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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 26. This is the beginning of the thread.
Posted by Phillipa on July 2, 2013, at 17:29:43
This is barbaric to me? Anyone know a child that had this done? And if so did it work? Phillipa
The American Psychiatric Association's 2013 Annual MeetingMedscape Medical News > Conference News
ECT in Kids: Safe, Effective, Robust and Underutilized
Caroline Cassels
Jun 27, 2013
SAN FRANCISCO Electroconvulsive therapy (ECT) for the treatment of severe mental illness in adolescents is safe, effective, and robust, new research suggests.A 20-year retrospective study by investigators at the Mayo Clinic in Rochester, Minnesota, one of the few centers in the United States that uses ECT to treat children and adolescents, showed that among a treatment-resistant pediatric population, the procedure reduced symptoms of affective disorders, psychotic disorders, and other disorders up to 1 year post-treatment with a single series of ECT.
"Despite the controversy that certainly surrounds ECT use in adolescents, these results demonstrate it is a safe, reasonably well-tolerated, and effective treatment, especially for the most severely ill patients who have shown resistance to both pharmacotherapy and psychotherapy," principal investigator Chad Puffer, DO, at the Mayo Clinic, told Medscape Medical News.
"The findings also suggest that while ECT improves outcomes, it is not a cure. It is, however, able to improve functionality to the point where many of these patients can be treated as outpatients," Dr. Puffer added.
The study was presented here at the American Psychiatric Association's 2013 Annual Meeting.
Poor Public Image
ECT is one of the most effective treatments for major depression, said Dr. Puffer, a general psychiatry resident at the Mayo Clinic, with response rates in adults that are higher than those achieved with pharmacotherapy alone, and although somewhat limited, the literature does supports its use in children and adolescents.
In addition, the American Academy of Child and Adolescent Psychiatry also acknowledges ECT as an effective treatment in children and adolescents with severe illness in a practice parameter published on the Academy's Web site.
However, access to the procedure appears to be a challenge due to a lack of ECT facilities servicing children and adolescents, said Dr. Puffer.
He believes that a poor public image based on outdated misconceptions and the controversy over its use have led to subsequent underutilization of the procedure.
"People tend to shy away from its use, especially in children and adolescents, due to concern about potential side effects, such as memory loss," he said.
Much of this concern about the use of ECT stems from its use in the early post-war era of the 1940s and '50s, when it was conducted without the use of anesthesia or muscle relaxants, causing patients to experience violent convulsions and sometimes broken bones.
"The idea that this is a barbaric treatment is typically perpetuated by those who have not seen the treatments as they are currently administered," he said.
Today, patients are under full general anesthesia, and medications are administered to control muscle twitching.
"So although we are inducing a seizure, there are no tonic clonic movements that are typical of a full-blown seizure," said Dr. Puffer. In addition, he noted, the duration of the treatment is extremely short. Typically, it takes longer to prepare the patient for ECT than it does to administer the procedure.
Furthermore, he said, the general anesthesia used in ECT is very short-acting, and patients begin waking up as soon as administration of the anesthesia ceases. In addition, at the Mayo Clinic, ECT is done under the supervision of an anesthesiologist as well as a psychiatrist.
Severely Ill Population
For the study, the investigators examined the medical records of all patients from the ages of 12 to 19 years treated with ECT at the Mayo Clinic from 1993 to 2012. The study included 46 patients; 1-year follow-up data were available for 29 of the patients.
Using the Clinical Global Impression rating scales of symptoms (CGI-S) and improvement (CGI-I), the researchers compared outcomes immediately before and up to 12 months after ECT treatment
The majority of patients, said Dr. Puffer, were suffering from severe, recalcitrant, and frequently comorbid mood, anxiety, and psychotic illnesses with about an even split between recurrent major depressive disorder and primary psychotic disorder. Other disorders included anorexia nervosa, catatonia, and schizoaffective disorder.
By and large, these were the most ill patients in the hospital. Most had attempted suicide at least once, and many had been hospitalized multiple times for a duration ranging from months to years, said Dr. Puffer.
"They were not in school, not functioning at any sort of high level, and were really, really struggling. Most were on at least 4 to 5 medications and, at a minimum, had experienced 3 medication failures prior to administration of ECT. Because the Mayo Clinic is a larger tertiary care center, many of these patients were referred to us from other psychiatric hospitals when they had failed to improve," said Dr. Puffer.
Of the 46 study patients 67% (n = 31), the majority were treated bitemporally, and 24% (n = 11) were treated unilaterally on the right side.
On average, patients received 10.4 treatments per treatment series; 76% (n = 35) only required a single treatment series. However, the investigators note that some patients required 2 (22%, n = 10) or even 3 series (2%, n = 1).
The researchers compared patients' status immediately prior to receiving their first treatment and immediately following the end of their first treatment series.
Reassuring Results
The investigators report that most adolescents who received ECT were able to reduce treatment intensity by 1 less medication 1 year after ECT than they were at treatment initiation. They also found that ECT reduced symptoms of affective disorders such as major depression and psychotic disorders, including schizophrenia.
"On average, patients went from being severely or extremely ill to moderately or markedly ill. So we are taking the sickest patients and we are getting them better we're not getting them all the way better, but we were able get them to a point where they didn't necessarily have to be in the hospital year-round or weren't trying to actively kill themselves.
"They were able to get back to school, get back to their outpatient psychiatrists for continuing management, and get back into life and most were able to achieve that in 1 course of 10 treatments," said Dr. Puffer.
The most common side effects were nausea (15.2%) and headaches (13%), followed by postemergent agitation (8.7%) and spontaneous seizure (4.3%).
One of the study's limitations was the lack of data on cognitive status before and after ECT, said Dr. Puffer. However, he noted, in general, the research suggests there is no global change in children's cognitive status following ECT.
"If anything, a lot of these kids [before treatment with ECT] were not attending school, and just the fact that we were able to get them back into school and back hanging out with their friends and developing appropriately represents an overall improvement in cognitive status."
"One of the questions I get asked a lot is whether we're concerned about causing memory impairment, and, of course, we don't want to cause any undue harm. But you really have to take a hard look at the risks and benefits [of ECT], recognizing these are the most severely ill children," he added.
In addition, ECT appeared to be durable, with the vast majority of study participants "doing well" up to 12 months with a single treatment series, a finding Dr. Puffer said is "encouraging."
Important Reminder
Commenting on the study for Medscape Medical News, Mark George, MD, professor of psychiatry, radiology, and neurosciences and director of the Medical University of South Carolina Center for Advanced Imaging Research as well as the Brain Stimulation Laboratory in Charleston, said that the study serves as a reminder to clinicians that ECT is a viable treatment option "available for extremely ill adolescents, and it works."
Dr. George added that more research is needed to improve the durability and reduce the side effect burden.
Also asked for comment, Charles Kellner, MD, director of the ECT service at Mount Sinai Hospital in New York City, said that the study verifies ECT's safety and efficacy in this patient population.
"I'm glad to see this study because it confirms what most experts in the field already know that ECT is as safe and effective when used in adolescents as it is in older patients," Dr. Kellner, who is also professor of psychiatry and director of the Division of Geriatric Psychiatry at the Mount Sinai School of Medicine, told Medscape Medical News.
It also shows that when institutions like the Mayo Clinic use ECT in this age group, the outcomes are good and the treatment is safe and well-tolerated, he added.
Dr. Kellner agreed with Dr. Puffer that ECT is likely underutilized and believes better education is the answer.
"I think it is underutilized to a large extent, and part of the issue is that child and adolescent psychiatrists are often very poorly educated in the indications for ECT and the technique of ECT.
"The more educated people in the medical field and the lay public become about ECT, the more accepting they are of the treatment as a safe, effective, modern part of psychiatric medicine," said Dr. Kellner.
He noted that even with the emergence of many new neuromodulator therapies, such as transcranial magnetic stimulation for psychiatric illnesses, including treatment-resistant depression, ECT remains the gold standard for severe illness.
Dr. Puffer, Dr. George, and Dr. Kellner report no relevant financial relationships.
The American Psychiatric Association's 2013 Annual Meeting. Abstract NR7-34. Presented May 20, 2013.
Posted by poser938 on July 2, 2013, at 18:22:32
In reply to ECT In Kids, Safe,Effective But Under utilizied, posted by Phillipa on July 2, 2013, at 17:29:43
Why is it that mental health "professionals" are about a 1000% more likely to praise ECT than the ones who are actually having the volts sent through their brain?
This is a bit like when they used to say Insulin Coma treatment "gets rid of bad brain cells".What is underutilized is Magnetic Seizure Therapy.
What ECT is good at is reducing symptoms of being alive.
Posted by Jeroen on July 2, 2013, at 18:44:02
In reply to ECT In Kids, Safe,Effective But Under utilizied, posted by Phillipa on July 2, 2013, at 17:29:43
hey why not take a needle and stick. it up your nose til it reaches the brain and lets say its good for the future of our children ;S
Posted by poser938 on July 2, 2013, at 19:08:49
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied, posted by poser938 on July 2, 2013, at 18:22:32
> Why is it that mental health "professionals" are about a 1000% more likely to praise ECT than the ones who are actually having the volts sent through their brain?
> This is a bit like when they used to say Insulin Coma treatment "gets rid of bad brain cells".
>
> What is underutilized is Magnetic Seizure Therapy.
>
> What ECT is good at is reducing symptoms of being alive.And the less life detected, the less depression can be detected as well.
The past few days I've had much fewer suicidal thoughts cross my mind than in quite some time. But this is because I have fewer thoughts in general, because I'm so unemotional. It is getting difficult to post my thoughts on here because they are barely accessible and before long I won't have any accessible thoughts to post on here or be able to talk about how bad I feel. Thanks to Mirapex and the lessening of the great effects Cyproheptadine had on digging me out of the hole Mirapex put me in.
But, since I won't be complaining, I'm certain the psychiatrists that did this study would mark this down as "improvement" in my condition.
Posted by linkadge on July 2, 2013, at 19:27:02
In reply to ECT In Kids, Safe,Effective But Under utilizied, posted by Phillipa on July 2, 2013, at 17:29:43
It makes me want to vomit.
Why can they start using ketamine before such considerations
Linkadge
Posted by poser938 on July 2, 2013, at 19:38:02
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied, posted by linkadge on July 2, 2013, at 19:27:02
But they do the same thing with other treatments as well. The treatments that come in pill form. Though though they may be much safer, when someones mental health situation becomes much worse after a round of meds had their way with someones brain, this is viewed in the mental health community as just a worsening of depression.. and that its nothing related to the chemicals (medicine) that passed through the patients blood-brain barrier.
Posted by Phillipa on July 2, 2013, at 20:25:43
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied, posted by poser938 on July 2, 2013, at 19:38:02
After personally watching it performed and then with the patient before & after I cried for real as he didn't remember a thing. Phillipa
Posted by poser938 on July 2, 2013, at 20:51:33
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » poser938, posted by Phillipa on July 2, 2013, at 20:25:43
> After personally watching it performed and then with the patient before & after I cried for real as he didn't remember a thing. Phillipa
:(
Posted by Bob on July 2, 2013, at 22:16:29
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied, posted by linkadge on July 2, 2013, at 19:27:02
> It makes me want to vomit.
>
> Why can they start using ketamine before such considerations
>
> Linkadge
I am so tired of seeing article after article being published about how promising Ketamine is as a treatment for depression but it never seems to be getting any closer to actually being a real, viable treatment for anyone outside of a study.Bob
Posted by SLS on July 3, 2013, at 5:12:02
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » linkadge, posted by Bob on July 2, 2013, at 22:16:29
> > It makes me want to vomit.
> >
> > Why can they start using ketamine before such considerations
> >
> > Linkadge
>
>
> I am so tired of seeing article after article being published about how promising Ketamine is as a treatment for depression but it never seems to be getting any closer to actually being a real, viable treatment for anyone outside of a study.
>
> Bob
Don't be too frustrated. The discovery regarding ketamine and depression initiated a fury of investigation into new drugs that work on the NMDA receptor. One of these is an orally-delivered compound that works on a different part of the receptor and is devoid of psychotomimetic side effects.
- Scott
Posted by SLS on July 3, 2013, at 5:18:01
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » Bob, posted by SLS on July 3, 2013, at 5:12:02
> > > It makes me want to vomit.
> > >
> > > Why can they start using ketamine before such considerations> > I am so tired of seeing article after article being published about how promising Ketamine is as a treatment for depression but it never seems to be getting any closer to actually being a real, viable treatment for anyone outside of a study.
> Don't be too frustrated. The discovery regarding ketamine and depression initiated a fury of investigation into new drugs that work on the NMDA receptor. One of these is an orally-delivered compound that works on a different part of the receptor and is devoid of psychotomimetic side effects.
- Scott
Posted by linkadge on July 3, 2013, at 7:22:09
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » linkadge, posted by Bob on July 2, 2013, at 22:16:29
>I am so tired of seeing article after article >being published about how promising Ketamine is >as a treatment for depression but it never seems >to be getting any closer to actually being a >real, viable treatment for anyone outside of a >study.
It seems that certain treatments need to be made available to the most desperate patients.
When they safe ect is 'safe' in kids, this just means that the kid doesn't die in the 6 months follow up.
They should make a commercial for ECT like they do cymbalta. Can you imagine the list of side effects and disclaimers?
Posted by linkadge on July 3, 2013, at 7:23:46
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » Bob, posted by SLS on July 3, 2013, at 5:12:02
No, but what is wrong with just ketamine?
In all the clinical trials I have read, patients do not develop any significant 'psychotic' reactions.
These companies likely want $$.
Linkadge
Posted by SLS on July 3, 2013, at 10:09:45
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » SLS, posted by linkadge on July 3, 2013, at 7:23:46
> No, but what is wrong with just ketamine?
>
> In all the clinical trials I have read, patients do not develop any significant 'psychotic' reactions.
>
> These companies likely want $$.
>
> Linkadge
These Naurex drugs are partial agonists at the glycine site of the NMDA receptor rather than being complete channel blockers like ketamine. I doubt there is a narrow therapeutic window to worry about. If you take even a little too much ketamine, you forfeit the antidepressant effect. Of course, taking a pill is more convenient than administering an i.v. drip. As an aside, i.v. administration of ketamine is probably necessary to deliver such a precise dose. Injections and nasal sprays can't do this, and I doubt these methods can hit the narrow window necessary to promote an antidepressant response.I don't care if they want $$. Just give me my drugs.
- Scott
Posted by linkadge on July 3, 2013, at 16:47:42
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » linkadge, posted by SLS on July 3, 2013, at 10:09:45
I don't think the mechanism (or therapeutic window) has been fully uncovered yet.
For instance, there has been desire for decades to replicate the efficacy of clozapine without the side effects on blood cells. We really haven't done that.
I think using ketamine right here right now in its present form would be perfectly acceptable. However, the greatest concern (of some) is likely abuse.
Linkadge
Posted by SLS on July 3, 2013, at 17:08:44
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied, posted by linkadge on July 3, 2013, at 16:47:42
> I don't think the mechanism (or therapeutic window) has been fully uncovered yet.
That a mechanism for an observed phenomenon has not yet been fully uncovered does not make the observation fictitious.
- Scott
Posted by Bob on July 3, 2013, at 17:28:41
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied, posted by linkadge on July 3, 2013, at 7:22:09
> >I am so tired of seeing article after article >being published about how promising Ketamine is >as a treatment for depression but it never seems >to be getting any closer to actually being a >real, viable treatment for anyone outside of a >study.
>
> It seems that certain treatments need to be made available to the most desperate patients.
>Agreed!
Posted by Phillipa on July 3, 2013, at 19:53:22
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » Bob, posted by SLS on July 3, 2013, at 5:12:02
Scott Byrn received IM injections I think it was a week of ketamine and this was in the city? So it is being used in forms other than IV. Plus a few other posters have had the IV treatment. Wasn't it in CA? Phillipa
Posted by Trevpr on July 4, 2013, at 1:04:00
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » SLS, posted by Phillipa on July 3, 2013, at 19:53:22
They are doing studies with other NMDA antagonists as well.
Also, I had no memory loss or cognitive difficulties even after 11 bilateral ECTs.
Posted by europerep on July 4, 2013, at 6:55:52
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » linkadge, posted by SLS on July 3, 2013, at 10:09:45
> If you take even a little too much ketamine, you forfeit the antidepressant effect.
Where did you read that? I've read reports from people who were suffering from depression and took recreational doses of ketamine, and got a strong antidepressant effect lasting for several days. And, at the time of using, these people didn't even know that ketamine was studied for potential antidepressant properties.
I think that the question of getting the right dose of ketamine is mostly, if not entirely, related to the psychedelic effects it produces at high(er) doses. After all, the pretty much universally used dosage of 0.5mg/kg, administered over 40 min. via IV infusion, has, at least as far as I know, not been "developed" or elaborated in any kind of way. It's just the dosage the first guys who studied ketamine in TRD came up with, and they sticked with it because it worked. It would be quite a coincidence if they had just accidentally found a "narrow therapeutic window."
Posted by SLS on July 4, 2013, at 7:05:06
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » SLS, posted by europerep on July 4, 2013, at 6:55:52
> > If you take even a little too much ketamine, you forfeit the antidepressant effect.
>
> Where did you read that?I'll see if I can find the lecture online.
- Scott
Posted by SLS on July 4, 2013, at 10:29:55
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » SLS, posted by europerep on July 4, 2013, at 6:55:52
> I think that the question of getting the right dose of ketamine is mostly, if not entirely, related to the psychedelic effects it produces at high(er) doses. After all, the pretty much universally used dosage of 0.5mg/kg, administered over 40 min. via IV infusion, has, at least as far as I know, not been "developed" or elaborated in any kind of way. It's just the dosage the first guys who studied ketamine in TRD came up with, and they sticked with it because it worked. It would be quite a coincidence if they had just accidentally found a "narrow therapeutic window."
You may be right. Perhaps I am mistaken in my recollection. Nevertheless, NMDA receptor partial agonism seems to be a more desirable mode of modulating glutamatergic neural activity than ketamine is. The risk of triggering psychosis is much reduced and oral agents now exist. The therapeutic indexes (safety / toxicity) of these drugs is quite a bit wider than that of ketamine.
- Scott
Posted by poser938 on July 4, 2013, at 17:26:18
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » europerep, posted by SLS on July 4, 2013, at 10:29:55
If Ketamine in IV form is not practical, why not intranasal Ketamine for take home use? That's how a psychiatrist prescribed it to me.
Posted by SLS on July 5, 2013, at 0:16:14
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied » SLS, posted by europerep on July 4, 2013, at 6:55:52
> > > If you take even a little too much ketamine, you forfeit the antidepressant effect.
> >
> > Where did you read that?
>
> I'll see if I can find the lecture online.
>
>
> - Scotthttp://mediasite.video.ufl.edu/Mediasite/Play/4a46e8f9a6f84560aadacc408f77f6b51d
Pay attention to the comments at the end of the lecture regarding the opposite actions on glutamate release of varying concentrations of ketamine (time - 00:59:00). I'd be curious to know how you interpret them.
- Scott
Posted by SLS on July 6, 2013, at 13:55:00
In reply to Re: ECT In Kids, Safe,Effective But Under utilizied, posted by poser938 on July 4, 2013, at 17:26:18
> If Ketamine in IV form is not practical, why not intranasal Ketamine for take home use? That's how a psychiatrist prescribed it to me.
Based upon the data currently available, my guess is that one would have to meter the delivery of ketamine rather precisely. You might need to administer many very low intranasal doses over the course of 40 minutes. Perhaps a transdermal patch would work. I don't know.
- Scott
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