New Review on ECT for Catatonia
Out on PubMed, from clinicians in Chicago and Austin, is this review:Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives.
Neuropsychiatr Dis Treat. 2020 Sep 25;16:2191-2208. doi: 10.2147/NDT.S231573. eCollection 2020.PMID: 33061390
The abstract is copied below:
Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.The pdf is here.
This is a truly excellent review in many ways. It is well written, comprehensive (203 references) and thoughtful. It starts with a dramatic case vignette and has an excellent section on differential diagnosis.
Where it can be faulted, is in some ambivalence and equivocation about using "robust forms" of ECT for catatonia. While the authors do present the case for adequately-dosed bilateral ECT, they also spend an inordinate amount of time on potential cognitive effects; in their complex treatment algorithm (which I expected to be more consistent with their text discussion) they devote half the chart to RUL-UBP ECT. This seems slightly misguided.
Overall, the main message here (catatonia is under recognized, there are barriers to timely ECT prescription) is very important and cogently presented. This review is definitely worth reading in its entirety (about 25 minutes).
For a different view of ECT technique in catatonia,
here is the pdf ofOptimizing ECT Technique in Treating Catatonia.
J ECT. 2016 Sep;32(3):149-50)
The below comment, from Dr. Max Fink, amplifies my critique of the use of RUL ECT for catatonia:
ReplyDeleteECT for Catatonia October 28, 2020
In a detailed literature review of ECT for catatonia, the authors err in considering RUL-UBP technique as an acceptable method . It is not. Excepting occasional reports of efficacy, RUL-UBP treatments are ineffective in catatonia.
Catatonia is a life-threatening illness, with inanition and embolization features frequent. Daily ECT is often required. The evidence was well documented in 2003 , and for the merit of bitemporal ECT, again by the Editors of JECT in 2016:
(Optimizing ECT Technique in Treating Catatonia. Fink M, Kellner CH, McCall WV.
J ECT. 2016 Sep;32(3):149-50.)
The recognition of catatonia as a life-threatening systemic disorder that is identifiable, verifiable, and treatable is a high water mark in modern medicine. Recommending ineffective treatments is a disservice .
Max Fink
Dear Drs Fink and Kellner,
ReplyDeleteOn behalf of my co-authors, I want to sincerely thank you both for your thoughts and posting of our article. We accept and appreciate the critique as well. Our hope was to present one algorithmic approach to ECT technique and hopefully spark future efforts to study some of the technical ECT decision points.
A previous review on this topic highlighted the lack of RCT data:
Leroy A, Naudet F, Vaiva G, Francis A, Thomas P, Amad A. Is electroconvulsive therapy an evidence-based treatment for catatonia? A systematic review and meta-analysis. Eur Arch Psychiatry Clin Neurosci. 2018 Oct;268(7):675-687. doi: 10.1007/s00406-017-0819-5. Epub 2017 Jun 21. PMID: 28639007.
We are hopeful to that the RCT database can be built and, while recognizing that a placebo-controlled trial would be unethical for catatonia, and that a non-ECT-like treatment arm would be an inadequate control, we are hopeful adequate options could be tested within ECT to identify the most effective and safest specific ECT techniques. Hopefully, our caveats in the text guide the reader to understanding our intention was to provide one algorithm rather than THE algorithm for ECT use in catatonia. Nonetheless, we appreciate the feedback and being a part of the ongoing conversation about catatonia and ECT.
Sincerely,
Joseph J. Cooper, MD
Associate Professor of Clinical Psychiatry
Director of Medical Student Education in Psychiatry
Co-Director, Behavioral Neurology and Neuropsychiatry Fellowship
University of Illinois at Chicago