Behavioral Health Educational Webinar Series:

Changing the Stigma and Images of Electroconvulsive Therapy (ECT)

Dennette Janus, MA, LPC Quality Improvement Specialist

Health Services Advisory Group (HSAG)Friday, August 10, 2018

Available After the Presentation

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• Slide of Prescription Assistance Resources

• Certificate of Attendance

• Resource Sheets‒ Crisis Intervention‒ Behavioral Health (BH) Treatment/Services‒ Substance Abuse Treatment/Services‒ Educational Opportunities‒ Everyday Needs

• The PowerPoint from today’s presentation will beavailable in approximately one week atwww.hsag.com/events

Online Poll: What Do You Say?

How do you rate your knowledge about Electroconvulsive Therapy (ECT) right now?

a. Very highb. Highc. Low d. Very low

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Who Is HSAG?

• Funded by the Centers for Medicare& Medicaid Services (CMS)– Subcontracted with CMS as a Quality

Improvement Organization (QIO) forspecific improvement tasks

– Focus population is MedicareFee-for-Service (FFS) Part-A, includingdual-eligible beneficiaries

– Largest federal program dedicated toimproving health quality at thecommunity level

– HSAG is the QIO in Arizona, California,Florida, Ohio, and U.S. Virgin Islands

– Reducing BH readmissions is one ofthe improvement tasks underthe contract

Department of Health & Human

Services

CMS

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BH by the Numbers

General BH Information• Rated the number one cause

of ill health and disability worldwide. (World Health Organization1 [WHO])

• 20% of adults in U.S. will experience mental illness. National Alliance on Mental Illness2 (NAMI)

Readmissions3 after an inpatient psychiatric stay

• More than 20% of patients readmit within 30 days

• 33% of those readmissions occur in less than 7 days

• Most readmissions are to a facility other than the one just left

Medical Behavioral

51. World Health Organization. http://www.who.int/mediacentre/news/releases/2017/world-health-day/en. 2. National Alliance on Mental Illness (NAMI): https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers3. HSAG Analysis of Medicare FFS Part-A claims for Q1 2017-Q4 2017, AZ

HSAG BH Webinars Presented to Date

1. Behavioral Health Basics2. Understanding Common Disorders3. De-escalation Techniques4. Community and Behavioral Health Resources5. Voluntary vs. Involuntary Evaluation

and Treatment6. Medication and Medical Issues that Mimic

Psychiatric Crisis7. Relationship Alphabet Soup:

Understanding Legally Defined Relationships8. Inpatient Psychiatric Treatment: A preview

These recorded webinars and related materials are available at no-cost at: https://www.hsag.com/bh-webinar-series6

Other HSAG BH Resources

• Top 10 Readmission Reduction Intervention series flyers

• Jane’s BH Experience – Patient videos

• Vetted Arizona and nationwide resource lists

• Teach-back resources and information

• 30-day Readmission Audit Tool Template

7These resources are part of HSAG’s ongoing work with PCPs, IPFs, and community stakeholders toward improved care coordination and readmission reduction: www.hsag.com/bh-resources.

Presenter Introduction:Gagandeep Singh, MD

Chief Medical Officer, Banner Behavioral Health,Associate Professor of Psychiatry,

University of Arizona College of Medicine-Phoenix

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Changing the Stigma and Images of Electroconvulsive Therapy (ECT)

Gagan Singh, MDChief Medical Officer, Banner Behavioral Health,

Associate Professor of Psychiatry, University of Arizona College of Medicine-Phoenix

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Agenda

• “the treatment of mental illness and especiallydepression by the application of electriccurrent to the head of a usually anesthetizedpatient that induces unconsciousness andconvulsive seizures in the brain”…MerriamWebster

• HISTORICAL PERSPECTIVE• BASICS OF MODERN ECT

10 "Electroconvulsive Therapy." Merriam-Webster.com. Merriam-Webster, n.d. Web. 30 July 2018.

(Pre)History

• Mental Health before ECT

• Biologic treatments– Julius Wagner-von Jauregg– Nobel prize for medicine 1927

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Convulsive Therapy• Ladislas Joseph Meduna• Camphor and Metrozol

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Cerletti & Bini (1938)—Electroconvulsive Therapy

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Anesthesia Developments

• 1940’s- ether, and curare extract developed• 1950’s- Succinylcholine and short acting

barbiturates

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British Journal of Anaesthesia. (1952), 24, 238.

SUCCINYLCHOLINE IODIDE*A NEW MUSCULAR RELAXANT

By S. THESLEFF, 0. v. DARDEL and G. HOLMBERGDepartment of Pharmacology, Karolinska Instutet,Department of Anesthetics and Psychiatric Clinic,

Karolinska, Sjukhuset, Stockholm

SUCCINYLCHOLINE IODIDE is a synthetic quaternary ammonium salt, which has a neuromuscular blocking action of short duration.

The substance was first discovered in 1906 by Hunt and Taveau, but they did not discover its paralysing effect. This property of succinylcholine was demonstrated for the first time by Bovet in 1949 (Bovet, Bovet-Nitti, Guarino, Longo and Marotta 1949).

S. THESLEFE, O.V. DARDEL, G. HOLMBERG. SUCCINYLCHOLINE IODIDE A NEW MUSCULAR RELAXANT.Available at: https://www.sciencedirect.com/science/article/pii/S0007091217526872. Accessed on:August 2, 2018. Copyright © 1952 Published by Elsevier Ltd.

Past Issues with ECT

• Optics Unmodified ECT• Unmodified with anesthesia• Lack of monitoring• Complications• High dose• Consent

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Video Link: https://www.youtube.com/watch?v=DCUmINGae44

Decline of ECT

• Antipsychiatry Movements

• Scientology• Medications

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Resurgence of ECT

• Predictions with modernpsychopharmacology

• Added safety/monitoring• Efficacy

17Anderson Cooper. CBSNews. Is Shock Therapy Making a Comeback? Available at: Good Reads. Shock: The Healing Power of Electroconvulsive Therapy. Available at:

IS SHOCK THERAPY MAKING A COMEBACK?For people with treatment-resistant depression, a controversial therapy gains ground and leads to innovation; 60 Minutes reports, Sunday at 7 p.m.

https://www.cbsnews.com/news/ect-is-shock-therapy-making-a-comeback/. Accessed on: August 2, 2018.

https://www.goodreads.com/book/show/1009271.Shock. Accessed on: August 2, 2018.

Efficacy rates

• At least 6 trials of real ECT vs simulated (placebo) ECT that show significant improvement with ECT (odds ration of 5:1)

• Over all response rates of 75% to 90%• 20%–45% more effective than

pharmacotherapy• Predictors of good response:

– presence of older age, psychosis, catatonia, pseudodementia, pathological guilt, anhedonia, agitation and neurovegetative

18Coffey, C. and Cummings, J. (2011). The American psychiatric publishing textbook of geriatric neuropsychiatry. Washington, DC: American Psychiatric Pub., pp.277-303.Pagnin, D., de Queiroz, V., Pini, S., & Cassano, G. (2004). Efficacy of ECT in Depression: A Meta-Analytic Review. The Journal Of ECT, 20(1), 13-20.

Procedure

• Modern ECT– Anesthesia– Physiology of ECT/Seizures– Monitoring: oxygenation, cardiac, brain wave– Electrode placement

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Video Link: https://www.youtube.com/watch?v=W8Ypt-vKI2U

Modern ECT- Improvements

• Anesthesia• Anesthesiologist and monitoring• EEG• Energy• Consent

20 Andrade C. Dose calculation with brief-pulse ECT demystified. Indian J Psychiatry 2010;52:276-8

Indications

• Major Depression • Bipolar disorder • Catatonia• Acute schizophrenic exacerbation/catatonia• Other: Neuroleptic Malignant Syndrome (NMS),

Chronic Pain syndromes, Parkinson's and intractable seizure disorders

• When to consider:– Treatment resistance– Pregnancy– When is it 1st line

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Phases of Treatment

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From: Nonpharmacological Versus Pharmacological Treatments for Adult Patients With Major Depressive Disorder. Available at: https://www.ncbi.nlm.nih.gov/books/NBK338234/figure/introduction.f1/.

Acute versus Maintenance and Location

• Acute– How often– How many

• Maintenance– How often– How many

• Inpatient versus Outpatient ECT

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Side effects and Complications

• Death• Cardiac issues• Memory• Headache/muscle pain• Seizures• Immediate/day of symptoms

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Evaluation before ECT and when not to do it

• Psychiatric history• Medical history• Physical Examination• Labs and investigations• Specialized investigations and consultations• Objective screening

– Cognition, Mood• Medications and ECT• Contraindications• Consent

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Role of ECT

• Role of ECT in modern medicine• Other somatic treatments

– Vagus Nerve Stimulation (VNS)– Transcranial Magnetic Stimulation (TMS)– Deep Brain Stimulation (DBS)

– THANK YOU!

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Online Poll: What Do You Say?

How do you rate your knowledge about Electroconvulsive Therapy (ECT) right now?

a. Very highb. Highc. Low d. Very low

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Questions?

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Please submit questions through the chat feature.

Deepest Appreciation to our Presenter!

Gagandeep Singh, MD,

Chief Medical Officer, Banner Behavioral Health

Associate Professor of Psychiatry, University of Arizona College of Medicine-Phoenix

Contact Information:Gagandeep.Singh@bannerhealth.com

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Thank You for participating!We value your feedback!

Please complete the brief evaluation at:

https://goo.gl/hUud83

Remember to download your certificate of attendance and resource lists!

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Prescription-Related Resources

For Prescribers: Formulary Verification by Insurance Plan“The easy and efficient way for physicians’ offices to complete prior authorization (PA) requests for any drug and nearly all health plans!” Cover My Meds. A no-cost, HIPAA-compliant online resource option. www.covermymeds.com or call 1.866.452.5017

Prescription Assistance ProgramsIndividual pharmaceutical companies Online prescription assistance guides can help identify other programs available by drug name or medical condition and offer printable medication discount cards. http://www.needymeds.org/ or call 1.800.503.6897http://rxassist.org/ or call 1.877.537.5537

Medicare Part-DA guide for applying for assistance with medication costs and for when a patient is in the Medicare “Donut Hole:” www.medicare.gov/find-a-plan or call 1.800.633.4227

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Nationwide Resources

• National Suicide Hotline800.273.TALK (8255)www.suicidepreventionlifeline.org

• National drug/alcohol referral service800.662.HELP (4357) #2 for Spanishwww.samhsa.gov/find-help/national-helpline

• Teen Lifeline: 1.877.YOUTHLINE

• Crisis Text Line: Text “help” to 741741 for anycrisis situation

• Poison Control: 800.222.1222

• National Alliance on Mental Illness (NAMI)www.nami.org | 800.950.6264

• Mental Health Americawww.mentalhealthamerica.net | 800.969.6642

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Arizona-Specific Statewide Resources

• Crisis Resources—Arizona

• Maricopa County: 800.631.1314 or 602.222.9444

• Cenpatico Counties: Pinal, Pima, Gila,* Yuma, Greenlee, Graham, Santa Crus, Cochise, and La Paz: 1.866.495.6735

• Health Choice Counties: Apache, Coconino, Mohave, Navajo, Yavapai, and Gila:* 1.877.756.4090

• Teen Lifeline: 800.248.TEEN (8336)

• General Community Resources:‒ AZ 211: Call “211” or https://211arizona.org‒ http://findhelpphx.org‒ http://arizonaselfhelp.org

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Maricopa County, Arizona-Specific Resources

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Maricopa County Crisis Line: 800.631.1314 or 602.222.9444

Find Help Phoenix: Free and almost free services/resources http://www.findhelpphx.org/

Southwest Network Help Book: Community and BH resources. http://www.southwestnetwork.org/nt19rg/default.htm

Mercy Maricopa Community Resource Guide:https://www.mercymaricopa.org/community-guide

Area Agency on Aging Region 1: Resources for individuals 60+, adults with a disability and long-term care needs, or adults with diagnosis of HIV or AIDS. http://aaaphx.org/home/elder-resource-guide/

National Alliance on Mental Illness, Valley of the Sun: Maricopa County affiliate of NAMI. http://namivalleyofthesun.org/

Download list for information on organizations offering 24/7 BH “Level of Care” Assessment.

Thank you!

Dennette Janus, MA, LPC,Quality Improvement Specialist, HSAG

djanus@hsag.com

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily

reflect CMS policy. Publication No. QN-11SOW-XC-08032018-01