ECT in Bipolaire Stoornissen.key
Transcription
ECT in Bipolaire Stoornissen.key
Bipolaire Stoornissen Uitgelicht Apeldoorn 9 februari 2012 Bipolaire Stoornis & ECT pascal sienaert upc-kul, campus kortenberg [email protected] Overview • ECT in Mania • ECT in Bipolar Depression • ECT in Catatonia • Treatment-emergent (hypo)mania • Lithium & Moodstabilizers • Maintenance ECT in Bipolar ECT Indications 100 75 Wallonia Bxl Flanders Total 50 25 0 MD Mania Psychosis Sienaert et al. J Aff Disord 2006 Other JMM, aged 71, … 25 episodes of manic delirium with an average duration of 3.8 months … …intensive electrotherapy was commenced on Oct 2, 1945 Geoghean, Canad MAJ 1946, 55, 54-55 Oct 2: acutely excited: 3 convulsions. Oct 3: less excited: 2 grand mal. Oct 4: very much less excited: 2 grand mal. Oct 5: no clinical evidence of excitement noted. …recovered from 26th manic attack within 9 days of the onset and within 4 days of receiving convulsive shock therapy. Geoghean, Canad MAJ 1946, 55, 54-55 ECT in Mania Retrospective studies Year N Schiele & Schneider 49 16 “Remission / Marked improvement” (13) 81% McCabe 76 28 (28) 96% McCabe & Norris 77 28 ECT=CPZ Thomas & Reddy 82 10 ECT=Li=CPZ Black et al 86 37 (29) 78% Alexander et al 88 27 (13) 48% Strömgren 88 17 (10) 59% Mukherjee & Debsikdar 92 30 (30) 100% Study ECT in Mania Prospective studies Authors N Study Outcome Small et al, 88 34 ECT(+AP) vs Li (+AP) ECT > Li (95% vs 81% reduction BR-MRS; p<.05) Mukherjee et al, 89 27 ECT vs Li+HAL 59% vs 0% (‘improved’; p<.025) Sikdar et al, 94 30 ECT+CPZ vs Sham+CPZ Ikeji et al, 99 20 ECT 12/15 vs Sham 1/15 (BR-MRS<6) BPRS reduction 46,7 vs 24,8 (p<.001) Schnur et al, 92 18 BT vs UL 67% improved Hiremani et al, 08 36 BF vs BT (+AP) 87% vs 72% (YMRS 50% reduction) Barekatain et al, 08 28 BF vs BT 100% response (completers) Mohan et al, 09 50 BT (ST vs 2.5 ST) + AP 88% YMRS<10; 92% CGI<3 Resolving mania... robustly... • N=36 • YMRS=42 • Response • BF: 87.5% • BT: 72.2% Hiremani et al. Double-blind randomized controlled study comparing short-term efficacy of bifrontal and bitemporal electroconvulsive therapy in acute mania. Bipolar Diorders, 2008. Resolving mania… rapidly severely ill people with mania who had not responded to conventional medication, and who continued to pose a risk to themselves or others. 88% remission! Mohan et al. Effects of stimulus intensity on the efficacy and safety of twice-weekly, bilateral ECT combined with antipsychotics in acute mania: a randomised controlled trial. Bipolar Diorders, 2009. ECT in Mania? • intolerance to lithium / antimanic agents • refractoriness to lithium / antimanic agents • significant risk of harming self or others • requiring physical restraint / large doses of sedatives • symptoms are life-threatening owing to exhaustion Sienaert. What We Have Learned About Electroconvulsive Therapy and Its Relevance for the Practising Psychiatrist. Can J Psychiatry, 2011 Richtlijn ECT Manie van den Broek et al, 2010 • 3 van 7 prospectieve trials (2 > 2008) • 1 review Richtlijn Bipolaire Stoornis Nolen et al, 2008 • Wanneer combinaties van 2 antimanische middelen ineffectief zijn (of geCI/), resten er diverse andere mogelijkheden (in willekeurige volgorde): • • combinatie Li, AC, AP (O); ECT • effectief bij patiënten met een al dan niet therapieresistente manie, en dient in elke stap overwogen te worden bij een ernstige manie met psychotische kenmerken en/of lichamelijke uitputting (A). Treatment Guidelines Nivoli et al, 2011 WFSBP CANMAT BAP NICE NHMRC Richtlijn ECT Bipolaire Depressie van den Broek et al, 2010 • 2 van 5 prospectieve trials • + 3 recente trials! Medda et al, 09; Sienaert et al, 09; Bailine et al, 10 Richtlijn Bipolaire Stoornis Nolen et al, 2008 • Bij onvoldoende respons op combinatie Li,VLP, AP + AD zijn er diverse alternatieve mogelijkheden (in willekeurige volgorde)... • ECT (R), vooral bij ernstige depressies, zoals een psychotische depressie (en dan eventueel ook eerder in de beslisboom). • CORE 3-EP • N=220 • 3/W • HDRS • CARS-M • Clinician-Administered Rating Scale for Mania Bailine et al. (2010). ECT is equally effective in unipolar and bipolar depression. Acta Psychiatr Scand, 121, 431 CORE 3 EP Study MDD, unipolar or bipolar, N=274 HDRS-24 ≥ 21 Randomization, N=230 N=72 1.5 ST Baseline N=81 1.5 ST End Course Post #4 PW 1 m s N=77 6 ST 8 W Follow-‐up 1 W Follow-‐up Kellner et al., 2010. Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial. Br J Psychiatry 196, 226-234. Bailine et al. (2010). ECT is equally effec8ve in unipolar and bipolar depression. Acta Psychiatr Scand, 121, 431 BIPOLAR N=50 (22.7%) UNIPOLAR N=170 (77.3%) 100 80 78,8 80,0 60 64,0 61,2 40 20 0 Response R 10 N ECT 6 6 Depression, ≥18 HDRS17 No history of Psycho8c disorder, Cogni8ve disorder, Substance abuse/ dependence past 12 m ,ECT past 6 m No concomitant AD N=81 PW 0.3 ms 1.5 x ST PW 0.3 ms 6 x ST Sienaert et al (2009). Randomized Comparison of Ultrabrief BF and UL ECT for Major Depression: clinical efficacy. Journal of Affec=ve Disorders, 116, 106-‐112 Sienaert et al. (2009). Ultrabrief pulse ECT in bipolar and unipolar depressive disorder: differences in speed of response. Bipolar Disorders 11(4), 418-‐424 Completers N=64 BIPOLAR N=13 (20.3%) * UNIPOLAR N=51 (79.7%) 100 80 84,6 76,4 60 64,7 69,2 53,8 40 35,3 20 0 Response R 10 R7 * Higher N° previous hospitalisa8ons (5.23±3 vs 3.39±2.79) Sienaert et al. (2009). Ultrabrief pulse ECT in bipolar and unipolar depressive disorder: differences in speed of response. Bipolar Disorders 11(4), 418-‐424 BIPOLAR N=13 (20.3%) UNIPOLAR N=51 (79.7%) 100 80 60 76,4 84,6 64,7 69,2 53,8 40 35,3 20 0 Response N ECT 9.5 6.9 p=.05 R 10 11.5 7.9 p=.03 R7 11.6 9.7 NS Daly et al (2001). ECT in bipolar and unipolar depression: differences is speed of response. Bipolar Disord, 3, 95-104 • UP , BP • 54% medication-resistant • 3 double-blind studies N=162 N=66 • N=80; RUL 1.5 - 2.5 - 6 ST, BT 2.5 ST • N=96; RUL 1.0 - 2.5 ST, BT 1.0 - 2.5 ST • N=52; RUL 1.0 ST, BT 1.0 ST Sackeim et al, 2000 Sackeim et al, 93 McCall et al, 2000 Response / EP Response Rate (%) 80 RUL 60 BT 75 64 40 42 34 20 0 UP BP Daly et al (2001). ECT in bipolar and unipolar depression: differences is speed of response. Bipolar Disord, 3, 95-104 Number of treatments % 70 UP 60 BP 66 50 40 38 30 26 20 10 0 26 20 10 1 <4 12 5-6 7-8 >8 ECT Daly et al (2001). ECT in bipolar and unipolar depression: differences is speed of response. Bipolar Disord, 3, 95-104 ECT is equally effective in unipolar and bipolar depression N UP/BP Efficacy Speed Stromgren, 73 26/26 BP=UP Daly et al, 01 162/66 BP=UP Grunhaus et al, 02 111/20 BP=UP Medda et al, 09 17/113 BP<UP Sienaert et al, 09 51/13 BP=UP BP>UP Bailine et al, 10 170/50 BP=UP BP=UP BP>UP • N=130 • BT, 2/W • HDRS, BPRS, CGI,YMRS • Baseline, 1W Post Medda et al. Response to ECT in bipolar I, bipolar II and unipolar depression. JAD, 2009 Medda et al, 2009 UP N=17 B-II N=67 B-I N=46 HDRS Base 26,5 25,6 25,0 HDRS End 7,3 10,1 10,7 HDRS (50%) 15 (88%) 49 (73%) 32 (70%) HDRS (<8) 12 (71%) 29 (43%) 16 (35%) YMRS 4,1 5,7 8,0 YMRS End 1,9 3,0 4,1 Final BPRS 5.5 (1.5) 5.5 (1.1) 7.1 (3.9) psychotic cluster UP > B-I (p<.01), B-II (p<.05); B-I > UP, B-II (p<.05); B-I > UP, B-II (p<.01) UP patients showed best clinical outcomes BP I patients tended to exhibit residual manic and psychotic symptomatology Medda et al. Response to ECT in bipolar I, bipolar II and unipolar depression. JAD, 2009 ECT is a consideration in a patient with a severe depressive episode, not responding to ongoing therapy, regardless of the primary diagnosis. Sienaert. What We Have Learned About Electroconvulsive Therapy and its Relevance for the Practicing Psychiatrist. Can J Psychiatry 2011 the psychiatrist should first assess whether there is an urgent indication for ECT, before considering other treatment options Ansari & Osser. The psychopharmacology algorithm project at the Harvard South Shore Program: an update on bipolar depression. Harv Rev Psychiatry. 2010;18:36-55. Catatonia • Common in schizoprenia, but more frequent in mood disorders - mania! • Benzodiazepines - remission rates 80% • Should treatment with benzodiazepines fail, ECT is to be used without delay. • ‘Always’ responds to ECT, regardless of the underlying condition Sienaert. What We Have Learned About Electroconvulsive Therapy and its Relevance for the Practicing Psychiatrist. Can J Psychiatry 2011 Treatment-emergent (hypo)mania • 2% • within 24h • offset 2-4d • clear consciousness / no disorientation • ‘Organic euphoria’, ‘euphoric-hypomanic adaptation’ Fink 79 Andrade 90; Andrade et al 88; Lewis & Nasrallah 86; Devanand et al 88; 92 Treatment-emergent (hypo)mania • No guidelines • Watchfull waiting • Pharmacotherapy • Continue ECT untill euthymia Lithium & ECT possible concerns • prolonged action neuromuscular blocker prolonged time to spontaneous respiration Jephcott & Kerry, 74 • prolonged confusion/delirium Hoenig & Chaulk, 77; Mandel • increased memory impairment Small et al, 80; Penney et • ECT does not increase lithium levels Vlissides et al, 79 et al, 80;Weiner et al, 80 al, 90 Lithium & ECT no increase in complications, memory impairment, or recovery times • 1 prospective study • Li: N=27 • 3 retrospective studies Thirthalli et al, 2011 Kukopoulos et al, 88; Jha et al, 96; O’Brien & Berrios, 93 • Li: N=293 • Case-reports, N=23 Dolenc & Rasmussen. The Safety of ECT and Lithium in Combination A Case Series and Review of the Literature. J ECT 2005, 21, 165 Lithium & ECT • • Li, N=27; No Li, N=28 No differences in seizure variables, apnea time, recovery time • • correlation lithiumlevel - recovery time Li: lower peak heart rate and BP Thirthalli et al. A prospective comparative study of interaction between lithium and modified electroconvulsive therapy WJBP, 2011; 12: 149–155 Sienaert et al. Concurrent Use of Lamotrigine and Electroconvulsive Therapy. J ECT 2010 • • • • N=19, ECT N=289 • ECT+LMT vs ECT-LMT, N=11 no influence on motor/EEG seizure duration no side-effects 6 restimulations • LMT N=5 (83%) • • LMT 100 mg: 1 missed, 1 inadequate LMT ≥200 mg: 3 missed Recommendations • • • Epilepsy • continue AC Bipolar disorder • continue AC “when judged important for the psychiatric condition or when it is decided to continue the AC after (…) ECT” • AC prophylaxis: “consider starting AC before the end of the ECT course” Difficulties eliciting seizures • • • lower AC dose and/or hold the morning dose before ECT change anesthetic regimen Sienaert & Peuskens. Anticonvulsants During Electroconvulsive Therapy: Review and Recommendations J ECT 2007 • ECT works both in mania & depression • ECT-induced mania is rare • M-ECT is an option in severe refractory cases • Lithium & AC do not necessarily have to be interupted before starting ECT