Journal Reading - ECT

8/11/2019 Journal Reading - ECT

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Treating

Depression withECT: An Objective

ReviewBasem Gohar, Christa R.Winter, Mark Benander,

Barbara Mandell, CassandraHobgood, Keith Z. Brewster

Email:[email protected]

Supervisor : dr. Sabar Siregar, Sp. KJ


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Introduction


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Depression is a mental disorder thatis currently on the rise in the world

analysis of the National ComorbiditySurvey Replication that theprevalence of the disorder amongadults in the United States is 16.2%,which is the most common andcostly illness

(Kessler, Aguilar-Gaxiola, Alonso, Chatterji, Lee, and stun 2009)

Additionally, Murray and Lopez(1996) indicated that majordepressive disorder (MDD) was listedas the fourth rankedcause of

premature death worldwide


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The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV- TR; AmericanPsychiatric Association, 2000)

inability toconcentrate

feeling sador tearful

psychomotoragitation

change inappetite

suicidalideations

loss ofinterest orpleasure

feelingworthless

Some of thesymptoms

ofdepression


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Causes of depression might differ foreach individual. Some researcherssuggested that depression is solelygenetic-based(Campbell & MacQueen, 2006;

Hasler, Drevets, Manji, & Charney,2004; Penttila et al., 2004; Ressler &Mayberg, 2007; Ruh, Mason, &Schene, 2007)

Other researchers suggested that it isdue to a joint contribution of geneticand environmental factors such asmajor life stressors(Cervilla et al., 2007; Duman &

Monteggia, 2006; Kendler, Gatz,Gardner, & Pederse, 2006; Kim,Stewart, Kim, Yang, & Shin, 2007; Rot,Mathew, & Charney, 2009)

de

pression is caused by a cumulative impact ofgenetics, adverse events in childhood and ongoing or recent stress.These findings portray that gene environment

interactions could better predict the risk ofdeveloping depression better than genes orenvironment alone.

Rot et al.concluded that


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In 1938, in Rome, with

his assistant Ugo LucioBini Cerleti perform ECTin patients withschizophrenia.

ECT is performed 11

times and the patientgave a good response.

The use of ECT and thenspread throughout the

world. ECT is now usedfor patients with severedepression andschizophrenia


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Electroconvulsive therapy (ECT) is

considered to be a last resort in treating

depression; after failing to see resultswith medication and psychotherapy. ECT

is considered as one of the most effectivetreatments for depression

(American Psychiatric Association, 2000;Sackeim, Prudic, Fuller, Keilp, Lavori, &

Olfson, 2006; Yatham et al., 2010)

It has been stated, The

results of ECT in treatingsevere depression are among

the most positive treatment

effects of all of medicine

(Dukakis & Tye, 2006: p. 132)


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ECT is used mainly for patientssuffering from unipolar and bipolardepression, psychotic disorders, as

well as with pregnant patients withsevere symptomology in the eventthat the necessary medication iscontraindicated for fetal health

Beyer et al. (1998) reported thatthe mortality rate in ECT is low.The researchers also reportedthat no contraindications have

been researched for ECT.


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However, there are factors that could increase therisk of complications and adverse effects medically

and cognitively.

From a medical perspective, ECT could be considered

higher in risk if there are any irregularities found inthe brain, such as detecting a tumor or hematoma

(Beyer et al., 1998).

Other conditions include recent myocardial infractions,intracerebral hemorrhage, unstable vascular aneurysm or

malformation. The researchers highlighted that a significantpositive correlation is found between mortality rate and

those with comorbid medical diseases, specifically

cardiovascular and respiratory diseases


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DIAGNOSIS


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The concern of subjectivity remains an issue in morerecent literature. Bloch, Ratzoni, Mendlovic, Gal, andLevkovitz (2005) criticized the inconsistencies indetermining maximal medical improvement (i.e.returning to baseline through treatment) of patientswith mental disorders across the literature.

Therefore, measuring progress, especially with atreatment such as ECT would benefit from the inclusionof an objective and standardized approach in additionto the psychiatrists assessments.

Zimmerman and Mattia (2001) accentuated theimportance of accurate, reliable, valid, and accessiblemeasures in evaluating the quality and efficiency ofcare in clinical practice.


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Thus, standardized measures such asselfreported instruments that measure

fluctuating affective states in psychiatricpatients are necessary.

The researchers described selfreport

questionnaires as a costeffective optionbecause they are inexpensive and require lesstime for completion.

In addition, the researchers pointed out thatthe results of self-report questionnairescorrelate highly with the ratings of clinicians.


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Among the newer self-reportquestionnaires used today is theClinically Useful OutcomeDepression Scale (CUDOS,Zimmerman, Chelminski,

McGlinchey, & Posternak, 2008). The questionnaire consists of 18

items. Of those items, 16 assessall of the DSM-IV-TR (AmericanPsychiatric Association, 2000)inclusion criteria for MDD and

dysthymic disorder. The two remaining items

examine psychosocialimpairment and quality of life. Ittakes approximately three min tocomplete by the patient andabout 15 s to score by theclinician, which works well in theECT treatment setting, where itwould not aggravate the patientsprior to the procedure.

Psychometric properties of theCUDOS are discussed in the

methods section


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Methods


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Sample

Data collected from achieved records ofpatients at Baystate Health (BH) fromSeptember 2010January 2012

The sample consisted of30 former

inpatients and outpatientsat BH whorequired ECT for treatment due todepression,failed to reach maximalmedical improvement by medication andtherapy and who received a minimum offour treatments in one series of ECT.


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ECT

Unilateral or bilateral (bitemporal)electrodes were placed on patientsbased on psychiatricts impressions

prior to treatment using the MECTA5000Q device at BH

Patients recieved 3 treatments perweek, as the clinical custom at BHand in the United States


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Measure

In this study, the researchers examined previousscores of the CUDOS in former depressedpatients of the hospital who had undergone ECTtreatment

The psychiatrist at BH favor the CUDOS anduse the questionnaire as a part of theprogress evaluations as it correlates with theirevaluations and takes little time to complete bypatients and to score by the psychiatrits


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Procedure

The researchers created a raw score

The researchers organized theinformation obtained from the databaseof the hospital which included:

Codes given to patients (e.g ECT1) Age

Gender

Pre-scores of CUDOS

Post-scores of the CUDOS


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Statical

Analyses

Descriptive statics were used todescribe participants in thestudy.

A 2x2 mixed factorial Analysis ofVariance (ANOVA) wascomputed to compare pretestand posttest scores of CUDOS aswell as gender

Zimmerman et all., 2008


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Results


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Variable Mean SD Minimum Maximum

Age

Male 53.38 14.99 31 73

Female 51.78 12.82 33 77

Number oftreatments

Male 7.77 1.83 5 11

Female 7.75 3.79 4 18

Tebel 1.

Desccriptive statistics of patients age, number of treatments, and mean seizure length

based on gender of the sample (N=30).

Note. Male n= 8, Female n=22


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Gender n Mean SD Minimum Maximum

Pre CUDOS

Male 8 46.25 8.58 32 65

Female 22 49.68 11.03 27 57

Total 30 48.77 10.40

Post CUDOS

Male 8 33.63 20.23 3 60

Female 22 23.32 12.44 4 44

Total 30 26.07 15.24

Tabel 2.

Descriptive statistics of patients CUDOS Score Pre and Post ECT treatment in series

(N=30)


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Discussion


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The results of the studyshowed a reduction in levelsof depression, as indicated by

the change of scores of theCUDOS after the completedECT treatment. Thus, the

results of this study supportthe efficacy of ECT in

patients suffering from

depression.


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It is important to note that the initiative behind using an objectivemeasure is not to replace the psychiatrists evaluations but to simply

reduce any form of subjectivity that may arise. Further , the processof ECT cannot be entirely left for standarized measures

For Example, the psychiatrists determine the placement of theelectrodes for each patient prior to treatment, a clinical judgementthat is based on knowledge and experience

Due to the complexity of each case, the psychiatrists must select thebest option for each patient, striving to deliver the lowest level of risk

in conjuction with the highest degree of benifits


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Other factors that psychiatrists must consider forECT include but are not limited to :

Treatmentfrequency

Sine waveintensity

Medication use

Medicalsondition

Stimulusintensity

AgeElectrode

placement

Beyer et al., 1998


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The inclusion ofstandardized measure in theprocess of ECT howevergenerates a number ofbenefits. A self-reportmeasure as simple as TheCUDOS provides a clear and

visible objective measure tothe patientsand their lovedones in order to monitorprogress.


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The results of this study suggest that both male and femalepatients had significant improvement after ECT series. However,

female patients showed more improvement than male patients, evidenced by the scores on the CUDOS

This finding resembles the findings of Bloch et al., whodetermined that female schizophrenic patients had significantlymore improvement than male schizophrenia patients after ECTtreatments.

Therefore, female patients with schizophrenia and depressionshow more improvement than male patient after ECT.


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For example, Gorman (2006)examined the difference ofdisplaying sadness betweenmen and women. The

researchers found thatwomen more visibleemotions of sadnessthenmen, who were more rigid.

In another study, reported thatmen displayed depression ina more aggresive andirritable behavior than

women.


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The possibilities listed above are

speculations due to lack of literature

with regards to gender differences in

ECT patients, specifically in patientssuffering from depression.

As a result, gender differences would

benefit more exploration in future

studies with more and equal numbersof male and female patients.


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There were some limitation to this study :

Depressedpatients mighthave presented

differentsymptomps

The duration ofthe disorder

might have variedfrom one patient

to another

As this was aretrospective chart for

review, the researcheeswere unable to account

for cognitive impairments

that might have occuredduring the treatments.

The selection processdelimited the study byselecting patients who were

diagnosed with a type ofdepression and received a

minimum of four ECT

treatments in a series.

This study did notcontrol for

medication duringECT treatments


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Conclusion

The findings of this study support the efficacyof ECT in treating depression.

More improvement was shown in femalepaients than male patients.

The CUDOS has shown to be a simpleandeffective self report measure in assessing

progress of depression including complextreatments, such as ECT.


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Is the study question relevant?

Yes, it researched about efficacy ofElectroconvulsive Theraphy (ECT) as atreatment method for unipolar and bipolar

depression


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Does the study add something new?

Yes, it was showing effectiveness using ECT astreatment method for unipolar and bipolardepression and more improvement at women

than male patients


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What type of research question isbeing asked?

Question about the effectiveness oftreatment, and this articles told abouteffectiveness using ECT as treatment method

for unipolar and bipolar depression


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Was the study design appropiate fortesearch question?

Yes but it had 4 limitation to this research. First,depressed patients might have presenteddifferent symptoms. Second, the duration of thedisoreder might have varied from one patient to

another. Third, as this was a retrospective chartreview, the researchers were unable to accountfor cognitive impairments that might haveoccured during the treatments. Fourth, the

selection process delimited the study by selectingpatients who were diagnosed with a typedepression and received a minimum of four ECTtreatments in a series.


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Did the study mehods adress the keypotential sources of Bias?

No, it had a spesific study design.


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Was the study performed according tothe original protocol?

Yes, the researchers examined previous andpost ECT treatments using CUDOS (ClinicallyUseful Outcome Depresion Scale) in 30

patients and anylsed by 2x2 mixed factorial.


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Does the study test a stateshypothesis?

Yes, ECT was efficacy in depression patients


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Were the stastical analyses perfomedcorrectly?

Yes, the statical analyses perfomed correctly


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Do the data justify the conlusions?

Yes, they do. The findings of this study supportthe efficacy of ECT in treating depression. TheCUDOS had shown to be a simple and

effective self report measure in assesingprogress of depression including complextreatments such as ECT


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Are there any conflicts of interest?

No, The findings of this study support theefficacy of ECT in treating depression.


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Journal Reading - ECT

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