The New Clinical Science of ECT

C. Edward Coffey, MD Affiliate Professor of Psychiatry and Behavioral Sciences Medical University of South Carolina Charleston, South Carolina Fellow and Past President, International Society of ECT and Neurostimulation (ISEN) Faculty Disclosure

• C. Edward Coffey, MD has no financial relationships to disclose relating to the subject matter of this presentation. 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. Learning Objectives

• Review the efficacy of and indications for electroconvulsive therapy (ECT)

• Review the safety of ECT

• Assess the importance of ECT technique to the efficacy and safety of ECT

• Describe the approach to creating a “family-centered” patient experience with ECT 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 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, 2019. The Expanding World of Brain Stimulation Therapies

Electroconvulsive therapy (ECT) Transcranial magnetic stimulation (TMS) Focal electrically-administered seizure therapy (FEAST) Magnetic seizure therapy (MST) Cranial electrotherapy stimulation (CES) Transcranial direct current stimulation (tDCS) Vagus nerve stimulation (VNS)

Deep brain stimulation (DBS) Case Presentation (with permission) ECT is the Most Effective Treatment Option for Major Depression

80 83 70

60 64

Remitted (%) Remitted 40

30 36 33 30 20 25 10 14

0 ECT ECT/Psychotic Dep Citalopram Ketamine rTMS (Open label) rTMS (Sham RCT) n=92 dTMS n=531 n=77 n=4,041 n=47 n=100 n=233 Treatment Modality

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. Brain Stimulation Therapies Compared

Mutz J, et al. BMJ. 2019;364:l1079. ECT Resolves Suicidal Behavior

Slide shows # of ECT needed to resolve suicidal ideation (≥ 3 out of 4, HAMD24 [n=131]) over course of ECT. Fink M, et al. J ECT. 2014;30(1):5-9. How Effective is ECT?

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 – “Balanced” 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). Mechanism(s) of Action of ECT

A Balance in Functional Neuroplasticity in Brain Regions Associated with: • Seizure initiation (green) • Seizure generalization (blue) • Seizure termination (red)

Leaver AM, et al. Biol Psychiatry. 2019;85(6):466-476. How Safe is ECT? • Low Mortality – ≤ 2 per 100,000 treatments, and improving – FDA Class II (moderate risk) devices in patients ≥ 13 y/o (12/2018) • 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; 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 ECT

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. ECT Stimulus Parameters and Dosage

Brief Pulse (0.5–1 ms)

Ultrabrief Pulse (≤ 0.3 ms)

Bitemporal Right Unilateral Bifrontal

BT = BF > RUL

Lisanby SH. N Engl J Med. 2007;357(19):1939-1945. How is ECT Best Administered?

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

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 Essential Role of Patient and Family Experience

Today’s Delivery Room

Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79. Coffey MJ, Coffey CE. J ECT. 2019;35(2):73-74. The Essential Role of Patient and Family Experience Today’s Pediatric Trauma Bay

Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79. Coffey MJ, Coffey CE. J ECT. 2019;35(2):73-74. Perfect ECT Care in Real Time

Coffey CE. J ECT. 2003;19(1):1-3. Coffey MJ, Coffey CE. NEJM Catalyst. June 12, 2019. http://catalyst.nejm.org/assessment-of-care-tool- real-time-pursuit/. Accessed July 10, 2019. ECT Family Focus Group (with permission)

Coffey MJ, Coffey CE. J ECT. 2016;32(2):78-79. Coffey MJ, Coffey CE. J ECT. 2019;35(2):73-74.