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