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A review of cognitive outcomes of modern day ECT, Kiri Luther

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A review of cognitive outcomes of modern day ECT, Kiri Luther

  1. 1. A Review of Cognitive Outcomes of Modern Day ECT<br />Kiri Luther DClinPsych Candidate <br />Massey University, Wellington<br />Professor Janet Leathem – Primary Supervisor<br />Dr Steve Humphries – Secondary Supervisor<br />Dr Nisar Contractor, C&CDHB – Professional Advisor<br />
  2. 2. ECT: Procedure<br />Patient anaesthetised, administered a muscle relaxant & an electrical stimulus is passed through the brain via electrodes placed on the scalp inducing a grand mal seizure<br />EEG monitoring<br />Seizure is treatment, not electricity<br />
  3. 3. Technical Context: Electrode Placement<br />Unilateral<br />Right hemisphere (initially)<br />Bilateral<br />Temporal<br />More cognitive difficulties<br />Frontal<br />Less research<br />Lisanby, 2007<br />
  4. 4. Technical Context: Guidelines<br />NICE <br />Short-term treatment after all other options have failed <br />depressive illness <br />catatonia <br />prolonged or severe mania <br />NZ Ministry of Health<br />when medication does not work<br />where psychotherapy is inappropriate <br />there is a risk of suicide or neglect <br />where there is a need for rapid therapeutic action<br />when ECT has already been used with good outcomes<br />For<br />depression<br />catatonia <br />mania<br />schizophrenia<br />
  5. 5. Rationale<br /><ul><li>Response to request
  6. 6. Evaluate & improve current assessment methods used in Wellington
  7. 7. Ultimately to come up with a time and cost effective test battery to monitor the effects that ECT has on Memory and Cognition
  8. 8. Research need identified
  9. 9. NICE Guidelines for ECT. (National Institute for Clinical Excellence 2003)
  10. 10. subjective assessment
  11. 11. long term outcomes.</li></li></ul><li>How do we do this?<br />Before we move forward we need to go back – retrospective research<br />How are historical patients now?<br />How were they back when they were having ECT?<br />What domains of memory and cognition are affected in the short and long term?<br />How do we best assess these?<br />Are current measures being used by CCDHB useful?<br />
  12. 12. Review <br />Review completed to ascertain which areas of memory are most commonly assessed and which of these show dysfunction<br />Review completed to ascertain which measures are commonly used to assess these areas<br />
  13. 13. Review<br />Literature search completed using <br />Web of Science<br />Google Scholar<br />Psych Info<br />Academic Search Elite<br />Medline<br />33 studies were included in the reviews<br />
  14. 14. Findings - Domains<br />
  15. 15. How were measures chosen?<br />Literature and Previous Research<br />Current Measures Used By C&CDHB<br />Other Measures<br />Depression: BDI-II, MADRS<br />Memory Malingering: TOMM<br />
  16. 16. Findings - Assessment<br />
  17. 17. Method<br />Health and Disability Ethics Approval<br />Invitations sent to historical patients<br />Participant consent<br />Access to patient files<br />ECT technical data collected<br />Participant historical assessment data collected if available<br />Participants underwent psychometric assessment to form current outcome data<br />Participants gave subjective accounts of their experiences<br />
  18. 18. Participants<br />Initial pool=222<br />Step-wise inclusion: <br />NHI number<br />Alive and listed as living in Wellington<br />≤65 yrs of age<br />No Dementia, Head Injury or ID<br />Able to participate<br />N=118<br />Agree to participate, N=27<br />5 withdrew, 2 withdrawn by researcher<br />Total Participants, N=20<br />
  19. 19. Potential Influences on Cognition<br />Electrode Placement<br />Dosage<br />Number and Frequency of Treatments<br />Age<br />Education<br />Time Since Last ECT<br />Current Depressive Symptomology<br />Some Medications e.g. Lithium<br />Malingering<br />
  20. 20. File Information<br />Diagnosis<br />Electrode Placement<br />Number of Treatments<br />Frequency of Treatments (# per week)<br />First and Last Treatment Dates<br />Dosage <br />Seizure Durations, EEG and Motor<br />Anaesthetic<br />Muscle Relaxant<br />Previous Assessments e.g. MMSE, MADRS<br />
  21. 21. Interviews<br />Assessment Protocol<br />Demographic Info e.g. D.O.B, Education, Ethnicity<br />TOMM Trial 1 and 2<br />BDI-II<br />MADRS<br />TOMM – Trial 3 if necessary<br />MoCA<br />RCFT – Copy then Immediate Recall<br />RAVLT – All trials, interference trial<br />MMSE<br />RCFT – Delayed Recall, Recognition<br />RAVLT – Delayed Recall, Recognition<br />AMI<br />Subjective Assessment - IPA<br />
  22. 22. Ideal Analysis<br />Comparisons between;<br />Past objective vs. present objective<br />Past subjective vs. present subjective <br />Present objective vs. present subjective <br />Past objective vs. past subjective<br />The relationship between depression and cognitive functioning<br />
  23. 23. Ideally what will this give us?<br />Information about memory and global cognitive difficulties in the short term – historical assessment<br />Information about memory and global cognitive difficulties in the long term – current assessment<br />A Time-Line of changes in Outcomes<br />Subjective information which can be compared to objective assessment<br />
  24. 24. What did we get?<br />Comparisons between;<br />Past objective vs. present objective<br />Some MMSE, MADRS & BDI-II<br />Past subjective vs. present subjective <br />Present objective vs. present subjective <br />Past objective vs. past subjective<br />As Above<br />The relationship between depression and cognitive functioning<br />
  25. 25. Some of the Problems<br />Sample size N=20<br />Large for IPA<br />Small for Quantitative<br />Most had bilateral ECT so couldn’t compare with RUL<br />Different machines used = different method of treatment<br />Titration vs. No titration therefore dose information was different e.g. (% vs. mC)<br />Lack of historical assessment data<br />No baseline data for comparison, very little monitoring data<br />Difficulties finding some patient files<br />Some ECT information was not recorded<br />One participant had very little information about dosage, electrode placement and seizure durations<br />Two participants refused some of the assessment – felt they were unable to do it.<br />
  26. 26. What Now?<br />Data Analysis<br />Qualitative Analysis<br />Conclusions<br />Recommendations<br />Assessment<br />Ongoing Research<br />
  27. 27. Initial Impressions<br />Researcher first person to talk to participants about ECT since their treatment (up to 13 years ago)<br />Very emotional<br />Participants didn’t just talk about their ECT<br />Time in Psychiatric Ward<br />Medications<br />Overall Treatment within the Health System<br />Childhood<br />Illness<br />
  28. 28. Initial Impressions<br />Costs<br />Not being listened too<br />Not being treated like a human being<br />Feeling like a guinea pig<br />No trust – Psychiatrists<br />No follow-up<br />Benefits<br />Feeling Safe – in hospital<br />Kind nurses and ECT staff<br />Getting better<br />Future orientated<br />
  29. 29. Initial Impressions<br />Memory and Cognition<br />Personal Memories<br />Own childhood<br />Their children growing up<br />Confused timelines<br />Chunks of time missing<br />Memory around time of ECT<br />Blanks<br />Not being aware of forgetting until remembering something<br />Mental fatigue<br />
  30. 30. Initial Impressions<br />ECT Participant Quotes-Costs<br />“I know that if I had to have shock treatment to the brain then it is highly likely that I would have a heart attack or die of shock at the thought of it about to happen”<br />“I remember thinking, I wonder if this is what it feels like to have a learning disability”<br />“I was scared of what would happen if I said no” – to ECT<br />“I have about a year I don’t remember” <br />“My brain feels half dead, feels drunk....it’s lost its crispness<br />
  31. 31. Initial Impressions<br />ECT Participant Quotes-Benefits<br />“Possibly there were times it bought me out of total destruction”<br />“I believe it cured my depression or was definitely the road to recovery”<br />”It cured me”<br />“Stopped me being grossly depressed”<br />“It saved my life after many Doctors, medications, therapists, counsellors, support groups and good intentions”<br />“I made it back to life”<br />
  32. 32. References/Bibliography<br />Lezak, M. D., Howieson, D. B., Loring, D. W., Hannay, H. J., & Fischer, J. S. (2004). Neuropsychological assessment (4th Ed.). New York: Oxford University Press<br />Lisanby, S. H. (2007). Electroconvulsive therapy for depression. The new England journal of medicine, 357(19), 1939-1945.<br />Ministry of Health (2006). Electroconvulsive therapy annual statistics: For the period 1 July 2003 to 30 June 2005. Wellington: Ministry of Health.<br />Ministry of Health (2004). Use of electroconvulsive therapy (ECT) in New Zealand: A review of the efficacy, safety, and regulatory controls. Wellington: Ministry of Health.<br />National Institute for Clinical Excellence (2003). Guidance on the use of electroconvulsive therapy: Technology appraisal 59. London: National Institute for Clinical Excellence.<br />Nasreddine, Z. S., Phillips, N. A., Bedirian, V., Charbonneau, S., Whitehead, V., et al. (2005). The montreal cognitive assessment, MoCA: A brief screening tool for mild cognitive impairment. J. Am Geriatr Soc, 53, 695-699.<br />Tiller, J. W. G., & Lyndon, R. W. (2003). Electroconvulsive therapy: An Australasian guide. Victoria: Australian Postgraduate Medicine.<br />
  33. 33. Thank-you for your time <br />Kiri Luther DClinPsych Candidate <br />Massey University, Wellington<br />k.luther@xtra.co.nz<br />

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