Wednesday, February 18, 2009

Not Your Grandma's ECT

ECT started back in the 1930’s as an alternative to medication induced seizures. The type of current generated then was sinusoidal whereas now physicians use a brief pulse of constant current (to reduce side effects). For the following two decades the procedure was carried out without the use of muscle relaxants resulting in injury caused by the convulsions associated with seizure.

How It Works

ECT may be given as either inpatient or outpatient treatment. The patient is anaesthetised and given a muscle relaxant to prevent injury during the process. Electrodes are placed on the scalp either on both sides of the head (bilateral ECT) or with both electrodes on the non-dominant side of the head (unilateral ECT). A current is administered for a few seconds to induce seizure. The strength of the current and the length of time the current is applied also vary depending on the history of the individual. For bilateral ECT currents are given at 1.5 times the patient’s seizure threshold and for unilateral ECT the currents can be up to 12 times the threshold.

In depressed and/or psychotic patients, the anterior cingulated cortex (ACC, Brodmann area 25) shows decreased theta band activity. Theta rhythms occur with the hippocampus and function in memory and voluntary behaviour. Response to ECT in patients with psychotic symptoms is related to increased theta band activity.

Who Receives It

ECT is used in people with depression, schizophrenia, and mania who do not respond to medications (Treatment resistance can be defined as low as two different types of medication, but given the variability of individual response to the many antidepressants available, as well as long term psychotherapy, I think this number should be closer to four). It is also used in the geriatric community and in pregnant women where medication is not an option. Additionally, it is used to treat psychiatric side effects of dopamine in people with Parkinson’s disease and to treat pain in factitious disorders.
Because results can sometimes be seen within two weeks, ECT may be used in severely affected people where waiting for the medication to, maybe, take effect isn’t desirable.

In depressed patients, unilateral ECT appears to have a slight advantage over bilateral ECT in that patients respond to it with a fewer number of treatments. One study demonstrated that manic patients responded more quickly to bifrontal ECT than to bitemporal treatment, with comparable post-ECT cognitive function.

Side Effects

Side effects include memory loss, confusion, disorientation, delirium, and transient amnesia. Though memory dysfunction is the side effect causing the most concern, reports vary on the severity and tolerability of the effect. Neurobiologically, the memory loss associated with ECT is related to a decrease in hippocampal volume (the hippocampus is an area of the brain that functions particularly in short-term memory and the formation of new memories. Damage to the hippocampus can also affect access to previously formed memories. These two memory dysfunctions are termed anterograde and retrograde amnesia, respectively.). Evidence suggests that bilateral ECT produced greater memory dysfunction and the time to return to regular memory processing was greater than in unilateral ECT.

Generally, memory function returns to normal within a few months of treatment though there are patients who report noticeable dysfunction years after the ECT. Whether these memory problems are associated with reoccurring depression (as depression is itself associated with decreased memory ability and subjective reports of cognitive function is lower in depressed patients) is debatable. Interestingly, though memory deficits definitely occur post treatment, subjective reports of those who responded to ECT were that they experienced no difference in their memory.

Other side effects include muscle tension, headache, and nausea.

A high number of patients do relapse after treatment. Therefore, maintenance treatments of psychotherapy, pharmacotherapy, and further ECT treatments are necessary.

Because of the associated memory dysfunction during treatment, it is advisable that post-treatment measures to help function during this time be set up beforehand. Depending on the person’s cognitive abilities, things like notes and lists may need to be made to assist with daily function. Some may want to record upcoming events in a calendar before their ECT. Others may want to set up a therapeutic network of family, friends, and therapist to assist with decision making and for emotional support during treatment. It may also be helpful to keep a daily record after treatment to help with short-term memory dysfunction.

Dr Shock’s stance is that ECT causes no clinically significant cognitive deficits and there are many studies supporting this. However, from the papers I have reviewed, cognitive assessments were done within weeks or months of treatment. As well, there are studies demonstrating persistent memory dysfunction and, of course, personal stories of severe adverse affects.

That’s all fine and dandy and the benefit certainly makes the risks more tolerable, but what if you’re a scientist or a literary professional where your life is centred around your cognitive abilities? Some people say that their cognitive impairment was so great, they were unable to return to work. Others say that impairments and lost knowledge were regained through practice and study. Brain exercises such as number games, crossword puzzles, math exercises, statistical mechanics (ok, maybe not that last one) may aid in redeveloping neural networks. Yet, impairment can persist to the point where cognitive abilities are never fully recovered and there are many stories of scientists and other workers who have had to give up their careers. For some people, living without depression is well worth having to use a calculator to do math and spending an extra two hours to write a short letter to a friend.

My advice – do a very serious, as objectively as possible, risk-benefit analysis of your situation before entering into ECT. How severe are your symptoms? If you are suicidal, how often do you self-injure/attempt and how serious are the consequences of this behaviour? How important are your memories to you (some people are glad to have lost the memories of their suffering, but miss memories like raising children or being with friends)? How important is it to you to retain new information (are you comfortable being dependent on others for reminders, do you have a strong network for support)? How much of your life/joy/ambition is dependent upon cognition and memory? How much time can you take off from work while your memory returns? Have you exhausted all other treatments? Is your illness preventing you from working?

It’s difficult to say much from personal stories without more information on what type of ECT they had done and how it was performed, but the stories do exist which means these problems are real. But there are also many success stories where people have undergone ECT and not only been relieved of their debilitating depression, but also retain their d=cognitive abilities and go on to graduate school and other professions. This may be things they would have accomplished without ECT, but it may also be that their illness would have interfered with goal setting/achieving, and with ECT they not only were able to accomplish their goals but did so without the weight of depression.

New alternatives to ECT include magnetic seizure therapy (MST), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). I will report on these in the coming weeks.

I am including here one person’s personal story of how ECT has helped him, not because of any bias of mine (ECT like any psychiatric treatment depends highly on the individual), but because the author does a wonderful job of narrating his experience with depression and with ECT. It is actually very well balanced; he doesn’t over-emphasise the good without mentioning the bad. But my reason for including it is because I think it is important for anyone suffering from what seems like an endless illness, that things can and do get better. For those with treatment resistant illnesses, this hoping and believing is probably the hardest thing to do, but there are people out there who have been in it and come out to live better lives. If something isn’t working for you, don’t give up, keep trying.

References: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10

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