a review of cognitive outcomes of modern day ect, kiri luther
TRANSCRIPT
A Review of Cognitive Outcomes of Modern Day ECT
Kiri Luther DClinPsych Candidate Massey University, Wellington
Professor Janet Leathem – Primary SupervisorDr Steve Humphries – Secondary Supervisor
Dr Nisar Contractor, C&CDHB – Professional Advisor
ECT: Procedure
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
EEG monitoring
Seizure is treatment, not electricity
Technical Context: Electrode Placement
Unilateral Right hemisphere (initially)
Bilateral Temporal
More cognitive difficulties Frontal
Less research
Lisanby, 2007
Technical Context: Guidelines
NICE Short-term treatment after all other options have failed
depressive illness catatonia prolonged or severe mania
NZ Ministry of Health when medication does not work where psychotherapy is inappropriate there is a risk of suicide or neglect where there is a need for rapid therapeutic action when ECT has already been used with good outcomes For
depression catatonia mania schizophrenia
Rationale
• Response to request• Evaluate & improve current assessment
methods used in Wellington • Ultimately to come up with a time and cost
effective test battery to monitor the effects that ECT has on Memory and Cognition
• Research need identified • NICE Guidelines for ECT. (National Institute
for Clinical Excellence 2003)• subjective assessment• long term outcomes.
How do we do this?
Before we move forward we need to go back – retrospective research How are historical patients now? How were they back when they were
having ECT? What domains of memory and cognition
are affected in the short and long term? How do we best assess these?
Are current measures being used by CCDHB useful?
Review
Review completed to ascertain which areas of memory are most commonly assessed and which of these show dysfunction
Review completed to ascertain which measures are commonly used to assess these areas
Review
Literature search completed using Web of Science Google Scholar Psych Info Academic Search Elite Medline
33 studies were included in the reviews
Findings - DomainsDomains Assessed Number of Studies % of Studies Showing
Dysfunction in Domain
Retrograde Amnesia 12 100
Autobiographical Memory 11 100
Subjective Memory 11 82
Verbal Learning & Memory 10 90
Visual Learning & Memory 8 63
Anterograde Amnesia 7 100
Attention/Concentration 7 71
Global Cognitive Status 7 71
Retrieval 6 100
Working Memory 5 80
Encoding 2 100
Semantic Memory 1 100
Every-day Memory 1 100
How were measures chosen?
Literature and Previous Research
Current Measures Used By C&CDHB
Other Measures Depression: BDI-II, MADRS Memory Malingering: TOMM
Findings - AssessmentDomains Assessed Measures Used in Current Research
Retrograde Amnesia Autobiographical Memory Inventory (AMI)
Autobiographical Memory AMI
Verbal Learning & Memory Rey Auditory Verbal Learning Test (RAVLT)
Visual Learning & Memory Rey Complex Figure (RCFT)
Global Cognitive Status Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA)
Subjective Memory Interpretive Phenomenological Analysis (IPA)
Anterograde Amnesia AMI, RCFT, RAVLT
Attention/Concentration RCFT, RAVLT, MoCA, MMSE
Retrieval RCFT, RAVLT, AMI, MMSE, MoCA
Working Memory MoCA, MMSE
Encoding RCFT, RAVLT
Semantic Memory AMI, MoCA, MMSE, IPA
Every-day Memory IPA
Method
Health and Disability Ethics Approval Invitations sent to historical patients Participant consent Access to patient files
ECT technical data collected Participant historical assessment data collected if
available Participants underwent psychometric
assessment to form current outcome data Participants gave subjective accounts of
their experiences
Participants Initial pool=222 Step-wise inclusion:
NHI number Alive and listed as living in Wellington ≤65 yrs of age No Dementia, Head Injury or ID Able to participate N=118 Agree to participate, N=27 5 withdrew, 2 withdrawn by researcher Total Participants, N=20
Potential Influences on Cognition
Electrode Placement Dosage Number and Frequency of Treatments Age Education Time Since Last ECT Current Depressive Symptomology Some Medications e.g. Lithium Malingering
File Information
Diagnosis Electrode Placement Number of Treatments Frequency of Treatments (# per week) First and Last Treatment Dates Dosage Seizure Durations, EEG and Motor Anaesthetic Muscle Relaxant Previous Assessments e.g. MMSE, MADRS
Interviews
Assessment Protocol Demographic Info e.g. D.O.B, Education, Ethnicity TOMM Trial 1 and 2 BDI-II MADRS TOMM – Trial 3 if necessary MoCA RCFT – Copy then Immediate Recall RAVLT – All trials, interference trial MMSE RCFT – Delayed Recall, Recognition RAVLT – Delayed Recall, Recognition AMI Subjective Assessment - IPA
Ideal Analysis
Comparisons between; Past objective vs. present objective Past subjective vs. present subjective Present objective vs. present subjective Past objective vs. past subjective The relationship between depression and
cognitive functioning
Ideally what will this give us?
Information about memory and global cognitive difficulties in the short term – historical assessment
Information about memory and global cognitive difficulties in the long term – current assessment
A Time-Line of changes in Outcomes Subjective information which can be
compared to objective assessment
What did we get?
Comparisons between; Past objective vs. present objective
Some MMSE, MADRS & BDI-II Past subjective vs. present subjective Present objective vs. present subjective Past objective vs. past subjective
As Above The relationship between depression
and cognitive functioning
Some of the Problems Sample size N=20
Large for IPA Small for Quantitative
Most had bilateral ECT so couldn’t compare with RUL Different machines used = different method of
treatment Titration vs. No titration therefore dose information was
different e.g. (% vs. mC) Lack of historical assessment data
No baseline data for comparison, very little monitoring data
Difficulties finding some patient files Some ECT information was not recorded
One participant had very little information about dosage, electrode placement and seizure durations
Two participants refused some of the assessment – felt they were unable to do it.
What Now?
Data Analysis Qualitative Analysis Conclusions Recommendations
Assessment Ongoing Research
Initial Impressions
Researcher first person to talk to participants about ECT since their treatment (up to 13 years ago)
Very emotional Participants didn’t just talk about
their ECT Time in Psychiatric Ward Medications Overall Treatment within the Health System Childhood Illness
Initial Impressions
Costs Not being listened too Not being treated like a human being Feeling like a guinea pig No trust – Psychiatrists No follow-up
Benefits Feeling Safe – in hospital Kind nurses and ECT staff Getting better Future orientated
Initial Impressions
Memory and Cognition Personal Memories
Own childhood Their children growing up Confused timelines Chunks of time missing
Memory around time of ECT Blanks Not being aware of forgetting until
remembering something Mental fatigue
Initial Impressions
ECT Participant Quotes-Costs “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”
“I remember thinking, I wonder if this is what it feels like to have a learning disability”
“I was scared of what would happen if I said no” – to ECT
“I have about a year I don’t remember” “My brain feels half dead, feels drunk....it’s
lost its crispness
Initial Impressions
ECT Participant Quotes-Benefits “Possibly there were times it bought me
out of total destruction” “I believe it cured my depression or was
definitely the road to recovery” ”It cured me” “Stopped me being grossly depressed” “It saved my life after many Doctors,
medications, therapists, counsellors, support groups and good intentions”
“I made it back to life”
References/Bibliography
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
Lisanby, S. H. (2007). Electroconvulsive therapy for depression. The new England journal of medicine, 357(19), 1939-1945.
Ministry of Health (2006). Electroconvulsive therapy annual statistics: For the period 1 July 2003 to 30 June 2005. Wellington: Ministry of Health.
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.
National Institute for Clinical Excellence (2003). Guidance on the use of electroconvulsive therapy: Technology appraisal 59. London: National Institute for Clinical Excellence.
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.
Tiller, J. W. G., & Lyndon, R. W. (2003). Electroconvulsive therapy: An Australasian guide. Victoria: Australian Postgraduate Medicine.
Thank-you for your time
Kiri Luther DClinPsych Candidate Massey University, Wellington