call by Monday, but at least then he can remind me. I saw him 2 days in a row this week and on the 2nd day, he referenced something we had talked about the day before, and I gave him a blank look and said, "Um...what were we talking about? I can't remember..."

It's so freaking frustrating. For someone who never had a single memory problem all my life....this is not me. But I've been this way for a couple of years now - and it waxes and wanes with how bad it gets. Right now it's just in a worst phase than usual.

Sorry - that was a somewhat sidenote since that wasn't the focus of your post - but it started off related - I was sort of thinking that I might be someone who could possibly be more susceptible to memory side effects of ECT - wonder if any research has been done on that sort of thing?

My research question of the week is why does maternal methadone use cause all babies born to white mothers on methadone to have the same look about them - bald! None of them have hair. Does methadone stunt fetal hair growth? I'm serious...it doesn't matter if they are 30 weeks or 42 weeks....if the mom was on methadone, then the baby does not have hair. Every time I bring this up, other nurses are like, "Oh really? Hmmm..yeah I guess you're right." I don't think they pay attention to things like that - but it's almost like some weird cult thing where they all look alike...pale, mottled, and lacking hair. And it sure isn't because they pulled it out in stress....that's us taking care of them that are more likely to be bald for that reason! Care to speculate on the methadone/hairless baby thing?

Dinah - thought of you this morning as the news showed an Amtrak issue from Philly to Washington affecting all trains going south from Philly today and all trains going north (with origins south of Philly) through Philadelphia on to New York. I was hoping that your husband wasn't having any commute problems due to this!

Take care,
Carrie :)

Sarebear said...

Carrie, that talking about something, and trailing off or stopping because I can't remember what I was talking about, what my point was, where I was going with what I was saying, . . . . . . . . . . . er, it happened just now, actually, as I was typing this, lol! That's ironically funny . . (pause inserted where I went blank, to indicate what happened)

In therapy, sometimes I'll just switch from a word in the middle of a sentence, to, "What was I talking about?", or, "What did I just say?"

Drives me NUTS, nuts, NUTS!

My memory problems are worrying to me, and I worry about being more susceptible to problems in the future, like Alzheimer's (I may have heard recently that long-term depression does damage the brain in ways that make one more likely to develop Alzheimer's and such than non-long-time-depressed). Not to alarm you. Although I worry about it.

Sometimes, when I'm away from an environment or type of place, I have a hard time remembering stuff about what I did in that environment or type of situation or whatever.

I can't say that all of our memory problems are the same, but I surely understand from experience alot of them.

Seriously, having one happen during this comment is ironically funny. Or something.

Sarabeara

ClinkShrink said...

Aack, I wish I had seen your program brochure sooner because I would have put in a special request. I'm really hoping you went to the Group A case study on "Repeated Ingestion of Razor Blades: Clinical and Ethical Challenges in Factitious Disorder". I have a few swallowers I'd love to get outside input on. (How's that for ending a sentence with a few prepositions?)

ClinkShrink said...

Ooo and what about the voodoo death lecture? And the one about making inexpensive podcasts? And the one about simulated sickle cell crises?

I think you picked a good conference.

Alison Cummins said...

Ooh, sorry Roy. I seem to be having a "Not Making Myself Clear" day. My apologies.

I understand perfectly that you went to a conference, took notes, and reported the notes. My comments related to my perception/intepretation of the presentation you attended, not to you. I have no idea how you talk to your patients about ECT, if at all. (While it's entirely possible that you are an unscrupulous jerk - anybody can be anything on the internet - I have seen no evidence whatever that this is the case.)

Yes, I did see the note about same-day amnesia. That was part of my concern: most people may only experience same-day amnesia, but the effects are variable. Other people may experience more; some, much more. Commenting only on the existence of same-day amnesia without noting the possibility of something worse seems peculiar at best, dishonest at worst.

In particular, given that the presentation was about how to manage ECT and make the treatment safer for a wide range of patients, I would have expected a note on left-hemisphere unilateral ECT, perhaps something along the lines of "left-hemisphere ECT is effective in limiting problems with memory recall; in a sequential population of 423 patients receiving left-hemisphere ECT, only same-day amnesia was reported." Or something. (I just made that whole thing up.)

Yes, we all know that memory loss is a concern; so why not mention (briefly perhaps, as we all know about it) the techniques used to reduce it? (Remember, this question is rhetorical and directed to the presenter, not to Roy the humble reporter.)

Also, one thing I didn't know was that ECT can be helpful for schizophrenia. Interesting.

Thanks Roy, and sorry again.

Sarebear said...

Geez! I never thought of all the interesting subjects you guys would have seminars or conferences on! I mean interesting in the abstract; of course I wouldn't be interested in the actuality of people swallowing razors! Although interesting to find out efficacious ways to treat and deal with such.

Voodoo! So if I make a lil doll of my as of yesterday no longer my iatrist, and poke pins in it . . . I can give him a PITA or a PITN, just like he's been to me? (yesterday did not go well, ugh).

Now I'm thinking of that voodoo/who do/you do exchange in Labyrinth. Fantasy version of Who's on first, kinda. Lol!

DAGNABBIT I'm all over the place today. Gotta grab all these spaghetti-like strands of thought/self and stuff em back down in the pot (self).

Sara (now craving spaghetti to go w/that lemonade and chocolate.)

Roy said...

No problem, Alison. The presenters did discuss that unilateral ECT has less cognitive impairment but is also less effective. Again, it wasn't my intent to be complete, just to put up some bullet points from the talk. (If only I had some flogging equipment, you'd be able to hear the entire speech and see some pix of the presenters. But then I'd need one of those nifty SenseCam devices (if anyone can snag me one, I am willing to wear it for a week and report here on the experience -- but I'd have to turn it off at work for confidentiality purposes).

"Anyone can be anything on the internet." True. Unscrupulous jerk? No. But my good language skills do belie my true physical identity.


Woof.

dinah said...

Roy an unscrupulous jerk?? So I tried to think, does he look like what he sounds like on the blog?
Roy is very mild mannered, soft spoken, smart and diplomatic. As psychiatrists go, he Looks more normal than the average shrink. I've never heard anyone say a bad word about him.

Clink? Oh gosh, she's pretty unique. Also very mild mannered, just unusual interests. No hair chemicals.

Dinah: I have a lot of hair.

Midwife with a Knife said...

Nice pictures! It's almost enough to inspire me to find a reason to go to Arizona. :)

Just a quick question: Did ECT improve motor function in non-depressed parkinsons patients or just depressed ones? (No real reason, just curious)

Alison Cummins said...

You all did get that I was being light-heartedly ironic, right? That I was not accusing Roy of being an unscrupulous jerk? That I was saying that while I couldn't exclude the possibility that he is secretly one in the meatworld, he doesn't appear to be one on the blog?

Oh, the worries of electronic mis/communication...

Roy said...

yes, Alison, that's what I got. My approach to perceived ambiguous online comments is to assume benign intent until unambiguously proven otherwise.
Thanks for asking.

foreva said...

Roy - thanks for the response! I hope you don't mind me asking some questions every once in a while. I'm just trying to figure out the specifics of practicing psychiatry in North America and how it differs from Poland.

One of the differences is that I've never heard of outpatients getting ECT in the hospitals I had my practicum in Poland. There is something I don't get from your post: you say that ECT is

"Generally reserved for folks who have not responded to multiple adequate med trials and are at risk of dying from poor nutrition or from suicide due to strong suicidal intent or persistent psychosis, and are voluntary and able to consent."

So are you saying that a person like that can still be an outpatient? And that in a given place there may be even more of them out, than in? How come? I mean, if somebody is at risk of dying due to any of the reasons you mentioned, doesn't that qualify as being a danger to themselves?

Btw, I'm not challenging what you said in any way. It's a genuine question about the system.

Thanks!

Roy said...

I can see why this doesn't make sense. So, not only is ECT used to TREAT depression, it is also used to PREVENT a relapse, or to sustain a remission.

For example, one of the presenters mentioned a pt with recurrent depression who responds to ECT (and nothing else), and whose depression will return unless she gets one shock every 6 weeks. Longer, and her depression sets it... once set in, it takes a full course to get it better again.

So, she gets MAINTENANCE ECT every 6 weeks. That's where the outpt treatments can outnumber the inpatient ones... either they are there for maintenance ECT, typically every 4-12 weeks, or they are completing a course of treatment that was initiated in the inpt setting, they get better (safe for outpt) but need a few more to get maximal response.

Hope that clarifies things.

foreva said...

Now I get it. Thank you Roy!