Among the 4 new ECT articles out on PubMed today (3/4 in Journal of Affective Disorders) is this interesting French study of how long it takes for ECT to be prescribed in patients with depression:
Adherence to treatment guidelines in clinical practice for using electroconvulsive therapy in major depressive episode
Samalin L, et al. J Affect Disord 2020. PMID 32056767
Here is the url for the pdf:
This is a multi center, retrospective chart review that included 745 patients who received ECT in France for an episode of either unipolar of bipolar depression. The authors looked at how these "first line indications" for ECT (taken from international guidelines) influenced the prescription of ECT: high suicidality, urgency (severe depression associated with insufficient oral intake),
catatonic features, psychotic features, prior ECT response, and patient preference.)
The overall mean duration of the major depressive episode (MDE) before ECT was 10.1 months (14.5 months for a first episode, 10.6 months for recurrent episodes, and 7.8 months in bipolar depression.)
Catatonic features reduced the duration before ECT to 6.7 months, psychotic features to 8.6 months, and prior ECT response to 6.2 months. Suicidality had little impact (9.8 months).
The mean number of treatment trials before ECT was 4.1 when no "first line indication" was present, 3.3 when at least one "first line indication" was present.
The take home message here is one that is all too-well known: prescription of ECT is delayed while medications trials are prolonged and repeated. These are very long durations for patients to remain seriously ill, with the consequent suffering and risk for medical complications and suicide. The authors note the problem of access to ECT in France; this is a problem in many countries, but the biggest reason for delay in ECT prescription is the reluctance of psychiatrists to embrace ECT as a standard and routine treatment in modern psychiatry and to prescribe it in a timely fashion.
The finding, in this large French survey of practice that ECT was delayed for an average of 3.4 medication trials, an average of 10 months. The "guidelines" that ECT be deferred for at least two medication trials is a disservice to patients and their families. Earlier consideration of ECT is surely to be preferred.
ReplyDeleteThe use of "MDD" and "BPD" criteria in classifying psychiatric patients and the "guideline" for 2 or more medication trials before ECT is recommended is a disservice. The "guideline" should be replaced by greater emphasis on the presence of melancholia (suicide risk, insomnia, weight loss, psychosis, abnormal hormone tests), catatonia (positive catatonia rating scale), delirium (confusion rating scale), or mania symptoms as guides to referral for ECT. Such criteria are predictive of good and rapid outcome with ECT.
DSM diagnoses are arbitrary, not verifiable, and do not predict outcomes. More definable and verifiable criteria would improve treatment outcomes and shorten periods of illness.