ECT for neurologists

1. Electroconvulsive therapy: a
neurologic perspective
Ahmad Eid al-Ajhuri
Board-certified in psychiatry, MScMed, MBChB
Emory mini-fellowship of ECT
Director of Abbassia Training Program (ATP)

2. Electroconvulsive therapy: ECT
 Epilepsy & Dementia Praecox
 Meduna: Camphor oil, 1934
 Cerletti & Bini: ECT, 1938
 More than 70 years of continuous
practice.
 Level (Ia) in depression management
 Still a controversial practice!
 Anti-ECT articles, more than 20
Hollywood movies, and lastly an
impressive stigma.
ajhuri@gmail.com Cairo, Jan 2012 2

3. “Neurologists are generally not well
versed in ECT and psychiatrists
tend to overlook ECT when it
comes to patients with co-morbid
neurological conditions”
Burgut FT, Kellner CH. Electroconvulsive therapy (ECT) for dementia
with Lewy bodies. Med Hypotheses. 2010 Aug;75(2):139-40.
ajhuri@gmail.com Cairo, Jan 2012 3

4. Tools of brain stimulation
Swartz CM (editor): Electroconvulsive and Neuromodulation Therapies. Cambridge University Press.
2009
ajhuri@gmail.com Cairo, Jan 2012 4

5. ECT helps brain to work: few
seconds with long effects !
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6. The centrencephalic theory of
seizure generalization
 Regional cerebral blood flow (rCBF):
increases extensively, particularly in
the centrencephalic structures in
generalized seizures.
Differences in cerebral blood flow between missed and generalized seizures with
electroconvulsive therapy: A positron emission tomographic study Harumasa
Takano, Nobutaka Motohashi, Takeshi Uema, Ken’ichi Ogawa, Takashi Ohnishi, Masami
Nishikawa, Hiroshi Matsuda Epilepsy research 1 November 2011 (volume 97 issue 1 Pages
225-228
ajhuri@gmail.com Cairo, Jan 2012 6

7. ajhuri@gmail.com Cairo, Jan 2012 7

8. ajhuri@gmail.com Cairo, Jan 2012 8

9. EEG
 Relative alpha activity (8.5 12.0 Hz)
increased in occipital lobe after a
course (qEEG analysis)
Y. Kitaura, K. Nishida, R. Hama, Y. Takekita, M. Yoshimura, A. Tajika, T. Kinoshita,
P27-6 Quantitative EEG analysis of electroconvulsive therapy response for senile depression: a
case report, Clinical Neurophysiology, Volume 121, Supplement 1, October 2010, Page S264
ajhuri@gmail.com Cairo, Jan 2012 9

10. Vagal system stimulation
 ECT increases vagal activity which
might be associated with the beneficial
effect seen following ECT
Bär KJ, Ebert A, Boettger MK, Merz S, Kiehntopf M, Jochum T, Juckel G, Agelink MW.
Is successful electroconvulsive therapy related to stimulation of the vagal system?
J Affect Disord. 2010 Sep;125(1-3):323-9.
ajhuri@gmail.com Cairo, Jan 2012 10

11. Electrode placement
BT RUL BF
d’Elia Letemendia
ajhuri@gmail.com Cairo, Jan 2012 11

12. ECT seizure Vs Epileptic seizure
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13. Official recommendations
 Three major practice
recommendations have been
published on ECT:
◦ APA Task Force on ECT (2001)
◦ Third report of the Royal College of
Psychiatrists’ Special Committee on ECT
(2004)
◦ National Institute for Health and Clinical
Excellence (NICE 2003; NICE 2009)
ajhuri@gmail.com Cairo, Jan 2012 13

14. Egyptian MHA, 2009
 Mandates: general anesthesia &
muscle relaxation.
 Informed consent / agreement of 2
assessments from 2 registered
specialists.
 National Accreditation Policy for ECT
units and clinics is now under-running
in NMHC.
MHA: mental health act
NMHC: national mental health commission
ajhuri@gmail.com Cairo, Jan 2012 14

15. ECT amnestic syndrome
 Transient / permanent
 Electrode placement or electrical
dosage :No significant evidence-base
that their predictive value regarding
cognitive outcome following brief-
pulse ECT after the subacute period.
M. Semkovska, O. Babalola, D. Keane, D.M. McLoughlin, P.1.g.008 Cognitive effects of
electrode placement and stimulus dose in brief-pulse electroconvulsive therapy for
depression, European Neuropsychopharmacology, Volume 20, Supplement 3, August
2010, Pages S312-S313,
ajhuri@gmail.com Cairo, Jan 2012 15

16. FDA executive summary, 2011
 Disorientation: acute NOT long term,
BL > UL
 Executive function: no effect, may
improve
 Anterograde memory: improves
 Retrograde memory: decline in subacute
phase EXCEPT with ultrabrief waves
 Autobiographical memory: decline in
subacute phase EXCEPT with ultrabrief
waves and BF ECT
FDA executive summary: Prepared for the January 27-28, 2011 meeting of the Neurological
Devices Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices
(ECT)
ajhuri@gmail.com Cairo, Jan 2012 16

17. Cerebrovascular stroke
 Post stroke depression in
common, esp with lesion in Lt
hemisphere
 Wait until 3 m after stroke
 Pts on anticoagulation
◦ Risk of ICH vs risk of embolic CVA
◦ INR = Takano, Miya Tominaga, recommended
Hideaki Suzuki, Takehisa2 – 3, TEE isKazumasa Suzuki, Yutaka Kagaya, Acute
embolic stroke in a patient with atrial fibrillation after electroconvulsive therapy, Journal of
Cardiology Cases, Volume 2, Issue 1, August 2010, Pages e12-e14, ISSN 1878-
5409, 10.1016/j.jccase.2010.01.004.
ajhuri@gmail.com Cairo, Jan 2012 17

18. Unresponsive pt
 Stupor vs Coma
 Stupor: varying degrees of
unresponsiveness due to an apparent
decreased level of consciousness
 Stupor / not
 Catatonic signs / not
 Psychiatric / Neurologic ds
 BZD then ECT
Hurwitz TA. Psychogenic unresponsiveness. Neurol Clin. 2011 Nov;29(4):995-1006.
ajhuri@gmail.com Cairo, Jan 2012 18

19. Super-refractory status
epilepticus
 SE that continues or recurs 24 h or
more after the onset of anesthetic
therapy, including those cases where
SE recurs on the reduction or
withdrawal of anaesthesia.
 ECT as an option was used since
1943
 After pharmacologic coma fails
Shorvon S, Ferlisi M. The treatment of super-refractory status epilepticus: a critical review of
available therapies and a clinical treatment protocol. Brain. Oct; (Pt -
ajhuri@gmail.com Cairo, Jan 2012 19

20. Pseudodementia
 Cognitive disorders resulting from functional
disorders
 Common: depression, Ganser syndrome
 Severe cognitive and memory impairments
often occur during episodes of depression
 Suspect when: dementia syndrome
appears suddenly in an adult, especially an
elderly adult.
 Remarkable response to ECT
 Fink M. Electroconvulsive therapy: a guide for professionals and their
patients. Oxford, 2009
ajhuri@gmail.com Cairo, Jan 2012 20

21. Multiple sclerosis
 Depression: up to 25 %, may be
delusional
 Mania: up to 14 %
 Suicide: 5 x other population
 Recurrent catatonia / psychosis: rare
Pontikes TK, Dinwiddie SH. Electroconvulsive therapy in a patient with multiple sclerosis and
recurrent catatonia. J ECT. 2010 Dec;26(4):270-1.
ajhuri@gmail.com Cairo, Jan 2012 21

22. Parkinson’s Disease (PD)
 Psychotic symptoms in Parkinson's
disease (PDP) are relatively common
 In a recent Japanese case series of 8
quetiapine-resistant PDP pts:
◦ significant ↑ in rCBF in the right middle
frontal gyrus after ECT
◦ notable improvements not only in PDP but
also in the severity of PD
Usui C, Hatta K, Doi N, Kubo S, Kamigaichi R, Nakanishi A, Nakamura H, Hattori N, Arai H.
Improvements in both psychosis and motor signs in Parkinson's disease, and changes
in regional cerebral blood flow after electroconvulsive therapy. Prog Neuropsychopharmacol Biol
Psychiatry. 2011 Aug 15;35(7):1704-8.
ajhuri@gmail.com Cairo, Jan 2012 22

23. Dementia with Lewy bodies
 Psychiatric Sx:
◦ Psychosis is an intrinsic part of DLB: 75%
have hallucinations and >50% have
delusions
◦ Depression: 20 – 65 %
 ‘Neuroleptic sensitivity’ phenomenon
 ECT has
antidepressant, antipsychotic, and
dopamine-enhancing effects
Burgut FT, Kellner CH. Electroconvulsive therapy (ECT) for dementia with Lewy bodies.
Med Hypotheses. 2010 Aug;75(2):139-40.
ajhuri@gmail.com Cairo, Jan 2012 23

24. Other movement disorders
 Successful case reports:
◦ NMS
◦ TD
◦ HD
◦ TS
Scott A. The ECT Handbook. 2nd Ed. The Third Report of the Royal College of
Psychiatrists’ Special Committee on ECT. 2005
ajhuri@gmail.com Cairo, Jan 2012 24

25. Drugs before ECT
 Symptomatic improvement of patients
who are on AEDs during ECT is
comparable to those who are not
 AEDs + ECT Vs ECT alone:
◦ Higher charge
◦ More sessions, esp titrations
◦ Delayed recovery
◦ Post ECT delirium
Comparison of electroconvulsive therapy (ECT) with or without anti-epileptic drugs in bipolar disorder
. Harve Shanmugam Virupaksha, Barki Shashidhara, Jagadisha Thirthalli, Channaveerachari
Naveen Kumar, Bangalore N. Gangadhar Journal of affective disorders 1 December 2010
(volume 127 issue 1 Pages 66-70
ajhuri@gmail.com Cairo, Jan 2012 25

26. Pts with increased ICP
 Increased ICP: SOLs, relatively safe
 May pre use steroids, diuretics, anti
HTN & HV
 Depression and catatonia: common
The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and
Privileging: A. Washington, DC: American Psychiatric Association; 2001. Task Force Report of
the American Psychiatric Association
Scott A. The ECT Handbook. 2nd Ed. The Third Report of the Royal College of Psychiatrists’
Special Committee on ECT. 2005
ajhuri@gmail.com Cairo, Jan 2012 26

27. Drugs that may induce status
epilepticus with ECT
 Herbal eg Ginkgo, Ginseng, Kava, SJW
 Xanthines eg theophylline, caffeine
ajhuri@gmail.com Cairo, Jan 2012 27

28. Drugs delay recovery and
prolong post ECT delirium
 Anti-Ch
 TCA
 Li
 AEDs
ajhuri@gmail.com Cairo, Jan 2012 28

29. ECT as a drug
 Antipsychotic
 Antidepressant
 Antimanic
 Mood stabilizer
 Antisuicidal
 Alerting
 Vegetative
 Antiepileptic
 Dopaminergic
ajhuri@gmail.com Cairo, Jan 2012 29

30. Take-home message
 ECT is a brain stimulation therapy NOT a
psychiatric treatment
 ECT has 2nd line indications in primary
neurologic disorders esp Parkinson
 ECT has the same indications in secondary
psychiatric disorders eg post stroke
depression
 Neurologist needs modulate drug therapy
before referral to ECT eg optimize INR, stop
herbal drugs
 ECT is still one of the RELATIVELY SAFE
and effective treatments without an
alternative when indicated
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31. Abbassia Hospital after sunset
ajhuri@gmail.com Cairo, Jan 2012 31