0
Stress and
Treatment Resistant Depression:
The Role of Electroconvulsive Therapy
and
Neuromodulation Therapies
Nelson F. R...
Personal Background
• Staff Psychiatrist
• Lindner Center of HOPE - Mason, Ohio
• Academic Affiliation
• Assistant Profess...
Objectives:
• Discuss chronic stress and its effects.
• Discuss depression and treatment-
resistant depression.
• Discuss ...
Video
Stress
• Acute Stress
• Chronic Stress
• Stress modifies disease-
relevant biological
processes in humans.
• Depression
• ...
Response to Stress
• Fight or Flight
• Chronic Stress-
increased
glucocorticoids
Charney, A m J Psych, 2004
Effects of Chronic Stress
• Longitudinal study of anxiety disorders among primary care
physicians; n=502
• Strong Associat...
Psychological Effects
• Resilience
• Demoralization
• Adjustment Disorder
• Major Depressive Disorder
• Anxiety Disorder
•...
Major Depressive Disorder
• In the US, prevalence of MDD is 17%, affecting almost 1
in 5 persons. (Kessler, 2005)
• In per...
Major Depressive Episode Manic Episode Hypomanic Episode
Five (or more) of the following
symptoms present nearly every
day...
Summary of Manic and Depressive Symptoms Criteria in
DSM-IV-TR Mood Disorders
Disorder Manic Symptom Depressive Symptom
Ma...
Comorbidity and Symptom Sharing
(Gordon, MO, et al, Arch Ophthalmology 2002, 120:714-720)
Mania MDD ADHD ODD Anxiety
Eleva...
Treatment Approach
• Major Depressive
Disorder
• Psychotherapy
• Group Therapy
• Medications
• SSRI
• SNRI
• Antipsychotic...
STAR*D - NIMH Trial
• Sequential Treatment
Alternatives to Relieve
Depression (STAR*D) Trial
• Largest National Institute ...
Response and Remission on STAR*D
• Response rate: 47%
• Remission rates:
• Level 1: 28%-33%
• Level 2: 18%-25% (switch); 3...
Treatment Resistant Depression
Treatment Resistant Depression
• Most experts would
agree that a lack of
response following
four adequate trials
would con...
Stages of Treatment Resistance
• Stage I: Failure of at least one adequate trial of one
major class of antidepressant
• St...
Therapeutic Neuromodulation
Therapeutic Neuromodulation
• Using electrical and
magnetic stimulation
to alter neurocircuitry
in the brain.
Therapeutic Neuromodulation
• Electroconvulsive therapy (ECT)
• Vagal Nerve Stimulation (VNS)
• Transcranial Magnetic Stim...
Neuronal networks implicated in psychiatric illness.
Tye S J et al. Mayo Clin Proc. 2009;84:522-532
© 2009 Mayo Foundation...
Therapeutic Neuromodulation
• Therapeutic neuromodulation: Categorization based on risk
• Noninvasive, nonseizurogenic
TMS...
Electroconvulsive Therapy (ECT)
• ECT is a procedure in
which generalized
seizures lasting 25-150
seconds, induced by the
...
History of ECT
• 16th Century – Phillipus Paracelsus
• 1764 – Dr. Leopold Auenbrugger of Vienna
• Seizures produced by cam...
APA on ECT
• 1978 – American
Psychiatric Association
published landmark report
on “Electroconvulsive
Therapy”
• 1990 – APA...
Mechanism of Action
• Hypothesis: ECT stabilizes dysregulated intracellular signaling
linked to multiple transmitter syste...
Indications for ECT
• Primary Use of ECT
• A need for rapid, definitive response because of the severity of a psychiatric ...
APA Practice Guideline for the Treatment of Patients with Major
Depressive Disorder, (Third Edition , October 2010)
• ECT ...
ECT in Special Populations
• Elderly
• ECT may be used regardless of age; doses of medications be modified; ECT
stimulus a...
Suicide Risk and ECT
• Suicide – 11th leading cause of death in the US
• Suicide has biological, psychological, sociologic...
Relief of Expressed Suicide Intent by
ECT
• Consortium for Research in Continuation ECT (CORE Study)
• Multisite, collabor...
Suicidality in Depression Resolved
Rapidly With ECT
• Patients received bilateral ECT 3X/week
• After a mean of 2.9 sessio...
ECT Treatment Areas
Pre-ECT Evaluation
• Psychiatric history and examination
• Medical evaluation
• There is no “absolute contraindication” fo...
Treatment Setting
• Inpatient
• High suicide risk
• Psychosis
• Substantial cognitive
impairment
• Severely incapacitated
...
Airway Management
• Establishing an airway
• Oxygenation
• Protecting Teeth and other oral structures
Medications Used with ECT
• Anticholinergic Agents
• Atropine or Glycopyrrolate
• Anesthetic Agents
• Methohexital 0.5-1.0...
Use of Medications During ECT
• Medications typically continued through the ECT course
• Medications administered prior to...
Post -ECT Pharmacotherapy
• Compared with placebo, continuation
pharmacotherapy with tricyclic
antidepressants and/or lith...
Treatment Following Completion of the
Index ECT
• Lack of Response to an Index ECT
Course
• Switching to bilateral electro...
Adverse Effects of ECT
• Cardiovascular Complications
• Prolonged Seizures
• Prolonged Apnea
• Headache, Muscle soreness, ...
Memory and Cognitive Deficits
• 20 patients in each group (BD with ECT and BD w/o ECT); bilateral
treatments; from 6-72 tr...
NICE Statement about ECT and Memory
• ECT may cause short- or long-term memory impairment for
• past events (retrograde am...
Mortality from ECT
• There was no evidence to suggest that the mortality
• associated with ECT is greater than that associ...
Other Neuromodulation Therapies
Vagal Nerve Stimulation (VNS)
• VNS is an implanted device.
• Established efficacy in pharmaco-
resistant epilepsy.
• Appr...
Transcranial Magnetic Stimulation (TMS)
• A noninvasive
procedure that uses
highly focused
magnetic pulses to
target speci...
ECT or TMS
ECT
• Efficacy – 70%-90%
(APA, 2010)
• Memory Effects are more
prominent
• Mostly covered by third-
party payer...
Deep Brain Stimulation (DBS)
• DBS is a reversible, neurosurgical
procedure consisting of implanting
electrodes at specifi...
Left, Intraoperative photograph during deep brain stimulation (DBS) surgery.
Tye S J et al. Mayo Clin Proc. 2009;84:522-53...
Possible therapeutic mechanisms of action of deep brain stimulation.
Tye S J et al. Mayo Clin Proc. 2009;84:522-532
© 2009...
Magnetic Seizure Therapy (MST)
• MST is the induction
of seizure through
magnet stimulation.
• Still in experimental
stage...
Neuromodulation Therapies
ECT VNS TMS DBS Medications
Indication MDD
Bipolar mania
Catatonic
Schizophreni
a
MDD MDD OCD
Pa...
Prevention
7 Best Practices to Deal with Stress
• ARSENAL
• Awareness
• Rest
• Support
• Exercise
• Nutrition
• Attitude
• Learning
T...
Awareness
“Watch your thoughts, they become words.
Watch your words, they become actions.
Watch your actions, they become ...
More Positive Quotes
• “Fear, uncertainty and discomfort are your
compasses toward growth”. - Unknown
• “Between stimulus ...
References
• The Practice of Electroconvulsive Therapy
Recommendations for Treatment, Training, and Privileging,
2nd Editi...
Thank You.
An Innovative Mental Health Center
“It is our vision to provide the most advanced diagnostic
and treatment services in the region, and to be a national
leade...
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  • Neuronal networks implicated in psychiatric illness. The prefrontal cortex, orbital frontal cortex, nucleus accumbens (NaC), and thalamus receive dopaminergic inputs from the ventral tegmental area (VTA) and substantia nigra (SN) regions of the midbrain. Reciprocal excitatory glutamatergic pathways connect the thalamus to the prefrontal and orbital frontal cortices. The prefrontal cortex, orbital frontal cortex, and thalamus project glutamatergic inputs to the NAc, which in turn activates inhibitory output neurons for γ-aminobutyric acid (GABA) that project to components of the basal ganglia, including the globus pallidum (GP) and VTA/SN, as well as to the thalamus. The subthalamic nucleus (STN) provides excitatory glutamatergic inputs to the VTA and SN. Connections also exist between Brodmann Area 25 in the subgenual cingulate cortex (Cg25), the NAc, and prefrontal and orbital frontal cortices; however, the neurotransmitter(s) involved remain to be confirmed. Blue = dopamine; green = glutamate; orange = GABA; yellow = unknown.
  • Left, Intraoperative photograph during deep brain stimulation (DBS) surgery. The patient is awake with stereotactic head frame in place, and the DBS electrode lead has been placed by the neurosurgeon. Fluoroscopy machine is lateral to the patient's head and helps to confirm that the leads are at target. The neurophysiologist (front) is giving test stimulation with an external hand-held stimulator to make sure there are no adverse effects. The patient does not feel pain as the brain is without pain receptors. Right, Close-up photograph of the stereotactic arc, burr hole, and DBS lead in place connected to the external pulse generator via connector wire.
  • Possible therapeutic mechanisms of action of deep brain stimulation. High-frequency stimulation is thought to inhibit local cell body activity and possibly stimulate orthodromic action potentials, antidromically activate afferent neuronal inputs, and stimulate neurons passing near the electrode. Local glial cell activity may also be modulated. Modulation of neurochemical efflux, including neurotransmitters, neuropeptides, and retrograde messengers, may occur both locally and distally. In addition to these short-term changes, long-term adaptations likely occur, including the formation of new synapses and/or regulation of receptor expression.
  • Transcript of "Slide 1"

    1. 1. Stress and Treatment Resistant Depression: The Role of Electroconvulsive Therapy and Neuromodulation Therapies Nelson F. Rodriguez, M.D., FAPA Staff Psychiatrist Lindner Center of HOPE
    2. 2. Personal Background • Staff Psychiatrist • Lindner Center of HOPE - Mason, Ohio • Academic Affiliation • Assistant Professor, Psychiatry, 2008-present • University of Cincinnati College of Medicine • Assistant Professor, Family Medicine, 2002 - present • University of Kentucky College of Medicine • Fellowship, 1997-1998 • The Cambridge Hospital, Cambridge, MA • Harvard Medical School Consolidated Department of Psychiatry • Residency, 1993-1997 • Harvard So. Shore Psychiatry Training Program, Brockton, MA • Harvard Medical School Consolidated Department of Psychiatry • Medical School, 1985 • University of Santo Tomas, Manila, Philippines
    3. 3. Objectives: • Discuss chronic stress and its effects. • Discuss depression and treatment- resistant depression. • Discuss neuromodulation and treatment modalities. • Discuss advances in the field.
    4. 4. Video
    5. 5. Stress • Acute Stress • Chronic Stress • Stress modifies disease- relevant biological processes in humans. • Depression • Cardiovascular disease • HIV/AIDS • Cancer Cohen et al, Psychological Stress and Disease, JAMA 2007;298(14), 1685-1687
    6. 6. Response to Stress • Fight or Flight • Chronic Stress- increased glucocorticoids Charney, A m J Psych, 2004
    7. 7. Effects of Chronic Stress • Longitudinal study of anxiety disorders among primary care physicians; n=502 • Strong Association with PTSD: • Anemia • Arthritis • Asthma • Back pain • Diabetes mellitus • Eczema • Kidney disease • Lung disease • Ulcer • Roger Mannell U Waterloo; Robert Brook, UNSW; HPRT lecture
    8. 8. Psychological Effects • Resilience • Demoralization • Adjustment Disorder • Major Depressive Disorder • Anxiety Disorder • Mood and /or Psychotic Disorder • Substance Abuse or Dependence
    9. 9. Major Depressive Disorder • In the US, prevalence of MDD is 17%, affecting almost 1 in 5 persons. (Kessler, 2005) • In persons aged 15-44 years, depression is the most disabling medical illness. (Murray 1997) • Up to 20% of patients fail to respond to first-line therapeutic interventions, (APA ,2000) • Correct Diagnosis is very important.
    10. 10. Major Depressive Episode Manic Episode Hypomanic Episode Five (or more) of the following symptoms present nearly every day for 2 weeks and represent change in functioning - Depressed mood - Diminished interest or pleasure - Insomnia or hypersomnia - Psychomotor agitation or retardation - Fatigue or loss of energy - feelings of worthlessness or guilt - Difficulty concentration or indecisiveness - Recurrent thoughts of death Symptoms cause significant distress or impairment Not due to direct physiological effects of a substance or GMC Distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) During the period of mood disturbance, 3 or 4 symptoms: - Distractibility - Insomnia - Grandiosity or inflated self- esteem - Flight of ideas/ racing thoughts - Activity increased - Speech is pressured - Sufficiently severe to cause marked impairment, necessitates hospitalization, or has psychotic features Distinct period of persistently elevated, expansive or irritable mood, lasting at least 4 days, Same Symptoms as a manic episode. The episode is associated with unequivocal change in functioning that is uncharacteristic of the person. The disturbance in mood is observable by others. The episode is not severe enough to cause marked impairment, does not necessitate hospitalization, and does not have psychotic features.
    11. 11. Summary of Manic and Depressive Symptoms Criteria in DSM-IV-TR Mood Disorders Disorder Manic Symptom Depressive Symptom Major Depressive Disorder No history of mania or hypomania History of major depressive episodes (single or recurrent) Dysthymic disorder No history of mania or hypomania Depressed mood, more days than not, for at least 2 years (but not meeting criteria for MDD) Bipolar I disorder History of manic or mixed episodes Major depressive episodes typical but not required for diagnosis Bipolar II disorder One or more episodes of hypomania; no manic or mixed episodes History of major depressive episodes Cyclothymic disorder For at least 2 years, the presence of numerous periods with hypomanic symptoms Numerous periods with depressive symptoms that do not meet criteria for MDD Bipolar disorder, NOS Manic symptoms present, not met criteria for BD I, BD II Not required for diagnosis
    12. 12. Comorbidity and Symptom Sharing (Gordon, MO, et al, Arch Ophthalmology 2002, 120:714-720) Mania MDD ADHD ODD Anxiety Elevated Mood Irritability 67% Low Frustration tolerance Touchy Easily annoyed Irritability Hyperactivity/ Agitation Distractibility Agitation Poor Concentration Hyperactivity Distractibility Restlessness Agitation Difficulty in concentration Flight of Ideas Communicatio n disorders Grandiosity Poor judgment Reduced Sleep need Insomnia Impulsivity Trouble sitting Wakes early Initial insomnia
    13. 13. Treatment Approach • Major Depressive Disorder • Psychotherapy • Group Therapy • Medications • SSRI • SNRI • Antipsychotic • TCA, MAOI • Neuromodulation
    14. 14. STAR*D - NIMH Trial • Sequential Treatment Alternatives to Relieve Depression (STAR*D) Trial • Largest National Institute of Mental Health (NIMH) prospective study • Conducted by 14 regional centers across the US • >4,000 patients over a three year period • STAR*D Treatment Levels • Level 1: SSRI-citalopram • Level 2: Randomized to different arms: • Switch to another: SSRI-sertraline, venlafaxine XR or bupropion SR • Switch to cognitive therapy • Augmentation with bupropion SR or buspirone • Augmentation with cognitive therapy • Level 3: Randomized to diff arms • Switch to mirtazapine or nortriptyline • Augment with lithium or T3 thyroid hormone • Level 4: Randomized to one of the ff: • Switch to MAOI- tranylcypromine • Switch to combination mirtazapine and venlafaxine XR
    15. 15. Response and Remission on STAR*D • Response rate: 47% • Remission rates: • Level 1: 28%-33% • Level 2: 18%-25% (switch); 30% (with augmentation) • Level 3: 12%-20% • Level 4: 7%-14% • Relapse Rate: 33% to 50% in one year Zifra, Gilmer, STAR*D Lessons Learned for Primary Care, Primary Psychiatry , accessed 11/13/2010
    16. 16. Treatment Resistant Depression
    17. 17. Treatment Resistant Depression • Most experts would agree that a lack of response following four adequate trials would constitute treatment resistant depression (TRD). • Dougherty, D. 2010 • The gold standard treatment for TRD is electroconvulsive treatment. • Dougherty, D, Psych Annals;40: Oct 2010, 458
    18. 18. Stages of Treatment Resistance • Stage I: Failure of at least one adequate trial of one major class of antidepressant • Stage II: Stage I resistance plus failure of an adequate trial of an antidepressant in a distinctly different class from that used in Stage 1. • Stage III: Stage II resistance plus failure of an adequate trial of a TCA. • Stage IV: Stage III resistance plus failure of MAOI trial • Stage V: Stage IV resistance plus failure of bilateral ECT Thase, ME, Rush, AJ, J. Clin Psych 1997
    19. 19. Therapeutic Neuromodulation
    20. 20. Therapeutic Neuromodulation • Using electrical and magnetic stimulation to alter neurocircuitry in the brain.
    21. 21. Therapeutic Neuromodulation • Electroconvulsive therapy (ECT) • Vagal Nerve Stimulation (VNS) • Transcranial Magnetic Stimulation (TMS) • Deep Brain Stimulation (DBS)
    22. 22. Neuronal networks implicated in psychiatric illness. Tye S J et al. Mayo Clin Proc. 2009;84:522-532 © 2009 Mayo Foundation for Medical Education and Research
    23. 23. Therapeutic Neuromodulation • Therapeutic neuromodulation: Categorization based on risk • Noninvasive, nonseizurogenic TMS, tDCS, CES • Noninvasive, seizurogenic ECT, MST, FEAST • Invasive, nonseizurogenic VNS, DBS, EpCS • CES: cranial electrotherapy stimulation; DBS: deep brain stimulation; ECT: electroconvulsive therapy; EpCS: epidural prefrontal cortical stimulation; FEAST: focal electrically administered seizure therapy; MST: magnetic seizure therapy; tDCS: transcranial direct current stimulation; TMS: transcranial magnetic stimulation; VNS: vagus nerve stimulation Janicak, P, Dowd S, Rado J et al, The Ree=-emerging role of therapeutic neuromodulation, Current Psychiatry,;9: Nov 2010 (accessed at www.currentpsychiatry.com 11/6/10
    24. 24. Electroconvulsive Therapy (ECT) • ECT is a procedure in which generalized seizures lasting 25-150 seconds, induced by the passage of an electrical current through the brain under general anesthesia, and muscle relaxation are used for therapeutic purposes. Comprehensive Textbook of Psychiatry, Kaplan HI, Sadock BJ, ed, 1995
    25. 25. History of ECT • 16th Century – Phillipus Paracelsus • 1764 – Dr. Leopold Auenbrugger of Vienna • Seizures produced by camphor were used to treat psychosis and mania • 1900 – Dr. Manfred Sakel – Insulin coma therapy • 1938 – development of Electroconvulsive Therapy. Ugo Cerleti and Lucio Bini (Rome, Italy) • 1940 – US started using electroshock therapy. • 1950-1960s – 1970’s = “shock factories”- 300 thousand patients per year • 1970-1980 = One Flew Over the Cuckoo’s Nest • 1990- current: ECT’s quiet comeback (100,000 per year in the US)
    26. 26. APA on ECT • 1978 – American Psychiatric Association published landmark report on “Electroconvulsive Therapy” • 1990 – APA published the first edition of The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging • 2001 – APA published the second edition
    27. 27. Mechanism of Action • Hypothesis: ECT stabilizes dysregulated intracellular signaling linked to multiple transmitter system. • Alterations in Neurotransmitter and Receptor Function • NE : Down-regulation and desensitization of B-receptors • 5HT: Upregulation and sensitization of post-synaptic 5HT2 receptors • Ach: Increased brain and CSF acetylcholine concentration • Down-regulation of cortical muscarinic receptors – Could be related to ECT-induced amnesia • DA: Increased dopamine-mediated behaviors • Increased CSF levels of brain-derived neurotrophic factor (BDNF) Kaplan and Saddock. Comp Textbook of Psych, 1995
    28. 28. Indications for ECT • Primary Use of ECT • A need for rapid, definitive response because of the severity of a psychiatric or medical condition • When the risks of other treatments outweigh the risks of ECT • A history of poor medication response or good ECT response in one or more previous episodes of illness • The patient’s preference • Secondary Use of ECT • Treatment resistance • Intolerance to or adverse effects with pharmacotherapy • Deterioration of the patient’s psychiatric or medical condition • Principal Diagnostic Indications • Major depressive disorder • Bipolar disorder, mania • Schizophrenia, catatonic type The Practice of Electroconvulsive Therapy 2nd ed 2001
    29. 29. APA Practice Guideline for the Treatment of Patients with Major Depressive Disorder, (Third Edition , October 2010) • ECT is recommended as a treatment of choice for patients with severe MDD that is not responsive to psychotherapeutic and/or pharmacological interventions, particularly in those with significant impairment or have not responded to numerous medication trials. • ECT is also recommended for MDD • With associated psychotic or catatonic features • Those with urgent need for response (e.g. patients who are suicidal or nutritionally compromised due to refusal of food or fluids) • Those who prefer ECT or have had a previous positive response to ECT
    30. 30. ECT in Special Populations • Elderly • ECT may be used regardless of age; doses of medications be modified; ECT stimulus adjusted – seizure threshold increases with age • Pregnancy and Puerperium • Obstetric consultation • Children and adolescents • Concurrence by two consultants • Concurrent Medical Illness • Neurologic • Cardiovascular • Diabetes Mellitus
    31. 31. Suicide Risk and ECT • Suicide – 11th leading cause of death in the US • Suicide has biological, psychological, sociological factors • Suicide affects family, clinical providers, community and society. • American Psychiatric Association • Canadian Agence d’Evaluation des Technologies et des Modes d’Intervention en Sante • U.K. National Institute for Clinical Excellence • Cited the reduction of suicide risk as a justification for the use of ECT. Kellner et al, Am J Psych 2005;162:077-982
    32. 32. Relief of Expressed Suicide Intent by ECT • Consortium for Research in Continuation ECT (CORE Study) • Multisite, collaborative, NIMH-funded study • Compare the efficacy of continuation pharmacotherapy (lithium plus nortriptyline) and continuation ECT • Remission rate for depression in the 355 patients who completed the course of treatment was 85.6%. • Among 102 patients in the high expressed suicidal intent group who completed acute course of ECT, 87.3% had scores drop to 0. Kellner CH, Fink M, Knapp R, et al, Am J Psych 2005;162:977-982
    33. 33. Suicidality in Depression Resolved Rapidly With ECT • Patients received bilateral ECT 3X/week • After a mean of 2.9 sessions, 95% of patients had HAM- D question 3 ratings of 0 • By the 3rd ECT session, more than 2/3 had become non- suicidal • By the 7th, 90% were nonsuicidal Kellner, C., Poster Presentation, New Clinical Drug Evaluation Unit, 2002
    34. 34. ECT Treatment Areas
    35. 35. Pre-ECT Evaluation • Psychiatric history and examination • Medical evaluation • There is no “absolute contraindication” for ECT • Evaluation by ECT psychiatrist • Anesthetic evaluation • An Informed Consent
    36. 36. Treatment Setting • Inpatient • High suicide risk • Psychosis • Substantial cognitive impairment • Severely incapacitated • Patients at risk for serious complications • Outpatient • The type and seriousness of the patient’s mental illness do not present a significant risk to management on an outpatient basis
    37. 37. Airway Management • Establishing an airway • Oxygenation • Protecting Teeth and other oral structures
    38. 38. Medications Used with ECT • Anticholinergic Agents • Atropine or Glycopyrrolate • Anesthetic Agents • Methohexital 0.5-1.0 mg/kg • Propofol, thiopental, etomidate • Muscle Relaxants • Succinylcholine 0.5-1.0 mg /kg • Agents Used to Modify the Cardiovascular Response to ECT
    39. 39. Use of Medications During ECT • Medications typically continued through the ECT course • Medications administered prior to each treatment • Antihypertensive, antiarrhythmics (except lidocaine), antireflux, bronchodilators (except theophylline), glaucoma (except long-acting anticholinesterase agents), corticosteroids • Medications witheld until after each treatment • Diuretics, hypoglycemic medications, psychotropic medications • Medications often decreased or withdrawn prior to or during the ECT course • Theophylline - status epilepticus • Lithium – higher risk of delirium and prolonged seizure • Benzodiazepines, Anticonvulsants medications – reduced seizures • Monoamine oxidase inhibitors • Pharmacologic Augmentation of ECT • Antipsychotic Medications; antidepressant medications
    40. 40. Post -ECT Pharmacotherapy • Compared with placebo, continuation pharmacotherapy with tricyclic antidepressants and/or lithium reduced the rate of relapses in people who had responded to ECT. NICE-UK 2010
    41. 41. Treatment Following Completion of the Index ECT • Lack of Response to an Index ECT Course • Switching to bilateral electrode placement and/or increasing stimulus intensity • Removing or diminishing the dose of medications with anticonvulsant properties • Provide at least 10 treatments
    42. 42. Adverse Effects of ECT • Cardiovascular Complications • Prolonged Seizures • Prolonged Apnea • Headache, Muscle soreness, and Nausea • Treatment-Emergent Mania • Postictal Delirium • Cognitive Side-Effects
    43. 43. Memory and Cognitive Deficits • 20 patients in each group (BD with ECT and BD w/o ECT); bilateral treatments; from 6-72 treatments • Average interval between last ECT treatment and participation= 45 months. • Cognitive Failure Questionnaire (CFQ) • Patients who had ECT perceived more memory impairment than did patients who had never received ECT • California Verbal Learning Test • Continuous Verbal Memory Task • Both patient groups had significant impairment on measures of verbal learning and recollection (memory deficits • BD with ECT performed at lower levels than those w/o ECT • “The long-term impact of treatment with electroconvulsive therapy on discrete memory systems in patients with bipolar disorder” • McQueen G, Parkin, C, et al • J Psychiatri Neurosci 2007,;32(4):241-249
    44. 44. NICE Statement about ECT and Memory • ECT may cause short- or long-term memory impairment for • past events (retrograde amnesia) and current events • (anterograde amnesia). • As this type of cognitive impairment • is a feature of many mental health problems it may • sometimes be difficult to differentiate the effects of ECT • from those associated with the condition itself. In addition • there are differences between individuals in the extent of • memory loss secondary to ECT and their perception of the • loss. • However, this should not detract from the fact that a • number of individuals find their memory loss extremely • damaging and for them this negates any benefit from ECT. National Institute for Clinical Excellence (NICE-UK) Technology Appraisal 59. Guidance on the use of electroconvulsive therapy, Update May 2010.
    45. 45. Mortality from ECT • There was no evidence to suggest that the mortality • associated with ECT is greater than that associated with • minor procedures involving general anaesthetics, and there • were limited data on mortality extending beyond the trial • periods. • The six reviewed studies that used brain-scanning • techniques did not provide any evidence that ECT causes • brain damage. • (NICE-UK May 2010)
    46. 46. Other Neuromodulation Therapies
    47. 47. Vagal Nerve Stimulation (VNS) • VNS is an implanted device. • Established efficacy in pharmaco- resistant epilepsy. • Approved for pharmacoresistant epilepsy in Europe in 1994 and in the US in 1997. • July 2005, FDA approved VNS for severe, chronic or recurrent unipolar and bipolar depression, with a history of failure of the depression to respond to at least four antidepressant interventions. Groves, Brown: Neurosci Biobehav Rev, 2005 Reardon JP et al, Psychiatry , 2006
    48. 48. Transcranial Magnetic Stimulation (TMS) • A noninvasive procedure that uses highly focused magnetic pulses to target specific mood circuits in the brain. • Recently approved by the Food and Drug Administration for Major depressive disorder.
    49. 49. ECT or TMS ECT • Efficacy – 70%-90% (APA, 2010) • Memory Effects are more prominent • Mostly covered by third- party payers -Insurance, Medicare, etc TMS • Preliminary studies indicate that ECT is more effective than repetitive transcranial magnetic stimulation. (NICE-UK) • LCOH date: 40% Efficacy • No significant memory impairment • Limited third-party coverage
    50. 50. Deep Brain Stimulation (DBS) • DBS is a reversible, neurosurgical procedure consisting of implanting electrodes at specific anatomical location- ventral capsule/ventral striatum (VC/VS) for OCD; and subgenual cingulate gyrus (SCG) for TRD. • First published report of DBS for psychiatric illness – 1990s • 2009 – FDA approved DBS at VC/VS for intractable OCD under Humanitarian device exemption (HDE) Psychiatric Annals, 40(10), Oct 2010
    51. 51. Left, Intraoperative photograph during deep brain stimulation (DBS) surgery. Tye S J et al. Mayo Clin Proc. 2009;84:522-532 © 2009 Mayo Foundation for Medical Education and Research
    52. 52. Possible therapeutic mechanisms of action of deep brain stimulation. Tye S J et al. Mayo Clin Proc. 2009;84:522-532 © 2009 Mayo Foundation for Medical Education and Research
    53. 53. Magnetic Seizure Therapy (MST) • MST is the induction of seizure through magnet stimulation. • Still in experimental stage in Europe and US • May have less cognitive side effects
    54. 54. Neuromodulation Therapies ECT VNS TMS DBS Medications Indication MDD Bipolar mania Catatonic Schizophreni a MDD MDD OCD Parkinson’s and dystonic reactions MDD Efficacy 70-90 % Acute Continuation Maintenance 15 – 25% Maintenance 40-50% Acute 33-60% Side-effects Memory General anesthesia risks – CV, Resp Voice alteration 50% Headache and discomfort at site of tx Cost/Coverage Mostly covered $25,000 out- of-pocket $9,000 to $10,000 for 30 txs varies
    55. 55. Prevention
    56. 56. 7 Best Practices to Deal with Stress • ARSENAL • Awareness • Rest • Support • Exercise • Nutrition • Attitude • Learning The Stress Effect by Henry L. Thompson
    57. 57. Awareness “Watch your thoughts, they become words. Watch your words, they become actions. Watch your actions, they become habits. Watch your habits, they become character. Watch your character, it becomes your destiny.” – Lao Tze
    58. 58. More Positive Quotes • “Fear, uncertainty and discomfort are your compasses toward growth”. - Unknown • “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and freedom”. - Victor Frankl
    59. 59. References • The Practice of Electroconvulsive Therapy Recommendations for Treatment, Training, and Privileging, 2nd Edition, 2001. • Comprehensive Textbook of Psychiatry, 6th Ed, 1995 • Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition, Am J Psych, 167(10), Oct 2010 • Current Psychiatry • Psychiatric Annals, Vol 40(10), Oct 2010 • National Institute for Clinical Excellence (NICE) May 2010 • Positivity app with iPhone
    60. 60. Thank You.
    61. 61. An Innovative Mental Health Center
    62. 62. “It is our vision to provide the most advanced diagnostic and treatment services in the region, and to be a national leader in innovative treatment and research. The Lindner Center of HOPE will be a resource to our community and will bring hope to people suffering from mental illness.” Paul E. Keck, Jr., M.D. President and Chief Executive Officer, Lindner Center of HOPE Professor, University of Cincinnati College of Medicine Paul E. Keck, Jr., M.D. Lindner Center of HOPE, President and CEO University of Cincinnati College of Medicine, The Craig and Frances Lindner Professor of Psychiatry and Neuroscience and Executive Vice Chairman of the Department of Psychiatry
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