Electroconvulsive therapy: a neurologic perspective

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ECT for neurologists

ECT for neurologists

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  • 1. Electroconvulsive therapy: aneurologic perspectiveAhmad Eid al-AjhuriBoard-certified in psychiatry, MScMed, MBChBEmory mini-fellowship of ECTDirector of Abbassia Training Program (ATP)
  • 2. Electroconvulsive therapy: ECT Epilepsy & Dementia Praecox Meduna: Camphor oil, 1934 Cerletti & Bini: ECT, 1938 More than 70 years of continuous practice. Level (Ia) in depression management Still a controversial practice! Anti-ECT articles, more than 20 Hollywood movies, and lastly an impressive stigma. ajhuri@gmail.com Cairo, Jan 2012 2
  • 3. “Neurologists are generally not well versed in ECT and psychiatrists tend to overlook ECT when it comes to patients with co-morbid neurological conditions”Burgut FT, Kellner CH. Electroconvulsive therapy (ECT) for dementia with Lewy bodies. Med Hypotheses. 2010 Aug;75(2):139-40. ajhuri@gmail.com Cairo, Jan 2012 3
  • 4. Tools of brain stimulationSwartz CM (editor): Electroconvulsive and Neuromodulation Therapies. Cambridge University Press. 2009 ajhuri@gmail.com Cairo, Jan 2012 4
  • 5. ECT helps brain to work: fewseconds with long effects ! ajhuri@gmail.com Cairo, Jan 2012 5
  • 6. The centrencephalic theory of seizure generalization  Regional cerebral blood flow (rCBF): increases extensively, particularly in the centrencephalic structures in generalized seizures.Differences in cerebral blood flow between missed and generalized seizures withelectroconvulsive therapy: A positron emission tomographic study HarumasaTakano, Nobutaka Motohashi, Takeshi Uema, Ken’ichi Ogawa, Takashi Ohnishi, MasamiNishikawa, Hiroshi Matsuda Epilepsy research 1 November 2011 (volume 97 issue 1 Pages225-228 ajhuri@gmail.com Cairo, Jan 2012 6
  • 7. ajhuri@gmail.com Cairo, Jan 2012 7
  • 8. ajhuri@gmail.com Cairo, Jan 2012 8
  • 9. EEG  Relative alpha activity (8.5 12.0 Hz) increased in occipital lobe after a course (qEEG analysis)Y. Kitaura, K. Nishida, R. Hama, Y. Takekita, M. Yoshimura, A. Tajika, T. Kinoshita,P27-6 Quantitative EEG analysis of electroconvulsive therapy response for senile depression: acase report, Clinical Neurophysiology, Volume 121, Supplement 1, October 2010, Page S264 ajhuri@gmail.com Cairo, Jan 2012 9
  • 10. Vagal system stimulation  ECT increases vagal activity which might be associated with the beneficial effect seen following ECTBär KJ, Ebert A, Boettger MK, Merz S, Kiehntopf M, Jochum T, Juckel G, Agelink MW.Is successful electroconvulsive therapy related to stimulation of the vagal system?J Affect Disord. 2010 Sep;125(1-3):323-9. ajhuri@gmail.com Cairo, Jan 2012 10
  • 11. Electrode placementBT RUL BF d’Elia Letemendia ajhuri@gmail.com Cairo, Jan 2012 11
  • 12. ECT seizure Vs Epileptic seizure ajhuri@gmail.com Cairo, Jan 2012 12
  • 13. Official recommendations Three major practice recommendations have been published on ECT: ◦ APA Task Force on ECT (2001) ◦ Third report of the Royal College of Psychiatrists’ Special Committee on ECT (2004) ◦ National Institute for Health and Clinical Excellence (NICE 2003; NICE 2009) ajhuri@gmail.com Cairo, Jan 2012 13
  • 14. Egyptian MHA, 2009 Mandates: general anesthesia & muscle relaxation. Informed consent / agreement of 2 assessments from 2 registered specialists. National Accreditation Policy for ECT units and clinics is now under-running in NMHC.MHA: mental health actNMHC: national mental health commission ajhuri@gmail.com Cairo, Jan 2012 14
  • 15. ECT amnestic syndrome  Transient / permanent  Electrode placement or electrical dosage :No significant evidence-base that their predictive value regarding cognitive outcome following brief- pulse ECT after the subacute period.M. Semkovska, O. Babalola, D. Keane, D.M. McLoughlin, P.1.g.008 Cognitive effects ofelectrode placement and stimulus dose in brief-pulse electroconvulsive therapy fordepression, European Neuropsychopharmacology, Volume 20, Supplement 3, August2010, Pages S312-S313, ajhuri@gmail.com Cairo, Jan 2012 15
  • 16. FDA executive summary, 2011  Disorientation: acute NOT long term, BL > UL  Executive function: no effect, may improve  Anterograde memory: improves  Retrograde memory: decline in subacute phase EXCEPT with ultrabrief waves  Autobiographical memory: decline in subacute phase EXCEPT with ultrabrief waves and BF ECTFDA executive summary: Prepared for the January 27-28, 2011 meeting of the NeurologicalDevices Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices(ECT) ajhuri@gmail.com Cairo, Jan 2012 16
  • 17. Cerebrovascular stroke  Post stroke depression in common, esp with lesion in Lt hemisphere  Wait until 3 m after stroke  Pts on anticoagulation ◦ Risk of ICH vs risk of embolic CVA ◦ INR = Takano, Miya Tominaga, recommendedHideaki Suzuki, Takehisa2 – 3, TEE isKazumasa Suzuki, Yutaka Kagaya, Acuteembolic stroke in a patient with atrial fibrillation after electroconvulsive therapy, Journal ofCardiology Cases, Volume 2, Issue 1, August 2010, Pages e12-e14, ISSN 1878-5409, 10.1016/j.jccase.2010.01.004. ajhuri@gmail.com Cairo, Jan 2012 17
  • 18. Unresponsive pt Stupor vs Coma Stupor: varying degrees of unresponsiveness due to an apparent decreased level of consciousness Stupor / not Catatonic signs / not Psychiatric / Neurologic ds BZD then ECTHurwitz TA. Psychogenic unresponsiveness. Neurol Clin. 2011 Nov;29(4):995-1006. ajhuri@gmail.com Cairo, Jan 2012 18
  • 19. Super-refractory status epilepticus  SE that continues or recurs 24 h or more after the onset of anesthetic therapy, including those cases where SE recurs on the reduction or withdrawal of anaesthesia.  ECT as an option was used since 1943  After pharmacologic coma failsShorvon S, Ferlisi M. The treatment of super-refractory status epilepticus: a critical review ofavailable therapies and a clinical treatment protocol. Brain. Oct; (Pt - ajhuri@gmail.com Cairo, Jan 2012 19
  • 20. Pseudodementia Cognitive disorders resulting from functional disorders Common: depression, Ganser syndrome Severe cognitive and memory impairments often occur during episodes of depression Suspect when: dementia syndrome appears suddenly in an adult, especially an elderly adult. Remarkable response to ECT Fink M. Electroconvulsive therapy: a guide for professionals and their patients. Oxford, 2009 ajhuri@gmail.com Cairo, Jan 2012 20
  • 21. Multiple sclerosis Depression: up to 25 %, may be delusional Mania: up to 14 % Suicide: 5 x other population Recurrent catatonia / psychosis: rarePontikes TK, Dinwiddie SH. Electroconvulsive therapy in a patient with multiple sclerosis and recurrent catatonia. J ECT. 2010 Dec;26(4):270-1. ajhuri@gmail.com Cairo, Jan 2012 21
  • 22. Parkinson’s Disease (PD)  Psychotic symptoms in Parkinsons disease (PDP) are relatively common  In a recent Japanese case series of 8 quetiapine-resistant PDP pts: ◦ significant ↑ in rCBF in the right middle frontal gyrus after ECT ◦ notable improvements not only in PDP but also in the severity of PDUsui C, Hatta K, Doi N, Kubo S, Kamigaichi R, Nakanishi A, Nakamura H, Hattori N, Arai H.Improvements in both psychosis and motor signs in Parkinsons disease, and changesin regional cerebral blood flow after electroconvulsive therapy. Prog Neuropsychopharmacol BiolPsychiatry. 2011 Aug 15;35(7):1704-8. ajhuri@gmail.com Cairo, Jan 2012 22
  • 23. Dementia with Lewy bodies  Psychiatric Sx: ◦ Psychosis is an intrinsic part of DLB: 75% have hallucinations and >50% have delusions ◦ Depression: 20 – 65 %  ‘Neuroleptic sensitivity’ phenomenon  ECT has antidepressant, antipsychotic, and dopamine-enhancing effectsBurgut FT, Kellner CH. Electroconvulsive therapy (ECT) for dementia with Lewy bodies.Med Hypotheses. 2010 Aug;75(2):139-40. ajhuri@gmail.com Cairo, Jan 2012 23
  • 24. Other movement disorders Successful case reports: ◦ NMS ◦ TD ◦ HD ◦ TSScott A. The ECT Handbook. 2nd Ed. The Third Report of the Royal College of Psychiatrists’ Special Committee on ECT. 2005 ajhuri@gmail.com Cairo, Jan 2012 24
  • 25. Drugs before ECT  Symptomatic improvement of patients who are on AEDs during ECT is comparable to those who are not  AEDs + ECT Vs ECT alone: ◦ Higher charge ◦ More sessions, esp titrations ◦ Delayed recovery ◦ Post ECT deliriumComparison of electroconvulsive therapy (ECT) with or without anti-epileptic drugs in bipolar disorder. Harve Shanmugam Virupaksha, Barki Shashidhara, Jagadisha Thirthalli, ChannaveerachariNaveen Kumar, Bangalore N. Gangadhar Journal of affective disorders 1 December 2010 (volume 127 issue 1 Pages 66-70 ajhuri@gmail.com Cairo, Jan 2012 25
  • 26. Pts with increased ICP  Increased ICP: SOLs, relatively safe  May pre use steroids, diuretics, anti HTN & HV  Depression and catatonia: commonThe Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, andPrivileging: A. Washington, DC: American Psychiatric Association; 2001. Task Force Report ofthe American Psychiatric AssociationScott A. The ECT Handbook. 2nd Ed. The Third Report of the Royal College of Psychiatrists’Special Committee on ECT. 2005 ajhuri@gmail.com Cairo, Jan 2012 26
  • 27. Drugs that may induce statusepilepticus with ECT Herbal eg Ginkgo, Ginseng, Kava, SJW Xanthines eg theophylline, caffeine ajhuri@gmail.com Cairo, Jan 2012 27
  • 28. Drugs delay recovery andprolong post ECT delirium Anti-Ch TCA Li AEDs ajhuri@gmail.com Cairo, Jan 2012 28
  • 29. ECT as a drug Antipsychotic Antidepressant Antimanic Mood stabilizer Antisuicidal Alerting Vegetative Antiepileptic Dopaminergic ajhuri@gmail.com Cairo, Jan 2012 29
  • 30. Take-home message ECT is a brain stimulation therapy NOT a psychiatric treatment ECT has 2nd line indications in primary neurologic disorders esp Parkinson ECT has the same indications in secondary psychiatric disorders eg post stroke depression Neurologist needs modulate drug therapy before referral to ECT eg optimize INR, stop herbal drugs ECT is still one of the RELATIVELY SAFE and effective treatments without an alternative when indicated ajhuri@gmail.com Cairo, Jan 2012 30
  • 31. Abbassia Hospital after sunset ajhuri@gmail.com Cairo, Jan 2012 31