A very short but accurate list of 5 questions to ask yourself when faced by this decision. From Johns Hopkins Health Alert.
Answers to other three important questions on the site of The Royal College of Psychiatrists 1. How is ECT given 2. The Pros and Cons of ECT 3. Controversies in ECT
Excellent lecture on ECT with his own experience with the treatment.
Sherwin Nuland, the surgeon and author, talks about the development of electroshock therapy as a cure for severe, life-threatening depression. Midway through, his story turns personal. It’s a moving and deeply felt talk about relief, redemption, second chances.
About Sherwin Nuland
A practicing surgeon for three decades, Sherwin Nuland witnessed life and death in every variety. Then he turned to writing, exploring what there is to people beyond just anatomy. Read full bio »
In this last week 2 additional sites with trustworthy information about ECT were discovered.
Electroconvulsive Therapy Consensus Development Conference Statement. This information is presented by National Institutes of Health in conjunction with the National Institute of Mental Health on a Consensus Development Conference on Electroconvulsive Therapy on June 10-12, 1985. A consensus panel representing psychiatry, psychology, neurology, psychopharmacology, epidemiology, law, and the general public considered the scientific evidence and agreed on answers to the important questions about this treatment.
More recent and up to date is information about Electroconvulsive Therapy (ECT) by Dr. Raymond Crowe, MD Professor of Psychiatry University of Iowa Department of Psychiatry Peer Review Status: Internally Peer Reviewed First Published: March 2000 Last Revised: December 2004
Previous articles about Electroconvulsive therapy (ECT) on this blog:
Your genes probably predict response to ECT more accurate then any clinical variable.
Genes, enzymes and neurotransmitters Genes are located on DNA in the nucleus of the cells in your body. You usually have two genes on each arm of a chromosome ( one from dad and one from mum). If the two genes are identical it’s called that they are homozygote, if they are different it is heterozygote. Genes are read by other cell nucleus material (RNA) which starts a sequence to produce proteins. The most important proteins being enzymes. Enzymes are needed for the metabolism of neurotransmitters among others. Neurotransmitters are chemicals that are used to relay, amplify and modulate electrical signals between a neuron and another cell in the brain. Catechol-O-MethylTransferase (COMT) is a major enzyme in the brain for the metabolism of dopamine, a neurotransmitter. A polymorphism in the gene coding for COMT results in substantial effects, with a homozygote allele variant leading to a three to fourfold reduction in enzymatic activity compared to the other homozygote variant. In general, polymorphism describes multiple possible states for a single property. This single property being a single amino-acid sequence in the allele for COMT. The presence of Met/Met and Met/Val or Val/Met results in a much lower activity of COMT than Val/Val (high activity).
Low Dopamine concentration in Prefrontal Cortex The high genotype of COMT was associated with better treatment response to ECT than low allele containing genotypes. Since high genotype results in a high activity of COMT and a low dopamine concentration in the prefrontal cortex we can assume that low dopaminergic activity in the prefrontal cortex is associated with a better response to ECT.
This was shown in 119 treatment-refractory depressed patients admitted consecutively for electroconvulsive therapy (ECT). The effect of clinical variables also related to a better response to ECT were studied using univariate analysis of variance. These covariates: higher illness severity, age, age at onset, sex and the number of ECT treatment did not affect the treatment response.
Not all studies with COMT polymorphism and response to antidepressants found an association between this polymorphism and response. COMT also plays a role in the metabolism of norepinephrine, another important neurotransmitter in the brain. Other limitations of this study are a small patient sample and the concomitant use of psychotropic drugs during ECT. ECT itself was properly performed.
Biological variables predicting response A very nice publication in a new field of research. Important topic predicting response in a patient with biological variables.
Publication: Catechol-O-methyltransferase(COMT) polymorphisms predict treatment response in electroconvulsivetherapy
No severe cognitive side effects of ECT used on adolescents could be demonstrated. ECT in adults causes memory complaints, retrograde and anterograde amnesia. The tests used in trials with adolescents are limited in measuring these side effects. Moreover there are no prospective studies on this subject with adolescents and the studies discussed have a small number of subjects with possible lack of statistical power.
Publications about ECT and side effects in adolescents So far I was able to find four articles about cognitive side effects of ECT in adolescents. They belonged to two different research groups. From the department of psychiatry of the university of Michigan there is a study in which 5 of 11 adolescents treated with ECT were tested both before and 1-5 days after the last ECT. The neuropsychological tests revealed a significant decline in attention, concentration and long-term memory search. In another publication by this group they collected retrospective data resulting from clinical care with naturalistic follow up of 16 adolescents treated with ECT for mood disorder. Cognitive tests administered before ECT were compared with results at 7 days following the last treatment as well as another testing at 8 months after the last treatment.
Cognitive side effects 1
Testing directly after ECT and compared to the test before ECT yielded significant impairments of concentration, attention, verbal- and visual delayed recall, and verbal fluency. A complete recovery of these functions was noted at the second post-ECT testing. There were no impairments of motor strength and executive processing, even during the early period post ECT.
These studies had little focus on memory disturbances with ECT in adolescents. The other group from Paris, France focused on memory function. 20 adolescent patients treated with ECT during the period 1987-1996 were contacted for follow up. For various reasons only 10 could be included. Another 10 subjects comparable for sex, age, date and place of hospitalization and diagnosis were considered as a control group. All subjects were given a battery of clinical and cognitive evaluations. The most important being the Wechsler Memory Scale and California Verbal Learning test , which assesses anterograde amnesia and verbal learning as well as Squire’s Subjective Memory Questionnaire for subjective memory complaints.
Cognitive side effects 2
The ECT group did not differ significantly on all cognitive tests at an average of 3.5 years after the last ECT compared to the matched control group.
Lousy tests Trouble is that all these tests are of no use for the memory effects of ECT at all. The Wechsler Memory test is like the original Wechsler Memory Scale, and provides only a rough estimate of overall memory functioning. The multidimensional index scores have not been shown effective in describing the nature or the pattern of memory deficits. The California Verbal Learning Test (CVLT) is a popular clinical and research test that claims to measure key constructs in cognitive psychology such as repetition learning, serial position effects, semantic organization, intrusion, and proactive inteference.
In an earlier article the lack of proper memory tests for testing retrograde and anterograde amnesia in adults treated with ECT is mentioned.
Hypoperfusion of parts of the brain in depressive disorder largely normalizes after response to antidepressants. Perfusion changes after response to electroconvulsive therapy (ECT) follows a different course. This interesting conclusion is recently published in the Journal of Nuclear Medicine. The design of this study delivers interesting results besides those already mentioned.
First they compared healthy controls with depressed patients without medication for at least 2 weeks before undergoing SPECT. Single photon emission computed tomography (SPECT) is a nuclear medicine tomographic imaging technique using gamma rays. It is very similar to conventional nuclear medicine planar imaging using a gamma camera. However, it is able to provide true 3D information. Usually the gamma-emitting tracer used in functional brain imaging is 99mTc-HMPAO (hexamethylpropylene amine oxime). 99mTc is a metastable nuclear isomer which emits gamma rays which can be detected by a gamma camera. When it is attached to HMPAO, this allows 99mTc to be taken up by brain tissue in a manner proportial to brain blood flow, in turn allowing brain blood flow to be assessed with the nuclear gamma camera. Because blood flow in the brain is tightly coupled to local brain metabolism and energy use, the 99mTc-HMPAO tracer (as well as the similar 99mTc-EC tracer) is used to assess brain metabolism regionally.
Compared with healthy controls depressed patients had a significant lower regional cerebral blood flow (rCBF) before treatment over the frontal lobes and the subcortical nuclei (amygdala, caudate, thalamus and hypothalamus). The effect of antidepressants and ECT were compared with these baseline measures after treatment. Another SPECT was performed after 6 weeks of medication or completion of the ECT course. For those patients who responded to antidepressants, a significant increase in rCBF was found in the right parietal lobe of depressed patients. No perfusion changes were found in non-responders. No perfusion differences were found between medication responders and controls. In other words, responders on antidepressants had regained normal cerebral blood flow comparable to normal controls.
In contrast, rCBF was still lower in ECT responders than in controls, in the same region as before treatment as well as in the occipital and cerebellar regions. Especially this last finding is of interest since previous studies used the cerebellum as reference region for data analysis assuming the cerebellum had nothing to do with depression. The cerebellum was not traditionally considered a major contributor to the neurocircuitry of mood regulation. This assumption has to be refuted, cerebellar dysfunction is known to have an impact on cognition and affect. The fact that further reduction in rCBF in posterior brain regions occur after response to ECT could be a state phenomenon or a trait phenomenon. Long term studies are needed to document the course of rCBF changes.
This is the Talairach under-surface view showing the Prefrontal Inferior Orbital area at the top of the picture and the Temporal lobes in the middle of the picture. With Major Depression we see significant decreased blood flow to both of these areas of the Brain as is shown here.
Reduced perfusion to the frontotemporal cortex bilaterally.
99mTc-HMPAO SPECT Study of Cerebral Perfusion After Treatment with Medication and Electroconvulsive Therapy in Major Depression Yoav Kohn,Nanette Freedman,Hava Lester,Yodphat Krausz,Roland Chisin,Bernard Lerer,and Omer Bonne. J Nucl Med 2007;48:1273–1278.
Electroconvulsive therapy during pregnancy should be performed with caution. In a case report a woman with a first time pregnancy received ECT during pregnancy. She was on maintenance ECT, every 2 weeks during her pregnancy she received ECT. She had a bipolar depression and was only partially responsive to conventional medical therapy.
Fetal heart rates were recorded after each treatment but it was unclear how soon after the treatments and at what gestational age this testing began.
At 36 weeks she had an elevated blood pressure and elevated protein on a 24-hour analysis. Labor was inducted because of preeclampsia. The newborn unexpectedly had severe neurological deficits associated with multiple brain infarcts.
Preeclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn baby. Affecting at least 5-8% of all pregnancies, it is a rapidly progressive condition characterized by high blood pressure and the presence of protein in the urine. Preeclampsia and other hypertensive disorders of pregnancy are a leading global cause of maternal and infant illness and death.
A cause and effect relationship between ECT and the inter hemispheric infarcts cannot be established. Whether ECT in this case led to tetanic uterine contractions causing a fetal bradycardia or possibly induced a fetal arrhythmia, resulting in fetal brain injury, is purely speculative. This chain of events does not seem likely because uterine contractions of sufficient strength to severely limit placental blood flow probably would have been noticed by the patient. Other possible explanations for this complication could be the preeclampsia, and medication use is not mentioned in this case report.
There are no prospective or controlled studies exploring the effects of ECT on pregnancy and the foetus. Many case reports have been written but these data do not provide evidence for definitive conclusions. According to the editorial in the same issue of this case report:
How likely is it that a study could be done to show a statistically significant association between ECT and fetal brain injury? If the rate of neurological impairment in an unexposed control group was in the range of 1 in 1,000 births and the rate of injury in infants of ECT-exposed women was 10 times higher, a prospective cohort study would have to enroll over 1,000 women in both the treated and control groups to demonstrate this difference with statistical significance. Given the rarity of ECT use in pregnancy, such a study would obviously not be feasible.
Nevertheless the American Psychiatric Association has published guidelines for management of a pregnant patient undergoing ECT.
These guidelines are aimed at minimizing potential complications including aspiration and altered uteroplacental blood flow. Specific recommendations include
1. Consultation with an obstetrician before initiation of treatment.
2. Treatments performed in a facility with immediate access to obstetric care for emergencies.
3. Monitoring of fetal heart rate before and after treatments. Increase in monitoring at viability to include a non stress test with tocometry after treatments. Perform a Level 2 ultrasonography between 18 weeks and 22 weeks gestational age.
4. Routine anesthetic measures (leftward tilt of trunk, adequate oxygenation, hydration, and muscle relaxation, nonparticulate antacid, consider intubation in the third trimester).
But above all ECT in pregnancy should only be used in cases of emergency in which any delay is life threatening or when medication has failed. Given the risks of non treatment of major depression and the undefined risk of ECT in pregnancy, we must, as the authors of this case report suggest, use drug therapy as our first-line approach to treatment. The neonatal risks with pharmacotherapy are real, but adverse effects generally do not have long-term consequences. Most importantly, in contrast to ECT, large-scale studies on drug therapy have been performed, allowing the risks to be quantified.
In our next post will be talking about postpartum tubal ligation after pregnancy complicated by preeclampsia or gestational hypertension. This is to determine the anesthetic and surgical morbidity associated with postpartum tubal ligation after pregnancy complicated by pregnancy induced hypertension. About the tubal surgeries you can look for Tubal Reversal Surgeon Birmingham AL which has the most advanced methods for tubal reversal or tubal sterilization reversal or tubal ligation reversal, this surgical procedure can restore fertility to women after a tubal ligation, and can give women the chance to become pregnant again, not with the matter of recent issues or diseases.
Let’s be careful out there. Sgt. Phil Esterhaus, Hill Street Blues.
Article:
Pinette MG, Santarpio C, Wax JR, Blackstone J. Electroconvulsive therapy in pregnancy. Obstet Gynecol 2007;110:465–6.
Editorial:
Is Electroconvulsive Therapy in Pregnancy Safe?[Editorial]
Obstetrics & Gynecology. 110(2, Part 2) (Supplement):451-452, August 2007.