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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 36. This is the beginning of the thread.
Posted by bleauberry on April 13, 2009, at 18:15:12
Department of Biological Psychiatry, New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA. has1@columbia.edu
CONTEXT: Electroconvulsive therapy (ECT) is highly effective for treatment of major depression, but naturalistic studies show a high rate of relapse after discontinuation of ECT. OBJECTIVE: To determine the efficacy of continuation pharmacotherapy with nortriptyline hydrochloride or combination nortriptyline and lithium carbonate in preventing post-ECT relapse. DESIGN: Randomized, double-blind, placebo-controlled trial conducted from 1993 to 1998, stratified by medication resistance or presence of psychotic depression in the index episode. SETTING: Two university-based hospitals and 1 private psychiatric hospital. PATIENTS: Of 290 patients with unipolar major depression recruited through clinical referral who completed an open ECT treatment phase, 159 patients met remitter criteria; 84 remitting patients were eligible and agreed to participate in the continuation study. INTERVENTIONS: Patients were randomly assigned to receive continuation treatment for 24 weeks with placebo (n = 29), nortriptyline (target steady-state level, 75-125 ng/mL) (n = 27), or combination nortriptyline and lithium (target steady-state level, 0.5-0.9 mEq/L) (n = 28). MAIN OUTCOME MEASURE: Relapse of major depressive episode, compared among the 3 continuation groups. RESULTS: Nortriptyline-lithium combination therapy had a marked advantage in time to relapse, superior to both placebo and nortriptyline alone. Over the 24-week trial, the relapse rate for placebo was 84% (95% confidence interval [CI], 70%-99%); for nortriptyline, 60% (95% CI, 41%-79%); and for nortriptyline-lithium, 39% (95% CI, 19%-59%). All but 1 instance of relapse with nortriptyline-lithium occurred within 5 weeks of ECT termination, while relapse continued throughout treatment with placebo or nortriptyline alone. Medication-resistant patients, female patients, and those with more severe depressive symptoms following ECT had more rapid relapse. CONCLUSIONS: Our study indicates that without active treatment, virtually all remitted patients relapse within 6 months of stopping ECT. Monotherapy with nortriptyline has limited efficacy. The combination of nortriptyline and lithium is more effective, but the relapse rate is still high, particularly during the first month of continuation therapy.
BASICALLY SAYS: If you respond and don't take meds, your relapse rate is 84% pretty soon. With meds, relapse is still high.
.BACKGROUND: Clinical trials indicate that electroconvulsive therapy (ECT) is the most effective treatment for major depression, but its effectiveness in community settings has not been examined. METHODS: In a prospective, naturalistic study involving 347 patients at seven hospitals, clinical outcomes immediately after ECT and over a 24-week follow-up period were examined in relation to patient characteristics and treatment variables. RESULTS: The sites differed markedly in patient features and ECT administration but did not differ in clinical outcomes. In contrast to the 70%-90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3%-46.7%. Longer episode duration, comorbid personality disorder, and schizoaffective disorder were associated with poorer outcome. Among remitters, the relapse rate during follow-up was 64.3%.
BASICALLY SAYS: Relapse rate, if it works, is 64%. The chance of it working, in the real world, is 30% to 46%. Why is ECT said to be so great? My own experience with it seems to be more in line with the real world and not the sanitary biased clinical settings.
Each patient received an average of 47 bilateral M-ECT under general anaesthesia at one to five weeks' intervals for a mean period of 43 months. All of them were also treated by antipsychotics; in addition, 30% received mood stabilizers and 10% antidepressants. The dosage of antidepressants and mood stabilizers was reduced during M-ECT treatment, especially in patients with schizoaffective disorder, probably in relation with the effectiveness of ECT on mood symptoms. RESULTS: During M-ECT, the mean duration of yearly hospitalizations was decreased by 80% and the mean duration of each hospitalization by 40% with a better ability to take part in activities, sometimes even to return home or go back to work. There was also a positive effect on quality of life considering the severity of symptoms and the long psychiatric history of these patients. The possibility to go from a full time hospitalization to a day-care facility or to live in a halfway house can be considered as a huge progress. M-ECT was efficient on mood symptoms, delusions, anorexia, suicidal impetus, anxiety symptoms and increased cooperation and treatment compliance. Efficacy on obsessive compulsive symptoms was less obvious. There was no effect on dissociation and negative symptoms. Relapses essentially occurred after a stressful life event, a too long interval between the M-ECT sessions or, in 50% of the cases, without any obvious etiology. It required a revision of the M-ECT program and, most of the time, an hospitalization for full ECT treatment.
BASICALLY SAYS: Your hospital stays will continue, but be reduced, and you will need longterm ECT to at least stay well enough to leave the hospital and "sometimes" even return home or to a halfway house.
The findings suggest that mECT may have a role in reducing the rate and duration of hospital stay of patients with major depressive disorder.
WHOOP-TI-DO. CHEERS. Heck, remission isn't even on the radar screen.
BACKGROUND: ECT, an effective treatment for major depression, is associated with a high relapse rate. Roughly half of all responders during the acute treatment phase relapse during continuation treatment. Recent literature has pointed out an "efficacy-effectiveness gap" in outcomes of patients enrolled in study protocols when compared to "care as usual." This study compares the effectiveness of usual care versus protocolized pharmacotherapy in preventing relapse following ECT. METHODS: One hundred twenty-six depressed patients responded to acute ECT. Seventy-three were randomized to continuation pharmacotherapy consisting of nortriptyline, nortriptyline-plus-lithium, or placebo. The 53 patients that refused to participate in the randomized trial were followed naturalistically for 6 months or until depression relapse in usual care settings. RESULTS: All but one "usual care" patient received pharmacotherapy following ECT; 27 (51%) relapsed within 6 months. Only one usual care patient received continuation ECT as a first-line treatment. The "usual care" relapse rate was intermediate to the relapse rates of the patients receiving protocolized nortriptyline (60%) and nortriptyline-plus-lithium (39%), but superior to placebo (84%). CONCLUSIONS: The relapse rate associated with usual care following ECT was comparable to that of protocolized pharmacotherapy. This suggests that high relapse rates following ECT are not due solely to an "efficacy-effectiveness gap."
PMID: 17453654 [PubMed - indexed for MEDLINE]
It amazes me how every article starts off saying how great ECT is, and then goes on to show how poorly it actually is. Almost as if the reader is too stupid to put two and two together.
It was comforting though to at least see a hint of honesty in some of these studies where they actually admit relapse rates are very high, and remission rates a bit on the iffy side.
I think for someone who is so ill that they will spend a good deal of the rest of their lives in and out of hospitals, and they are not productive, and won't be, in society, then ECT probably is a decent option. It at least gives them the best life they can have under the circumstances.
I think its real calling is for chemotherapy patients in the hospital...helps them feel better, helps them forget, and actually helps kill the tumors.
One thing I discovered that could be a major fault of ECT is that it is usually stopped when the patient remits. If it were continued for a couple months past remission, my hunch is it would have some holding power.
ECT has its place. But it is overglorified for the majority of us.
The above articles were just a 15 minute sample of what I could find. Believe me, there is a lot more. Just too darn depressed today to do any more.
Posted by Sigismund on April 13, 2009, at 18:28:20
In reply to ECT, posted by bleauberry on April 13, 2009, at 18:15:12
>Clinical trials indicate that electroconvulsive therapy (ECT) is the most effective treatment for major depression,
I have my doubts that this is true, and yet I fear it is. It says volumes about us if so.
Posted by Sigismund on April 13, 2009, at 18:31:33
In reply to ECT, posted by bleauberry on April 13, 2009, at 18:15:12
My psych said this to me....
I was taught that ECT was the one thing that worked for depression. When I was an intern psych I used it. Later I taught the same thing to others. But you know? I *never* saw it. I did see that people who had had ECT complained less subsequent to treatment.
Posted by Sigismund on April 13, 2009, at 18:39:27
In reply to ECT, posted by bleauberry on April 13, 2009, at 18:15:12
My psych wanted to do some double blind studies into ECT but was over-ruled by the ethics committee.
When I see a decent double blind study into it I will feel better about it, say ECT against acute hashish intoxication with symptoms controlled by benzos and opiates.
The truth is that depressed people going to have ECT have quite different standards of care applied to them.
I wouldn't so much mind that if they would simply say so, you know....'look, you're f*ck*d mate. Too bad.'Wasn't it developed from processing pigs in slaughterhouses by some Portuguese fascist?
Posted by linkadge on April 13, 2009, at 18:59:41
In reply to Re: ECT, posted by Sigismund on April 13, 2009, at 18:39:27
The safety and efficacy of ECT needs to be seriously revisited.
Think of it this way. If your only goal is to temporarily get the patient out of a bad place, then why not use opiates?I would be willing to bet that theraputic use of opiates would be as (if not more) effective than ECT and you would probably have less long negative health consequences.
Linkadge
Posted by Larry Hoover on April 13, 2009, at 19:19:50
In reply to Re: ECT, posted by Sigismund on April 13, 2009, at 18:39:27
I think ECT was developed as a safer way to induce seizures than by using insulin shock. Anyway, here is the result of the first prospective study of cognitive function and ECT, published in 2007. Think of that, no one had ever systematically studied pre- and post-ECT cognitive function before 2007. Sackheim, one of the most vociferous proponents of ECT, is the lead author.
http://www.ect.org/wp-content/uploads/2007/01/1301180a.pdf
Lar
Posted by Sigismund on April 13, 2009, at 19:35:03
In reply to Re: ECT » Sigismund, posted by Larry Hoover on April 13, 2009, at 19:19:50
And they used cardiozol too for this perhaps?
When Stalin had his stroke his physicians gave him injections of camphor.
And they used insulin for induced comas, rather like deep sleep treatment.
I'd certainly feel less conflicted if this treatment was given me by someone other than a doctor, but I have always been so innocent.
Was it Sackheim who gave multiple doses of ECT to women to help them be more ideal housewives?
>Think of that, no one had ever systematically studied pre- and post-ECT cognitive function before 2007.
Well, that says heaps about who counts and who doesn't.
Like Linkadge said, try opiates.
Get cancer, then you can get some opiates.
Posted by Sigismund on April 13, 2009, at 19:37:59
In reply to Re: ECT, posted by linkadge on April 13, 2009, at 18:59:41
>I would be willing to bet that theraputic use of opiates would be as (if not more) effective than ECT and you would probably have less long negative health consequences.
I'd bet my bottom dollar on it, at least until the end of the study.
Posted by Zyprexa on April 13, 2009, at 20:01:15
In reply to ECT, posted by bleauberry on April 13, 2009, at 18:15:12
How about if you take your meds in the first place would you need the ECTs to begin with?
I wish I had never gotten ECTs to begin with and that I had just taken the meds they were giving me. Would I have gotten the ECTs and ended up in the hospital twice in one year and then took the meds and didn't need to go back.
Posted by Larry Hoover on April 13, 2009, at 20:09:08
In reply to Re: ECT, posted by Sigismund on April 13, 2009, at 19:35:03
> Was it Sackheim who gave multiple doses of ECT to women to help them be more ideal housewives?
Maybe that was Max Fink. Not only does he have a conflict of interest (he owns a manufacturer of ECT devices), but he would shock just about anybody. Parkinson's patients, Alzheimer's patients, schizophrenics, those with Tourette's, brain tumours, the 'mentally retarded' (his own language). His oldest subject was 102 years old. The youngest, I think, was 7.
In 2007, he published a paper suggesting that the loss of personal memories following ECT was really evidence of a somatoform disorder, and that psychotherapy was warranted.
Another proponent was Abrams. But I think Fink was the one that advocated ECT for behavioural modification, noting in his 1979 textbook, "patients become more compliant and acquiescent with treatment".
Lar
Posted by linkadge on April 13, 2009, at 20:09:25
In reply to Re: ECT » Sigismund, posted by Larry Hoover on April 13, 2009, at 19:19:50
Thats what I don't understand. Why is there is so called 'medical conscensus' that ECT is safe and effective, when the data to support the notion is not really existent.
Linkadge
Posted by linkadge on April 13, 2009, at 20:10:59
In reply to Re: ECT » Sigismund, posted by Larry Hoover on April 13, 2009, at 20:09:08
Perhaps try the lithium nortriptyline combo before the ECT.
Linkadge
Posted by linkadge on April 13, 2009, at 20:12:19
In reply to Re: ECT, posted by Zyprexa on April 13, 2009, at 20:01:15
If you need a temporary break from your memories 25mg of scopolamine should do.
Linkadge
Posted by Zyprexa on April 13, 2009, at 20:17:28
In reply to Re: ECT, posted by linkadge on April 13, 2009, at 20:12:19
Or how about good old pot? Atleast it wouldn't be so bad.
Posted by Zana on April 13, 2009, at 20:37:48
In reply to Re: ECT, posted by Zyprexa on April 13, 2009, at 20:17:28
I was evaluated at both Mass General by the doc Kitty Dukakis was treated by in the book "Shock" (not just me, he evaluates any patient who comes to MGH) and at McLeans. I was told there was a 90% chance that I would have a complete recovery from my depression and a 100% chance that I would relapse without meds and continuing less and less frequent ECT for a year. The biggest predictors of relapse? Light, exercise and situational stress. Got lots of information about the different kinds of memory loss I could expect,I might forget where I parked the car or how to get to previously familiar placed. I would likely lose chunks of stored memories like a friends wedding and I would probably have trouble learning new information for a while. But what about the right hemisphere, the side where they place the electrodes to protect the left hemisphere where memory and language live. Ah well "a dancer might remember her correography but be unable to make her dance beautiful. A musican might remember his score but be unable to make his instrument sing." And would this be permanent? Might be. Might not be.
That's was soured me on the deal.
But I will tell you, if the current med changes are unsuccessful- the pristiq seems to be helping but I have been on lots of meds that helped for a while and then pooped out- if the depression returns I've got oral MAOIs to try and then we're down to ECT. And I think I would do just about anything to have a chance of killing the depression. Even risk ECT.Zana
Posted by Larry Hoover on April 13, 2009, at 20:48:24
In reply to Re: ECT, posted by linkadge on April 13, 2009, at 20:09:25
> Thats what I don't understand. Why is there is so called 'medical conscensus' that ECT is safe and effective, when the data to support the notion is not really existent.
>
> LinkadgeI have no idea. There is no evidence that it is safe. Max Fink claimed in his 1956 text that the basis for improvement from ECT is cranio-cerebral trauma. In 1966, Fink reported that his own research indicates that there is a relation between clinical improvement and the production of brain damage or an altered state of brain function.
Funny how none of the proponents make similar claims today.
The American Psychiatric Association publishes literature that claims that 1 in 200 subjects experience memory loss. Fink provided them with that "statistic", and when pressed on its source, admitted that it was not based on any scientific research, but was instead "an impressionistic statistic". In other words, he made it up.
Harold Sackheim, the APA's main public proponent of ECT, is not a medical doctor. He's a psychologist, whose Ph.D. was in self-deception. In 2001, he claimed (in sworn testimony) to never once observing a case of anterograde amnesia following ECT. In fact, he wrote the statement that ECT improves memory into the standard APA consent form.
If evidence-based medicine ever catches up to ECT, it's done for. But the devices were grandfathered in by the FDA because they were in use before medical devices came under regulatory control. As modern devices are substantially unchanged from the original, they are exempt from all regulatory oversight.
Lar
Posted by garnet71 on April 13, 2009, at 20:53:37
In reply to ECT, posted by bleauberry on April 13, 2009, at 18:15:12
Well if you forget what you were depressed about, you might not be depressed anymore.
what = childhood trauma that shaped your developing mind, etc. Yeah I can see why ECT might work sometimes
Posted by Sigismund on April 13, 2009, at 21:16:32
In reply to Re: ECT » Sigismund, posted by Larry Hoover on April 13, 2009, at 20:09:08
>"patients become more compliant and acquiescent with treatment".
That cracks me up.
Posted by Sigismund on April 13, 2009, at 21:22:12
In reply to Re: ECT » Larry Hoover, posted by Sigismund on April 13, 2009, at 21:16:32
Some of the people who have ECT perhaps do not care about the damage and even welcome it?
It has a bit of 'the road to Golgotha' feel about it, and certainly did when I saw it done on my mother.
Posted by Sigismund on April 13, 2009, at 21:27:05
In reply to Re: ECT, posted by Sigismund on April 13, 2009, at 21:22:12
But then she got cancer and therefore morphine, which (of course) worked.
Cancer is no fun, but it is a piece of cake compared to serious depression.
Posted by Larry Hoover on April 13, 2009, at 21:27:50
In reply to Re: ECT, posted by garnet71 on April 13, 2009, at 20:53:37
If only the memory loss was so specific, perhaps. But there are other kinds of cognitive losses, too. I've seen accounts of professionals, a nurse, an engineer, an accountant, who not only lost their professional training, they could not learn it again. Artistic people who lost their art. And the relapse rate is close to 100%.
Lar
Posted by sowhysosad on April 13, 2009, at 21:46:39
In reply to Re: ECT » garnet71, posted by Larry Hoover on April 13, 2009, at 21:27:50
Probably a stupid question, but why do these studies all seem to use nortip as the follow-up AD?
Why not something with a broader action, like an MAOI, clomipramine or an SRI+TCA combo?
Is there something about ECT responders that suggests they need noradrenergic drugs?
Posted by Phillipa on April 14, 2009, at 0:16:34
In reply to Re: ECT, posted by sowhysosad on April 13, 2009, at 21:46:39
I wouldn't do it I know opiods rid my depression anxiety if forced to would go that route. Heck if benzos worked for 37 years then at my age what do I have to lose might gain some years of quality. Addicted? Who would care not me. Love Phillipa
Posted by linkadge on April 14, 2009, at 21:25:41
In reply to Re: ECT, posted by Phillipa on April 14, 2009, at 0:16:34
That what I am saying. If you just take a drug to reduce memory formation and recall you can usually get it back by discontinuing the drug. Nothing like a highly anticholinergic TCA to forget what they hell the problem really was.
With ECT however, the changes may be permanant, unwelcome and more extensive than desired. As Larry mentioned, you are not just affecting memory formation, you are also affecting all aspects of the way the brain functions.
I think it is ironic how you have this whole branch of medicine emerging whose primary purpose is to research the neuroprotective effects of certain agents during animal ECT procedures. If ECT doesn't cause brain damage, then what needs is there to protect it during ECT??
Sure, if all you want to do is sit around and 'forget', then perhaps ECT is a viable option. Many people don't return to a state of wellness with ECT - i.e. being able to return to their jobs - or returning to the things in their life that require a full brain to perform and appreciate.
Linkadge
Posted by linkadge on April 14, 2009, at 21:27:58
In reply to Re: ECT, posted by sowhysosad on April 13, 2009, at 21:46:39
Thats the thing though. So your depression is almost certain to return - and now you're in a worse positon then when you went in - i.e. back to being depressed - and with potential brain damage - possibly less capable of climbing out.
Linkadge
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