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Jake Johnston: [00:00:14] Welcome to PsychED, the psychiatry podcast for medical learners by medical learners. This episode covers Electroconvulsive Therapy or ECT for short. I'm Jake Johnston, a fourth year medical student at UBC, and I'll be the host for this episode. I join my wonderful colleagues who will be co-hosting. Why don't you all introduce yourselves?
Arielle Geist: [00:00:36] Hi, I'm Arielle Geist. I'm a second year psychiatry resident at the University of Toronto.
Randi Wang: [00:00:42] Hi. I'm Randi Wang. I'm a first-year resident also at the University of Toronto.
Alex Raben: [00:00:48] And I'm Alex Raben. I'm a staff psychiatrist at Camh and a lecturer at the University of Toronto.
Jake Johnston: [00:00:55] And last but certainly not least, it's my pleasure to introduce our guest expert for this episode, Dr. Wei Song, a psychiatrist who are several different hats. Dr. Song is the Department Head of Psychiatry, Director of Mood Disorder Services and Director of ECT Services in Victoria, British Columbia. He is also a clinical professor at the University of British Columbia and a past president of the Canadian Psychiatric Association. Thank you, Dr. Song, for joining us for this episode. Do you want to introduce yourself?
Dr. Wei Song: [00:01:26] Thank you, Jake, for a kind introduction, and I don't really need to introduce myself as you have already introduced. I'm so glad to be here and very privileged to be able to discuss the topic of ECT. As you know, it's a perennial topic. It's been going on for almost a century. So I'm happy to be here to answer your questions.
Jake Johnston: [00:01:51] Thank you very much, Dr. Song, for joining us. Let's dive into our learning objectives. By the end of this episode, the listener should be able to one briefly describe the history of ECT from inception to the present to debunk common misconceptions about ECT. Three, describe the major proposed mechanisms of action of ECT. Four, describe the efficacy of ECT for common psychiatric illnesses. Five, list the indications, contraindications, side effects and risks of ECT. Six, understand how the procedure of ECT is performed. Now that introductions are made and learning objectives are covered, let's get into electroconvulsive therapy. Randi, do you want to start us off with some questions for Dr. Song?
Arielle Geist: [00:02:45] Yeah, that sounds good. So I'll focus on the first part, which is for us to briefly describe the history of ECT from inception to the present. So based on our background readings, we read on uptodate some background information. So we know that ECT is a treatment during which small electric currents produce a generalised seizure under anaesthesia. We know that it's mainly used for severe depression, but can also be used for a bipolar disorder, schizophrenia, schizoaffective disorder, catatonia and even NMS. So from a historical standpoint, it started when physicians observed that patients with schizophrenia actually get better after they spontaneously have a seizure. So that led to some physicians actually inducing seizures, using medications to help treat these conditions. And then beginning in 1938, physicians actually began inducing these seizures, using the electric currents that first there were some physical injuries that were associated with treatment. But now that we have much better understanding of anaesthesia and muscle relaxants, that's really gone away. So nowadays almost all psychiatric facilities offer ECT. And based on data that we've collected, we know that patients who are they're more likely to receive ECT are those who are white and of higher socioeconomic status. So Dr. Song, I'll give you the stage to maybe talk about anything that we've missed. And yeah, why don't you describe what you see is to us?
Alex Raben: [00:04:30] Well, I think you captured very nicely that brief history and remember the treatment way before modern psychopharmacology. So, you know, mental illness has been plaguing, I think. Our human species since written a history. So for thousands of years and and there are a lot of search for a cure and not to sort of a distant past. You know, you're talking about hydrotherapy and essentially having some sort of an induction of fever that may actually cure mental illness. And I remember my professor in McGill and Dr. Heinz Lehmann talking about injecting sort of comfort oil in the peritoneal and then causing sort of a fever and then having seizure as well to cure catatonia. When you talk about EKGs, do you remember the residency time, the picture of this? 1938. That facility, this Italian psychiatrist and holding this switch of this electric current. And there was a five orderlies jumping on the patient. It was pretty gruesome in some ways. But on the other hand some of the patients were dying of catatonia and psychosis. Right. So certainly it provided dramatic improvement. Of course, like you said, Randi, associated with some of the side effects because those days the ECT was unmodified. I think in some parts of the world, as far as I know, sometimes a modifier is still being conducted because the limited resources and so on. But in the developed world the ECT is very refined. I'm sure you have questions about how it is conducted and so on.
Arielle Geist: [00:06:36] All right. Thank you. So next, moving on to some common misconceptions that we want to help debunk. We have an article here called Ten Myths about ECT from Current Psychiatry. And I guess I will just get started on some of the most common ones. So the first one, I guess you have alluded to it already. The first misconception is that ECT is very barbaric. So this is actually untrue because those of us who've actually seen ECT know that it's conducted in a very controlled medical environment. We have a psychiatrist there, anaesthesiologist, and many nurses present. Patients are given anaesthetics beforehand to not feel pain and muscle relaxant, so they're not jerking around or experience any physical injuries. And of course, we monitor their vitals the entire time and make sure they're medically stable. And another misconception is that it's very dangerous when in reality, death from ECT is extremely rare. The mortality rate is actually only 2.1 in 100,000 treatments, which is lower than that of just anyone going of an average person going through general anaesthesia. And we can even it's so safe that we can even use it on patients who are pregnant and on patients who have a history of epilepsy. Another misconception is that it could cause brain damage and this is untrue. Studies using MRI's have shown no evidence of negative changes before and after ECT. If anything, it can cause an increase in neurotrophic factors which support growth of brain cells. And then finally, a lot of people have this misconception that it creates permanent memory loss and this is also untrue. So ECT may temporarily impair anterograde memory, which are the events that happen right after the treatments for a few days, maybe a few weeks, and very rarely may cause retrograde amnesia, but overall it is not harmful to memory. So, Dr. Song, please correct me if any of these facts were incorrect. And what are some of the misconceptions you often hear from your own patients?
Alex Raben: [00:09:02] Stigma is number one. So people, even staff who have not been exposed to ECT. You still remember the movie One Flew Cuckoo's Nest and that movie itself had killed ECT treatment for over a decade, so sometimes the media can have pretty strong influence, be it positive or negative. I'm hoping this is a positive influence doing this podcast. So the reality is ECT, safe, ECT is life saving for a lot of our seriously ill patients. And it's done, just like I say, in a very controlled environment and it's been refined over the last number of decades in terms of anaesthetics, paramedics and even the ECT machine. So the side effects, as you know, it can happen with memory. And like you mentioned, the memory loss is mostly transient. Most of studies will say it's transient and once the ECT treatment is discontinued, most of the cognitive problems will restore within the first two months post-ECT. However, there are patients that we have rely on ECT for maintenance and they can go on basically as a sort of a dialysis for kidney failure. So for years and obviously these patients will say they have some permanent memory difficulties. What I would say is because they have ongoing ECT and there is evidence showing that the more you have, then obviously the more likely you're going to have more cognitive difficulties like memory problem. So stigma is number one. I think people just feel like it's something that's barbaric. And then the misconception, obviously, the some of the practice in certain parts of the world may not have contributed to the positive image of the ECT. For example, conversion therapy or ECT for homosexuality, for example, in history. And those were obviously misuse of treatment just like any other treatment. But with the right patient's right condition, it is one of the treatments that I don't think anything else has surpassed.
Arielle Geist: [00:11:47] Thank you.
Jake Johnston: [00:11:49] Yeah. Thank you very much for going over all of that Dr. Song. It seems like a detrimental cycle where misconceptions about propagate stigma and stigma propagates these misconceptions. And moving on down a list of learning objectives. I'm wondering if you could discuss the mechanism of action of ECT. So research over the years has eliminated much about the neurobiology behind its therapeutic effects, although its exact mechanisms remain to be elucidated. So without going into too much detail, can you outline some of the major theories of its mechanism of action?
Alex Raben: [00:12:26] Oh, that's I think that's a very, very large topic. And I think one can say it's still largely unknown, but there are increasing evidence in research showing that [00:12:42] OECD works. [00:12:43] And why it works involves a number of things, including neurobiology and connectivity and neurophysiology. So one of the theories actually is about the seizure itself. And this actually stemmed from what Randi had mentioned, the history of the evolution of ECT. So the seizure has a lot to do with it. And one of the mechanism perhaps relates to the seizure itself. As we know, with the ECT treatment, every treatment does seem to increase the seizure threshold and then the duration of seizure activity actually seem to shorten with every treatment. And there are some studies stating that using PET scan and EEG, looking at the post, ECT as a reduction in the original cerebral blood flow, glucose utilisation and neuronal activities in the cortex. And there are some increase in the blood flow across certain brain regions, particularly in patients with depression. There are studies also looking at the neurotransmission systems, looking at serotonergic, dopaminergic and adrenergic systems and as well as glutamatergic. So, going back to the theory about the myth about ECT damaging brain, there were some studies that have been done, particularly using a sort of animal studies where the primates, sort of shocking the brain and then surprise the primates and slicing the brain. And there's absolutely no evidence showing the brain damage. On the contrary, for some of the animal studies and we show there is perhaps increase in sort of a neuroplasticity and sort of a connectivity in terms of brain regions and synaptic genesis and neurogenesis and biogenesis. So it's actually it's still emerging. And I think in time we probably have a better understanding. As you know, there is a theory about depression and a lot of psychiatric conditions being sort of neuroinflammatory process. A lot of the treatments we do actually is anti-inflammatory in the CNS system. So I wouldn't be surprised there would be some data showing that ECT itself can be sort of an anti-inflammatory in the in the process. So, you know, really, we don't have a one single explanation why it works. I wish I had anyone who as you have a one some theory I think it will be destined for a Nobel Prize.
Jake Johnston: [00:15:57] So thank you for taking us through that Dr. Song. I realise it's a very large area of research. Just to summarise for our listeners, the mechanism of action of ECT is multimodal involving neurophysiological processes such as changes to the seizure threshold and regional cerebral blood flow. Neurobiochemical processes such as neurotransmitter, neuroendocrine and neurotrophic changes and neoplastic processes such as alterations in synaptic wiring and changes to the volume of certain brain structures. Is that a fair summary?
Dr. Wei Song: [00:16:36] Yes.
Jake Johnston: [00:16:39] All right. Fantastic. All right. Do you want to take it away and tackle our next learning objective?
Arielle Geist: [00:16:46] Yeah. Thanks, Jake. So now that we've spoken about the mechanism of action of ECT, I'm wondering if you can tell us about what the indications for ECT are. So what might we consider? When might we consider recommending ECT?
Dr. Wei Song: [00:17:02] The number one indication, at least from what I know and also what we do in Victoria is the treatment-resistant depression. So patients who have failed trials of medications, patients who are the index episode of depression that is very severe and obviously patients who need an urgent sort of a symptom reduction, for example, acute suicidality or inability to have nutritional intake due to catatonia or severe depression. So these are the conditions we do ECT and we do ECT on the pregnant women on a regular basis. As you know, it's very important to have a rapid resolution of depressive symptoms during pregnancy. Depression itself, it's probably more teratogenic to the fetus than some of the medications. However we also just have a very limited amount of approved medications for treatment of pregnant women. So that's what depression. The interesting thing about ECT responses, the sicker the patient, the better the response. And also the patients who are more elderly, they tend not to respond to pharmacotherapy and the ECT also shows a lot more robust response and it is lifesaving for some of the suicidal patients. A lot of times you can see the difference within the first two or three sessions, particularly those individuals who are showing catatonic features who can't eat or drink, who have psychotic symptoms in a depressive episode.
Dr. Wei Song: [00:19:09] So that's the main indications for depression. Of course, there are other indications as well, like bipolar depression, bipolar mania. I just had a patient who was refractory manic episodes, was in hospital for a good two months. And with multiple antipsychotics and mood stabilizing medications after three or four sessions of ECT, she showed dramatic improvement. So that's another indication. And then some other indications when I was the resident is about 30 years ago now and the we have seen some response with patients who have Parkinson's Disease and we treated actually the depression. The Parkinson's symptoms actually got better. And in literature, you see that new Neuroleptic Malignant Syndrome is one of the indications a few years ago there is emerging sort of evidence looking at treatment-resistant psychosis in schizophrenia patients, particularly patients who have partial or no response to Clozapine. And so we've seen some good results in those patients as well. So these are the major indications. And obviously, number one thing also is the patient preference as well. And some of the patients who can tolerate medications and neurostimulation may be one of the options.
Arielle Geist: [00:20:45] Thank you.
Dr. Wei Song: [00:20:46] I hope I answer your question.
Arielle Geist: [00:20:47] You did. That was very helpful. And it's good to get a sense of what the indications are going forward in our training, thinking when we might want to recommend ECT. I'm also wondering what are some of the contraindications to ECT?
Alex Raben: [00:21:04] I think it's really there's no absolutes, absolute contraindication that if somebody has got a brain tumour, sort of the space occupying lesion in the brain. So one has to be very careful and probably if you have a known aneurysm, you probably won't want to apply ECT because there is a transient increase in terms of intracranial pressure. Right. But, you know, you've got to be careful. What we do is we always have anaesthesia consult and particularly people with a complex medical comorbidities like cardiac and pulmonary and endocrine. So we want to make sure that those parameters are under control. For example, if somebody has uncontrolled hypertension and that's probably one of the things we need to do is really getting that out of control. I will walk you through about what we do in the ECT suite. And this morning for example, I was doing ECT and this patient's blood pressure was 220 over 100. Anaesthesiologist obviously said, well, you know, I'm going to give some asthma. And so we actually, in a very controlled environment, making sure that blood pressure is down to the acceptable level and then we proceed with the treatment. So I would say those are the space-occupying sort of lesions in the brain and aneurysms and some serious cardiac conditions. You know, that may be even a relative contraindication. I've done ECT on post-stroke post in my patients who are very, very ill and didn't respond to medications and very in within the first couple of months. Even with ICD or pacemakers, it's not a contraindication. Some sides will say, "Okay, let's turn off the ICD or pacemaker". And in my experience, actually, we don't even turn off the pacemaker and because it's really focal right in terms of stimulation to the brain.
Arielle Geist: [00:23:28] Thank you. That's super helpful! And one of the other things we were wondering about, we did briefly touch on before you had talked about memory impairment, but we're wondering if you could go into a little more detail about some of the possible side effects of ECT?
Dr. Wei Song: [00:23:45] Yeah, the main side effects actually are headaches, which is fairly common. And I think it's because despite the Paralympics, patients are well modified in terms of what we use in the colon or other muscle relaxant. But we when we do the electrode placement, usually straight to the your temple area. So you will induce whether you have paralysed sort of a major muscle groups or you induce your sort of a jaw clenching. And so that perhaps causes some headaches and maybe other reasons that cause headaches too. And a lot of times those can be mitigated as patients to take Tylenol before ECT at times we'll just give a IV pre-ECT and so on to mitigate that. A memory is another major one, but usually the first treatment, especially index treatment we use anywhere between 6 to 12 treatment sessions. And memory is not a major issue at all. As you know, when one is depressed cognition, there are three major sort of symptom domain, right? You have your emotional symptoms, you have your physical symptoms and you have your cognitive symptoms of depression and cognitive symptoms. Depression, usually a very profound and that's probably why when they do the studies for their acute ECT, even though patients may complain about memory problems and when you look at the results, actually there's not much of difference because depressed patients already have cognitive impairment.
Dr. Wei Song: [00:25:34] Yeah. So I think, there is some truth about short-term memory and anterograde and retrograde memory problems, but it's not a major issue. You know, the times people have we have had patients may have had dental issues. So we have to be very careful and there's a bite block and making sure that you have the partial if it's secured or not. And those are just related to due diligence, really making sure that the patient's oral cavities sort of checks. Right. You know, some patients may have some nausea, but those can be mitigated as well. Anaesthesiology is of great thing doing that also with psychiatrist, we always communicate on an ongoing basis. Right. And some patients may need to take Ondansetron before or after ECT and that can be done as well. So in short, actually, the side effects is minimal. It's not that much.
Arielle Geist: [00:26:46] Okay. Thank you. That's helpful to learn about. And I think kind of speaks back to some of the the myths that Randi was talking about earlier in the podcast. One of my last questions for you before I hand it back over to Jake is about some of the risks of ECT and if you could tell us what the risks are. When you say risks, you're talking about side effects or death or more. The second one, we're just kind of wondering about maybe what the mortality rate might be or when do you consider that?
Dr. Wei Song: [00:27:25] I think the number one risk, what I see is that not the right indication. You've got to be very careful. You know, if it's not the right selection, because we actually do turn down when we do ECT consultations, not everybody comes for consultation, we'll get it right. So, you know, if it's not the right indication, primarily, for example, if somebody has a severe personality disorder and you're using ECT and the outcome is not that great. But you know, in terms of potential mortality, I have never seen a case of death and I've spoken with a lot of people across the country. I don't think anybody's seen that, that there is a theoretical risk of death. And I think the anaesthesia risk is about one in 70,000 because this is a general anaesthesia. Right. And I think there are some reports saying that maybe two per 100,000. So, it's more or less in line with the risk of an anaesthesia. If you select the right patients and you do the right medical screening and control the medical comorbidities, I don't think the risk is negligible, really.
Arielle Geist: [00:28:53] Thank you. I'm going to hand it back over to Jake now to talk about the efficacy of it.
Jake Johnston: [00:28:59] Yeah. Thanks, Ari. I know that you've already touched on it a little bit earlier in this episode, Dr. Song, but now that we've heard about how ECT works and why we should use it, can you please fill us in on how well it works? Let's start with its efficacy in major depression.
Dr. Wei Song: [00:29:17] I think it's a very efficacious treatment and it's still the gold standard if any new treatment comes out and they always want to sort of compare it to ECT, right? So if you look at the literature, it's anywhere between 70 to 90%. Some of the older literature even higher, I think in part is because in the seventies there were not a lot of medications but ECT were the pre. One Flew Over the Cuckoo's Nest sort of a time it probably was used a lot more readily. I mean in the fifties actually ECT was the office procedure in New York because it was so popular. And so if one comes in depressed and you sign up for ECT, your chance of response is really high. And I think, more recent studies may not be as high priced because there is a lot of comorbidities. And sometimes you may miss the sort of a therapeutic window, as you know, that the index episode of depression. The longer it goes, longer it goes under treated or untreated, the longer it takes to get well to get into remission. So I suspect if you see the numbers like 70, 80 or 75, that's probably one of the reasons. But still it's probably still the most efficacious treatment compared to any other interventions for major depression.
Jake Johnston: [00:30:56] Thank you. The fifties in New York sound like a wild time. The efficacy of ECT for major depression is quite impressive. Are there factors that can help predict whether or not a patient will respond to ECT treatment? You've already mentioned one of them that longer lengths of depressive episodes are associated with poorer response to ECT.
Dr. Wei Song: [00:31:19] Now I mentioned about old age, right? So you see the geriatric psychiatry we use is a lot more is because there is more medical comorbidities and also the geriatric patients tend to have a poor response to medication treatments and so they actually tend to have better if you compare it to other treatments with ECT, the more severe the symptoms, including psychosis catatonia, the better the response to ECT. Nowadays, we call it endogenous depression, which is reactive and so on, but we don't differentiate that anymore. And essentially, if you have endogenous severe depression, catatonic features and psychotic features and the response to ECT usually is very predictable and the remarkable and I do want to mention, I did mention about personality disorder, it's probably more of a negative sort of predictor of a response to ECT if you have a severe personality disorder. That said, if somebody who has episodic depression along with personality disorder, it is still an indication to use ECT.
Jake Johnston: [00:32:41] Okay. Thank you. That's a pretty remarkable takeaway point that the more severe depressive episode is, the better. It seems to work. We can't say that about many other treatments in medicine. So Dr. Song. Well, ECT is primarily used in the treatment resistant depression. You've mentioned it can also be used for other illnesses such as bipolar disorder or schizophrenia. Can you please comment on its efficacy in these other disorders?
Dr. Wei Song: [00:33:09] Yes, I think a lot of our patients actually tend to be bipolar depression, as you will learn. Actually, bipolar depression probably is one of the most difficult to treat condition because there is always a worry about switching to mania and it's a very unpredictable in terms of response to treatment. We tend to use mood stabilising medications we tend to use. I mean, we only have, what, two or three medications that have official indication for bipolar depression. And if you look at the guidelines, it's like sort of a soup recipe for all different kind of medications and so on. It's very difficult to predict. So in that sense, I think bipolar depression, using these, it's probably even better choice because it's more predictable. It does have a similar response rate as compared to a unipolar depression. You're looking at about 70 to 80% response and efficacy. And then we touched base on the schizophrenia, right? So, this is probably more in the last ten years, ten, 15 years. And I think. 50, 60, 70 years ago institutionalised patients with catatonia, with psychosis, they tended to use ECT.
Dr. Wei Song: [00:34:38] But since the the utilization of antipsychotics and also de-institutionalisation, I think it probably was not used as frequently for schizophrenia patients only in the last, I would say, 20 years. There is some literature suggesting, for example, a combination of Clozapine was a plus, ECT has shown some additive benefit and efficacy and this is probably a treatment algorithm for a lot of refractory psychosis program. You're looking at about between 40 to 50% sort of improvement in terms of response in that population. Still a lot of room to improve for sure. And my experience with that also is it tends to have more you going to actually go extra mile, so to speak, because for depression, we don't usually go beyond 12. If somebody is not responding right, but it predictably 80, 90% of the patients will respond after 6 to 9 sessions, some of them human response much earlier on. Whereas for schizophrenia, we tend to go beyond 12 and 24. A lot of times we see patients actually start to show response after 13, 14, 15 treatments. So that's a bit of a caveat there.
Jake Johnston: [00:36:01] Thanks for that Dr. Song. It's good to know that in cases of severe schizophrenia, it often takes more treatments to see response. But patients and providers shouldn't lose hope because symptoms do often remit or improve after upwards of 15 or 16 treatments. Dr. Song you mentioned earlier this episode that one of your patients with refractory mania underwent ECT with good effect. Can you expand on the use and effectiveness of ECT for bipolar mania?
Dr. Wei Song: [00:36:32] It's quite high in terms of success rate. The issue with refractory mania is obviously a consenting process, you know, and it's we don't usually do involuntary ECT but in life, if it's life-saving, we will have to get the patient's advocates and family members involved or substitute decision makers involved. But even that I think, we don't take it lightly to impose ECT as involuntary so that probably one of the barriers and also we know that with time with the treatment milieu reduced stimulation in the inpatient environment and that itself it's anti-manic. So we just don't know when that will happen. So this particular individual actually was a psychiatric nurse and she had good insight, but she was really manic but a good insight. So it's quite interesting and psychotic, but a good insight. So and it is I can't go on like this. And then we went on to get consent and after four or five treatments and she's done she actually we only did in total eight and she's out of the hospital. So she was in the hospital for two months before that. In other words, it's very efficacious, but it's not done as frequent as, say, depressed patients. Right.
Jake Johnston: [00:38:13] Wonderful. Glad to hear that she had a good outcome in the end. So to wrap up this section on the efficacy of ECT for various psychiatric disorders, let's recap. The literature shows that ECT has a response rate of 70 to 90% in unipolar major depression, 70 to 80% in bipolar depression, 80% in bipolar mania, and approximately 50% in people with Clozapine-resistant schizophrenia. I'll pass the mic over to Alex now to go over our next learning objective.
Alex Raben: [00:38:47] Yeah. Thanks, Jake. So I'm in charge of helping our audience understand how the actual procedure of act is performed or looks like this is a difficult thing for us to do over a podcast. Of course, it'd be nice to invite you guys to an ECT suite to see it in person, and I would encourage our listeners who have opportunities to certainly shadow people who are doing psychiatrists who are doing it. But Dr. Song, if we can put this challenge to you, because we've talked about how bits and pieces of how act is done, right? There's an anaesthesiologist, there's nurses, there's a psychiatrist, there's these electrodes that are placed on the temples. But maybe you could take us through like a chronological order of how this is actually performed, maybe with a patient who's starting to act for the first time.
Dr. Wei Song: [00:39:42] Thank you, Alex. For those of you who didn't study in UBC, I mean, I've been involved with the undergrad curriculum for many years. ECT is a must see too. So we made sure that we actually developed a module for ECT. Jacob I've gone through that module and even it was an embedded video. And so for those of you listening to this podcast, I can walk you through. So once patients sign a consent or deem that it's life-saving, so basically through the consultation process and anaesthesia has done the consultation.
Dr. Wei Song: [00:40:33] So we every setting is different. In Victoria the are of hospital. We do ECT in our PACU, the post-anaesthetic recovery room. We have a little ECT suite within the PACU. So the patient, the porter will take the patient in or patients of outpatients will come in and check in with our porter and then they get changed a lot of times. Some patients may not, and in summertime it doesn't really matter that much. But in wintertime, a lot of them just get changed into screw ups and downs, and then they will be comfortably lying on the stretcher and wheeled into the ECT suite. And then the nurse psychiatrist anaesthesiologist will greet the patient and really trying to make patients comfortable. Imagine the first time doing ECT. You have no idea what's going on and we tend to show some of the information, including videos. There are a number of good's sort of videos out there on YouTube, right from Australia, for example, and from the Duke and other universities. So we show the patients to give them a sort of a bit of comfort, this is what's going on. And then I'll explain. I usually make a joke and say, "well, I'm going to prep your scalp", right? Usually it's your foreheads. And so "I'm doing a facial for you this morning" and sort of put patients at ease and using basically wanting to make sure that patients will have a good sort of a conduction.
Dr. Wei Song: [00:42:18] So the impedance minimize the impedance if you look at the physiology of sort of a physics of it. So by doing the skin prep and chatting with the patients, I will ask patients how they're feeling and so on and so forth to do a quick mental status while I'm doing that. And then we put the leads on and usually we're monitoring the EEG, EMG and EEG. We have a telemetry sort of monitoring and two sides and anaesthesiologists will establish IV while we're doing all the prep and some of the centres will use the paddles putting on the dependence by temporal or by frontal or unilateral in our sensor. Many years ago I thought to eliminate some of the variabilities, we use these thermal pads actually just stickers. And that actually I believe it's more consistency. So it's not really dependent on the practitioner's strength or how they sort of hold the paddles. So once that's done most of the time we do the by frontal as sort of starting point and then we determine the seizure threshold for the first treatment. So what happens is the anaesthesiologist will give anaesthetic. A lot of times we use Propofol. Sometimes patients if they have resistance or not having good seizure and they may use some other induction agents such as accommodate or Methotrexate, which are more difficult to come by because it's a special access drug.
Dr. Wei Song: [00:44:12] So Propofol is probably standard across the country and then they use the suction and colon to as a muscle relaxant. And then we hyperventilate the patients and within minutes, patients are already anaesthetised and the muscle a minute or two. And then we apply the electric current. Missing is the only two types of machine that's approved by FDA and Health Canada. Right. So it was back to the other ones. So we have the time machine and we started with 10% sort of an energy and help to give it to somebody 50 and over over the younger it started 5%. So basically we're looking at the seizure threshold. Once we determine the seizure threshold and then we apply one and a half or two times of energy above the seizure threshold as a therapeutic sort of intervention. So we induce a seizure that probably takes about looking at 25 to 60 seconds, sometimes a bit longer, sometimes less. And we look at the seizure quality by looking at the tracing, looking at the EEG, the morphology, the symmetry, the cleanliness and the possible suppression. So the few things that we look at. I'm describing the whole seizure, but actually it goes very quickly. So after the patient complete the seizure and within a minute or two the patient wakes up and the anaesthesiologists will assist patients for recover.
Dr. Wei Song: [00:46:07] The whole process probably takes about the actual treatment. Getting into the suite and getting out of the suite is about 10 minutes. Well, we can do six ECT in an hour or sometimes nine and a half to 2 hours. So sometimes in this morning we've got a little bit longer because one of the patients had a difficult to establish an IV. So that part is more of a sort of an issue in terms of time. It takes a long time, try to like 7 to 8 sort of access to establish IV. That was more of a time consuming. And then patient goes to recovery sites and usually within 20 to 30 minutes they get up and they go to have a we provide a tea and muffins. This is pretty covered, though, but now I don't think we actually can. And then they go home or the wheeled to the ward if they're inpatient. That's the walk, you know. Give you a visual if you can.
Alex Raben: [00:47:12] That was amazing, Dr. Song. Thank you so much. You really painted a picture there of walking us through that. And yeah, I don't think people realise how fast this procedure is. I mean, even in the time we're talking, we spent talking today, multiple people could have been going through treatments.
Jake Johnston: [00:47:29] But do the poor anaesthesiologist, they'll have time to do their Sudoku puzzles.
Dr. Wei Song: [00:47:34] No, you don't have to check the stock markets us to do that. I think one of the things, though, it's very important to have a good relationship with anaesthesiologist because trying to have the optimal seat for the patient. We have to give the input. Because I talk to anaesthesiology on a regular basis as well. You know, we should probably reduce the Propofol or anaesthetic because I know I've seen it even by ten milligram reduction patients, seizure can be so much better. You know, you can just have this kind of discussions and and whether some patients need to have some other intervention to have a seizure and so on. And as a psychiatrist, I think it's important to be able to give the valuable input to anaesthesiology I you mentioned by temporal by frontal unilateral electrode placement.
Alex Raben: [00:48:46] Could you take us through the differences there and why you would choose one or another? So I think there have been studies looking at these sort of electoral placement, whether looking at the efficacy versus certain side effects, particularly they're looking at cognitive side effects. So you want to minimize the cognitive side effects. There were a couple of studies sort of comparing head to head, so to speak, looking at the high temporal by frontal and and unilateral. I think if you look at unilateral, the the efficacy is more or less the same as compared to by frontal.
Dr. Wei Song: [00:49:39] The difficulty was unilateral is you got to have a five or six times of a seizure threshold. And the most machines governed in such a way. We started with the point five, the pulse width, and that's the sort of a short pulse and 2.75 of one. So if you use unilateral what they describe as an ultra brief unilateral, so you have 0.25 pulse width. If my machine if patients set a seizure threshold, for example, is determined that this machine is 40% of my the machine that the output, that means I have to go. Hundreds. Worth 200% which is impossible because the machines 100% is 101 joules. And unless I sort of overwrite. So in other words, a lot of our patients we can't do unilateral because of the depending on the seizure threshold, giving our machine the limitation of the machine. And then if you look at the comparison, the probably the most I mean, it's very slight in terms of differences, in terms of side effects, but there are some differences. So the bitemporal tend to have probably more cognitive short-term memory problems as compared to unilateral and conversely bitemporal may have a bit higher efficacy compared to unilateral. So we chose actually by frontal as a sort of default to begin with.
Dr. Wei Song: [00:51:30] Based on that, it's simple, it's easy. Perhaps it's in the middle in terms of the chance of having cognitive side effects and then they're looking at the established efficacy. But if patients is not improving, it's just like prescribing medication, right? We'll titrate the stimulus in terms of the how much of a current we were delivering. And then when we changed the electoral placement from by frontal to temporal, we may increase the pulse width as well, just like a titrating the dosage of antidepressant or antipsychotic in accordance of the response. So I'm hearing there that there are some maybe modest differences in terms of maybe by temporal being slightly more effective, but also possibly causing more cognitive side effects and sort of vice versa for unilateral by frontal, you mentioned this word called sweat, so maybe we should just briefly define that. What does that mean exactly? Well, I think the modern city machine versus the old the one I described the doctor selected in 1938. And I think those are a sine wave current. Right. That's as you see, it's not like a whole thing. Whereas modern ECT treatment essentially has these sort of abrupt sort of pulses of electricity, sort of more of a resembles the action potentials endogenous in our brain. So instead of a sine wave, you just have a spurt, right? And there is a frequency.
Dr. Wei Song: [00:53:19] Basically how many pairs of pulses per second and versus the mini seconds. We use point five as a sort of a standard. Some people even even shorter, which becomes more of a ultra brief. 0.5 is a brief one is probably considered in the past, maybe more standard. And then obviously there's a currency of the amp. So all these actually parameters determine the current how much you gave to induce a seizure. I mean, in the end, we want to induce ultimate sort of a good seizure response. And then that can be measured by the EEG monitoring. And obviously, we also have to look at the patient sort of response in terms of a symptomatology.
Alex Raben: [00:54:22] Thank you so much for taking us through that a concept that is definitely hard also to talk about without a visual. But we will link to a lot of those videos that you were describing and others that we find as well for our audience. One thing, this wasn't really a planned question, but I think it's something we didn't yet talk about. I just wanted to maybe and I think it's a good topic to wrap up on is we've talked about how effective ECT is, but we haven't really talked about the relapse that can happen post-treatment and how we can mitigate that. I mean, you did mention Dr. Song maintenance treatment, but what does that actually look like?
Dr. Wei Song: [00:55:08] There's not a lot of studies on maintenance. I mean, there have been a couple of good studies. As you know, depression is a chronic illness and that is sort of episodic for a lot of our patients. So patients may respond very nicely to a course of treatment. But for patients who has severe depression or chronic depression, the relapse rate is quite high when you stop Ect. So in other words, you have to have a very good maintenance strategy. When I was in residency in the nineties actually, I remember looking at the American Psychiatric Association guidelines for ECT. They actually want you to stop mitigation when you do ECT, which is not the practice anymore. So we want to initiate if they're not on medication or we want to make sure that we plan to have an adequate medication for maintenance. So when we say adequate medication, we're talking about more standard. I know you guys use a Kellner Charles as a reference of who is an ECT guru. And he had led several sort of studies, including the maintenance study they use, for example, comparing maintenance these see versus. No trips. Plus Lithium or vaccine doses plus Lithium. So these are what we would say, very robust, potent and sort of maintenance strategies.
Dr. Wei Song: [00:57:00] So maintenance versus medication, the relapse prevention seem fairly similar. But in reality, some of our patients, even with a potent medication, they still have to have a maintenance. What we usually determine that is if patients relapse and come back and do it again, then we would discuss about options. Obviously, you need to have to be on good medication regimen. For me, I would use something plus Lithium, that kind of a regiment or high doses of vaccine and so on, and then we'll taper ECT once they reach remission like once, once a week, times four weeks, and then every other week times four weeks, times four times, and then monthly. Sometimes in this kind of a process, patients know I can actually from every two weeks to one once a month, because by the third week, you know, I started having symptoms. So then we can sort of really titrate according to patients. So there is a sort of a whole range of sort of time frame for our maintenance program patients. Some patients I have patients who had ECT, one of our patients actually had a severe schizoaffective disorder, started having this when she was 14 years old. And she's 34 now and she's still on weekly ECT. Every time I try to space it, her psychosis just became so much worse. So that's extreme right weekly for decades.
Dr. Wei Song: [00:58:48] Another is will do every four weeks and then after a year or two, some of our patients view stable is every a monthly for two, one or two years. And I try to space it to say five or six weeks. In my experience, once you're done, you can maintain wellness or your remission after five, six weeks space, probably you can stop ECT. I mean, the idea is always trying to wean people off ECT. Right. As I mentioned earlier on the to sort of if you have a permanent sort of a memory problems is because you have repeated ECT on an ongoing basis for years.
Alex Raben: [00:59:31] Great! Thank you so much for taking us through that. So if I understand correctly, the relapse rates can be high and that's because depression is a chronic mental illness, as we know, and or it can be relapsing and remitting. But you have options in terms of medication as it maintenance usually Nortryptophan plus Lithium or Venlafaxine or maintenance ECT which is sort of this tapering schedule, as you described it. And you try to get to the kind of lowest frequency that keeps people well. But in reality, often those are not maybe not often, but they can be combined for people who benefit from them. So thank you so much for taking us through that. I'll hand back over to Jake.
Jake Johnston: [01:00:18] Yeah. Thank you very much, Dr. Song, for taking us through. It's a large topic to cover, but you did an excellent job at conveying the salient points. Do you have any closing thoughts before we wrap up the episode?
Alex Raben: [01:00:33] Well, I think this is a great opportunity. I'm so glad that you provided the opportunity for me to talk about this subjects and particularly for learners. And it's always amazing to see the learners who has never watched the ECT and exposed to ECT for the first time and realize, "Wow, this is what it is". Because a lot of times you have these pre-conceived notions then from media and from what you talked about. So, I think it's very important to demystify to really educate our learners, but hopefully, actually educate the public. Right? So this is actually a very effective treatment. It's not barbaric, it's scientific and it's safe and it should be available to anybody who wants it who is suitable for it.
Jake Johnston: [01:01:39] Thanks again, Dr. Song, for joining us. That concludes our episode on Electroconvulsive Therapy. PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. They've used endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Jake Johnston, Arielle Geist, Randi Wong and Alex Raben. The audio editing was done by Jake Johnston. Our theme song is Working Solutions by All Live Music and special thanks to the incredible guest, Dr. Wei Song for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thank you so much for listening!