Depression and ECT

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Guest: Milton J. Foust, M.D.

Host: Dr. Linda Austin

Dr. Linda Austin: Welcome to What’s On Your Mind, a podcast program from the Medical University of South Carolina. I am Dr. Linda Austin. We are going to be talking today about ECT Electroconvulsive therapy and I am pleased to be able to talk with Dr. Milton Foust, who is assistant professor of Psychiatry at the Medical University here in Charleston and is also Director of the ECT Program. Welcome Dr. Foust.

Milton J. Foust: Good afternoon, I am very happy to be here.

Dr. Linda Austin: Dr. Foust, so many of us think of ECT or shock therapy based on One Flew Over the Cuckoo’s Nest and that was a pretty scary movie for a lot of people, but ECT is done very differently now than in the 50’s. Is that right? Is it still a scary procedure for a lot of people though?

Milton J. Foust: Well, actually my favorite portrayal of ECT in the movie is granny in the Beverly Hillbillies movie, not very clinically accurate, but not nearly as frightening as Jack Nicholson’s experience in One Flew Over the Cuckoo’s Nest. We try to prepare people for ECT with a lot of instructions and education before they are treated and we also try to make it as relaxing and I won’t necessarily say pleasant, but it is as tolerable a procedure is possible. It’s essentially done under general anesthesia, so there is no discomfort and there is no sensation of shock or anything like that associated with the treatment.

Dr. Linda Austin:S o, why is it then that with all of the anti-depressant that we have now and it seems like there is a new one every year. Why in the world are we still using ECT?

Milton J. Foust: Well, most people, who are treated with antidepressants are going to do reasonably well. Unfortunately, there is a significant minority of people, who will either fail to respond or who will have a temporary, but not a particularly long lasting response, maybe a partial response. I see people who often have been treated with multiple anti-depressants and are still severely depressed. I also see people, who have been treated with antidepressants, but have relapsed after a number of weeks or a number of months and they have either lost confidence in antidepressant or they have been treated with so many that their physicians have lost confidence in antidepressants and they are really ready to try something different.

Dr. Linda Austin: Can you give me a rough estimate as to what percent of patients with serious depression don’t respond to a number of antidepressants?

Milton J. Foust: I am reluctant to quote any statistics about that, but I can tell you that probably 90% of the patients we treat have been treated with either three or four different antidepressants and are not responding.

Dr. Linda Austin: Then to ask a question in another way, if you take that group of patient whom you treat, who have had multiple problems with antidepressants or multiple treatment, let’s say partial responses, what fractions of those are at least somewhat helped with ECT?

Milton J. Foust: Well, when you treat people with ECT the ideal patient is actually someone who has never been treated with an antidepressant and is severely depressed, disabled by depression, possibly even having psychotic symptoms or catatonic, those people would probably respond about 90% or more often. If we only treated patients like that we would have wonderful success rate. The longer a person has been depressed and the more antidepressant a person has been treated with unfortunately the less likely that person will be to even respond to ECT. Nevertheless, at least 50% if not more of those patients are going to respond to ECT and those kinds of patient deserve a trial of ECT.

Dr. Linda Austin: So, it sounds like basically you get the most, not just severely ill, but the most resistant to treatment of all and even with those you have a pretty good response. You know, I find myself hedging my words because at one time I used the word treatment failure to describe this patient and someone said to me, ?you know Linda when you use that word failure you make it sound like it’s the patient’s fault? and of course it’s not their fault, right.

Milton J. Foust: None of our patients are failure and we don’t like to fail either. We do unfortunately treat a small number of people, who have not responded to a variety of treatments including antidepressants, psychotherapy, occasionally even vagus nerve stimulation, which is a new invasive technology for treating depression and some of those patients respond to ECT and some of those patients don’t, but in any given year treating more than a hundred people with ECT, I can usually count on the fingers of one hand the number of people, who seem to have absolutely no response at all.

Dr. Linda Austin: So, let’s walk through the process, okay. Let’s imagine I am that patient and I have not responded to several different antidepressants and I am saying I just want to get well fast, let’s do the ECT. What would be the first thing that would happen?

Milton J. Foust: Well, the first thing that would happen would be that we would need to sit down and have a conventional sort of consultation. We would meet for at least an hour. Usually with me, it’s longer because I want to know something about your background, your history, what kind of treatments you have had in the past, I will ask your doctor, your referring doctor to send me some records, so I can review those. I want to have a pretty clear idea of what your life has been like, what your symptoms, and the kind of suffering you have had has been like, and what kind of responses if any you have had to treatment?

Dr. Linda Austin: And are there any things that I might have that would make you say, AhAh! can’t do ECT here.

Milton J. Foust: Well, the primary reason not to do ECT would be if there were a problem in diagnosis or indication that is the ideal indication for ECT if someone with a severe or Treatment-Resisted Mood Disorder, someone who has primarily an anxiety disorder for example like generalized anxiety disorder or specific kind or phobia or posttraumatic stress disorder that’s sort of thing. Someone like that is highly unlikely to benefit from ECT.

Dr. Linda Austin: So let’s imagine now its day one of treatment and would I have to be an inpatient or could I do this as an outpatient?

Milton J. Foust: Well, probably up to about 10 years ago, most people who had ECT would have it in the hospital. In fact almost everyone would have it the hospital and as time has gone by we have shifted just as people in various kind of surgery have shifted towards outpatient procedure we have shifted more towards outpatient ECT.

Dr. Linda Austin: Okay, so let’s say it’s Monday morning, and I get driven to the hospital I would assume and I show up there at where you do this and what happens next?

Milton J. Foust: Well, you do need to be driven at the hospital because when you are having ECT you can drive yourself and we don’t want you just to be dropped off on a cab. We tell people you can’t just come in a cab unless your spouse or significant others is a cab driver because we want someone to be there to help you, but you will come with someone to accompany you, assist you, and take you home. We would like for that person to wait outside. You will come in, you will lie down on a stretcher, you will have to take off your clothes to change into a gown or any thing like that, and you can just wear ordinary street clothes. While you are on a stretcher, we will ask you to answer a few questions, maybe fill out some minimal paper work, you will have a IV line started because the intravenous line is the means by which you will receive general anesthesia and it is a procedure done under general anesthesia, but it is extremely brief anesthesia, not more than 10 to 15 minutes of anesthesia. From there, you will come in to the main treatment area, where you will have cardiac monitor as well as an EEG that is a brain wave monitor what we call a pulse oximeter or a device that measures the level of oxygen in your blood, a blood pressure cuff. All these different monitors will be attached and I will also put what we call electrodes, which really look like little flexible refrigerator magnets on your either forehead or temples and this will be the electrodes which will actually provide the electrical stimulation while you are anesthetized and while you are asleep, so there would be no discomfort associated at all.

Dr. Linda Austin: So, I nod off, then I fall asleep, and then what you do?

Milton J. Foust: Well, once you are fully asleep and we determine that your muscles are sufficiently relaxed because you will also get a muscle relaxant usually a drug called succinylcholine. Then I will apply a stimulus, this stimulus will be a maximum of - in energy terms, it would be a maximum of no more than a 100 joules of energy, which is comfortable to what might be used for stimulating someone’s heart, who has an abnormality of heart rhythm and the stimulus will last typically no more than 8 seconds.

Dr. Linda Austin: So, you put the paddles, the ECT paddles to my head, right.

Dr. Milton J. Foust: We don’t use paddles, they might use paddle at Duke University or Emory.

Dr. Linda Austin: Back in the 70’s when I learnt how to do this. I guess, right.

Dr. Milton J. Foust: And Jack Nicholson had paddles applied to his head and we do have some old paddles stuck away in the drawer somewhere, but we prefer a different sort of arrangement, which is more comfortable for the patient, easier to use, and these are little pads that we call them 10:24 pads that’s the trade name and these are little pads that I refer to as being like refrigerator magnets and they stick to your head and those are stuck with a kind of adhesive and they will stay on your head without any kind of pressure or paddle or any thing like that and they go on actually before you go and sleep unless you are really nervous and then we will until you are asleep and then put them on.

Dr. Linda Austin: I see okay, so then the stimulus electrical jolt one could say the electrical current correct goes through.

Dr. Milton J. Foust: The only one who is going to be jolted is me if I put my hands on the wrong way and may be make a short circuit between my thumb and forefinger, which I have done before. It is a little bit uncomfortable, but you are not going to be jolted it and you are not going to be shocked because you are going to be asleep. You are not going to feel anything that’s why we don’t like to call it electroshock therapy because there is no sensation of shock involved.

Dr. Linda Austin: Okay, but what goes on in the brain is what?

Dr. Milton J. Foust: The production of a seizure.

Dr. Linda Austin: Okay.

Dr. Milton J. Foust: Under ordinary circumstance, the brain is a biological computer and different parts of the brain, cells in the brain communicate with each other electrically. There is a complex of electrical pattern going on. What we do with the ECT is we superimpose a simple pattern, a simple rhythmic pattern. This is a though a complex symphony was suddenly converted to a very simple drum beat and this drum beat, this simple pattern of electrical activity electrophysiologically inside the brain this is what we call a seizure. Clinically, what we can observe is movement typically of the arms and the legs. If you see someone naturally have a seizure, you will see what we call a convulsion or you see contraction of the limbs. You don’t see very much of that with the ECT because the muscles are relaxed, but you will see a little bit because we actually put a tourniquet on one of the limb we want to be able to see little bit of muscle activity as a signal to us that the seizure is actually taking place.

Dr. Linda Austin: And that lasts how long? How long does a seizure go?

Dr. Milton J. Foust: It will typically last some where between 15 and 60 seconds.

Dr. Linda Austin: Very short.

Dr. Milton J. Foust: Very short.

Dr. Linda Austin: And then how long after that ? if I were the patient, when I will wake up.

Dr. Milton J. Foust: After the seizure is over you will wake up probably within the next 5 to 10 minutes.

Dr. Linda Austin: Feeling how?

Dr. Milton J. Foust: A little bit confused. Momentarily confused and then over the course of about say 30 minutes you will become more focused, more aware of where you are and what’s going on and by end of an hour or so you should be wide, awake and alert and well you are probably - you are ready to go home.

Dr. Linda Austin: Boy, that’s pretty quick. Headache.

Dr. Milton J. Foust: Many people have headaches and the reason they have a headache is actually because of muscle contraction. When you apply an electric stimulus to the head, there is going to be contraction of the muscle even if you give a muscle relaxant that’s just a technical issue that has to do with the stimulation and with the way the muscle relax and drugs work. You can’t really abolish that muscle contraction with routinely used muscle relaxing drugs. So, there is this muscle contraction of the head, so people awake up and they frequently have a typical sort of muscle contraction retention headache. That headache can be treated with Motrin or Tylenol. Occasionally, if people have severe headache we can give them some medication for pain with the anesthesia so they are less likely to have persistent headache after they wake up.

Dr. Linda Austin: So then I go home. I 14:05 during the day and my understanding is you give a number of treatments, usually how many for a given patient?

Dr. Milton J. Foust: The average number of treatment is going to be about 7 and that will be space out over a period of 2 to 3 weeks.

Dr. Linda Austin: So say Monday, Wednesday, and Friday for 2 to 3 weeks is that.

Dr. Milton J. Foust: Monday, Wednesday, Friday for 2 to 3 weeks if you are coming for a long way away we can be flexible we can make it Tuesday, Thursday. Some patients who are having more side effects or more difficulty with recovering from anesthesia might prefer to wait longer and we will treat them twice a week instead of three times a week.

Dr. Linda Austin: Now, Dr. Foust, the big controversy with ECT is memory loss and certainly there has been a lot of discussion and complaints really about people saying that they have long term memory loss. What is that controversy about and what are the facts about memory loss from ECT.

Dr. Milton J. Foust: People who have ECT are going to have two kinds of memory loss. They are going to have what we refer to technically as retrograde amnesia that is they are going to forget events or facts that they have previously learned. They are going to have anterograde amnesia that is they are going to have difficulty learning new information. Now that obviously sounds very bad. In actual practice what happens is most people - the vast majority of people who have ECT will say things like, ?I had ECT and I can’t remember having met someone that I was supposed to have met a week ago or I can’t remember going on vacation six months ago.? These are particular events or gaps in memory that people describe. They also have difficulty learning new information and that difficulty with learning is typically resolved within two or three weeks after the last treatments. So, the vast majority of people who have ECT have memory loss that they may be able to detect, but it is not disabling. We have treated members of our own medical staff. We have treated medical students, we have treated professionals in the community, and these people are able to return to work. They are not disabled by the memory loss that occurs with ECT. The memory loss that occurs with ECT is real, but it is usually not really significant in terms of a person’s ability to function.

Dr. Linda Austin: So, in another words they lose memory for may be specific events around the time of ECT. Is that correct or might they forget a vacation three years before the ECT?

Dr. Milton J. Foust :Well, I don’t remember very much about my vacations three years ago and that’s where the issue becomes complex and controversial because there will be persons and you can read about these persons on the internet or in some of the literature, who will claim that having had ECT well. One person for example will say, ?I had ECT and I forgot my entire college education.? Well I haven’t had ECT and there is a lot of things I don’t remember about college either. One person claimed that having had ECT she forgot the births of all her of children. Now, these kinds of claims are extraordinary and we really can’t explain them, but I try to reassure patients by telling them that, although an event like this is possible, it is extremely unusual. There was one person reported in Japan for example who had ECT and supposedly forgot everything he ever knew, and then two weeks later remembered it again. So, there are always going to be very unusual kinds of claims, and symptoms, and presentations, but over the course of a year treating over 100 people the typical patterns is what I describe; very limited sorts of memory loss and of course people will tend to forget more about the minutes or the hours immediately preceding treatment than they do other things.

Dr. Linda Austin: And I have to say, having been a psychiatrist for last 30 years now and having sent a lot people for ECT, one of the things I always say to them is if after the first treatment you don’t want to have a second treatment or a third treatment you can always stop. It’s America it is a free country. I don’t think I ever had anyone say that. In the vast majority, patients are so glad that they did it because they got better. Dr. Foust a final question now, so called maintenance ECT, some people go on and have ECT periodically after they have had their first course. Can tell why do they do that?

Dr. Milton J. Foust: Well, I have one patient who has been getting ECT every two weeks for probably the last 10 years and he is tolerates it very well and he needs it to remain stable, but he is pretty unusual. The typical formula for maintenance ECT is a person, who has had ECT, had a satisfactory response, but then may be a few months later typically within a year has had a serious relapse despite efforts at good outpatient treatment with medications and psychotherapy. This person comes back for a second course of ECT. So following the second course of ECT then we talk about maintenance ECT that’s there are exceptions, but that’s the typical formula. After a second course of successful ECT, we suggest to people that they want to have what’s called maintenance and maintenance usually follows a schedule of single treatment once a week for a month, followed by a treatment every 2 weeks the next month, and then once a month thereafter either for 6 months or longer.

Dr. Linda Austin: Dr. Milton J. Foust thank you so much for joining us for this edition of What’s On Your Mind?

Dr. Milton J. Foust: Thank you

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