Psychiatry & Psychotherapy Podcast - ECT Efficacy and Controversies with Dr. Cummings

Episode Date: July 1, 2022

In this episode of the podcast, we sit down with Dr. Cummings to discuss the benefits, progress, and fears related to electroconvulsive therapy. For years the efficacy of electroconvulsive therapy has been debated, but we've learned that it still remains an essential part of psychiatric treatment in patients with severe mental health disorders. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.  

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast. Go to Psychiatrypodcast.com, sign in, take the test, and the certification is emailed to you in seconds. Dr. Cummings and Dr. Pudor have no conflicts of interest to announce. Let's start the show. All right, welcome back to the podcast.

I am joined today with Dr. Michael Cummings. He is a regular on this podcast. He isn't an expert, psychopharmacologist, and I was talking about ECT. We were sending some emails back, and I sent him this article that was recently written by the Independent called Thousands of Women Given Dangerous Electric Shocks

as Mental Health Treatment in England. And this study, you know, talked about how ECT and placebo are the same, and, you know, there's horrible side effects, and they give an example of someone who had severe memory issues. And then this article quotes another article by John Reed, who has written critically about ECT. And I was reading this article, actually, and I sent it to Dr. Cummings. and Dr. Cummings was like, oh, I've actually written a counter to that article, and he sent that to me. And so this is where we'll pick up our discussion of ECT.

So how are you doing today, Dr. Cummings? I'm doing well, thank you. I'm happy to be back. Indeed, I wrote an editorial along with one of my colleagues, Jennifer O'Day, for Steve Stahl and CNS Spectrums at the beginning of 20. 2021, shortly after the article by Reid. Adel, was published, essentially rebutting much of what they said. This was a case where Dr. Reed, who was quite biased against electroconvulsive therapy, looked at five meta-analyses that in turn looked at between one and seven prior sham-controlled studies of ECT. And even though all of those studies had concluded that ECT was safe and effective, he made the point that the last of those studies had occurred in 1985 and that meta-analysis procedures were not as sophisticated 35, 40 years ago. And based on that, criticism, his group proposed that ECT should be banned.

on this case, banned at least in the United Kingdom. Frankly, I took issue with that for several reasons. One, he looked at a fairly small set of data and ignored literally dozens to hundreds of observational studies that had been done since ECT was first discovered and promoted by Surly. and Benny in 1938. So, you know, we're coming up on 84 years since the introduction of electroconvulsive therapy and 88 years since Dr. Meduna, Hungarian neurosychiatrist, first introduced convulsive therapy, first using camphor and then metazole, also called cardiazole, chemically induced. seizures. Aside from ignoring huge amounts of data, Dr. Reed's group also had focused only on

studies of major depression and had entirely ignored the use of ECT for other purposes, such as treatment of catatonia, treatment of bipolar illness, and treatment of schizophrenia, as well as other mental illnesses that have data to support ECT use. So essentially, we objected on that basis and also then went on to cite some of the data that has found, indeed, that as an adjunctive treatment in schizophrenia, ECT provides benefit in the moderate effect size range, which is frankly better than pharmacological augmentation of clozapine in most cases. In this particular study, Wang at all,

they compared clozapine with ECT versus chlosephine alone in treatment resistance, schizophrenia, right? Yes, they did. And the effect size was, I think, 1.44 favoring ECT with closepine at the end of the trial, which is pretty strong. Yes, yes. It's pretty strong effect size.

And indeed, that's consistent with other prior studies. including one by John Cain's group in 2015 and 17, as well as a Cochran review of use of ECT to treat tremor resistance schizophrenia where they again found that addition of ECT provided a moderate effect-sized benefit. So essentially our conclusion in the editorial was that, while certainly newer and better controlled studies would be welcome. Given that this is an existing treatment, not something brand new, and that it has literally hundreds and hundreds of publications supporting its use,

it would deprive a huge number of patients of much-needed treatment because often the people who need ECT the most don't have. have any other viable alternatives that will work for them. And the article that you sent that was based on Dr. Reid's article, I had some bones to pick with them, too, although they weren't mentioned in the editorial. One, they make it sound as though women are being conspired against in terms of use of ECT. Well, you know, the primary indication for ECT remains major depression.

women become depressed at three to five times the prevalence rate of men. So it's not surprising that ECT is more often used in women. They also make the assertion that ECT causes brain damage. Frankly, there have been literally hundreds of both animal and human studies in which none of those studies demonstrate any structural brain damage from ECT. I think one of the, okay, so there's a lot of things, a lot of directions we could go here. I imagine there's going to be two people listening to this episode, people who are medical professionals and may have some degree of knowledge about ECT.

And there's also going to be like the layperson who's like maybe they have a family member who is considering an ECT. And, you know, I think it's hard to stumble upon articles like this. if you are someone who hasn't sort of been in the medical system treating very, very treatment-resistant patients for a long time. Because you don't have the perspective of what this treatment does for this group of people. Like, for example, in my outpatient clinic, over the course of my career, 10 years of treating patients, I've referred three people to ECT. One catatonic patient who literally stopped drinking and eating and had lost 60 pounds, I referred one schizophrenic patient

who was not responding to a combination of clozapine and xypraxia and had some catatonic symptoms. And I referred another severely melancholic patient who was not responding to about six months of partial programs and about four or five medications and had failed TMS. So, you know, that's my outpatient practice. Now, inpatient, we'd refer maybe four patients out of 30 or 40 would be going to ECT at a university setting. For those four patients, this is a life transforming procedure.

I am not like a person who's going to be doing ECT. in my career. Like, I don't enjoy it. My brain isn't wire that way. I'm more of a psychotherapist. But I have a deep, profound respect for the ability to have this life-preserving procedure done to the people who need it done. And so I think that's why we're having this conversation today to give you some sort of larger framework. And I think that the images, like if you go down on Hollywood Drive, there's this like anti-psychiatry group that's a part of the Church of Scientology. And they have these images of people receiving electric shocks and the people are shaking, you know, their bodies are shaking and they're convulsing. This is not what ECT looks like. It's a very calm environment.

They give you muscle relaxance. So your muscles are not having a seizure. And you have a seizure like episode in your brain only. And then you're wheeled back very safely into a waiting room. There may be a little memory issues during the procedure. But I'd like to hear from you as well, like six months out, eight months out, have they ever done, you know, what kind of memory issues are people having statistically out that far, would you say? They have done studies looking at cognitive and memory functioning everywhere from days to months after ECT. Typically the person who has had ECT will often have some retrograde memory deficits. for the period of time during which they were receiving the ECT. We're not talking dense amnesia.

We're talking they have kind of a foggy or fuzzy recall of the one, two or three weeks that they were receiving treatments. Their antrograde memory, that is their ability to lay down new memory, however, is perfectly intact. Essentially, fitting the notion that, ECT does not cause permanent brain damage. It does disrupt the functioning of the hippocampus while the treatments are going on, particularly if it's bi-temporal electrode placement as opposed to unilateral electrode placement.

But it just is not true that ECT causes brain damage or permanent memory loss, except for the period of the treatment. Right. So then you can look at like articles like this one in the independent and you can see some antidotal, you know, like these are some stories of people. Could the depression itself cause memory issues that this person struggled with? Indeed, it could. Indeed, people who have severe depression, which are usually the people who wind up receiving electric convulsive therapy, often have memory and cognitive impairment as a result of the depressive illness. In fact, it is sometimes termed pseudo-dementia because they're not actually demented if their depression improves to the point that they become euphymic, their memory recovers.

I think that the other thing that the anti-ECT group don't take into account is that for people with severe depression, treatment resistance, schizophrenia, severe catatonia, these are severe. mental illnesses that are life-threatening and themselves cause severe cognitive and memory impairment. During an episode of major depression, there is often a 20 to 40% reduction in metabolic rate in the brain. There is literally atrophy of the dendritic arborization of neurons, the parts that communicate with the neighboring neurons. So it's not at all surprising. that the person who is severely depressed has a brain that is not functioning very well. Yeah. And the same is true.

And schizophrenia, bipolar, both can have huge impacts. You know, it's like, I almost wish that some people had an experience of third world psychiatry. I've been to Haiti before. And it's like the patients who are untreated for decades, it just looks, you know, you can tell. It's like a huge difference. And sometimes we don't see those patients as as visually. I mean, maybe you see like a homeless person who's talking to themselves or, you know, who seems very sort of agitated or upset. Sometimes you'll see that. I remember at the APA one year when I was there, it was like there was a homeless person yelling outside the door. And it was just, to me, it was kind of

like a sad, a sad thing that you had a room full of people that could treat this person. And there's like a homeless person out there. It's just like suffering. As you know, I work in a state hospital and frankly, we have a number of patients who have gone at times for years without any psychiatric treatment. And it takes a toll on their brain. They are their cognition, their memory, their very personality has deteriorated over time. Yes, it's absolutely tragic. So my other thought, whenever I hear these like anti-psychiatry things, I think to myself, do these people treat this population? Because there's something about actually, you know, and if you're like in New York and you're charging a cash pay, you're not seeing as many of these people who are going to need this treatment.

You're just not. but usually the people who write these types of things it's it's like they may have like some uh experience having some bad experience knowing someone but they themselves are not treating this population out of you have thoughts on that uh typically no uh in the case of the article by dr reed and his group the people who wrote uh the article that i responded to with an editorial are a group of psychologists. They are not physicians. So, okay, but I'd like to sort of get your take on some of these early articles, like the 1985 article that looked at, they're looking at placebo versus non-plicebo ECT, which to me is kind of interesting because, you know,

when you think about like a placebo for ECT, it's like, how do you give that? Well, you put the person to sleep and you wake them up and then they maybe don't know or if they had a CT or not right and so the idea is that by doing this you're going to see less of an effect size than if you just did a wait list or something like that and so in this one study i looked at the noddingham ecst study this you know the madras m a d rs which is a psychiatry scale decrease in the simulated ECT group was 8.7, whereas the unilateral EC was 24, and the bilateral ECT was 24.7. So it seems to me like that was a pretty big difference between getting the ECT and not getting the ECT. Yes, and that's been replicated in a variety of studies. ECT is not a

perfect treatment. There is no such thing. However, it is highly effective. One of the things that has been repeated over and over again, if you look at studies where they've looked at individuals who have failed an adequate trial of antidepressant, they've had an antidepressant given, it's been titrated, it's been present for long enough, the person does not respond, their odds of responding to ECT are right around 40 or 50 percent. if they've had inadequate treatment with an antidepressant, well, no surprise if it's inadequate, it may not work very well. Their odds of responding to ECT are up around 79, 80%.

So ECT is clearly a robust treatment. One of the criticisms as well by the anti-ECT groups are often that, well, the effects of the ECT are not permanent. Well, that's true if you give somebody a course of ECT and then you stop, usually somewhere between six and 12 treatments, and you do nothing else for the individual. It's likely that their mental illness will recur, will come back. That seems like a very specious argument to me, though,

and that most people don't follow that course, Most people who receive ECT then go on to receive an antidepressant if they are depressed. In some cases, if they're entirely resistant to antidepressants, they may receive maintenance ECT over time. But I would agree if you give somebody a medication and then you stop it and their illness is still active, it's not a huge surprise that they become ill again. Yeah. like if someone is this ill where you know they're going to be receiving some sort of treatment afterwards it's unlikely that they're going to have no treatment and you know having you know in when i was part of lomelinda i would go in and do like what's called a third opinion a third psychiatrist comes in

gives the patient side effects alternative treatments and so i would talk to these patients who had been doing this some for a couple years they were getting treatments every three months and even that once every three months seem to make a huge difference for these people. You know, you talk to them and be like, I was depressed for 20 years and then I got ECT and I've been on maintenance and I don't want to stop maintenance because I'm doing great. Any thoughts on maintenance or what the data says on that sort of like long-term ongoing treatment? Yes, maintenance ECT works. And it has clearly a place in those individuals who simply don't have an adequate response to an antidepressant medication. One of the things that's true of recurring major depression, that is depression where the person has multiple episodes across their lifetime, is there is a tendency for the depression to become more and more resistant to pharmacotherapy only.

So that often as people with recurring major depression reach later life, they often wind up needing electric and falsive therapy or. transcranial magnetic stimulation, something in addition to medication. That's not at all an unusual outcome. One of the things I've always been fascinated by is why is it that ECT is more effective and more rapidly effective than antidepressant medications? I don't think we entirely understand the answer to that question, but there are some titillating clues. the medications we give people alter neurotransmitter levels, serotonin, norapherin, most commonly. Those kind of knock on the door at the outside of the cell, cause a change in second messengers inside the cell. And eventually, if we're lucky, that produces some changes in the DNA transcription in that cell.

It begins to work better. ECT appears to reach in directly and alter DNA transcription immediately. It turns on what are called rapid response genes, FOS, and Kreb. Those genes are in turn responsible for turning on other genes. So it's as if you're turning the lights back on in this neuron and it perks up. and begins to produce growth factors, respouts, its dendritic spines, and it begins to function.

You know, it's not at all uncommon for people receiving ECT to begin to, frankly, look less depressed after their very first treatment, and it's very common for them to achieve a very robust response by the time they're out six to 12 treatments, is typically two to four weeks. We don't have anything in terms of medication that does something quite like that.

Yeah. I think it's worth noting some of the things that, having talked to how we do our ECT sort of selection. You know, we get these referrals from the community. One thing that we're trying to sort of not push into ECT but pushing alternative things is if they come in heavily on, medications which would maybe not be the right cocktail of medications like that it doesn't make any sense at all or if someone comes in with a history of something like borderline personality disorder

or heavily neurotic and we try to get them to do partial program first i don't know if you have any thoughts on like borderline personality disorder and eCT i was looking at this before i have you i answer that brandon at all and it's one of the placebo controlled trials in 1984 and they found that the neurotic patients did not seem to get a treatment effect, whereas the other two groups, the diluted and retarded, I'm not sure what retarded means in this context, but probably like some sort of slowdown. Go ahead. Yeah, I think they were talking about in this case, actually people with primary intellectual deficits. And indeed, there's no evidence that ECT is beneficial there or for treatment of personality disorder unless the personality disorder has given

rise to a more classic major depressive episode. Right. So you get these patients who are, okay, yeah, go ahead. Yeah, I was going to say that, yeah, you know, we're talking about ECT, but certainly ECT is not where we began, except in emergent cases such as, um, some cases of neuroleptic malignant syndrome or severe catatonia or melancholic depression where the person has essentially stopped eating, stopped drinking, and they're going to die if you don't do something that is rapidly effective.

ECT, though, it's not that it should be promoted as the first treatment, but neither should it be removed from the armamentarium. It's way too effective in circumstances that may do away with the person. if they're not treated. Yeah, and I think it's good for someone who doesn't quite understand this to realize like, okay, you have a big medical system. You literally have hundreds of patients that come through every week, like an inpatient psychiatric hospital, acutely suicidal,

acutely suicidal, acutely psychotic. You're talking about out of those hundred, maybe two a week are referred for ECT. In an outpatient treating setting, you know, like, literally after maybe seeing 3,000 patients, maybe three of those. So we're talking about like on a bell curve of acuity and severity being very, very high. Interesting, one of the articles you sent me on the prison system, it seemed like it wasn't even like it was maybe underutilized in a prison system,

which, you know, for those of you who don't know, the prison system is like where a lot of mental illness now goes because there just isn't another place where these people are. There's no state facilities for mentally ill, like there are prison systems. Yes, and that's been one of the problems with the biases against ECT is that in some settings like the correctional setting, ECT, is often very difficult to obtain. I'm pleased to say that in California, the prisons,

while they don't have ECT themselves, they are not at all opposed to referring people for treatment when it's appropriate. Among the five state psychiatric hospitals in California, two of them have ECT suites on site. In California, Metropolitan State Hospital near Los Angeles and Napa State Hospital, both offered. ECT and the other hospitals refer patients to those locations when ECT is appropriate. We don't use ECT very much. We have, at Patton, where I work, we have 1,600 patients. We currently have six patients who are receiving electroconvulsive therapy. Yeah, and it's like the stigma is still there because I think it's poorly understood

what would you say are some of the biggest things that maybe even therapists or people who are in mental health but not psychiatrists would have stigma about ECT? I think a lot of them still, you know, if you talk to most people in the public, the one thing there, if you say the word ECT, the scene that comes to mind for them is Jack Nicholson and one flew over the Cuckoo's Nest. receiving unmodified ECT, which was without anesthesia, without paralysis using a drug like succinctyl-coline. Essentially, unmodified electric-convulsive therapy has been gone since the late 1950s, globally. in the U.S.

all ECT that's done is modified ECT. The person is indeed put to sleep with a short acting anesthetic agent, something like Propofal or Brevitol, a barbiturate. They're then paralyzed, usually with succinctal coline. And then the ECT stimulus is administered

using these days square wave electrical stimulus, which is less likely to cause post-tical confusion than sine wave electricity. They then have their seizure, which lasts usually between 30 and 45 seconds. They're then wake up. They're kept in recovery usually for about a half hour, and then they go on their way. Is the amount of electricity that's given more than a seizure? and why is it more? The amount of electricity that's given is just enough to cause a spreading depolarization.

The current ECT machines actually measure the amount of impedance or resistance of the scalp and the skull. And literally, they're just giving enough electrical stimulus. to bring the neurons that are in the path between the electrodes up to about minus 30 millivolt, which causes them to fire in action potential. And since they're all fire in unison, that triggers recruitment of nearby neurons, and essentially, you have a seizure, which lasts, you want it to last 30 to 45 seconds. If it's shorter than that, it may not provide benefit. Frankly, we don't know whether it's the seizure or the immediate post-ictal neuronal suppression that triggers the response I was speaking about earlier in terms of kind of turning on the neuron, causing it to begin to activate fast response genes, which in turn then turn on other genes.

That's been an ongoing debate literally for decades now about which, which is it? Is it the activation of a large number of neurons, or is it the immediate post-ictal, post-seizure, very brief quiescent period, then they start working again? Something in that essentially, something in that sequence essentially acts almost as if it were a reset switch. sometimes they give ketamine with ECT do you think that that changes outcomes I have read some anecdotal data that suggests it might

I think the research at this point is too early to say for sure whether it alters the response to ECT or not clearly ketamine either infusion or S-ketamine inhalation both have antidepressant properties on their own, as well as dissociative properties.

Ketamine is another element in the armamentarian, which has come along, which can produce a very rapid antidepressant response. Its limitations are that the response is time limited, usually on the order of days. And if, in the case of repeated treatments, the antidepressant effect of the ketamine tends to diminish over time. The combination of ECT and ketamine, I think, is an area that needs further exploration on study

to know if the two modalities may have synergistic effects. Did you see this study that came out? I think it was in, yeah, 2021 on ketamine as an alternative to ECT for unibular depression. a randomized open label non-inferiority trial? Yes. Any thoughts on that study, or shall I read the findings? Yeah, go ahead and read the findings. It's been a while since I read it.

Yeah. I know you have an almost like photographic memory for this kind of stuff. So the results. In a total of 186 inpatients that were included and received treatment among the patients receiving ECT, 63% remitted compared to 46% receiving ketamine infusion.

Both ketamine and ECT require a median of six treatment sessions to induce remission. That was the basic findings. Yeah, and that fits with my conclusion, well, it's an interesting finding needs more

study. Clearly, the ECT has a slightly higher response rate. I think ketamine has become a viable alternative for people who may need a rapid treatment that will reverse depression and in particular suicidality. I don't see ketamine being an ongoing treatment for most people, just as ECT is not. I think it may be an alternative for those people who have severe illness and for one or more reasons may prefer not to pursue ECT.

I think the field as a whole, Benox psychiatry hasn't quite figured out where ketamine and es ketamine fit in entirely, or, if you will, what the niche is for this new treatment. Are there any medications you would take someone off before they received ECT? Basically, lithium is probably the one that I would most likely discontinue for two reasons. One, if the person is going to be paralyzed using succinylcholine, lithium can prolong the effects of succineal coline,

which means the person's muscles may not recover rapidly from the paralysis so that they have to be artificially ventilated for a prolonged period. Also, lithium tends to worsen the immediate postdictal confusion following the ECT treatment. So lithium would be one medication I would consider, at least holding, getting it to a lower plasma concentration before an ECT treatment. And the other consideration that comes up most often in terms of medical issues, I mean, what they teach everyone in medical school is look out for space occupying lesions in the head. Well, that doesn't actually turn up very often. When somebody has a stimulus applied to the brain, there is initially a parasympathetic response. So if the person is prone to brady arrhythmias, slow heart rate, slow irregular heart rate, the anesthesiologist definitely needs to be aware of that.

During the seizure, there is a sympathetic discharge, so blood pressure and heart rate rise, which raises issues of if you have somebody with unstable hypertension, or fairly severe cardiac illness where profusion of the heart, is impaired, that's also something that where the anesthesiologist may want to use an intravenous beta blocker to moderate that sympathetic response. That's good. Yeah. What about like having a pacemaker?

Are there any other contraindications? Pacemaker, no. Pacemakers are pretty much not responsive to the fact. that the person's having a seizure, because, of course, the electrodes in this case are on the person's head, nowhere near the pacemaker per se. The principal issue are people who may be vulnerable to either brady arrhythmias or tachy arrhythmias or have brittle hypertension. Those are the issues that you have to look out for during the treatment. Yeah. I think it's worth talking about.

a little bit about Catatonia, giving a little refresher for that. I think the more times I can sort of get people to think about Catatonia, the better. We've talked about Ativan, we've done an episode on Catatonia, but I'm curious, like, maybe break down where ECT fits in the treatment of it. Catatonia, of course, can arise from a whole host of underlying conditions, including psychiatric conditions like major depression and schizophrenia, characterized by either catatonic stupor with loss of motor activity, staring into space, waxy flexibilities, echolalia, or simply loss of speech, or excited catatonia where the person is just motorically revved up to a truly impressive

extent, most individuals will respond to a benzodiazepine in addition to whatever the primary treatment is for their primary illness. However, not everyone responds to a benzodiazepine. And that's where ECT is sort of then the next step beyond benzodiazepine treatment for the person who has catatonia that is non-benzodiazepine responsive yeah you give me a couple reviews on this and one of the things that i think is a good takeaway is the the bush francis catatonia rating scale should be used i think if you if you're on an inpatient setting if you're a third year print that out take that in with you put in your binder think about it with each patient you know go through it um just as an exercise to get yourself used to diagnosing it Yeah.

One of the things, indeed, that still is a problem is most people are not adequately on the lookout for catatonic features. It's estimated that among people with major depression and schizophrenia, upwards of around 10% of them, will exhibit some of the elements of catatonia, not necessarily the fully developed catatonic stupor or excited catatonia. But if people have increased speech latency, they're becoming motorically slowed, the guy who you find him just standing and staring, and you can kind of shake him out of it, but he has a tendency in that direction. You're likely looking at somebody who may be having issues with Catatonia. So we need to up our index of suspicion just a bit. And indeed, the Bush-Francis rating scale is an excellent instrument for identifying catatonia and actually quantifying the features of the person's catatonia. Tell me about the echolalia and the echopraxia, and what does that look like? The echolalia, often when you're talking with a person who is on their way to becoming catatonic,

or they are catatonic, but not completely silent yet. Often their only verbal response is to repeat the last part of what you said. Mr. Jones, how are you today? Are you today? Are you today? Yeah, exactly. Yeah, and the same thing with the echopraxia. Often if you stand facing the person with catatonia and you make a particular movement,

they will make the mirror image. movement. You see people do that as an acting exercise sometimes, but in the case of catatonia, it's an involuntary mirroring of motor activity. Yeah. One of my favorite things

to do when I was on call, although call was pretty miserable in general, was you get on a unit with like 30 patients and it's going to be a busy day. And you find that one patient with catatonia. And then you inject them with like,

two milligrams of Ativan, and you have all of your students gather around the before and after, not as like a, in a calm, respectful way, of course. But afterwards, just if they are catatonic, often they will start talking again. Yeah, it is literally as if they come back to life right in front of your eyes. Yep. I think the mistake that I made, and this was one time, there was one guy who was very very slow and he was positive for atavan and so we decided to refer him to ect but we didn't continue the adifan we're just like oh let's push them into ecti now and um i think in retrospect it's like eccc is really good for the the people that don't respond to atavan that have catatonia um i don't

or if don't fully respond yeah either don't respond at all or have a very limited response to the benzodiazepine. Now, the other mistake people make sometimes with lorazepam, many people are used to using doses that are inappropriate for treating acute anxiety. The doses for catatone are much higher. A typical dose range for lorazepam in catatonia is six to nine milligrams a day. It can go even higher than that. or a corresponding dose of clonazepam, if you want something with a longer half-life.

The other pharmacologic error I see people make is to give somebody a 2 milligram challenge dose of lorazepam orally, and then nothing happens. The oral dose doesn't rise rapidly enough or to a high enough peak to give you a definitive Loresapam challenge in catatonia. Yeah. And, you know, if they don't have catatonia, they may just go to sleep, right? Yes.

They may just... Yeah, that's a nice thing about lorazepam as a test agent is, you know, it's a very safe medication. It's reliably cleared because it only requires conjugation by the liver. It's not actually, you know, other than having a gloron. I'd attach to it, nothing else happens that the liver has to do. So it's reliably cleared if the person does not need the lorazepam.

Indeed, all that will happen is you will have made them sleepy for a period of three or four hours. Yeah. So Catatonia, you know, think that if you have a unit of like 30 people, maybe one might be catatonic and you may just be missing them, right? And so, okay, here's, here's the problem that I've had. A couple of people have messaged me about this since we did our episode on Catatonia. Dr. Puter, I am a student, or I am a nursing student, or I'm a nurse, and this patient has Catatonia. I got out the Bush Francis Catatonia rating scale, and they scored positive. And I go to my psychologist supervisor, and they said, oh, that's what the psychiatrist do. No, you can't share that with the

psychiatrist, and so they don't get treatment. What would you do in that setting? Well, one, I certainly disagree with the supervisor in this case. You know, because I think I've always been in favor of treatment teams actually functioning as a team, which means if a nursing student or a nurse or anyone else on the team spots pathology that the rest of us aren't aware of or haven't been aware of, they certainly should not keep it to themselves. Right. So my advice was like, in this setting, because of the severity and the necessity for treatment, this is something where you need to go directly to the psychiatrist and report the information. Get them on the phone, page them to your number, and, you know, maybe approach it as a student, say,

hey, I'm a student. I obviously don't have as much information and knowledge as you, but I was talking to this patient today for an extended period of time. I ended up doing the Bush-Francis Catatonia rating scale. They scored this out of this. You know, what do you think? Like, is this something you want to consider? And most of those people will be very open to hearing that.

You know, so. Well, yes. I mean, frankly, you know, something I've told medical students. and residents across my entire career is pay attention to your nursing staff. They spend a lot more time with your patients than you do. If they make observations, you should always encourage them to share the observation because, frankly, they may be seeing things that you're entirely unaware of because when you made your rounds and you talked with the patient for 15, 30 minutes, and then you went on your way to see

other patients, you may not have captured the critical epoch in that patient's day. Yep. I always made it a practice to check in with my front staff even when I was doing an outpatient because the patients will treat the front staff very differently than they will treat you. they're on their best behavior with you as the provider. It's like if they can glue their brain together for five minutes, like I currently have a patient with schizophrenia. The first five minutes, he sounds very normal. But as we go on in our discussion,

he sounds more and more, you know, someone who needs higher doses of meds and the proper meds. And it's because like that, you know, we can glue our brains together for a limited amount of time. So you as the provider with your limited content, with the patient should always be utilizing your team. Oh, very definitely. In fact, a very good piece of advice for interns and residents is always be very nice to your nursing staff. It is they who will save you. Yep. They will. Because frankly,

frankly, when you're a trainee, most of them actually know a lot more than you do. And they have practical knowledge, right? If they've been on the unit for 20 years and you're coming in as a fresh resident they have practical knowledge which you probably don't have at that point yes and so because that's what you're there to learn in part and they are likely already aware of all of those things and uh indeed as with the student you just described who spots somebody who looks catatonic and does the bush francis rating scale pay attention to that. They may have seen dozens of cases of catatonia,

and you may not have ever seen one yet. Okay, so we talked about catatonia. I'm curious where you think of in the treatment of schizophrenia, like when should someone start to think about ECT? I think ECT makes sense in schizophrenia for somebody who has treatment-resistant schizophrenia and who has either a very either no response or a very limited response to chlozapine is one indication or for some reason they can't or won't take chlizapine and their other antipsychotic is appropriate it's adequate amount adequate dose but it's just not doing the

job. ECT may be a reasonable adjunct in either of those cases. Okay. When do you think we should consider ECT for bipolar? Bipolar illness in particular for, for example, again, if somebody has severe bipolar depression, or often if they have a mixed mood state that is unresponsive, or I'll be at the This is fairly rare a manic state that is unresponsive to antipsychotic or mood stabilizer, often both. Again, ECT fills in that role where you've run out of the appropriate pharmacological options and the person is still not doing well. Their illness is better than the meds you've used. ECT may save you in that case and may save them.

Yeah. What do you think about when ECT would be good for a pregnant female? Certainly in cases where there are reasons where the individual should not be exposed to psychotropic medications, or in some cases where the person is adamantly opposed to taking medications, but is, for example, depressed. that may be an appropriate role for ECT because one of the things about ECT is, of course, unlike medications, there are no ongoing chemical agents present. You know, there's a brief exposure to anesthetic agent and a succinctilcholine, but we're talking exposure over minutes rather than an ongoing exposure. So certainly in those cases, ECT can be used safely in pregnancy. What about ECT for Parkinson's with depression?

Has been used with some success. People with Parkinson's disease are more prone to post-treatment, post-ictal confusion. So the treatment may need to be moderated. And indeed, in some cases, some ECT providers will prefer a bifrontal electrode placement as opposed to a unilateral placement in Parkinson's patients. But again, it certainly can be used in Parkinson's disease with depression. You know, the safety record for ECT is impressive.

the estimated mortality rate in most of the things I've read is in the neighborhood of four per hundred thousand, which is a very tiny mortality rate for any medical procedure. How do you as a provider sort of distinguish someone maybe who has some level of factitious disorder that's sort of leading them to want ECT? That involves getting to know the person well enough to know that they may be seeking the sick role. There's often, if you can get it, collateral history can be very helpful in that case. One of the things I always ask people when I'm figuring out if they're competent to consent for ECT is why they want the ECT and what do they think it will do for ECT? for them. Before I explained what it can do for them, I want to hear their interpretation.

Sometimes in my patients, because I have a lot of psychotic patients, their thoughts about what ECT will do are sometimes rather novel. I had one guy indeed who thought he was a robot, and he thought the ECT would charge up his batteries. we laugh but we laugh because it's i don't know it's it's funny but it's also of course like not something you want to laugh at like some psychotic person but no although in a way he was because he was also depressed he was actually kind of right but not in a literal sense that he was saying it yeah um so okay let's say let's say let's say you're a patient and someone has recommended ECT to you and you've stumbled upon this

podcast, do you have any other words that you would like to express to that person? I think that if they are ill and other treatments have not worked for them, ECT is definitely worth considering if they're suffering from, well, the three major indications are depression, schizophrenia, catatonia. There are other indications for ECT, and I would encourage people to ask their provider about ECT and or to ask their provider to refer them to somebody with expertise in ECT to discuss the pros and cons of the treatment. In other words, ECT is like everything else.

People should become educated about what ECT has to offer, like all treatments, it has some very positive features. It also does have negative features, albeit frankly, far fewer than many medications. So I think the thing I would tell people is to, you know, if you're suffering from something that might benefit from ECT, take the time to educate yourself about it. Okay.

And anything, like let's say you were a resident who wanted to become an ECT provider. Any advice you would give them? Yes. There are a number of programs in the U.S. that offer essentially a brief certification fellowship in ECT. Usually, most of them are on the order of 10 days to two weeks. And frankly, attending one of those

and essentially getting a fairly intensive trading that leads to certification, and ECT is a worthwhile thing to do. I know of the people in the state hospital here who provide ECT, one of them went to the University of Pittsburgh Hospital and got certified, took her two weeks. Another person went to Duke University, a very similar program.

You can look online, And if you type in the search terms, ECT training or ECT certification, you'll get a whole list of academic programs that offer specialized training in ECT. I think it's worth noting to someone who's just listening to that who might say, oh, it only takes two weeks to learn how to do this. By that time that that person's getting that training, they've already done 10,000 hours of patient care, diagnosis, you know so yes it's like they're getting some of the details of how to deliver this treatment but

they already know how to follow very sick populations and manage very sick populations yeah the two weeks is specifically on how to uh essentially the technical aspects of providing ecct yeah well excellent any um any closing words in general about ecc that you would like to put out there Well, I'm always prone to some extent to puns. In this case, I would say it's certainly an electrifying topic. It's shocking you would say that, Dr. Covarez. Yeah, I would just close with like, this is one of the tools in our, you know, toolbox as mental health professionals. We need to be aware of it, even if we're not providing it.

we need to know who in the community that we serve maybe does this so that we can have someone to talk to about very difficult cases that come our way. I favor partial hospitalization and IOPs and all the other things that we can do psychotherapy-wise, but there are certain patients that this is the treatment of the gold standard treatment that is going to help them. So happy to put this out there. All right, we'll leave it there. Thank you for coming on. Okay. Really appreciate it. Thank you. You know,