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Electroconvulsive Therapy (ECT)
Soumya Sivaraman, MD, discusses Electroconvulsive Therapy (ECT) and how important it is that referring physicians understand that this is a more humane treatment than in past decades and has better results than other methods.
Featuring:
Learn more about Soumya Sivaraman, MD
Release Date: August 16, 2018
Reissue Date: July 28, 2021
Expiration Date: July 27, 2024
Disclosure Information:
Dr. Sivaraman has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
Soumya Sivaraman, MD
Soumya Sivaraman, MD is an Assistant Professor, Psychiatry at UAB Medicine.Learn more about Soumya Sivaraman, MD
Release Date: August 16, 2018
Reissue Date: July 28, 2021
Expiration Date: July 27, 2024
Disclosure Information:
Dr. Sivaraman has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
Transcription:
Melanie Cole (Host): Our topic today is electroconvulsive therapy, and my guest is Dr. Soumya Sivaraman. She's an Assistant Professor in the Department of Psychiatry and Behavioral Neurobiology at UAB Medicine. Welcome to the show, Doctor. Explain a little bit about electroconvulsive therapy. What's the evolution of it, and what's different now?
Dr. Soumya Sivaraman, MD (Guest): Hi, Melanie. Thank you for having me on the show and giving me the opportunity to speak about ECT. So ECT, or electroconvulsive therapy, is a very safe medical procedure during which a very small amount of electricity is applied to the brain to elicit a seizure under general anesthesia under the supervision of a team of psychiatrists, anesthesiologists, nurse anesthetists, and nurses.
Stigma, negative portrayal in the media and misinformation has been one of the major barriers to access this effective and safe treatment. In the past, ECT was done using machines giving very high doses of currents, causing memory impairment, they were not done under general anesthesia, and this resulted in a lot of fractures.
Modern ECT, however, is very different. It's done under general anesthesia, under the supervision of a medical team. The patient is kept on empty stomach overnight. During the treatment or before the treatment they are given IV anesthetic for a brief sedation, followed by administration of a muscle relaxant so that the patient is asleep and the muscles are fully relaxed during the procedure, following which a small dose of electricity is applied to elicit a brief seizure. During the whole time, the patient's vitals including blood pressure, pulse rate, electrocardiogram, oxygen saturation are constantly monitored.
Within a few minutes after the treatment, once the seizure stops, the patient is able to wake up, go to the recovery room or go back to their home with their family members or to the inpatient unit if they are admitted to the hospital.
Modern ECT machines also deliver a carefully calibrated amount of current, which also has reduced the amount of cognitive impairment that's being caused, and since they are giving anesthesia and muscle relaxation, the incidents of fractures have significantly gone down, or I would say even will.
Melanie: Doctor, when is it considered? And is this considered when rapid response is indicated? Or only for patients who have failed other treatments? Explain about when you would consider this treatment.
Dr. Sivaraman: That's a really valid question. Actually both are indications for ECT. So when we say rapid response is required, it's usually when we need to immediately control the symptoms in someone who's severely mentally ill and they have a significant load of depression, or symptoms of mania, that's one of the times that we need a rapid response.
ECT is also considered when a rapid response is desired in a patient who is actively suicidal, and you don't have time to wait for medications to act and control the symptoms.
The other indication where rapid response is required is when patients are catatonic, where they're withdrawn to the point that they're not eating, drinking, they're agitated, and putting themselves in danger. So these are like an emergency indication for ECT.
The other patient population that we usually consider for ECT are the patients of failed multiple medications like in treatment of treatment resistant depression. In some patients with schizophrenia who ECT is another alternative if that antipsychotics are not managing their symptoms. In pregnancy too, ECT may be a better option.
There's also emerging evidence of using ECT in managing agitation and dementia, especially in patients who have failed other measures. Other indications would be when patients prefer ECT because of their past response to the treatment. The rarer indications for ECT are neuroleptic malignant syndrome, refractory stages of epilepticus, for which there are few case reports.
So it's usually an effective procedure when a rapid response is required. But we also reiterate that ECT does not cure you of the psychiatric disorder or the medical illness. To prevent the return of symptoms, patients on ECT need to be on their maintenance medications, psychotherapy, or ongoing ECT treatment.
Melanie: Is it the first line of treatment for any condition?
Dr. Sivaraman: Yes, like I previously mentioned, like in catatonia when patients have to respond immediately, they are too withdrawn, they're not talking, they're not eating, and they're putting themselves in danger. So that is one of the first indications. Like we try to give a benzodiazepine challenge, but if patients are not responding, we usually go ahead with the ECT in patients who are catatonic and someone who is like actively suicidal from their psychiatric condition that you need to manage them and you need to prevent danger to themselves.
Melanie: So how do you discuss this with the patient and their families as an option? Because you know, they've heard in the media and on TV and in the movies, so tell referring physicians how you discuss this with the patient and let them know that this is a more humane treatment and has better results than it used to.
Dr. Sivaraman: So we do ECT consults. Most consults are outpatient and some are inpatient consults that we do. So whenever a clinician consults us to refer a patient for ECT, if it's an outpatient, we see them in our ECT clinic.
So we always encourage patients to come in with the loud ones or family members so that we can go through with them what ECT means and why their psychiatrist has requested ECT for them.
So initially we get a thorough psychiatric and a medical history from the patient to see if they are appropriate for ECT. If the patient is an appropriate candidate for ECT, we explain to them regarding ECT as to we educate them about ECT as to why it's the preferred treatment for their current condition.
We also have educational ECT videos for the patient to watch that actually shows them like how ECT is done- how the modern ECT is done under general anesthesia and muscle relaxation, and how the monitoring is done. We try to answer as many questions from the patients and families as much as possible. We also go through with them the informed consent process because that's very important. So we discuss with them about how the treatment is done, the side effects, the course of treatment, and why we are considering this treatment in this particular case, the risk benefit analysis.
Patients typically require six to twelve ECT treatments three times a week initially for symptomatic response. This is what we call as an acute series. So we explain that clearly to the family and the patient saying that, "Hey, this is how the treatment series is going to be." We explain to them about the side effects, especially the memory side effects that is very concerning for the family members. And once the patient is stabilized, we tell them how the tapering regiment is going to be started.
Again, like I said previously, we reiterate with them that ECT is effective for immediate symptoms control, for management of the symptoms, but to prevent a relapse they need to follow up with their psychiatrist to maintain their medication, their psychotherapy, or ongoing ECT treatments.
Melanie: As far as benefits, Doctor, are there any brain growth benefits from ECT? And as far as negative effects and long-term, does it increase the risk for dementia?
Dr. Sivaraman: Okay, recent studies have actually shown that there's an increase in volume of hippocampus for long and acute series of ECT. Some studies have also demonstrated an increase in BDNF, what we call brain-derived neurotrophic factors, which actually has a nerve cell growth- a neuronal growth following ECT.
There have been a lot of studies and there's no increased risk of dementia or brain damage per se. Like none of the studies have shown that ECT increases the risk for dementia. The long-term- the memory side effects or the cognitive side of things are the ones that patients are actually worried about. They're worried if their memories are going to be wiped out, or if they won't be able to remember things. The typical pattern of memory problems are patients are going to have anterograde and retrograde amnesia for the time surrounding the ECT. That is they may not remember even leading up to the ECT treatment, or even what's happening around the time that they're getting their acute series treatments. Like how they got to the hospital, or how they were in the recovery room.
So that is a critical area when patients might experience memory problems and we tell them not to drive during those times or take any major legal medications.
As we start the tapering course, the common side effects usually start getting better. But if we notice that patients are having a lot of memory problems, we try to space the treatments out so that it helps them with their memory.
The other side effect that some patients may notice is a lot of what we call autobiographical memory where they might forget about a movie that they have watched in the past, or a restaurant they have visited, or a vacation that they had. But those are the small patchy losses, or are your ability to form new memories, or your personality- it's not going to change because of the ECT. Your memories are not going to be wiped off because of ECT.
You might have a patchy memory loss for small incidents, but overall the risk for an untreated psychiatric problem like a depression, or a mania, or schizophrenia puts you more at risk rather than getting treated for ECT that may actually relieve those symptoms and make you more functional.
Melanie: You've cleared that up so beautifully for us, Doctor. And as far as what you're doing at UAB that other physicians may not be aware of, please summarize what you would like them to know about ECT, and when to refer, and to let referring physicians know that this is a more humane treatment and has better results than other methods, and that what they used to hear in the past is not necessarily what's going on today.
Dr. Sivaraman: Modern ECT is very safe, well-tolerated, effective, evidence-based, humane, and life-saving procedure, especially in patients who need rapid response like in catatonia, severe depression with psychotic symptoms, acutely suicidal patients.
Patients who have unipolar or bipolar depression who have failed multiple medications, or unable to tolerate medication, or pregnant patients, ECT can be safely considered for improvement of their symptoms.
A recent meta-analysis has also shown that ECT mortality rate is like 2.1 in 100,000 treatments in patients who are at low medical risk. In patients with depression, the response rate for ECT is particularly high. It's somewhere between 50% to 80% depending on the study. ECT's effectiveness in treating severe mental illness is recognized by the American Psychiatric Association, American Medical Association, and the National Institute of Mental Health.
Modern ECT, being retrained, is a very safe and humane procedure. We always discuss with the patients about the whole process, and only if the patients are comfortable or the family members are comfortable, we go through an informed consent process and then proceed with the treatment.
To summarize, I would like our other physicians in UAB and outside to know that we welcome your referrals. We have a UAB website which states how the referrals need to be made. We have a physician referral form and a patient form that you can fax it over to us. We'll review your record and we'll go ahead and schedule your patient in the ECT clinic and assist them, and see if they're an appropriate candidate for ECT.
But I think if patients- we are always willing to get in touch with you to let you know what our thoughts are, how the treatments need to be scheduled, what medical workup needs to be done, and the labs that need to be obtained, and we'll coordinate with you as to how the treatment process needs to proceed. And we always welcome your calls about the ECT treatment. If you have any questions, please feel free to call us about them.
Melanie: Thank you so much, Doctor, for being with us today and sharing your expertise on this topic that some people have many questions about. So thank you for clearing it up for us today. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1(800) UAB-MIST. That's 1(800) 822-6478. You're listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to www.UABMedicine.org/physician. That's www.UABMedicine.org/physician. This is Melanie Cole, thanks so much for listening.
Melanie Cole (Host): Our topic today is electroconvulsive therapy, and my guest is Dr. Soumya Sivaraman. She's an Assistant Professor in the Department of Psychiatry and Behavioral Neurobiology at UAB Medicine. Welcome to the show, Doctor. Explain a little bit about electroconvulsive therapy. What's the evolution of it, and what's different now?
Dr. Soumya Sivaraman, MD (Guest): Hi, Melanie. Thank you for having me on the show and giving me the opportunity to speak about ECT. So ECT, or electroconvulsive therapy, is a very safe medical procedure during which a very small amount of electricity is applied to the brain to elicit a seizure under general anesthesia under the supervision of a team of psychiatrists, anesthesiologists, nurse anesthetists, and nurses.
Stigma, negative portrayal in the media and misinformation has been one of the major barriers to access this effective and safe treatment. In the past, ECT was done using machines giving very high doses of currents, causing memory impairment, they were not done under general anesthesia, and this resulted in a lot of fractures.
Modern ECT, however, is very different. It's done under general anesthesia, under the supervision of a medical team. The patient is kept on empty stomach overnight. During the treatment or before the treatment they are given IV anesthetic for a brief sedation, followed by administration of a muscle relaxant so that the patient is asleep and the muscles are fully relaxed during the procedure, following which a small dose of electricity is applied to elicit a brief seizure. During the whole time, the patient's vitals including blood pressure, pulse rate, electrocardiogram, oxygen saturation are constantly monitored.
Within a few minutes after the treatment, once the seizure stops, the patient is able to wake up, go to the recovery room or go back to their home with their family members or to the inpatient unit if they are admitted to the hospital.
Modern ECT machines also deliver a carefully calibrated amount of current, which also has reduced the amount of cognitive impairment that's being caused, and since they are giving anesthesia and muscle relaxation, the incidents of fractures have significantly gone down, or I would say even will.
Melanie: Doctor, when is it considered? And is this considered when rapid response is indicated? Or only for patients who have failed other treatments? Explain about when you would consider this treatment.
Dr. Sivaraman: That's a really valid question. Actually both are indications for ECT. So when we say rapid response is required, it's usually when we need to immediately control the symptoms in someone who's severely mentally ill and they have a significant load of depression, or symptoms of mania, that's one of the times that we need a rapid response.
ECT is also considered when a rapid response is desired in a patient who is actively suicidal, and you don't have time to wait for medications to act and control the symptoms.
The other indication where rapid response is required is when patients are catatonic, where they're withdrawn to the point that they're not eating, drinking, they're agitated, and putting themselves in danger. So these are like an emergency indication for ECT.
The other patient population that we usually consider for ECT are the patients of failed multiple medications like in treatment of treatment resistant depression. In some patients with schizophrenia who ECT is another alternative if that antipsychotics are not managing their symptoms. In pregnancy too, ECT may be a better option.
There's also emerging evidence of using ECT in managing agitation and dementia, especially in patients who have failed other measures. Other indications would be when patients prefer ECT because of their past response to the treatment. The rarer indications for ECT are neuroleptic malignant syndrome, refractory stages of epilepticus, for which there are few case reports.
So it's usually an effective procedure when a rapid response is required. But we also reiterate that ECT does not cure you of the psychiatric disorder or the medical illness. To prevent the return of symptoms, patients on ECT need to be on their maintenance medications, psychotherapy, or ongoing ECT treatment.
Melanie: Is it the first line of treatment for any condition?
Dr. Sivaraman: Yes, like I previously mentioned, like in catatonia when patients have to respond immediately, they are too withdrawn, they're not talking, they're not eating, and they're putting themselves in danger. So that is one of the first indications. Like we try to give a benzodiazepine challenge, but if patients are not responding, we usually go ahead with the ECT in patients who are catatonic and someone who is like actively suicidal from their psychiatric condition that you need to manage them and you need to prevent danger to themselves.
Melanie: So how do you discuss this with the patient and their families as an option? Because you know, they've heard in the media and on TV and in the movies, so tell referring physicians how you discuss this with the patient and let them know that this is a more humane treatment and has better results than it used to.
Dr. Sivaraman: So we do ECT consults. Most consults are outpatient and some are inpatient consults that we do. So whenever a clinician consults us to refer a patient for ECT, if it's an outpatient, we see them in our ECT clinic.
So we always encourage patients to come in with the loud ones or family members so that we can go through with them what ECT means and why their psychiatrist has requested ECT for them.
So initially we get a thorough psychiatric and a medical history from the patient to see if they are appropriate for ECT. If the patient is an appropriate candidate for ECT, we explain to them regarding ECT as to we educate them about ECT as to why it's the preferred treatment for their current condition.
We also have educational ECT videos for the patient to watch that actually shows them like how ECT is done- how the modern ECT is done under general anesthesia and muscle relaxation, and how the monitoring is done. We try to answer as many questions from the patients and families as much as possible. We also go through with them the informed consent process because that's very important. So we discuss with them about how the treatment is done, the side effects, the course of treatment, and why we are considering this treatment in this particular case, the risk benefit analysis.
Patients typically require six to twelve ECT treatments three times a week initially for symptomatic response. This is what we call as an acute series. So we explain that clearly to the family and the patient saying that, "Hey, this is how the treatment series is going to be." We explain to them about the side effects, especially the memory side effects that is very concerning for the family members. And once the patient is stabilized, we tell them how the tapering regiment is going to be started.
Again, like I said previously, we reiterate with them that ECT is effective for immediate symptoms control, for management of the symptoms, but to prevent a relapse they need to follow up with their psychiatrist to maintain their medication, their psychotherapy, or ongoing ECT treatments.
Melanie: As far as benefits, Doctor, are there any brain growth benefits from ECT? And as far as negative effects and long-term, does it increase the risk for dementia?
Dr. Sivaraman: Okay, recent studies have actually shown that there's an increase in volume of hippocampus for long and acute series of ECT. Some studies have also demonstrated an increase in BDNF, what we call brain-derived neurotrophic factors, which actually has a nerve cell growth- a neuronal growth following ECT.
There have been a lot of studies and there's no increased risk of dementia or brain damage per se. Like none of the studies have shown that ECT increases the risk for dementia. The long-term- the memory side effects or the cognitive side of things are the ones that patients are actually worried about. They're worried if their memories are going to be wiped out, or if they won't be able to remember things. The typical pattern of memory problems are patients are going to have anterograde and retrograde amnesia for the time surrounding the ECT. That is they may not remember even leading up to the ECT treatment, or even what's happening around the time that they're getting their acute series treatments. Like how they got to the hospital, or how they were in the recovery room.
So that is a critical area when patients might experience memory problems and we tell them not to drive during those times or take any major legal medications.
As we start the tapering course, the common side effects usually start getting better. But if we notice that patients are having a lot of memory problems, we try to space the treatments out so that it helps them with their memory.
The other side effect that some patients may notice is a lot of what we call autobiographical memory where they might forget about a movie that they have watched in the past, or a restaurant they have visited, or a vacation that they had. But those are the small patchy losses, or are your ability to form new memories, or your personality- it's not going to change because of the ECT. Your memories are not going to be wiped off because of ECT.
You might have a patchy memory loss for small incidents, but overall the risk for an untreated psychiatric problem like a depression, or a mania, or schizophrenia puts you more at risk rather than getting treated for ECT that may actually relieve those symptoms and make you more functional.
Melanie: You've cleared that up so beautifully for us, Doctor. And as far as what you're doing at UAB that other physicians may not be aware of, please summarize what you would like them to know about ECT, and when to refer, and to let referring physicians know that this is a more humane treatment and has better results than other methods, and that what they used to hear in the past is not necessarily what's going on today.
Dr. Sivaraman: Modern ECT is very safe, well-tolerated, effective, evidence-based, humane, and life-saving procedure, especially in patients who need rapid response like in catatonia, severe depression with psychotic symptoms, acutely suicidal patients.
Patients who have unipolar or bipolar depression who have failed multiple medications, or unable to tolerate medication, or pregnant patients, ECT can be safely considered for improvement of their symptoms.
A recent meta-analysis has also shown that ECT mortality rate is like 2.1 in 100,000 treatments in patients who are at low medical risk. In patients with depression, the response rate for ECT is particularly high. It's somewhere between 50% to 80% depending on the study. ECT's effectiveness in treating severe mental illness is recognized by the American Psychiatric Association, American Medical Association, and the National Institute of Mental Health.
Modern ECT, being retrained, is a very safe and humane procedure. We always discuss with the patients about the whole process, and only if the patients are comfortable or the family members are comfortable, we go through an informed consent process and then proceed with the treatment.
To summarize, I would like our other physicians in UAB and outside to know that we welcome your referrals. We have a UAB website which states how the referrals need to be made. We have a physician referral form and a patient form that you can fax it over to us. We'll review your record and we'll go ahead and schedule your patient in the ECT clinic and assist them, and see if they're an appropriate candidate for ECT.
But I think if patients- we are always willing to get in touch with you to let you know what our thoughts are, how the treatments need to be scheduled, what medical workup needs to be done, and the labs that need to be obtained, and we'll coordinate with you as to how the treatment process needs to proceed. And we always welcome your calls about the ECT treatment. If you have any questions, please feel free to call us about them.
Melanie: Thank you so much, Doctor, for being with us today and sharing your expertise on this topic that some people have many questions about. So thank you for clearing it up for us today. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1(800) UAB-MIST. That's 1(800) 822-6478. You're listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to www.UABMedicine.org/physician. That's www.UABMedicine.org/physician. This is Melanie Cole, thanks so much for listening.