Dr Shock MD PhD » ECT

ECT Hands On Experience

Dr Shock — Mon, 12 Jul 2010 18:48:59 +0000

Aqua is a very good writer, an inspiration for this old doctor. Recently see underwent ECT and is writing her experiences with this treatment on her blog: honestly, nuanced and informative. Not all is good news, but than you will not undergo ECT for nothing and she has been there.

Please read her first post on this subject on her blog: ECT 1, Making The Decision, hope a lot will follow.

How is ECT depicted in the British Press?

Dr Shock — Fri, 19 Mar 2010 07:12:59 +0000

From all the newspapers in the last seven years in British national newspapers about 348 mentioned ECT or electroconvulsive therapy or electroshock and it’s other synonyms. Overall 111 articles (31,9%) portrayed ECT negatively, 198 articles were neutral and 39 were positive. A substantial comment on ECT was published in 44 (12,6%) articles. The negative comments (14/16) were published in liberal newspapers whereas most positive comments about ECT (10/12) were published in conservative newspapers.

Overall most depictions of ECT were neutral, with smaller numbers of negative (111) and positive (39) representations. Not bad compared to the depiction of ECT in Hollywood movies.

Euba R, & Crugel M (2009). The depiction of electroconvulsive therapy in the British press. The journal of ECT, 25 (4), 265-9 PMID: 19444139

Blogging About ECT, Hands on Experience

Dr Shock — Thu, 12 Nov 2009 11:08:21 +0000

The best information in health care is from patients who have been there. Those who underwent treatment, suffer from a certain illness. It’s the kind of hands on experience physicians can’t deliver. On this blog I have collected some examples of these “hands on experiences”. Some recent posts were written about ECT by them with hands on experience.

Aqua on Vicarious Therapy wrote a post on ECT and media portrayals of depression treatment options. She is irritated by the negative portrayal of ECT in the media.

It irritates me, (and does not help me explain potential treatments to concerned family members), when the media, either by negative portrayal or by leaving positive and informative information about ECT out of stories about depression treatments, subtly dismisses or devalues an effective and proven helpful treatment for resistant/refractory depression.

Besides here opinion on ECT she also writes about treatment resistant depression. Rightfully she points to the fact that despite all the treatment options sometimes depression is not a treatable disease. Read her post on this topic here….

On jumpstarting a life with a little spark on the head the 7th lesson about ECT is presented. Yes this blog has some excellent lessons for ECT patients. This 7th lesson is about being informed on ECT. Two books about ECT are discussed:

Both of these books are not long (about 100 pages) but more detailed than much of the information I gathered on the web. These books are definitely more clinical in nature, but they are easy to understand and I think these details help you be more calm when you go through treatment.

For a more prosaic discussion on ECT and it’s efficacy please read: An E.C.T. morning by pistolpete on Necessary Therapy

Almost a year later and I’m still wondering if E.C.T. was right for my particular case. Given the information we had at the time, I have to believe it was worth a shot.

Mental health Update discusses a recent article: Rayner, Lauren … [et al] – The patient perspective of the consent process and side effects of electroconvulsive therapy Journal of Mental Health October 2009, 18(5), 379-388. It’s a survey of 389 people who had had ECT focusing on the consent process and side effects of the treatment. Interesting read.

ECT Update A Year Later

Dr Shock — Thu, 22 Oct 2009 06:48:29 +0000

This courageous young woman Rachel Star (on twitter) tells about the negative an positive aspects of ECT, a year later. Very impressive story from someone who has been there and is getting along.

A kind of sequel of a video at the beginning of this year just before and during the course of ECT on this blog: Hands on experience on video about electroshock therapy.

A young woman and her mother on this video about ECT. Very impressive story about having ECT, side-effects and how she improved on ECT.

ECT Lessons

Dr Shock — Fri, 02 Oct 2009 12:58:21 +0000

Told you earlier this year about an excellent blog of someone undergoing Maintenance ECT at the moment: Jumpstarting a life with a little sparkle to the head.

After the fourth lesson there is now a fifth ECT lesson: After ECT treatment continues:

I know that by the time we’re considering ECT, we are barely able to make it through the day, but I think it’s better to ask and know upfront what turns your life could take post-ECT rather than be surprised by something that’s already been documented that it might happen.

And even a sixth ECT lesson: Communication is key

If you experience any physical discomfort after ECT, such as a really bad headache or a sore throat/jaw pain, you should let your doctor know. S/he may be able to adjust your mouth guard or give you something for the pain.

The author also describes the maintenance treatments: ECT #21 (my sixth maintenance treatment….and the 200th post)

What Every Doctor Should Know About ECT

Dr Shock — Thu, 03 Sep 2009 06:55:44 +0000

This week we had to treat a patient with electroconvulsive therapy (ECT). He had a pacemaker. The cardiologist offered to be there during the first treatment to see how things were going with the pacemaker during ECT. Everything went just fine except for the astonishment of the cardiologist. He was flabbergasted about the ECT procedure. He never realized that his ideas and fantasies were far beyond reality. He still had “one flew over the cuckoo’s nest” in his mind. Moreover, he now better understood the challenges faced during ECT. Heart rate and blood pressure can increase for a short while.

This is not our first experience with other doctors from other specialties. Doctors still have the wrong ideas about ECT. In The Netherlands most physicians especially those trained in the sixties, seventies, eighties and nineties of the previous century never saw an ECT treatment. They haven’t got a clue what is actually happening during the procedure. That’s why we always oblige to questions from other specialists but also psychiatrists who never have seen ECT to witness the procedure in our department.

Things have changed. Every medical students now hears and sees ECT at least on video. At least one lecture is given during medical education. All medical students during clerkship in our hospital witness ECT at least once.

During the making of our new guidelines for ECT we had the pleasure of discussing our new guidelines with a focus group with patients who were still undergoing maintenance ECT or who had been treated with ECT in the past. Some of them told us that when they were admitted to a hospital or visiting an outpatient department other than psychiatry and the doctor or nurses learned that they were or had been treated with ECT there faces usually turned pale and they suddenly acted very different from before, mostly with anxiety. That’s not new, other patients with a psychiatric history are sometimes met with fright and disbelief by other health professionals.

Besides these more opinionated views on ECT, doctors also definitely need to know more about the physical consequences of ECT. Luckily two excellent reviews were published on Medical Evaluation of Patients Undergoing Electroconvulsive Therapy and Electroconvulsive therapy: What the internist needs to know. The first in the New England journal of Medicine and the latter in the Cleveland Clinical Journal of Medicine.

The two links above will take you to Scribd were you can read both excellent papers with iPaper. Please read them when in need of information about ECT, risk assessment and patient optimization before ECT or management of preexisting medical conditions.

Usually just an history and physical examination is all the routine evaluation takes. This is to screen patients for conditions that may increase the risk associated with ECT. Laboratory testing can be tailored to the patient’s medical history and medications. ECG are only needed in patients older than 50 years and those patients with a history or signs with physical examination that warrant further analysis.

Conditions that might increase the risk associated with ECT are: cardiovascular disease (ischemic heart disease, heart failure, and arrhythmia), intracranial mass lesions, recent stroke, and pulmonary conditions (chronic obstructive pulmonary disease, asthma, and pneumonia).

Before ECT is performed, patients require a medical evaluation to undergo anesthesia, and some may need special consultation.

Hands On Experience with ECT

Dr Shock — Fri, 24 Jul 2009 06:30:11 +0000

Found another excellent blog of someone undergoing ECT. Besides writing about his or her experiences with ECT there are also posts on other topics as well such as depression, mental health rsources etc.

ECT lessons I’ve learned #4, write them down:

When I went through ECT the first time around, I wrote down my passwords to the various online accounts that I have on a sheet of paper. This advice came from the book Shock by Kitty Dukakis and Larry Tye. It’s a great safeguard measure, and it was probably good to have my memory refreshed about those passwords anyway.

Keep a record of what you did each day during your ECT series. I think my main reason why I was able to remember a lot of the events surrounding my ECT treatments is because I wrote stuff down. Even just writing down your mood may be helpful in tracking how you are doing.

If there’s something you’re supposed to remember (even if you remember at that moment), write it down.

Another blog written by ECT/Psychiatric RN: ECT Today, has only 2 posts but they are very good, one is a FAQ post, hope he or she will continu writing this excellent information.

Related posts on this blog:

Hands on experience on video about electroshock therapy

Another Hands On Experience with ECT

“Hands-on” Expert writes about her Experiences with ECT, electroconvulsive therapy

Lou Reed and ECT, or A Perfect Day

Major enhancements to Electroconvulsive therapy

Dr Shock — Fri, 29 May 2009 07:25:55 +0000

The major recent enhancements to ECT technique are:

Right Unilateral electrode placement. The cognitive side-effects of ECT such as retrograde and anterograde amnesia are significantly less compared to Bilateral electrode placement.
Brief pulse stimulus currents. The characteristics of the electrical stimulus affect the effectiveness and cognitive outcomes of the seizure. Sine wave stimuli have been replaced with rectangular pulses on modern ECT devices, leading to a substantial decrease in cognitive effects
Improved anesthesia techniques makes it possible to regulate the cardiac output during ECT when necessary
The “dose titration” technique to individualize treatment stimulus dosing
The discovery of the dose-response relationship between electrical stimulus dosing and antidepressant outcome with RUL electrode placement
Pulse width. Several studies conclude that right unilateral (RUL) electroconvulsive therapy (ECT) given with ultrabrief pulse-width stimulus packages causes less cognitive impairment than other techniques

Contemporary ECT devices can be set to deliver pulse-widths between 0.25 and 2.0 milliseconds. Stimuli between 0.5 and 2.0 milliseconds are called “brief,” and those less than 0.5 millisecond are called “ultrabrief.”

A recent study from Sackeim and colleagues was published about ultrabrief puls width and efficcay and cognitiev side-effects. Those participating in this trial were assessed for depressive symptoms and cognition at baseline, during and after the acute course of ECT, and at 2 and 6 month time points. Responders were monitored for 1 year. Reported remission rates were 73% for ultrabrief RUL, 65% for brief pulse BL, 59% for brief pulse RUL, and 35% for ultrabrief BL. Ultrabrief pulse RUL produced less severe cognitive effects than the other 3 treatment groups, both acutely and long-term, on multiple measures in several cognitive domains, including subjective assessment of memory function. Relapse in the year following acute ECT was unrelated to treatment group. These authors concluded, “the use of an ultrabrief stimulus coupled with high-dosage RUL stimulation is a strategy that appears to retain the therapeutic properties of ECT, although substantially reducing its potential for adverse cognitive side effects.”

The big problem is that ultrabrief bilateral treatment is less efficacious in this trial than Right unilateral electrode placement. Normally bilateral ECT is the most efficacious form of ECT. Is this a real difference or is this another strange finding from the Columbia University Group comparable to their results with medication resistant depressed patients. According to their research patients with “medication resistance” as defined by arbitrary (ATHF) criteria were less responsive to ECT. Other researchers couldn’t find any influence of medication resistance on efficacy of subsequent ECT. It seems that medication resistance is irrelevant in the decision for a trial of ECT in patients with severe depressive illness, whether psychotic or non-psychotic.

Does pulse width influence efficacy of bilateral ECT? Opinion from another expert, Charles H Kellner:

Fortunately, the nature of ECT is such that if, after several RUL treatments with ultrabrief pulse stimuli, the patient is not responding adequately, the treatment technique can be switched, either to a different waveform or electrode placement, or both.

We did a retrospective study comparing bilateral ultrabrief pulse width compared to brief pulse width for depressive disorder. We couldn’t find a significant difference. Is to be continued.

SACKEIM, H., PRUDIC, J., NOBLER, M., FITZSIMONS, L., LISANBY, S., PAYNE, N., BERMAN, R., BRAKEMEIER, E., PERERA, T., & DEVANAND, D. (2008). Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy Brain Stimulation, 1 (2), 71-83 DOI: 10.1016/j.brs.2008.03.001

Hands on experience on video about electroshock therapy

Dr Shock — Fri, 13 Mar 2009 06:12:44 +0000

Watch If You Forget @ Yahoo! Video

A young woman and her mother on this video about ECT. Very impressive story about having ECT, side-effects and how she improved on ECT.

She also has a website The Amazing Rachel Star

Hey, I’m Rachel Star! I am a lot of things: stunt girl, producer, visionary, rapper, writer, mastermind, a cuddly form of evil, poet, and schizophrenic. I work with different TV shows around the world and I love creating and working on all forms of entertainment.

The use of ECT declines in the United Kingdom, what about the rest of Europe?

Dr Shock — Mon, 16 Feb 2009 04:53:40 +0000

Compared to 1999 and 2002 data from a recent survey in 2006 show an overall decline in the number of ECT applications and the number of patients treated in the United Kingdom over the 7-year period between 1999 and 2006. An increasing proportion of patients were treated under the Mental Health Act (1983).

Clinical implications

The number of ECT clinics is likely to continue to decrease and psychiatrists may have decreasing experience of treating patients with ECT.

In The Netherlands there is an opposing trend. In the past decades the number of clinics preforming ECT has increased and the number of patients being treated also increased, but than the state of ECT was deplorable in the eighties of the previous century. In 1992 only 30 patients in 1 year were treated with ECT on a population of 13 million people. In 2000 it were around 300 patients a year. The restricted use of ECT in The Netherlands in those day was due to socio-political factors such as unfavourable public perception and professional attitude.

From a recent survey in The Netherlands (Journal of ECT, published ahead of print) (2008) of all Dutch facilities with mental health beds in 2008, all 8 university hospitals (100 %), 16 of 86 (19 %) general hospitals and 11 of 48 (23 %) psychiatric hospitals had an ECT service. The total amount of ECT sessions in the Netherlands was approximately 13,500 a year (8.5 sessions per 10,000 inhabitants). This is low compared with e.g. the 14 treatments per 10,000 in Scotland and the approximately 27 per 10,000 in the USA. However, use of ECT in the Netherlands has increased substantially since 1999, at which time it was only 1.8 per 10,000 inhabitants

For comparison in Belgium a recent nationwide survey among all the psychiatric services providing ECT revealed that in 2003-2004 ECT was performed in 32 psychiatric services (21.5% of all psychiatric services). ECT is available in 13.6% of psychiatric hospitals and 32.8% of general hospitals with a psychiatric department, but two thirds of these ECT facilities treat less than 2 patients per month. The annual rate of ECT use in Belgium is increasing. In 2000, the ECT rate was 4.8/10,000 inhabitants. By 2006 it had increased to 6.6/10,000 inhabitants. For more information from one of the experts of ECT in Belgium please see the blog: Electroconvulsive therapy

According to the University of Munich, the renaissance of ECT in Germany is still ongoing; from 1995 to 2002 the number of treatments in that hospital more than doubled. From personal communications we learned that in Portugal, in the past few years, a total of 6 ECT-units became active, 3 of which are situated in the Lisbon area (Lisbon, Amadora). These units performed a total of 500-1200 treatment sessions in 2007. This corresponds to an ECT-rate of 0.5-1.2/10.000 inhabitants. Data on the use of ECT in France and Spain are scarce or very limited.

Since recent the European Forum For Electroconvulsive Therapy EFFECT was founded. The mission of EFFECT is:

EFFECT aims to promote access to safe and effective ECT when appropriate for patients across Europe by promoting research into ECT, combating the stigma associated with ECT, educating and informing both mental health professionals and the general public about ECT and its use.

This seems to benefit the deplorable state of the use of ECT in some European countries. Now back to the UK. The authors of this publication of the survey stated the following reasons for the decline:

The National Institute for Health and Clinical Excellence (NICE) has recommended restricting its use to severe depression, catatonia or severe mania when other treatments have failed
Electroconvulsive therapy is under a process of centralisation and rationalisation, which may reflect the lower numbers of patients treated and a need to concentrate resources and local expertise in driving up standards
Availability of a greater variety of safe alternative antidepressants
Patient resistance
A reduction in in-patient bed numbers

Probably the amount of patients treated in the UK and the rest of Europe will meet somewhere in between. In the UK, ECT used to be frequently used, in the rest of Europe ECT was underutilized until recent. What do you think?