In the last episode, I gave a brief discussion about how electroconvulsive therapy (ECT) works by causing convulsive seizures and discussed some of the proposed mechanisms by which seizures might result in benefit. In this episode, I discuss who you should consider sending for ECT, some of the considerations for different patient populations, and how you might approach explaining to a patient that you want to electrify their skull and make them seize.
Please leave feedback at https://www.psydactic.com.
References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.
In the last episode, I gave a brief discussion about how electroconvulsive therapy (ECT) works by causing convulsive seizures and discussed some of the proposed mechanisms by which seizures might result in benefit. In this episode, I discuss who you should consider sending for ECT, some of the considerations for different patient populations, and how you might approach explaining to a patient that you want to electrify their skull and make them seize.
Please leave feedback at https://www.psydactic.com.
References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.
Welcome to PsyDactic - Residency Edition - Your podcast resource to survive and thrive in your psych residency.
I am Dr. O’Leary, and as of this recording I am a 2nd Year Resident in the National Capital Consortium Psychiatry Residency Program. However, make no mistake, I do not speak for this program, nor do I speak for the Department of Defense or the Federal Government or anyone else for that matter. What I say is my opinion, and I reserve the right to be wrong, so trust me at your own risk. It’s a risk some are willing to take.
In the last episode, I gave a brief discussion about how ECT works by causing convulsive seizures and discussed some of the proposed mechanisms by which seizures might result in benefit. Today, I want to discuss who you should consider sending for ECT, some of the considerations for different patient populations, and how you might approach explaining to a patient that you want to electrify their skull and make them seize.
There are patient presentations that should make you think, “Let’s shock some heads.” ECT is often talked about as a last ditch effort, but there are many patients for whom ECT should be the first or second treatment tried. Think, patients who aren’t able to care for themselves. Patients who are catatonic or who have a large burden of neurovegetative symptoms from depression are likely to benefit much more quickly from ECT than starting or increasing medications.
Let’s take the case of catatonia. Catatonia is a type of brain failure that similar to delirium requires a broad differential and treatment focussed on fixing the cause. So let's say you’ve treated the suspected cause of a patient’s catatonia or ruled out things like toxins, medicine side effects, strokes, seizures, and the many infectious or autoimmune encephalitides. Then you try IV benzodiazepines like lorazepam. Benzos can produce profound and immediate results. But not all patients respond to these medications and it can become apparent within a few minutes if they are going to have an effect. It’s amazing to see patients emerge from a statuesque state into friendly conversation, like watching a gargoyle emerge from it’s magical sleep as the sun sets. Other patients with catatonia might have only a partial response to benzos, requiring escalated dosing without sustained benefits. These patients should try ECT and, please, don’t wait until their BMI is 17%. Shock some heads.
For another group of patients who are not doing the things they need to do to stay alive, like eating, sleeping, and moving around, ECT should be near or at the top of your list. These are your majorly depressed patients with neurovegetative symptoms (things like anorexia, psychomotor retardation, & insomnia). We think of the symptoms of depression and other psychiatric disorders as subjective, but weight loss, hours of sleep, and the speed and amount of movement are objective signs of illness. These patients are not going to be able to out-think their symptoms with cognitive behavioral therapy as their mild to moderately depressed peers might, and they do not have time to wait weeks for a trial of a medication that has a 2/3rd chance of not working. Talk to them or their family about ECT right away.
Another group of depressed patients for whom ECT may be a first line treatment are pregnant or postpartum mothers. Mom needs to be able to care for herself and her infant. Failure to do so can result in failure to thrive or even death of the infant and similar poor outcomes for the mother. We hear of depressed mothers drowning infants in the bathtub when experiencing an affective psychosis. This is rare. What is more common is a mother who fails to establish the kind of bond and caring relationship that sets her baby up for success in life. Mothers suffering from depression may also be fearful of taking a medication every day that might affect her fetus or pass through the breast milk. ECT is here to help.
ECT is broadly effective in affective disorders. It can treat depression with psychotic features, and can also help break mania, especially if patients are extremely unsafe or suicidal, and along with medications can be used in maintenance of depression, bipolar, or schizoaffective disorder.
Another group that would benefit from not waiting for ECT are those with Neuroleptic Malignant Syndrome or malignant catatonia, both characterized by hyperthermia and muscle rigidity. The main difference between NMS and malignant catatonia is that the former is caused by the use of psychotropic medication (neuroleptics) and the latter caused by something else (anything else), but they are clinically often indistinguishable and, luckily, both are responsive to ECT. It should not be withheld or postponed if pharmacotherapy is not sufficient.
Aside from urgency, another time you should consider using ECT first is if ECT has been effective before and the patient wants it again. Why force your patient to trial medications first if there is a track record of a good response to ECT. There is also no reason why you can’t do both.
So, I’ve discussed a bunch of times when ECT should be at or near the top of your list for treatment, but from my experience medical students, residents, and many graduated physicians do not think of ECT this way. The most common response to, “Who should get ECT?” Is likely to be, “Someone who has failed all other medical treatment options.” This just isn’t the case. ECT is the first or second line treatment in a number of conditions, and should be more broadly available than it is.
However, ECT can also be a “last ditch effort” so to speak and should be offered to a patient who has less urgent needs after adequate trials of pharmacotherapy or psychotherapy have not yielded fruit. Twelve weeks of ineffective treatment with adequate doses of any two antidepressants should prompt a conversation about ECT. In my own very limited experience, I notice that ECT is not really recommended to patients as often as it should be. A conversation about ECT is often ignored, and patients may be recommended transcranial magnetic stimulation of the brain (or TMS for short), which although safe, is currently not nearly as effective as ECT. Patients also may prefer to try ketamine infusions or esketamine under the assumption that it is safer than ECT, but I haven’t seen any evidence to suggest that this is actually true, and post marketing studies are revealing that these medications may have previously under-reported side effects.
ECT can also be used in status epilepticus refractory to medication treatment. This is interesting because inducing seizures can also cause status epilepticus, especially if used in patients with seizure disorders who have stopped taking their anti-epileptic medications, but there are case series and many other personal reports that ECT may be able to interrupt refractory status epilepticus. If available, and drugs are not working, it is definitely indicated.
There are no absolute contraindications for ECT. There is no age limit. There are no comorbid diseases that would absolutely prevent ECT in patients that need it. It may be that a patient should receive other stabilizing medical treatment prior to ECT (e.g. a patient in a car accident on the way to the hospital for ECT who needs surgery should get that first).
But just because there are no absolute contraindications for ECT, not every patient is an ideal ECT candidate and some patients inherit more risk than others while undergoing the procedure. When evaluating a patient, their personal risk is modified by their comorbid conditions, treatment adherence, and some special considerations I’ll touch on briefly.
ECT requires brief paralysis and anesthesia often with succinylcholine and methohexital, but other agents can be used. ECT is usually followed by a period of tachycardia and relative hypertension, so cardiovascular diseases can increase risk. Care should be taken that patients are adherent to their treatments and medications to lower overall risk of cardiovascular events which is low, even with implanted devices. In a case series of patients encompassing courses of ECT with 26 pacemakers and 3 implanted defibrillators, there was only a single serious event, characterized as non-sustained supraventricular tachycardia.
Patients may also have conditions like asthma, and there is a risk of brochospasm and status asthmaticus following ECT. Patients may have kidney or liver failure, which need special consideration for medication dosing. Patients with diabetes need special care to manage their blood glucose, especially since there is a need to avoid oral intake prior to the procedure.
Most medications should be continued prior to ECT. There are some which can interfere with a seizure, such as antiepileptic drugs or drugs used to interrupt a seizure, like benzodiazepines. In general, a good rule of thumb is: try ECT with these medications in place first, and if seizures are difficult to elicit, experts can try lowering doses or reversing effects (for example, with flumazenil a few minutes before the procedure for the patient taking benzos).
There is a low chance of bleeding with ECT (and bite blocks are used to help prevent cheek or tongue biting or breaking teeth). Patients on anticoagulation or antiplatelet therapy should have a thorough risk benefit analysis conducted with their internist or specialist to determine the best course of action.
So here is a good spot to transition into formulating a consent process for your patient. I call it a process because there are multiple levels of consent. The consent I am talking about here is the consent to start the evaluation for ECT. Because ECT’s “reputation” precedes it and distorts it, this begs for a thorough yet understandable discussion with the patient, even more so than you would expect for a similarly minor procedure.
ECT is not an experimental procedure. It has proven itself over the past 100 years and been developed to avoid unnecessary complications. What you need to focus on are the indications for treatment, the expected or desired outcomes, the risks versus benefits, and discussion of alternatives (which often have already have been tried). The consent I am going to model is one I would give in the office or psychiatric inpatient ward prior to referring for the procedure. Other consents will follow, but this is the initial go at it, in order to establish that elusive therapeutic alliance.
I will assume for the sake of time, the patient has capacity to understand and decide between ECT and alternatives including no treatment. ECT is often performed on acutely ill hospitalized patients. If the patient lacks concurrent decision-making capacity, then a surrogate should be found according to your local laws and policies. I will also assume the patient is voluntarily participating and not coerced.
Here I am going to use the term “your condition” as a placeholder for any number of indications.
Ms. Wilder, I would like to recommend Electroconvulsive Therapy or ECT for short to you in order to treat your condition, the symptoms of which include (fill in the blank), and represent a heavy burden on your life. Without treatment, I would expect your symptoms to continue or even worsen over time. I strongly feel treatment is necessary, and the best treatment is ECT.
In short, ECT is a procedure in which we cause a seizure in your brain in order to stimulate your brain to change in ways that we don’t fully understand. ECT is over 100 years old, and has been found to be an excellent and safe treatment for your condition. In the vast majority of patients ECT results in substantial improvement or remission, which is defined as reduction of your symptoms to a level that allows you to function in a similar way you were able to before this condition developed. It is not a cure, and in many cases patients still need to use medications or have ECT at less frequent intervals in the future.
ECT requires placing you under a brief anesthesia which artificially puts you in a sleep-like state so that you are not conscious during the procedure. We also give medicines that cause your muscles to relax and prevent them from contracting for a brief period of time. Because we relax most of your muscles, you will also briefly stop breathing, so we give you oxygen before the procedure and aid your breathing with a mask during the procedure. We also place stickers with electrodes on your head so we can monitor your brain activity. When you are asleep and relaxed, we apply a controlled amount of electricity to your head. This causes a seizure which we can see as spikes of electrical activity throughout a large portion of your brain. This electrical activity is expected to last from about 30 seconds to 2 minutes. A few minutes later you will wake up and recover in our post-anesthesia unit. You will be able to go home the same day, but you will need someone to drive you. It usually takes 6-12 sessions for patients to report noticeable improvements, but rarely improvements can be seen after 1 or 2 treatments.
One of the effects of ECT is to temporarily increase your heart rate and blood pressure, but the risk of any serious events from this is very low. If your blood pressure becomes very high, we may need to give medications to lower it, but this is done in a small minority of patients. The most recent studies estimated the risk of death from ECT at less than 1 per 100 thousand treatments, making ECT one of the safest procedures performed under general anesthesia.
It is also possible that you can bite your tongue or cheek, or that you might break a tooth during the procedure, so we apply a bite block in your mouth to prevent this. You need to eat nothing overnight before the procedure to reduce the risk of aspiration, which is breathing in fluids or food particles into your lungs which might cause pneumonia.
The most common things people complain about after ECT is a headache, nausea, muscle aches, concentration and memory issues. These all tend to resolve within minutes to hours following the procedure. You should not make any important decisions within 24 hours of receiving ECT, and if possible, postpone decisions like these for a week. Some people report that memory issues continue for a few days to weeks after the procedure. Studies have shown that while your memories around the time you get the procedure may be compromised, your long term memories remain intact. Bilateral ECT, where the electrical leads are placed on your temples tends to result in more memory and word finding difficulties. ECT focused only on the right side of your head reduces these complaints. The type of ECT you will receive is (fill in the blank).
***I’m going to pause for a second. For most patients, alternatives to ECT have already been tried and that’s why they are starting ECT, but there will be patients for whom you don’t think waiting for medications to be effective is the right course so you could approach the issue like this. I’ll take the case of severe or psychotic depression.***
You might say: I think you could benefit from taking antidepressants. These medications are safe. Your chances of benefiting from these medications within 6 weeks, however, is only about one in three. Overall, I think the risk of waiting for a trial of these medications is higher than the risk of ECT because (and here you fill in patient specific concerns). Do you have any concerns I can address about doing ECT versus taking medications?
In this episode, I tried to establish that ECT is in fact a first line treatment for many seriously mentally ill patients. It is a treatment of last resort for patients that have already tried a lot of other things that haven’t worked, but it should not be thought of only as the treatment for treatment resistant conditions. It is a great treatment for severe depression, catatonia, NMS, mania, etc. Also, there are no absolute contraindications for its use, though each patient should have a thorough medical evaluation to identify areas of specific risk mitigation efforts. Finally, informed consent for ECT is a process that starts by exposing it to the patient as the safe and effective treatment that it is, so that the patient does not decline simply based on fear inculcated into them by a fearful society. 1–3