1. A Review of Cognitive Outcomes of Modern Day ECT Kiri Luther DClinPsych Candidate Massey University, Wellington Professor Janet Leathem – Primary Supervisor Dr Steve Humphries – Secondary Supervisor Dr Nisar Contractor, C&CDHB – Professional Advisor

2. ECT: Procedure Patient anaesthetised, administered a muscle relaxant & an electrical stimulus is passed through the brain via electrodes placed on the scalp inducing a grand mal seizure EEG monitoring Seizure is treatment, not electricity

3. Technical Context: Electrode Placement Unilateral Right hemisphere (initially) Bilateral Temporal More cognitive difficulties Frontal Less research Lisanby, 2007

4. Technical Context: Guidelines NICE Short-term treatment after all other options have failed depressive illness catatonia prolonged or severe mania NZ Ministry of Health when medication does not work where psychotherapy is inappropriate there is a risk of suicide or neglect where there is a need for rapid therapeutic action when ECT has already been used with good outcomes For depression catatonia mania schizophrenia

6. Evaluate & improve current assessment methods used in Wellington

7. Ultimately to come up with a time and cost effective test battery to monitor the effects that ECT has on Memory and Cognition

8. Research need identified

9. NICE Guidelines for ECT. (National Institute for Clinical Excellence 2003)

10. subjective assessment

12. Review Review completed to ascertain which areas of memory are most commonly assessed and which of these show dysfunction Review completed to ascertain which measures are commonly used to assess these areas

13. Review Literature search completed using Web of Science Google Scholar Psych Info Academic Search Elite Medline 33 studies were included in the reviews

14. Findings - Domains

15. How were measures chosen? Literature and Previous Research Current Measures Used By C&CDHB Other Measures Depression: BDI-II, MADRS Memory Malingering: TOMM

16. Findings - Assessment

17. Method Health and Disability Ethics Approval Invitations sent to historical patients Participant consent Access to patient files ECT technical data collected Participant historical assessment data collected if available Participants underwent psychometric assessment to form current outcome data Participants gave subjective accounts of their experiences

18. Participants Initial pool=222 Step-wise inclusion: NHI number Alive and listed as living in Wellington ≤65 yrs of age No Dementia, Head Injury or ID Able to participate N=118 Agree to participate, N=27 5 withdrew, 2 withdrawn by researcher Total Participants, N=20

19. Potential Influences on Cognition Electrode Placement Dosage Number and Frequency of Treatments Age Education Time Since Last ECT Current Depressive Symptomology Some Medications e.g. Lithium Malingering

20. File Information Diagnosis Electrode Placement Number of Treatments Frequency of Treatments (# per week) First and Last Treatment Dates Dosage Seizure Durations, EEG and Motor Anaesthetic Muscle Relaxant Previous Assessments e.g. MMSE, MADRS

21. Interviews Assessment Protocol Demographic Info e.g. D.O.B, Education, Ethnicity TOMM Trial 1 and 2 BDI-II MADRS TOMM – Trial 3 if necessary MoCA RCFT – Copy then Immediate Recall RAVLT – All trials, interference trial MMSE RCFT – Delayed Recall, Recognition RAVLT – Delayed Recall, Recognition AMI Subjective Assessment - IPA

22. Ideal Analysis Comparisons between; Past objective vs. present objective Past subjective vs. present subjective Present objective vs. present subjective Past objective vs. past subjective The relationship between depression and cognitive functioning

23. Ideally what will this give us? Information about memory and global cognitive difficulties in the short term – historical assessment Information about memory and global cognitive difficulties in the long term – current assessment A Time-Line of changes in Outcomes Subjective information which can be compared to objective assessment

24. What did we get? Comparisons between; Past objective vs. present objective Some MMSE, MADRS & BDI-II Past subjective vs. present subjective Present objective vs. present subjective Past objective vs. past subjective As Above The relationship between depression and cognitive functioning

25. Some of the Problems Sample size N=20 Large for IPA Small for Quantitative Most had bilateral ECT so couldn’t compare with RUL Different machines used = different method of treatment Titration vs. No titration therefore dose information was different e.g. (% vs. mC) Lack of historical assessment data No baseline data for comparison, very little monitoring data Difficulties finding some patient files Some ECT information was not recorded One participant had very little information about dosage, electrode placement and seizure durations Two participants refused some of the assessment – felt they were unable to do it.

26. What Now? Data Analysis Qualitative Analysis Conclusions Recommendations Assessment Ongoing Research

27. Initial Impressions Researcher first person to talk to participants about ECT since their treatment (up to 13 years ago) Very emotional Participants didn’t just talk about their ECT Time in Psychiatric Ward Medications Overall Treatment within the Health System Childhood Illness

28. Initial Impressions Costs Not being listened too Not being treated like a human being Feeling like a guinea pig No trust – Psychiatrists No follow-up Benefits Feeling Safe – in hospital Kind nurses and ECT staff Getting better Future orientated

29. Initial Impressions Memory and Cognition Personal Memories Own childhood Their children growing up Confused timelines Chunks of time missing Memory around time of ECT Blanks Not being aware of forgetting until remembering something Mental fatigue

30. Initial Impressions ECT Participant Quotes-Costs “I know that if I had to have shock treatment to the brain then it is highly likely that I would have a heart attack or die of shock at the thought of it about to happen” “I remember thinking, I wonder if this is what it feels like to have a learning disability” “I was scared of what would happen if I said no” – to ECT “I have about a year I don’t remember” “My brain feels half dead, feels drunk....it’s lost its crispness

31. Initial Impressions ECT Participant Quotes-Benefits “Possibly there were times it bought me out of total destruction” “I believe it cured my depression or was definitely the road to recovery” ”It cured me” “Stopped me being grossly depressed” “It saved my life after many Doctors, medications, therapists, counsellors, support groups and good intentions” “I made it back to life”

32. References/Bibliography Lezak, M. D., Howieson, D. B., Loring, D. W., Hannay, H. J., & Fischer, J. S. (2004). Neuropsychological assessment (4th Ed.). New York: Oxford University Press Lisanby, S. H. (2007). Electroconvulsive therapy for depression. The new England journal of medicine, 357(19), 1939-1945. Ministry of Health (2006). Electroconvulsive therapy annual statistics: For the period 1 July 2003 to 30 June 2005. Wellington: Ministry of Health. Ministry of Health (2004). Use of electroconvulsive therapy (ECT) in New Zealand: A review of the efficacy, safety, and regulatory controls. Wellington: Ministry of Health. National Institute for Clinical Excellence (2003). Guidance on the use of electroconvulsive therapy: Technology appraisal 59. London: National Institute for Clinical Excellence. Nasreddine, Z. S., Phillips, N. A., Bedirian, V., Charbonneau, S., Whitehead, V., et al. (2005). The montreal cognitive assessment, MoCA: A brief screening tool for mild cognitive impairment. J. Am Geriatr Soc, 53, 695-699. Tiller, J. W. G., & Lyndon, R. W. (2003). Electroconvulsive therapy: An Australasian guide. Victoria: Australian Postgraduate Medicine.

33. Thank-you for your time Kiri Luther DClinPsych Candidate Massey University, Wellington k.luther@xtra.co.nz