WEBVTT - Ep 221 Electroconvulsive Therapy Part 2: A current conversation 0:00:00.070 --> 0:00:03.090 So this patient was actually five at the time that 0:00:03.310 --> 0:00:08.400 she was diagnosed. She presented initially with seizures, was diagnosed 0:00:08.420 --> 0:00:11.320 with epilepsy, was sent home from a hospital, and then 0:00:11.400 --> 0:00:16.800 came back with unusual movements and mutism and was diagnosed 0:00:16.820 --> 0:00:19.750 by the team there with catatonia, which is a psychiatric 0:00:19.790 --> 0:00:22.829 syndrome that we see across a variety of illnesses, both 0:00:22.890 --> 0:00:27.930 psychiatric and medical. That provoked a further medical workup, including 0:00:28.290 --> 0:00:31.410 lumbar puncture, spinal tap, and she was found to have 0:00:31.650 --> 0:00:36.840 what is known as anti-NMDA receptor encephalitis. This condition is 0:00:36.900 --> 0:00:40.739 frequently characterized by the things I just mentioned, seizures, catatonia, 0:00:40.820 --> 0:00:45.699 other psychiatric symptoms, and is treated with a combination of 0:00:45.729 --> 0:00:49.290 immunotherapies to deal with the overactivity of the immune system, 0:00:49.950 --> 0:00:53.519 and also sort of conventional treatments to manage seizures, catatonia, etc., 0:00:54.590 --> 0:01:00.410 This patient received immunotherapy, many immunotherapies actually, and received lorazepam 0:01:00.450 --> 0:01:03.540 or Ativan, which is the standard medication that we give 0:01:03.560 --> 0:01:07.520 for catatonia, to very, very high doses and continued to 0:01:07.580 --> 0:01:11.480 receive these treatments over the course of Of about nine months. 0:01:11.970 --> 0:01:15.569 And after that nine-month period, she remained very catatonic. She 0:01:15.610 --> 0:01:18.610 could not speak. She could not dress herself, which she'd 0:01:18.630 --> 0:01:21.050 been able to do previously. She could not feed herself. 0:01:21.130 --> 0:01:24.310 She required a gastrostomy tube or a feeding tube for 0:01:24.350 --> 0:01:27.800 all her feeding. She required total care from her family 0:01:27.840 --> 0:01:31.590 and from the nursing staff. And so at that time, 0:01:31.610 --> 0:01:34.690 the team at the hospital where she was a patient 0:01:34.709 --> 0:01:38.520 at the time started discussing the possibility of treating her 0:01:38.560 --> 0:01:42.520 with ECT. ECT is a gold standard treatment for catatonia, 0:01:42.540 --> 0:01:47.309 has very high response rates across all causes of catatonia, 0:01:47.390 --> 0:01:51.820 both psychiatric and medical. However, it is not typical to 0:01:51.920 --> 0:01:54.540 treat ECT in patients so young, in part because it's 0:01:54.580 --> 0:01:57.840 not typical to see catatonia in patients so young, or anyway, 0:01:57.860 --> 0:02:01.050 it has not been recognized in patients so young historically. 0:02:01.070 --> 0:02:04.130 It's almost certainly been under-recognized. So it would have been 0:02:04.150 --> 0:02:07.990 unusual to treat a patient this age with ECT. But 0:02:08.050 --> 0:02:09.430 they had sort of run out of options. They had 0:02:09.470 --> 0:02:13.130 given her many, many doses of immunotherapies that are also 0:02:13.190 --> 0:02:15.840 used as chemotherapeutic agents that have their own side effects 0:02:15.900 --> 0:02:18.380 that had treated her with very high dose lorazepam, as 0:02:18.460 --> 0:02:22.060 I said. And so the decision was made to transfer 0:02:22.100 --> 0:02:24.320 her to our hospital, of course, with the consent of 0:02:24.380 --> 0:02:27.760 her parents, to treat her with ECT. That was the 0:02:27.780 --> 0:02:30.359 youngest case that we've treated, one of the youngest cases 0:02:30.660 --> 0:02:34.770 in the literature. We began treatment of her nine months 0:02:34.910 --> 0:02:39.430 into her illness. And after about eight weeks, her catatonia 0:02:39.470 --> 0:02:44.040 had resolved entirely. She was speaking again, walking again. She 0:02:44.100 --> 0:02:47.739 was able to play games with her hands and draw 0:02:47.930 --> 0:02:50.510 and play. blow bubbles and all these things. So we, 0:02:50.810 --> 0:02:53.169 in fact, had her well enough to eat again. So 0:02:53.210 --> 0:02:56.530 she had come in September and we got her eating 0:02:56.870 --> 0:02:59.010 enough just in time for Thanksgiving dinner. So she was 0:02:59.070 --> 0:03:01.490 able to eat a full Thanksgiving with her family, which 0:03:01.510 --> 0:03:04.470 is very exciting for us. So it's just a testament 0:03:04.550 --> 0:03:08.970 to the power of the treatment, particularly for catatonia and 0:03:09.250 --> 0:03:13.450 sort of a reminder that we do have this treatment 0:03:13.470 --> 0:03:16.630 available for anyone who needs it. And we should always 0:03:16.669 --> 0:04:04.320 be thinking about it in these cases. Thank you. Dr. 0:04:04.360 --> 0:04:07.120 Lopez, thank you so much for sharing that story with us. 0:04:07.560 --> 0:04:09.000 It still blows my mind. 0:04:09.020 --> 0:04:09.640 I know. 0:04:09.820 --> 0:04:12.380 And there's a full episode on it and the Advances 0:04:12.540 --> 0:04:15.770 in Care podcast, so go check it out. But Whoa. 0:04:16.170 --> 0:04:16.390 Yeah. 0:04:16.430 --> 0:04:18.620 There's also a YouTube video, Erin, that you had sent me. 0:04:18.650 --> 0:04:19.200 Yes. 0:04:19.279 --> 0:04:22.260 That the hospital put together that's also really moving. And yeah, 0:04:22.300 --> 0:04:25.500 thank you so much for taking the time. And everyone, 0:04:25.520 --> 0:04:27.599 you'll get to hear more from Dr. Lopez later in 0:04:27.620 --> 0:04:28.100 the episode. 0:04:28.160 --> 0:04:31.229 Yes, you will. Yes, you will. Hi, I'm Erin Welsh. 0:04:31.460 --> 0:04:32.670 And I'm Erin Allman-Updike. 0:04:32.790 --> 0:04:34.750 And this is This Podcast Will Kill You. 0:04:35.050 --> 0:04:36.270 Welcome to ECT. 0:04:36.970 --> 0:04:40.920 Part two. ECT part two. If this is your first 0:04:40.940 --> 0:04:43.580 time tuning in, check out last week's episode on the 0:04:43.620 --> 0:04:48.080 history of ECT, helpful context. Is it necessary to understand 0:04:48.100 --> 0:04:49.080 ECT today? 0:04:49.720 --> 0:04:49.960 Yeah. 0:04:50.320 --> 0:04:53.200 I feel like it is. Definitely feel like it is. 0:04:53.360 --> 0:04:53.620 Okay. 0:04:54.440 --> 0:04:56.080 Go listen to it if you haven't already. 0:04:56.360 --> 0:04:56.860 Yeah. 0:04:57.220 --> 0:04:59.340 If you haven't already, then you might not know ECT 0:04:59.600 --> 0:05:00.960 is electroconvulsive therapy. 0:05:01.279 --> 0:05:01.539 See? 0:05:01.860 --> 0:05:03.540 There's important things you need to learn from that episode. 0:05:04.100 --> 0:05:04.320 Yeah. 0:05:04.420 --> 0:05:05.659 Pretty important. Pretty important. 0:05:06.160 --> 0:05:08.480 But today we're going to be talking all about what 0:05:08.839 --> 0:05:11.020 is ECT? How does it actually work? How do we 0:05:11.140 --> 0:05:13.640 use it today? And of course, we're going to be 0:05:13.700 --> 0:05:15.140 interviewing an expert. 0:05:15.520 --> 0:05:16.480 That is Dr. 0:05:16.520 --> 0:05:19.670 Leonardo Lopez, who is vice chair for inpatient services and 0:05:19.790 --> 0:05:23.310 associate professor of clinical psychiatry at Weill Cornell Medical College. 0:05:23.550 --> 0:05:28.190 And he oversees a lot of inpatient psychiatric services Including ECT. 0:05:28.330 --> 0:05:29.529 Including ECT. 0:05:29.589 --> 0:05:29.849 Yeah. 0:05:30.740 --> 0:05:35.000 It is really thrilling to get this actual expert to 0:05:35.120 --> 0:05:38.700 chat about this therapy that we've talked so much about. 0:05:38.800 --> 0:05:39.360 So, yeah. 0:05:39.700 --> 0:05:40.900 That'll be later in the episode. 0:05:40.920 --> 0:05:41.200 Yeah. 0:05:41.360 --> 0:05:42.960 But for now, we still have a few important things 0:05:42.980 --> 0:05:47.540 to cover, such as... Like quarantini time. Quarantini time. This week, 0:05:47.880 --> 0:05:51.010 as with last week, we are drinking Shock Talk. Shock Talk. 0:05:51.390 --> 0:05:56.110 Which is grapefruit, ginger ale, basil. It's tasty. Yeah. Check 0:05:56.150 --> 0:05:59.390 out our recipe online. On our website, thispodcastwillkillyou.com, as well 0:05:59.410 --> 0:06:01.830 as on all of our social media channels. Follow us 0:06:01.870 --> 0:06:04.770 if you're not already. Our website has lots of things. 0:06:04.830 --> 0:06:06.890 If you listened to last week's episode, you know. 0:06:07.089 --> 0:06:07.630 Check it out. You know. 0:06:07.870 --> 0:06:08.350 Check it out. 0:06:08.730 --> 0:06:11.849 Thispodcastwillkillyou.com. Rate, review, and subscribe. We're on YouTube. 0:06:11.990 --> 0:06:12.830 Hi. Hi. 0:06:13.730 --> 0:06:15.090 Shall we get into this? There's a lot to cover. 0:06:15.250 --> 0:06:17.110 I would love to. Let's take a quick break and 0:06:17.390 --> 0:06:24.830 get started. Okay. Hi. 0:06:32.740 --> 0:06:35.680 So last week, Erin, you walked us through the history 0:06:35.960 --> 0:06:41.219 of ECT as a practice from the pretty gruesome. to 0:06:41.440 --> 0:06:45.500 the remarkably effective and kind of left off with where 0:06:45.940 --> 0:06:48.060 are we now and kind of where do we go? 0:06:48.520 --> 0:06:53.039 So my goal for today is to make ECT feel, 0:06:53.380 --> 0:06:55.800 for so many of us who maybe have never witnessed 0:06:55.900 --> 0:06:59.370 it or who have never experienced it, feel like something 0:06:59.400 --> 0:07:02.350 that is real, that we have a concept of in 0:07:02.430 --> 0:07:05.289 our mind that we can visualize. Because I think for 0:07:05.410 --> 0:07:07.229 so many of us, we might be able to picture 0:07:07.270 --> 0:07:09.880 like what a surgery looks like. We might be able 0:07:09.920 --> 0:07:11.640 to picture in our mind what it might be like 0:07:11.680 --> 0:07:14.860 to have to take a medication every day. But the 0:07:14.960 --> 0:07:18.110 images that we likely have of ECT, like you talked 0:07:18.130 --> 0:07:20.650 about so much last week, Erin, they're tinged with so 0:07:20.830 --> 0:07:22.130 much sensationalism. 0:07:22.150 --> 0:07:22.220 Yes. 0:07:23.330 --> 0:07:26.090 And it might be that one flew over the cuckoo's 0:07:26.130 --> 0:07:29.560 nest is our best image of what ECT is. And 0:07:29.600 --> 0:07:31.540 that's not a picture of what it actually looks like 0:07:31.580 --> 0:07:34.630 today at all. Correct. So what we're going to talk 0:07:34.650 --> 0:07:37.650 about today is what this actually looks like as a 0:07:37.690 --> 0:07:41.350 medical procedure, what the situations are that we use it 0:07:41.450 --> 0:07:44.590 for today. And then, like I said already, at the end, 0:07:44.610 --> 0:07:46.590 we're going to be joined by Dr. Leonardo Lopez to 0:07:46.650 --> 0:07:49.470 talk about kind of the future of ECT. 0:07:49.770 --> 0:07:52.940 So there's a lot to cover. There really is. 0:07:54.140 --> 0:07:55.660 Just a few things on the agenda. 0:07:55.680 --> 0:07:55.760 Yeah. 0:07:56.890 --> 0:07:58.740 At the very top of last week's episode, Erin, you 0:07:58.760 --> 0:08:03.260 defined ECT for us. Electroconvulsive therapy is basically delivering electricity 0:08:03.480 --> 0:08:06.820 to our brain with the goal of provoking a seizure 0:08:07.640 --> 0:08:10.880 to treat a variety, a really kind of wider variety 0:08:10.930 --> 0:08:14.430 than you might think, of what we call affective disorders. 0:08:14.650 --> 0:08:17.990 So those are things like treatment-resistant depression, which might mean 0:08:18.110 --> 0:08:21.610 either unipolar depression, so that's things like major depressive disorder, 0:08:22.130 --> 0:08:26.200 or bipolar depression. We also use it for psychotic disorders, 0:08:26.280 --> 0:08:32.040 including psychotic depression, schizoaffective disorder and schizophrenia, and catatonia and 0:08:32.080 --> 0:08:34.719 related disorders, which we're going to talk about in a 0:08:34.740 --> 0:08:37.800 lot more detail and can present in both more neurologic 0:08:37.950 --> 0:08:41.969 and more kind of psychiatric conditions. But what does it 0:08:42.110 --> 0:08:45.970 actually look like? So if you or I were going 0:08:46.030 --> 0:08:48.550 to go get ECT, if we had a need for 0:08:48.570 --> 0:08:51.089 this procedure, this is kind of the steps that we 0:08:51.130 --> 0:08:51.630 would go through. 0:08:52.950 --> 0:08:53.350 First. 0:08:53.950 --> 0:08:56.590 There would be a very lengthy discussion of the risks 0:08:56.929 --> 0:09:00.830 and the benefits of this procedure. The person who's performing 0:09:00.950 --> 0:09:03.130 it would be talking with us. They would be talking 0:09:03.170 --> 0:09:06.370 with our family or our friends and other like surrogate 0:09:06.390 --> 0:09:10.990 decision makers if needed. There is a really robust informed 0:09:11.030 --> 0:09:14.770 consent process that has to be gone through. Usually there's 0:09:14.850 --> 0:09:17.410 also a general physical exam that has to be done 0:09:17.550 --> 0:09:20.540 either by a primary care or hospitalist physician or sometimes 0:09:20.580 --> 0:09:22.960 by a cardiologist. To make sure that our heart and 0:09:23.000 --> 0:09:26.360 our body is overall healthy enough to withstand this procedure, 0:09:26.700 --> 0:09:30.360 especially the anesthesia. We would then have to not eat 0:09:30.440 --> 0:09:34.750 anything for an entire night. And then the next morning, 0:09:34.870 --> 0:09:37.550 we'd arrive to a room, either in a hospital or 0:09:37.650 --> 0:09:41.670 an outpatient clinic, depending on the situation. We would be 0:09:41.690 --> 0:09:44.110 wearing a hospital gown, like we always do for any 0:09:44.130 --> 0:09:47.190 of these kinds of procedures. And we'd probably be greeted 0:09:47.270 --> 0:09:50.890 by either a nurse or a technician and an anesthetist. 0:09:52.090 --> 0:09:54.300 We'd get an IV put in our arm. We'd have 0:09:54.340 --> 0:09:57.020 a blood pressure cuff. They'd take our vitals. Actually, they'd 0:09:57.059 --> 0:09:59.010 put two blood pressure cuffs on, one on our arm 0:09:59.090 --> 0:10:01.680 and one on our right leg. We'll talk about why 0:10:01.710 --> 0:10:02.140 in a second. 0:10:02.160 --> 0:10:02.469 Okay. 0:10:03.090 --> 0:10:05.450 And then while they're chatting with you, they'll start to 0:10:05.510 --> 0:10:07.330 hook up a whole bunch of wires that they're going 0:10:07.350 --> 0:10:10.209 to use for monitoring us. There'd be an EKG on 0:10:10.250 --> 0:10:13.590 our chest to monitor our heart during the procedure. There'd 0:10:13.630 --> 0:10:17.430 be an EEG on our head to monitor the seizure 0:10:17.470 --> 0:10:20.170 in our brain. And there would be an EMG or 0:10:20.210 --> 0:10:23.069 an electromyogram that would be placed on our right foot. 0:10:23.670 --> 0:10:25.600 I'll tell you again why in a little bit. 0:10:25.620 --> 0:10:26.650 Okay, the right foot, yeah. 0:10:26.740 --> 0:10:29.400 And that's to monitor the seizure in the muscle itself. 0:10:30.660 --> 0:10:33.040 We'd probably get a little bit of extra oxygen via 0:10:33.120 --> 0:10:35.020 a mask. There might be a little thing put up 0:10:35.080 --> 0:10:37.860 our nose to monitor our CO2 levels, one of those 0:10:37.940 --> 0:10:40.540 clippies on our finger to monitor our blood oxygen. And 0:10:41.720 --> 0:10:44.239 depending on what type of electrodes that are going to 0:10:44.260 --> 0:10:46.449 be used for this procedure, we They might put those 0:10:46.490 --> 0:10:49.290 on our head right now if they're the sticky kind, 0:10:49.590 --> 0:10:51.590 or they might use the kind of more old school 0:10:51.610 --> 0:10:53.990 kind that are handheld. In that case, you might not 0:10:54.030 --> 0:10:57.410 see those yet. And then the anesthetist is going to 0:10:57.450 --> 0:10:59.630 give us a medication that will put us to sleep. 0:10:59.809 --> 0:11:02.209 There's a few different medicines that they use. They're pretty 0:11:02.250 --> 0:11:06.490 standard anesthetics like Propofol or Atomidate. No one cares about 0:11:06.530 --> 0:11:11.270 these names. Okay. Once you're unconscious then, that second blood 0:11:11.290 --> 0:11:13.610 pressure cuff, the one around our ankle, our right. 0:11:13.480 --> 0:11:14.770 Leg, is inflated. 0:11:15.490 --> 0:11:18.270 The reason for this is that that's going to reduce 0:11:18.290 --> 0:11:21.390 the amount of blood flow to our right foot. Not 0:11:21.429 --> 0:11:23.640 cut it off completely, but reduce the amount of blood 0:11:23.660 --> 0:11:26.380 flow to that foot. And then they're going to administer 0:11:26.520 --> 0:11:30.400 another medication after we're unconscious. And this one is a 0:11:30.460 --> 0:11:35.240 muscle relaxant. Usually it's something called succinylcholine. This kicks in 0:11:35.300 --> 0:11:37.920 pretty quickly. And you can tell when it's kicked in 0:11:37.980 --> 0:11:40.650 because as you're administering it, it actually causes kind of 0:11:40.710 --> 0:11:43.790 these twitchings, these little tremors in your muscles. And then 0:11:43.830 --> 0:11:47.329 those tremors will stop. Once those tremors stop, it means 0:11:47.370 --> 0:11:52.130 that the muscles are completely relaxed, okay? And then they're 0:11:52.150 --> 0:11:54.950 going to put a bite block in your mouth, and 0:11:54.990 --> 0:11:56.550 that's to protect your teeth and your tongue. 0:11:57.400 --> 0:11:58.720 And then they're going to. 0:11:58.600 --> 0:12:02.860 Administer a very brief pulse of electricity via those electrodes 0:12:03.059 --> 0:12:05.920 that either they stuck already onto your head or they're 0:12:05.960 --> 0:12:09.000 holding onto your head. And by a very brief pulse 0:12:09.080 --> 0:12:12.080 of electricity, I literally mean on the order of seconds 0:12:12.260 --> 0:12:15.160 or sometimes even a half of a second of electricity. 0:12:15.179 --> 0:12:15.699 Okay. 0:12:16.420 --> 0:12:19.569 The amount of electricity specifically that they're going to deliver 0:12:19.630 --> 0:12:24.110 depends on what your seizure threshold is. But the goal 0:12:24.210 --> 0:12:29.319 is that it's enough electricity to cause a generalized seizure. Okay. Now, 0:12:29.420 --> 0:12:31.959 this seizure is not going to be visible in your 0:12:32.020 --> 0:12:35.460 muscles the way that a grand mal or a generalized 0:12:35.700 --> 0:12:39.450 tonic-clonic seizure would be because all of your muscles are relaxed. 0:12:39.760 --> 0:12:41.650 But what you will be able to see is the 0:12:41.690 --> 0:12:46.430 seizure on EEG, which we're monitoring, and on EMG attached 0:12:46.470 --> 0:12:48.650 to the right foot, which has less blood flow, so 0:12:48.670 --> 0:12:52.370 has not been affected by the muscle relaxant succinylcholine. That 0:12:52.450 --> 0:12:55.790 seizure is only going to last between 25 and 70 seconds. 0:12:56.410 --> 0:13:00.000 That's how long the whole seizure itself should last. And 0:13:00.080 --> 0:13:03.400 then that's it. The procedure is over. You're disconnected from 0:13:03.440 --> 0:13:06.100 all of your wires. The anesthetic will wear off within 0:13:06.140 --> 0:13:08.220 a matter of minutes, maybe a half an hour, maybe 0:13:08.260 --> 0:13:10.589 an hour. And then that's the end of the procedure. 0:13:11.610 --> 0:13:14.140 And you'll be wheeled to the recovery room to wake up. 0:13:15.330 --> 0:13:19.850 That was so helpful. Thank you. That was really great. 0:13:19.890 --> 0:13:23.140 I worked actually really hard on that. So thank you. No, 0:13:23.130 --> 0:13:25.660 it really was like a helpful contrast to like, okay, 0:13:25.700 --> 0:13:29.130 what do we see on movies. When we hear this 0:13:29.190 --> 0:13:33.349 in our head, what do we picture? Yeah. And it 0:13:33.429 --> 0:13:35.310 is often a far cry. And so I think that 0:13:35.350 --> 0:13:36.910 was really, really great. 0:13:37.080 --> 0:13:37.240 Okay. 0:13:37.250 --> 0:13:39.360 Exactly. I have some questions. I know you have a 0:13:39.360 --> 0:13:39.859 lot of questions. 0:13:39.940 --> 0:13:40.060 Yeah. 0:13:40.080 --> 0:13:41.120 Okay. Give them to me. 0:13:41.300 --> 0:13:41.599 Okay. 0:13:42.340 --> 0:13:44.860 Right foot. Right foot. Why the right foot? 0:13:45.020 --> 0:13:45.160 Yeah. 0:13:45.580 --> 0:13:46.959 Oh, that's such a great question. 0:13:47.600 --> 0:13:47.860 Okay. 0:13:47.920 --> 0:13:50.600 There's a few reasons for this. In part, it's not 0:13:50.660 --> 0:13:54.410 completely random. To answer that question, I want to actually 0:13:54.510 --> 0:13:56.130 answer first where we put the electrodes. 0:13:56.690 --> 0:13:56.930 Okay. 0:13:57.070 --> 0:13:58.010 Because then I'll be able to. 0:13:57.970 --> 0:14:00.800 Kind of like long way get to that question. 0:14:01.000 --> 0:14:01.160 Sure. 0:14:01.179 --> 0:14:01.400 Okay. 0:14:01.660 --> 0:14:01.880 Okay. 0:14:02.679 --> 0:14:04.220 So the electrodes are placed. 0:14:04.860 --> 0:14:06.750 There's a few different ways that you can place the electrodes. 0:14:07.740 --> 0:14:11.080 In most of the, like, media representations, the electrodes are 0:14:11.100 --> 0:14:13.579 placed on the temples, on both of them. So kind 0:14:13.620 --> 0:14:15.319 of like if you draw an imaginary line from the 0:14:15.360 --> 0:14:17.370 corner of your eyes back to your ears, it's kind 0:14:17.380 --> 0:14:19.990 of midway along that line just above it, right on 0:14:20.030 --> 0:14:23.850 your temples. And that is kind of old school standard placement, 0:14:23.950 --> 0:14:27.130 still used quite often, but not necessarily the. 0:14:27.150 --> 0:14:27.930 First line placement. 0:14:28.350 --> 0:14:31.310 Treatment option for a lot of people in the US today, 0:14:31.390 --> 0:14:35.190 but that's a perfectly decent option. Sometimes instead of being 0:14:35.370 --> 0:14:38.030 on the temporal, people will put them bifrontal. So like 0:14:38.110 --> 0:14:40.770 on the forehead, kind of like outer corners of the eyebrows. 0:14:40.990 --> 0:14:41.250 Okay. 0:14:41.770 --> 0:14:45.650 But there's also another option and that is right unilateral placement. 0:14:46.310 --> 0:14:48.390 And so this means that you'll have one electrode on 0:14:48.410 --> 0:14:51.680 the right side in that same like temporal position. And 0:14:51.700 --> 0:14:53.640 then the other one just to the right of the 0:14:53.700 --> 0:14:56.620 very top of your skull, right at the apex there. 0:14:57.560 --> 0:15:00.980 A lot of times we start with this right lobe only, 0:15:01.080 --> 0:15:04.850 right unilateral placement because it's associated with a lower risk 0:15:04.910 --> 0:15:07.910 of side effects. However, it tends to also be slightly 0:15:08.010 --> 0:15:12.210 less effective than bilateral placement. The reason that they chose 0:15:12.350 --> 0:15:16.870 initially to do right rather than left is because for 0:15:17.130 --> 0:15:22.080 most people, like 98% of right-handed people and 70 to 90% 0:15:22.080 --> 0:15:25.100 of left-handed people, our language function is all on the 0:15:25.140 --> 0:15:27.860 left temporal lobe. So the thought was that maybe there 0:15:27.880 --> 0:15:31.100 would be less side effects, especially with language, if we 0:15:31.280 --> 0:15:34.180 avoid direct current to that left temporal lobe. 0:15:34.200 --> 0:15:34.860 Huh. 0:15:35.530 --> 0:15:39.670 But so the right foot, regardless of the position of 0:15:39.690 --> 0:15:43.670 those electrodes, is a place that you can easily isolate 0:15:43.890 --> 0:15:47.420 and is going to still have motor activity regardless of where. 0:15:47.480 --> 0:15:49.780 I mean, really, you should have motor activity anywhere. So 0:15:49.820 --> 0:15:51.760 I think right foot is just like that has become 0:15:51.800 --> 0:15:53.460 the standard of where you do it. It could be 0:15:53.480 --> 0:15:55.320 the left foot. Sometimes people use the arm if they 0:15:55.360 --> 0:15:56.940 have to. Let's say you don't have a right foot 0:15:56.980 --> 0:15:58.740 or something like that. You can use something else. 0:15:58.760 --> 0:15:59.600 Yeah. 0:16:00.180 --> 0:16:00.880 Okay. 0:16:01.120 --> 0:16:01.540 Okay. 0:16:01.800 --> 0:16:04.450 I guess I didn't really need to answer the placement question. 0:16:04.540 --> 0:16:05.500 No, but it was helpful. 0:16:05.730 --> 0:16:05.940 Thank you. 0:16:05.950 --> 0:16:10.470 It was a helpful context. Interesting. The seizure threshold, how 0:16:10.550 --> 0:16:11.670 is that determined? 0:16:11.690 --> 0:16:13.530 I knew that you were going to ask that question. 0:16:13.890 --> 0:16:20.170 So the seizure threshold means the lowest amount of electricity 0:16:20.390 --> 0:16:22.550 that's going to give you a seizure. 0:16:22.750 --> 0:16:22.890 Yeah. 0:16:23.530 --> 0:16:26.950 How we determine what that seizure threshold is kind of 0:16:26.990 --> 0:16:29.090 depends on where you're going to be getting ECT and 0:16:29.150 --> 0:16:31.560 how they're going to do it. There are like age-based 0:16:31.640 --> 0:16:34.460 guesstimates that we can use. The other thing that you 0:16:34.480 --> 0:16:36.280 can do to try and estimate it is to start 0:16:36.320 --> 0:16:39.490 with a really low charge and then go up in 0:16:39.590 --> 0:16:42.290 increments until you get to a seizure. And then you know, okay, 0:16:42.310 --> 0:16:45.770 the threshold was somewhere in between the the most lowest 0:16:45.870 --> 0:16:47.510 that didn't do it, and then this one that did. 0:16:48.350 --> 0:16:51.400 But the key, actually, is that we're not just hitting 0:16:51.420 --> 0:16:55.540 that seizure threshold. The goal is actually to give an 0:16:55.580 --> 0:16:58.040 amount of electricity that's between two and a half to 0:16:58.220 --> 0:17:03.290 five times that minimum seizure threshold. That, based on all 0:17:03.310 --> 0:17:05.510 the data that we have, is what seems to be 0:17:05.550 --> 0:17:08.879 the most effective for ECT. Two and a half if 0:17:08.900 --> 0:17:11.440 you're doing bilateral. So two and a half times threshold 0:17:11.520 --> 0:17:14.220 for bilateral and about five times if you're doing only unilateral. 0:17:14.260 --> 0:17:17.950 So you need a higher charge if you're doing unilateral placement. 0:17:18.330 --> 0:17:18.750 Okay. 0:17:19.350 --> 0:17:19.629 So. 0:17:20.250 --> 0:17:23.850 This is, I think, maybe getting into like a bigger 0:17:23.890 --> 0:17:27.620 question or like something that you will address. But you've 0:17:27.630 --> 0:17:32.040 mentioned placement when it comes to efficacy or effectiveness. And 0:17:32.100 --> 0:17:37.850 you've mentioned... the actual like stimulation provided yeah how do 0:17:37.869 --> 0:17:39.990 we measure effectiveness what does that mean oh. 0:17:39.930 --> 0:17:43.879 That's such a great question effectiveness is measured by resolution 0:17:43.900 --> 0:17:46.820 of symptoms okay and so that's going to depend on 0:17:47.119 --> 0:17:49.740 what the thing is that you are treating but there's 0:17:49.920 --> 0:17:53.600 usually like let's say that it's depression unipolar or bipolar 0:17:53.619 --> 0:17:56.409 depression You've got a bunch of questionnaires that people are 0:17:56.430 --> 0:17:59.470 being given on how bad their depressive symptoms are prior 0:17:59.510 --> 0:18:01.470 to ECT. And then you're going to be giving those 0:18:01.510 --> 0:18:04.129 same questionnaires after ECT. And that's how you're going to 0:18:04.190 --> 0:18:08.340 judge how effective the ECT has been. You're also going 0:18:08.380 --> 0:18:11.659 to be estimating side effects, right? So then you're always 0:18:11.720 --> 0:18:14.719 going to be doing kind of a cost-benefit analysis. Did 0:18:14.760 --> 0:18:17.320 we start with bilateral and we're having too many side effects? Well, 0:18:17.340 --> 0:18:19.480 then maybe we want to switch to unilateral. Did we 0:18:19.500 --> 0:18:21.600 start with unilateral and maybe we're not having as great 0:18:21.619 --> 0:18:23.300 of an effect as we want? Then maybe we switch 0:18:23.320 --> 0:18:25.429 to bilateral. Okay. 0:18:25.450 --> 0:18:27.830 Isn't that interesting? It is really interesting. 0:18:28.010 --> 0:18:30.130 It is definitely one of these places where we talk 0:18:30.150 --> 0:18:32.030 about this a lot. There is both art and science 0:18:32.090 --> 0:18:34.790 in medicine, and that is definitely true for ECT because 0:18:34.810 --> 0:18:37.560 there is not like one standard protocol that everyone is 0:18:37.600 --> 0:18:39.620 going to respond to or that everyone is going to get. 0:18:39.640 --> 0:18:40.860 Okay. 0:18:40.900 --> 0:18:45.100 So you also mentioned that the seizure that is induced 0:18:45.240 --> 0:18:49.139 can last up to 75 seconds, whatever. It's relatively short. 0:18:49.160 --> 0:18:50.180 Like a minute, 30 seconds to a minute. 0:18:50.240 --> 0:18:52.540 Yep. What happens if it doesn't stop? 0:18:52.960 --> 0:18:53.220 Yeah. 0:18:53.300 --> 0:18:55.420 If it doesn't stop, then you give medications the same 0:18:55.440 --> 0:18:58.180 way you would with any other seizure that's lasting too 0:18:58.220 --> 0:19:01.670 long to stop that seizure. And that does happen sometimes. 0:19:02.050 --> 0:19:04.950 It also can happen where somebody maybe doesn't have a seizure. 0:19:05.070 --> 0:19:07.090 And so then you might have to give a second 0:19:07.109 --> 0:19:10.210 dose or decide if you're going to increase the amount 0:19:10.250 --> 0:19:12.109 of electricity to try and induce a seizure or if 0:19:12.150 --> 0:19:15.139 someone had what's considered an inadequate, so less than 25 0:19:15.140 --> 0:19:16.060 seconds of a seizure. 0:19:17.190 --> 0:19:18.230 Wow. Fascinating. 0:19:18.340 --> 0:19:21.300 Okay. And then each, oh, can I, one thing that 0:19:21.320 --> 0:19:24.260 I'm guessing you might ask, I said that this was this, 0:19:24.619 --> 0:19:27.540 after that, you know, 60 seconds or so of the seizure, 0:19:27.740 --> 0:19:29.980 that's it. The procedure is over, but that is not 0:19:30.000 --> 0:19:33.820 the end of ECT because ECT is generally something that 0:19:33.920 --> 0:19:37.280 is done multiple times. So usually it starts about three 0:19:37.340 --> 0:19:40.060 times a week and can last anywhere from like six 0:19:40.119 --> 0:19:43.320 to 18 sessions or so. And for some people, it 0:19:43.400 --> 0:19:46.040 might even be that they have continuation or maintenance therapy 0:19:46.060 --> 0:19:48.399 where they kind of, taper it down so it's no 0:19:48.420 --> 0:19:51.000 longer three days a week. Maybe it's twice a week, 0:19:51.020 --> 0:19:52.820 and then once a week, maybe it's once a month. 0:19:53.500 --> 0:19:56.899 But in general, it's quite rapid acting, especially compared to 0:19:56.980 --> 0:19:58.639 so many other therapies that we have. 0:19:59.140 --> 0:20:00.160 We usually see. 0:20:00.020 --> 0:20:03.109 Substantial improvement in symptoms within the first few sessions. So 0:20:03.130 --> 0:20:04.410 within the first couple of weeks. 0:20:05.740 --> 0:20:08.859 OK, I mean, I guess I don't the next questions 0:20:08.920 --> 0:20:11.070 I have are is like how this works. What do 0:20:11.090 --> 0:20:12.950 we use this for? Yeah. 0:20:13.050 --> 0:20:13.330 Yeah. 0:20:13.490 --> 0:20:13.710 Yes. 0:20:14.210 --> 0:20:15.080 OK, let's get into it. 0:20:16.190 --> 0:20:19.270 Of course, the short answer to how does this work 0:20:19.330 --> 0:20:22.230 is that we still don't really know. We don't really know. 0:20:22.590 --> 0:20:25.750 And that's in part because we don't know the biological 0:20:25.790 --> 0:20:28.239 mechanisms of so many of these disorders that we can 0:20:28.260 --> 0:20:29.380 treat with ECT. Right. 0:20:29.700 --> 0:20:31.399 But that doesn't mean we don't have hypotheses. Right. 0:20:31.890 --> 0:20:34.890 There are a few main hypotheses as to how ECT 0:20:34.930 --> 0:20:37.850 works in our brains. The first is that we see 0:20:37.970 --> 0:20:42.369 substantial increases and changes in a bunch of our neurotransmitters. 0:20:42.670 --> 0:20:44.870 These are friends that we know well from other episodes 0:20:44.890 --> 0:20:50.260 like dopamine, serotonin, etc. We also see big changes in GABA, 0:20:50.540 --> 0:20:55.540 which is an inhibitory neurotransmitter. And what's interesting about GABA 0:20:55.640 --> 0:20:57.260 is that we think, well, maybe this is just like 0:20:57.280 --> 0:20:58.840 a neurotransmitter. 0:20:58.160 --> 0:20:59.300 Effect, but also. 0:21:00.119 --> 0:21:04.920 GABA is involved in seizures because it's like an inhibitory neurotransmitter. 0:21:05.060 --> 0:21:08.879 If GABA levels are low, then your seizure threshold is lower. 0:21:09.380 --> 0:21:13.800 And we know that ECT actually raises the seizure threshold. 0:21:14.140 --> 0:21:18.170 So during a course of ECT, seizures. 0:21:17.830 --> 0:21:18.850 Tend to get shorter. 0:21:19.420 --> 0:21:22.179 And sometimes we have to go up on that electricity 0:21:22.220 --> 0:21:25.800 dose in order to have an actual seizure because our 0:21:25.820 --> 0:21:27.659 threshold is rising with increasing treatments. 0:21:28.060 --> 0:21:29.060 So there's some thought that. 0:21:29.000 --> 0:21:35.670 Maybe it's actually a GABA-related anticonvulsant effect that somehow is 0:21:35.750 --> 0:21:36.930 how ECT is working. 0:21:37.230 --> 0:21:39.890 Like it's like stimulating your brain to produce more GABA 0:21:39.990 --> 0:21:40.970 and that's having other. 0:21:41.310 --> 0:21:44.080 That's an anticonvulsive effect. And then why is that also 0:21:44.320 --> 0:21:47.600 affecting all these other things? There's some involvement there that 0:21:47.619 --> 0:21:51.869 we don't know. Okay. We also know that ECT has 0:21:52.170 --> 0:21:55.780 induces really big fluctuations in a whole bunch of hormones 0:21:55.820 --> 0:21:59.119 that our brain releases. So inside of our brain, there's 0:21:59.160 --> 0:22:02.420 these areas called the hypothalamus and the pituitary gland. We've 0:22:02.440 --> 0:22:06.260 talked about these in other episodes. And these produce hormones 0:22:06.480 --> 0:22:09.180 that go throughout our body and interact with a whole 0:22:09.220 --> 0:22:11.820 bunch of other organs like our thyroid, our ovaries, our testes, 0:22:11.840 --> 0:22:14.560 our adrenal glands. And what we see after ECT is 0:22:14.780 --> 0:22:17.480 increases in a lot of these hormones that are produced 0:22:17.530 --> 0:22:22.130 by the hypothalamus and the pituitary, things like prolactin, ACTH, 0:22:22.190 --> 0:22:25.790 which stimulates the release of cortisol. We also see increases 0:22:25.830 --> 0:22:28.810 in TSH and just a bunch of changes that happen 0:22:28.850 --> 0:22:32.640 in our hormones that How does this then directly cause 0:22:32.680 --> 0:22:35.160 improvements in symptoms? We don't know, but we see these 0:22:35.220 --> 0:22:40.209 changes from ECT. And finally, there's also evidence, and this 0:22:40.270 --> 0:22:45.230 one is so interesting, Erin. ECT induces what's called neurogenesis, 0:22:45.450 --> 0:22:50.200 which really means like structural brain changes in various parts, 0:22:50.300 --> 0:22:54.040 in various different cell types. And this, we think, is 0:22:54.100 --> 0:22:58.480 mostly mediated by this really interesting compound called BDNF or 0:22:58.580 --> 0:23:03.540 brain-derived neurotrophic factor. And this actually induces neurogenesis. And so 0:23:03.560 --> 0:23:06.160 we think maybe it's down to that. Maybe it's some 0:23:06.220 --> 0:23:08.530 combination of all of these different things that are all 0:23:08.609 --> 0:23:10.950 happening as a result of ECT. And we don't necessarily 0:23:10.990 --> 0:23:13.470 have like a one-to-one mechanism of like, this is the 0:23:13.510 --> 0:23:15.950 thing that helps with depression. This is the thing that 0:23:15.970 --> 0:23:18.970 helps with suicidality. This is the thing, you know, we 0:23:19.010 --> 0:23:19.689 don't necessarily know. 0:23:20.220 --> 0:23:23.860 Well, and I feel like this wide range of effects 0:23:24.680 --> 0:23:29.399 explains why it has helped in so many different things 0:23:29.480 --> 0:23:31.590 that we don't, I mean, I guess we don't necessarily 0:23:31.640 --> 0:23:35.869 know if there's the same physiological mechanism underpinning them all. 0:23:35.890 --> 0:23:36.050 Yeah. 0:23:37.310 --> 0:23:39.190 Yeah. And there probably isn't, right? 0:23:39.310 --> 0:23:39.590 Yeah. 0:23:39.730 --> 0:23:43.750 The things that cause psychosis and schizophrenia are probably not 0:23:43.850 --> 0:23:47.780 exactly the same things that are causing treatment-resistant depression, right? 0:23:47.859 --> 0:23:49.920 That doesn't make sense that those are the same exact thing, 0:23:50.160 --> 0:23:52.680 but we can treat both of them with something like ECT. 0:23:52.920 --> 0:23:54.260 So it is really interesting. 0:23:54.280 --> 0:23:56.810 It's really interesting. It's really interesting. 0:23:57.369 --> 0:24:02.169 And really, like we talked about last week, Erin, ECT works. 0:24:03.390 --> 0:24:08.270 It is remarkably effective. One of the main indications for ACT, 0:24:08.350 --> 0:24:10.010 one of the main reasons that we use it, especially 0:24:10.050 --> 0:24:12.600 here in the States and in a lot of European 0:24:12.630 --> 0:24:16.800 countries and Australia and New Zealand, is treatment-resistant depression. And 0:24:16.840 --> 0:24:19.740 that can be depression with or without psychosis and with 0:24:19.859 --> 0:24:23.870 or without suicidal ideation. It can be unipolar or bipolar depression. 0:24:24.609 --> 0:24:27.210 But most of the studies on remission and response rates 0:24:27.490 --> 0:24:27.709 are wrong. 0:24:28.280 --> 0:24:28.970 Remarkable. 0:24:29.080 --> 0:24:30.340 We can see anywhere from like. 0:24:30.210 --> 0:24:31.899 50 to 60 percent. 0:24:31.780 --> 0:24:36.900 Or more remission, meaning you have essentially no depressive symptoms, 0:24:37.080 --> 0:24:40.580 like you have gone into quote-unquote remission. And response rates, 0:24:40.619 --> 0:24:43.540 meaning improvement in your depressive symptoms, can be anywhere from 0:24:43.540 --> 0:24:47.699 60 to 90 percent in some studies. And when we 0:24:47.740 --> 0:24:50.340 compare this to SSRIs, which we talked about in a 0:24:50.560 --> 0:24:54.119 prior episode, they have a remission rate at best of 0:24:54.140 --> 0:24:55.920 around 40 percent, right? 0:24:56.240 --> 0:24:59.159 Wow, yeah. There's also data that ECT. 0:24:58.780 --> 0:25:01.860 Can cut readmission rates in the first 30 days in half. 0:25:03.140 --> 0:25:04.180 It's not perfect. 0:25:04.340 --> 0:25:07.939 There is certainly still the risk of remission in the 0:25:08.000 --> 0:25:10.200 first 6 to 12 months especially or the risk of 0:25:10.260 --> 0:25:15.210 relapse essentially. And the recommendations on maintenance therapy are not 0:25:15.350 --> 0:25:17.690 clear cut by any means. Yeah. 0:25:17.710 --> 0:25:17.790 Yeah. 0:25:18.720 --> 0:25:22.510 And of course, there are definite side effects to ECT. 0:25:22.790 --> 0:25:23.070 Yes. 0:25:23.609 --> 0:25:23.850 Yes. 0:25:24.510 --> 0:25:25.570 There are minor. 0:25:25.290 --> 0:25:29.090 Side effects that often don't even get mentioned because they're 0:25:29.230 --> 0:25:32.170 considered so minor. But these might be things like headache 0:25:32.450 --> 0:25:36.590 or muscle aches, especially actually from the succinylcholine because it 0:25:36.650 --> 0:25:39.090 causes those twitchings at first. So you might actually get 0:25:39.109 --> 0:25:42.490 muscle aches from that, which is so interesting. Nausea, which 0:25:42.540 --> 0:25:46.000 is usually from the general anesthetic more than anything. These 0:25:46.060 --> 0:25:49.899 are all typically very easily controlled with things like antiemetics 0:25:50.060 --> 0:25:53.660 and like acetaminophen, over-the-counter medications. And that's why I think 0:25:53.720 --> 0:25:55.619 no one really talks about those, but those are definitely 0:25:55.660 --> 0:25:59.660 post-procedural side effects. But it's the cognitive effects and specifically 0:25:59.700 --> 0:26:02.700 the memory effects that are the main complication of ECT. 0:26:03.100 --> 0:26:03.280 Yeah. 0:26:04.000 --> 0:26:06.439 And these can happen actually on a few different timescales. 0:26:07.359 --> 0:26:10.040 Immediately after the procedure, people are going to be a 0:26:10.060 --> 0:26:13.720 little bit confused. That's from the seizure itself, and that's 0:26:13.800 --> 0:26:17.090 also from coming out of anesthesia. But this is something 0:26:17.130 --> 0:26:19.550 that usually only lasts a few minutes, maybe like 30 0:26:19.550 --> 0:26:21.610 minutes or so. Some people might have a harder time 0:26:21.690 --> 0:26:23.880 coming out of anesthesia. They might even get a little 0:26:23.890 --> 0:26:27.520 bit agitated, but this is pretty rare. And it's usually 0:26:27.560 --> 0:26:29.700 just the first 30 minutes where people are quite confused 0:26:29.740 --> 0:26:33.880 about what just happened. The first couple of weeks, Some 0:26:33.940 --> 0:26:37.940 people might have problems with attention or things like executive functioning, 0:26:37.960 --> 0:26:40.320 like being able to do the kind of high-level tasks 0:26:40.340 --> 0:26:41.700 that you might have to do to, say, run a 0:26:41.740 --> 0:26:45.770 household or something like that. But what's really interesting is 0:26:45.790 --> 0:26:50.169 that most of the data on most aspects of cognitive 0:26:50.250 --> 0:26:54.369 function are that they actually improve after ECT. 0:26:55.350 --> 0:26:56.290 In the long term. 0:26:56.430 --> 0:26:59.219 In the long term, exactly. Okay. And we don't know 0:26:59.280 --> 0:27:02.620 why that is, except that maybe it's because we've improved 0:27:02.840 --> 0:27:04.140 the depressive. 0:27:03.600 --> 0:27:04.920 Symptoms especially, right? 0:27:04.960 --> 0:27:08.260 And that depression has a huge impact on cognitive functioning. 0:27:09.420 --> 0:27:11.480 But memory is a different story. 0:27:11.820 --> 0:27:13.220 Memory is a different story, yes. 0:27:13.280 --> 0:27:15.570 And there's two types of memory loss that can happen 0:27:15.609 --> 0:27:20.960 with ECT. There's something called anterograde amnesia. And that's difficulty 0:27:21.109 --> 0:27:25.190 retaining new information after the procedure. So like you do 0:27:25.230 --> 0:27:27.090 the procedure, you go home and you're like, I don't 0:27:27.130 --> 0:27:29.629 know where I put my keys today. I can't remember 0:27:29.670 --> 0:27:32.050 what's on the schedule for today. What did you tell 0:27:32.070 --> 0:27:34.670 me this morning? Did we have a conversation? Those kinds 0:27:34.710 --> 0:27:35.010 of things. 0:27:35.090 --> 0:27:36.010 Forming memories. 0:27:36.310 --> 0:27:39.909 Forming new memories. And this can actually get worse over 0:27:39.950 --> 0:27:42.290 the course of ECT since this is going to be, 0:27:42.350 --> 0:27:45.170 you know, anywhere from six to 18 or more sessions. 0:27:46.280 --> 0:27:49.139 And that is why often during ECT therapy, even if 0:27:49.180 --> 0:27:51.659 people are going home in between each session and are 0:27:51.680 --> 0:27:55.090 not hospitalized, they might have restrictions on things like driving. 0:27:55.550 --> 0:27:58.689 They might be advised not to make big life decisions. 0:27:58.750 --> 0:28:01.260 They probably aren't able to work and things like that. 0:28:02.220 --> 0:28:06.179 But this type of anterograde amnesia, the difficulty forming new memories, 0:28:06.359 --> 0:28:09.480 it almost always resolves within a few weeks of completing 0:28:09.520 --> 0:28:10.350 the course of therapy. 0:28:10.660 --> 0:28:10.940 Okay. 0:28:11.350 --> 0:28:13.830 So people are usually able to start forming new memories 0:28:13.910 --> 0:28:17.790 again after they have finished a course of ECT. The 0:28:17.830 --> 0:28:22.090 bigger concern for most people is retrograde amnesia. This is 0:28:22.150 --> 0:28:25.070 the loss of memories of things that happened before the 0:28:25.130 --> 0:28:29.910 ECT procedure. It's usually cited as more recent events. So 0:28:30.070 --> 0:28:32.310 like the last few weeks or months tend to be 0:28:32.330 --> 0:28:34.909 the most affected. Do you remember, Erin, because I know 0:28:34.930 --> 0:28:38.640 you just watched Mad Men recently, but there was Peter 0:28:39.440 --> 0:28:42.320 Campbell was having an affair with Alexis Bledel. 0:28:42.340 --> 0:28:44.160 From Gilmore Girls. From Gilmore Girls. 0:28:44.340 --> 0:28:45.979 Yes. And she like went to him and she's like, 0:28:46.020 --> 0:28:47.479 I just wanted to talk to you because I'm not 0:28:47.520 --> 0:28:50.170 going to remember who you are after this because I'm 0:28:50.210 --> 0:28:51.370 going to go in and have ECT. 0:28:51.390 --> 0:28:51.630 Okay. 0:28:52.200 --> 0:28:53.920 And I thought that was so interesting. And then sure enough, 0:28:53.960 --> 0:28:55.910 she didn't remember him after he went in and she 0:28:55.930 --> 0:28:58.210 was like, oh, who are you? Thanks for coming to visit. 0:28:58.290 --> 0:28:59.650 And she was much better. 0:28:59.670 --> 0:29:01.390 I remember that now. 0:29:01.470 --> 0:29:02.270 Yeah. Yeah. 0:29:02.550 --> 0:29:05.050 And so that's not uncommon that you might have a loss. 0:29:05.130 --> 0:29:07.330 It's usually not a complete loss of like all of 0:29:07.370 --> 0:29:09.770 your memory, but there can be kind of spotty memory loss. 0:29:10.790 --> 0:29:12.990 Usually we say the first few weeks or months, but 0:29:13.090 --> 0:29:18.470 it can go back years. And while for most people... 0:29:18.870 --> 0:29:22.040 these memories will come back or this memory loss will 0:29:22.080 --> 0:29:23.140 resolve over time. 0:29:23.560 --> 0:29:24.580 It doesn't always. 0:29:25.060 --> 0:29:28.600 And for some people, this memory loss can be permanent. 0:29:29.740 --> 0:29:33.480 It's much more common with bilateral treatment rather than unilateral treatment. 0:29:34.010 --> 0:29:36.550 And what's really interesting, especially when you read through some 0:29:36.570 --> 0:29:38.990 of the papers, people have a lot of really strong 0:29:39.050 --> 0:29:42.060 opinions about ECT. I know that you encountered this as well, Erin. 0:29:42.160 --> 0:29:42.440 Yes. 0:29:43.460 --> 0:29:44.900 And you can tell as soon as you start reading 0:29:44.940 --> 0:29:47.280 a paper if this is someone who's like super pro-ECT 0:29:47.400 --> 0:29:51.600 or actually anti-ECT. And I read a paper by someone, 0:29:51.640 --> 0:29:54.860 it was actually a commentary, but it wasn't a peer-reviewed journal, 0:29:54.960 --> 0:29:58.060 but it was by someone who has done ECT research 0:29:58.100 --> 0:30:03.070 for decades, right? So he's very pro-ECT, but he was 0:30:03.310 --> 0:30:07.810 railing against people who were trying to claim that we 0:30:07.990 --> 0:30:10.890 don't have good data, that this permanent memory loss is 0:30:10.950 --> 0:30:11.510 a real thing. 0:30:11.950 --> 0:30:13.630 I think I came across that commentary. 0:30:13.870 --> 0:30:16.390 Yeah, it was a really interesting commentary because I think 0:30:16.430 --> 0:30:19.760 that what's so important about this conversation is when it 0:30:19.800 --> 0:30:21.960 comes to memory loss is that this kind of memory loss, 0:30:22.200 --> 0:30:24.400 even if. 0:30:25.000 --> 0:30:25.740 It's not like your. 0:30:25.640 --> 0:30:29.040 Whole life is being erased, right? It's usually spotty memories, 0:30:29.360 --> 0:30:31.940 but it can be memories of times or places or 0:30:32.000 --> 0:30:34.860 events that were really personally important to you. You might 0:30:34.900 --> 0:30:38.480 not remember your wedding. You might not remember specific events 0:30:38.530 --> 0:30:41.570 that happened or vacations that you took, things that you 0:30:41.710 --> 0:30:45.390 used to remember. And that may or may not be 0:30:45.550 --> 0:30:46.810 really distressing to you. 0:30:46.830 --> 0:30:47.370 Mm-hmm. 0:30:47.700 --> 0:30:49.340 And we don't know for sure if it's going to 0:30:49.380 --> 0:30:50.720 happen or if it's going to come back. 0:30:51.300 --> 0:30:54.020 I think that's sort of what is, you know, when 0:30:54.040 --> 0:30:56.620 you were talking about the procedure and you were talking 0:30:56.680 --> 0:31:02.670 about unilateral versus bilateral application and, you know, language on 0:31:02.690 --> 0:31:06.750 this side versus that, is that we don't fully understand 0:31:07.150 --> 0:31:10.850 why it causes memory loss. And we don't fully understand... 0:31:11.180 --> 0:31:13.500 why it happens to some people and not others to 0:31:13.960 --> 0:31:16.690 then sort of say, well, what's the risk of this 0:31:16.730 --> 0:31:19.850 happening to you? And I was wondering, do you have 0:31:19.990 --> 0:31:22.710 numbers for this? That's a good question. 0:31:22.930 --> 0:31:25.050 I didn't see great numbers on like how many people 0:31:25.090 --> 0:31:29.230 do we expect to have permanent versus temporary memory loss? 0:31:29.310 --> 0:31:31.600 Most of them just say that most people, it's going 0:31:31.620 --> 0:31:33.160 to come back. How much is most? 0:31:33.420 --> 0:31:36.620 Right, right. And I think it's, I mean, it's all 0:31:36.660 --> 0:31:40.400 part of the cost benefit weighing those and saying like, 0:31:41.110 --> 0:31:43.490 If you can't function or if you feel like there's 0:31:43.550 --> 0:31:46.630 no hope left and it seems like pretty likely that 0:31:46.990 --> 0:31:49.950 most people will experience some benefit. It's not guaranteed. 0:31:49.970 --> 0:31:50.450 Yep. 0:31:50.690 --> 0:31:53.790 But we don't know. It's like much harder to articulate. 0:31:53.930 --> 0:31:54.130 Right. 0:31:54.190 --> 0:31:57.070 To like put exact numbers on the chances that you're 0:31:57.090 --> 0:31:59.510 going to have worse side effects, really. 0:31:59.530 --> 0:32:00.320 Yeah. 0:32:00.490 --> 0:32:02.540 And it is one of those situations where we have to, 0:32:02.640 --> 0:32:04.540 like we said in last episode, hold a lot of 0:32:04.640 --> 0:32:06.560 truths that are conflicting all at once. 0:32:06.580 --> 0:32:06.680 Right. 0:32:06.700 --> 0:32:09.970 Right. ECT is one of the most effective treatments that 0:32:10.010 --> 0:32:14.760 we have for severe affective disorders, among other things. And 0:32:15.300 --> 0:32:18.680 we've come so far in how this procedure is done, 0:32:19.380 --> 0:32:22.280 how we do informed consent for it, the safety of 0:32:22.320 --> 0:32:26.570 this procedure. It's incredibly safe. And it has the potential 0:32:26.590 --> 0:32:29.530 for substantial side effects. Yeah. All of that is true 0:32:29.610 --> 0:32:30.410 all at the same time. 0:32:30.470 --> 0:32:31.490 All of these things are true. 0:32:31.790 --> 0:32:31.970 Yeah. 0:32:32.570 --> 0:32:53.210 Yeah. We also don't use it as much as we could. 0:32:53.230 --> 0:32:54.350 Yeah. 0:32:55.190 --> 0:32:59.470 For a lot of reasons. Cost, especially in the U.S. Access, 0:32:59.770 --> 0:33:02.850 especially in the U.S. You're much more likely to get 0:33:02.990 --> 0:33:06.490 access to ECT as an option if you have private 0:33:06.530 --> 0:33:09.610 insurance or Medicare than if you're on Medicaid or Medi-Cal. 0:33:10.090 --> 0:33:13.910 Which is just all medical things in general. It's so 0:33:13.930 --> 0:33:14.370 many things. 0:33:14.470 --> 0:33:14.670 Yeah. 0:33:15.920 --> 0:33:18.010 We don't have really great numbers on like how many 0:33:18.050 --> 0:33:20.690 people really get ECT worldwide every year. But in a 0:33:20.710 --> 0:33:23.670 lot of papers, it'll be like maybe one, one and 0:33:23.690 --> 0:33:27.890 a half, two percent of people with severe depression who 0:33:27.970 --> 0:33:31.990 actually got ECT, which I think is really interesting. Yeah. 0:33:32.110 --> 0:33:36.750 So it's pretty low percentage wise. It's interesting because you mentioned, Erin, 0:33:36.830 --> 0:33:40.840 that in it was the 1950s that it became standard 0:33:40.980 --> 0:33:45.450 to do ECT under anesthesia and with muscle relaxants. But 0:33:45.470 --> 0:33:48.260 there was a paper from 2012 that noted that in 0:33:48.360 --> 0:33:51.740 some parts of the world, ECT is still done what's 0:33:51.760 --> 0:33:55.940 called unmodified. So without anesthesia and without muscle relaxers, which 0:33:55.980 --> 0:33:59.320 I think is really wild because those are totally available. 0:33:59.340 --> 0:34:00.160 Yeah. 0:34:00.540 --> 0:34:03.590 It probably comes down to the lack of availability of anesthesiology. 0:34:04.770 --> 0:34:05.190 I see. 0:34:05.230 --> 0:34:06.550 Is what it probably comes down to. Okay. 0:34:06.570 --> 0:34:06.870 Okay. 0:34:08.190 --> 0:34:09.420 And we also use it. 0:34:09.469 --> 0:34:12.989 I've talked a lot about severe or treatment-resistant depression, but 0:34:13.010 --> 0:34:15.840 we use ECT for a lot of other things as well. 0:34:16.800 --> 0:34:19.940 In bipolar disorder, it's most often used for a depressive episode, 0:34:19.960 --> 0:34:22.820 but it can also sometimes be used for manic episodes 0:34:22.860 --> 0:34:27.060 as well, but less commonly. And it started out, like 0:34:27.100 --> 0:34:31.070 you mentioned, as a treatment for schizophrenia. Yeah. Globally, this 0:34:31.120 --> 0:34:33.969 is probably still the number one indication that ECT is 0:34:34.070 --> 0:34:36.850 used for. But in the U.S., it's much less common 0:34:36.870 --> 0:34:39.670 to use it for schizophrenia or schizoaffective disorder than it 0:34:39.750 --> 0:34:41.410 is for depressive disorders. 0:34:42.910 --> 0:34:43.859 Interesting. 0:34:44.160 --> 0:34:47.960 Except for something called catatonia. Yeah. So I want to 0:34:48.000 --> 0:34:51.360 take a second to talk about catatonia. We should do 0:34:51.400 --> 0:34:52.620 an episode on catatonia, Erin. 0:34:52.920 --> 0:34:55.610 Yeah. We should. There's a lot there. There's a lot. 0:34:55.800 --> 0:34:59.960 But briefly, catatonia is considered a psychomotor condition, meaning there's 0:35:00.000 --> 0:35:02.940 psychological symptoms and then there's actually these motor symptoms that 0:35:02.960 --> 0:35:06.420 we see. It used to be considered just a subset 0:35:06.480 --> 0:35:09.410 of schizophrenia, but it is not by any means a 0:35:09.450 --> 0:35:10.549 subset of schizophrenia. 0:35:10.670 --> 0:35:11.650 It can happen in. 0:35:11.610 --> 0:35:16.950 A pretty wide variety of psychological and neurological conditions. But 0:35:16.969 --> 0:35:21.710 what we see in catatonia is this profound unresponsiveness where 0:35:21.750 --> 0:35:25.089 people are awake, their eyes are open, but they are 0:35:25.210 --> 0:35:29.319 not responsive to the world around them. They're often, they 0:35:29.360 --> 0:35:31.820 don't talk at all. So they have what's considered mutism. 0:35:32.360 --> 0:35:35.060 Or sometimes they'll have something called echolalia, which is this 0:35:35.120 --> 0:35:39.400 like repetitive vocalizations, either repeating specific words or maybe repeating 0:35:39.440 --> 0:35:40.300 a word that you said. 0:35:41.340 --> 0:35:43.280 Their body is very rigid. 0:35:43.620 --> 0:35:47.969 There's something called catalepsy. which is where, and also this 0:35:48.010 --> 0:35:51.129 thing they call waxy flexibility, where you, like, let's say 0:35:51.150 --> 0:35:55.279 that I moved someone's arm into this upright position and 0:35:55.300 --> 0:35:57.640 then I took my hand away, it would just stay there. 0:35:58.940 --> 0:36:02.200 They wouldn't move back down. And so people are very, 0:36:02.280 --> 0:36:06.540 very immobile in this kind of rigid state. And because 0:36:06.620 --> 0:36:10.180 of how immobile and because of how unresponsive people are 0:36:10.260 --> 0:36:14.530 in catatonia, this is a pretty life-threatening condition. People generally 0:36:14.550 --> 0:36:18.540 cannot eat. They're going to have substantial weight loss and malnutrition. 0:36:19.100 --> 0:36:21.759 They're not moving, so they're at risk of developing things 0:36:21.780 --> 0:36:24.420 like pressure ulcers, which of course can get infected and 0:36:24.460 --> 0:36:27.580 cause major problems. And depending on what position they're in 0:36:27.620 --> 0:36:29.549 and how rigid they are, they also can start to 0:36:29.590 --> 0:36:32.770 have like muscle breakdown and things, right? You imagine that 0:36:32.810 --> 0:36:35.390 your muscle is in this contracted position for a really 0:36:35.430 --> 0:36:37.610 long time. You can end up with contractures in the 0:36:37.630 --> 0:36:42.290 long term. Catatonia from any cause can have a mortality 0:36:42.350 --> 0:36:44.510 rate of up to 20% if it's untreated. 0:36:44.790 --> 0:36:45.110 Whoa. 0:36:46.340 --> 0:36:49.239 And there's also a kind of subset of catatonia called 0:36:49.280 --> 0:36:54.180 malignant catatonia and another condition that's life-threatening called NMS or 0:36:54.239 --> 0:36:58.620 neuroleptic malignant syndrome. That is very similar to catatonia, but 0:36:58.700 --> 0:37:03.010 caused by antipsychotic medications or other drugs. And so similarly, 0:37:03.050 --> 0:37:06.390 you have this rigidity, you have this unresponsiveness, but you 0:37:06.530 --> 0:37:11.009 also see fever, tremors, muscle cramps, and it's usually a 0:37:11.030 --> 0:37:15.220 pretty sudden onset. So malignant catatonia, as well as NMS 0:37:15.440 --> 0:37:20.420 and catatonia, regardless of the cause, is another reason that 0:37:20.440 --> 0:37:24.840 we might use ECT. And it's incredibly effective for catatonia. 0:37:25.300 --> 0:37:26.259 Hmm. Yep. 0:37:26.560 --> 0:37:27.640 How effective? 0:37:28.320 --> 0:37:29.640 Oh, I don't have a number on that. 0:37:32.690 --> 0:37:37.010 And again, we don't fully know why. No, we don't 0:37:37.050 --> 0:37:37.520 fully know. 0:37:37.600 --> 0:37:42.020 And it's usually not like first-line therapy for catatonia. It's usually, 0:37:42.239 --> 0:37:46.780 if we've tried other things, usually benzodiazepines are a first-line therapy. 0:37:46.800 --> 0:37:48.900 So that's what we would use to like, which interesting 0:37:48.960 --> 0:37:51.609 is we use it to stop a seizure. But there's 0:37:51.640 --> 0:37:54.969 a lot of things that can cause catatonia. One of 0:37:55.010 --> 0:37:59.069 the things that can cause catatonia quite frequently is NMDA 0:37:59.310 --> 0:38:00.589 receptor encephalitis. 0:38:00.610 --> 0:38:00.690 Okay. 0:38:01.810 --> 0:38:03.290 Many of you might think that you've never heard of 0:38:03.310 --> 0:38:05.070 that because it sounds like a fancy medical word. But 0:38:05.270 --> 0:38:07.230 if you've ever read the book or watched the movie 0:38:07.290 --> 0:38:07.950 Brain on Fire. 0:38:07.969 --> 0:38:08.890 It's great. 0:38:09.469 --> 0:38:14.030 That is an example of NMDA receptor encephalitis. And that 0:38:14.310 --> 0:38:17.590 like 30% of cases can end up with catatonia. And 0:38:17.640 --> 0:38:22.259 while it's first line treated with immunotherapy, in some cases, 0:38:22.500 --> 0:38:26.940 ECT has been used effectively to treat catatonia in those 0:38:26.980 --> 0:38:29.379 cases as well. So kind of just like really bolsters that. 0:38:30.200 --> 0:38:33.739 the use of ECT in all forms of catatonia, which 0:38:33.800 --> 0:38:34.580 is really interesting. 0:38:34.980 --> 0:38:37.500 Maybe this is a bigger question, but ECT never seems 0:38:37.520 --> 0:38:43.430 like a standalone therapy for one condition. It's usually used 0:38:43.610 --> 0:38:45.170 along with a suite of other therapies. 0:38:45.190 --> 0:38:46.350 In combination. 0:38:46.630 --> 0:38:50.450 But are there situations where it is not last resort? 0:38:52.660 --> 0:38:56.910 If it's an emergency... Okay. So something like a catatonia 0:38:57.150 --> 0:38:59.850 or a neuroleptic malignant syndrome, I mean, honestly, even then 0:38:59.870 --> 0:39:01.810 you're going to start with other therapies first. But if 0:39:01.830 --> 0:39:05.790 they're not improving, if someone has really severe treatment-resistant depression 0:39:06.170 --> 0:39:07.590 and they come in and they've had a lot of 0:39:07.650 --> 0:39:12.860 weight loss, they're not eating, they're really severely suicidal or 0:39:12.890 --> 0:39:15.759 something like that, then it might be... But it's kind 0:39:15.780 --> 0:39:17.640 of hard to say that that's really first line, right? 0:39:17.660 --> 0:39:19.560 Because those... Treatment-resistant. 0:39:19.860 --> 0:39:20.260 Exactly. 0:39:20.300 --> 0:39:22.560 They've already gone through so much to get to that point. 0:39:22.660 --> 0:39:22.819 But. 0:39:23.660 --> 0:39:27.739 In 2001, the American Psychiatric Association, I'm going to get 0:39:28.370 --> 0:39:30.969 that acronym wrong, but they... basically came out and they 0:39:30.989 --> 0:39:34.020 were like, ECT should not be last line therapy. ECT 0:39:34.040 --> 0:39:35.960 should not be the thing that we think of when 0:39:36.100 --> 0:39:39.100 everything else has tried and failed so many times. And 0:39:39.180 --> 0:39:41.960 yet still, that's what it often is, which is unfortunate. 0:39:42.360 --> 0:39:42.660 It is. 0:39:42.680 --> 0:39:46.850 I mean, I think it's where like, timeline, the timeline, 0:39:46.890 --> 0:39:50.970 the urgency, the severity all are kind of weighed within this. 0:39:51.310 --> 0:39:55.230 Catatonia is interesting because the person is non-responsive and so, 0:39:55.270 --> 0:39:58.970 but there's still an informed consent process. Can you tell 0:39:59.010 --> 0:40:00.259 me what that's like? 0:40:00.510 --> 0:40:06.600 Yeah, it's, it is an interesting, for all of the 0:40:06.620 --> 0:40:08.860 cases that we're going to use ECT, I think that 0:40:08.880 --> 0:40:12.100 the informed consent process is a really interesting and incredibly 0:40:12.160 --> 0:40:15.850 important part of that process. Because even if someone is 0:40:15.969 --> 0:40:18.089 not so severe that they have catatonia where they're not 0:40:18.130 --> 0:40:21.390 responding at all, but even if they have really severe depression, 0:40:22.430 --> 0:40:28.170 their sickness, their illness is causing them to not care 0:40:28.450 --> 0:40:30.950 in many cases about getting better, right? 0:40:30.969 --> 0:40:31.489 Yeah. 0:40:31.790 --> 0:40:34.250 And not always, that's not, it's a generalization, but that 0:40:34.310 --> 0:40:36.509 like that is part of the nature of so many 0:40:36.610 --> 0:40:40.029 of these disorders. So the informed consent process is quite 0:40:40.070 --> 0:40:43.180 long and detailed. If someone is not able to make 0:40:43.219 --> 0:40:45.900 decisions for themselves, and this is actually true for all procedures, 0:40:45.980 --> 0:40:48.719 not just ECT, but then we have what's called a 0:40:48.739 --> 0:40:51.259 surrogate decision maker. And so you have to identify who 0:40:51.300 --> 0:40:54.260 that person is. Is it their spouse? Is it their parent? 0:40:54.960 --> 0:40:57.420 Is it someone that they have designated as their healthcare 0:40:57.440 --> 0:40:59.180 power of attorney, which is so important that everyone has 0:40:59.200 --> 0:41:01.020 a healthcare power of attorney to make your decisions if 0:41:01.060 --> 0:41:04.550 you can't make decisions for yourself? But that's really extra important. 0:41:04.710 --> 0:41:08.210 And family and or friends or whoever those people are, 0:41:08.350 --> 0:41:13.150 are usually always involved in the ECT process, even if someone, 0:41:13.330 --> 0:41:16.270 you know, is able to respond. It's usually recommended that 0:41:16.320 --> 0:41:19.040 it's kind of everyone is on board with this. But 0:41:19.200 --> 0:41:21.339 of course, in the case of catatonia or when someone 0:41:21.380 --> 0:41:23.460 is unresponsive, then yes, it's someone else who is going 0:41:23.480 --> 0:41:26.700 to be going through that informed consent process for them. Okay. 0:41:27.219 --> 0:41:27.500 Okay. 0:41:27.700 --> 0:41:32.299 Yeah. So yeah, Erin, that is what we know. about 0:41:32.380 --> 0:41:36.000 ECT and how it works. And I ended with talking 0:41:36.040 --> 0:41:40.880 about ECT in catatonia and NMDA receptor encephalitis because now 0:41:40.900 --> 0:41:45.650 we get to pause and be joined by Dr. Leonardo Lopez, 0:41:45.850 --> 0:41:50.069 who is an expert in ECT, including in the use 0:41:50.150 --> 0:41:55.110 of ECT for catatonia, including in cases of NMDA receptor encephalitis. 0:41:55.190 --> 0:41:57.549 And I am really excited to be joined by him. 0:41:58.290 --> 0:41:59.700 So let's go. Let's go. 0:42:29.460 --> 0:42:29.680 Dr. 0:42:29.739 --> 0:42:32.390 Lopez, thank you so much for joining us today. We're 0:42:32.430 --> 0:42:33.070 really excited. 0:42:33.090 --> 0:42:33.739 My pleasure. 0:42:33.950 --> 0:42:36.660 Could you give us a sense of how you use 0:42:36.780 --> 0:42:40.359 ECT in your practice, some of the diverse applications that 0:42:40.380 --> 0:42:41.500 you use ECT for? 0:42:42.719 --> 0:42:47.140 Sure, absolutely. So we use ECT for a variety of illnesses, 0:42:47.480 --> 0:42:52.160 largely illnesses that have traditionally been considered psychiatric, although there 0:42:52.200 --> 0:42:55.790 are other conditions that are sort of in a more 0:42:56.050 --> 0:42:59.350 liminal space that we also use ECT for. The most 0:42:59.390 --> 0:43:02.840 common indication is for treatment-resistant depression, patients who have depression 0:43:02.860 --> 0:43:08.350 and have received medication for depression therapy and have not 0:43:08.410 --> 0:43:12.120 responded and remain ill. And then there are a variety 0:43:12.160 --> 0:43:15.180 of others. So we use it for bipolar disorder, both 0:43:15.300 --> 0:43:19.270 in the depressed phase and the manic phase. We use 0:43:19.330 --> 0:43:22.669 it for what's called psychotic depression, which is a form 0:43:22.690 --> 0:43:27.430 of depression where patients also have delusions and or hallucinations. 0:43:28.290 --> 0:43:31.810 We use it in schizophrenia, particularly in patients who have 0:43:31.890 --> 0:43:36.219 not responded to treatment with antipsychotics or who cannot tolerate them. 0:43:37.120 --> 0:43:41.759 Then we use it in catatonia, which is a neuropsychiatric 0:43:41.800 --> 0:43:46.689 condition characterized by changes in speech and motor behavior that 0:43:46.790 --> 0:43:49.730 sort of spans a number of diagnoses. So it can 0:43:49.930 --> 0:43:54.580 occur with schizophrenia, depression, bipolar disorder, but can also occur 0:43:54.600 --> 0:43:59.630 with in a variety of medical illnesses, including autoimmune diseases 0:43:59.730 --> 0:44:05.450 like lupus, autoimmune encephalitis, and a variety of other neuropsychiatric conditions. 0:44:05.910 --> 0:44:07.919 Those are the most common indications. There are other things 0:44:07.980 --> 0:44:10.779 that we do use it for outside of the psychiatric realm. 0:44:10.880 --> 0:44:15.140 For example, it can be used to treat super refractory 0:44:15.239 --> 0:44:20.120 status epilepticus when patients are seizing continuously and are on 0:44:20.219 --> 0:44:22.770 high doses of antiepileptic drugs, and yet their seizures have 0:44:22.810 --> 0:44:27.190 not been brought under control. But its most common usage 0:44:27.390 --> 0:44:30.450 is in what's now considered the psychiatric realm. 0:44:31.530 --> 0:44:35.270 How much at the hospitals or hospital that you work 0:44:35.290 --> 0:44:38.790 in patient volumes are you seeing? Is it sort of 0:44:38.989 --> 0:44:41.739 an everyday practice for you or kind of how common 0:44:41.800 --> 0:44:43.800 is it that you're using ECT? 0:44:44.660 --> 0:44:47.400 It's very common where we work. It's an everyday practice 0:44:47.640 --> 0:44:52.510 for us. We are scheduled three days a week, although 0:44:52.530 --> 0:44:56.370 I oversee services at two different hospitals, and the days 0:44:56.410 --> 0:44:59.640 are different, so it ends up being a five-day-a-week practice. 0:45:00.390 --> 0:45:04.380 I can tell you that the average patient will receive 0:45:04.380 --> 0:45:09.060 10 to 12 treatments, some more, some fewer. And a 0:45:09.140 --> 0:45:15.730 given year, we perform... in excess of 6,000 treatments between 0:45:15.750 --> 0:45:20.810 the two hospitals that I oversee. So quite frequent. On 0:45:20.850 --> 0:45:25.330 a given day, we might treat anywhere between 25 and 0:45:25.330 --> 0:45:29.510 30 patients at one campus, depending. That includes both patients 0:45:29.530 --> 0:45:33.750 who are hospitalized for psychiatric reasons and patients who are 0:45:33.790 --> 0:45:38.779 coming in from home and receiving either maintenance treatment, meaning 0:45:38.890 --> 0:45:41.279 they've responded to the treatment previously and they're receiving it 0:45:41.320 --> 0:45:44.640 to prevent relapse, or they're ill but not enough to 0:45:44.719 --> 0:45:47.180 be in the hospital, and so they're brought in from 0:45:47.239 --> 0:45:51.549 home for treatment there. also occasionally includes patients who are 0:45:51.630 --> 0:45:55.230 hospitalized on medical floors rather than psychiatric floors in the hospital, 0:45:55.290 --> 0:45:59.109 and occasionally patients who are in the intensive care unit. 0:46:00.110 --> 0:46:03.560 In the firsthand account that you shared of that young 0:46:03.719 --> 0:46:07.260 child with anti-NMDA receptor encephalitis, I mean, there was clearly 0:46:07.360 --> 0:46:11.100 such a profound impact. And throughout the episodes, we have 0:46:11.140 --> 0:46:14.980 discussed how effective ECT has been and shown to be 0:46:15.000 --> 0:46:19.210 in treating a multitude of conditions, And yet there is 0:46:19.290 --> 0:46:22.850 so much resistance. Of course, there's like from the general 0:46:22.890 --> 0:46:25.689 public side of things, the fear and the stigma and misinformation. 0:46:26.190 --> 0:46:29.950 But even among medical fields, there seems to be kind 0:46:29.969 --> 0:46:33.240 of a divide or a reluctance. How do you think 0:46:33.300 --> 0:46:37.839 the perception of ECT across different fields of medicine contributes 0:46:37.920 --> 0:46:39.460 to its underutilization? 0:46:39.480 --> 0:46:44.140 Mm-hmm. I think that insofar as there's reluctance in other 0:46:44.180 --> 0:46:46.680 medical fields to think about or use ECT, which I 0:46:46.700 --> 0:46:51.239 think there is, it largely stems from a lack of exposure. 0:46:51.570 --> 0:46:54.830 If people have not seen patients treated with ECT, both 0:46:54.850 --> 0:46:58.410 just witnessed the procedure with their own eyes and seen 0:46:58.450 --> 0:47:02.509 the progression of the patient when they're treated. Then the 0:47:02.550 --> 0:47:04.469 only exposure they have to it is, you know, in 0:47:04.510 --> 0:47:09.089 a textbook in medical school or the many, many depictions 0:47:10.010 --> 0:47:12.630 that they see in the media and all their medical professionals. 0:47:12.650 --> 0:47:16.799 And they know those those depictions are often inaccurate. Still, 0:47:16.820 --> 0:47:19.960 they leave a mark, right? They leave an impression. 0:47:19.980 --> 0:47:21.520 I think what we. 0:47:21.480 --> 0:47:26.000 Find is that when we have a colleague in another 0:47:26.480 --> 0:47:30.420 discipline with whom we're collaborating and treating their patient, and 0:47:30.700 --> 0:47:34.980 they see the procedure and see how unremarkable, it appears, 0:47:35.480 --> 0:47:41.640 and also see the development, then they become converted, if 0:47:41.660 --> 0:47:44.190 you will, to the utility of the treatment very quickly. 0:47:44.210 --> 0:47:47.410 So most of this is about exposure, I think. The 0:47:47.469 --> 0:47:52.410 more that we're able to show our colleagues in other 0:47:52.469 --> 0:47:56.210 fields the value of this treatment, the more they support it. 0:47:56.230 --> 0:47:58.140 I think that's been a big reason why we have 0:47:58.180 --> 0:48:03.390 tried at my hospital to sort of be very forward-facing 0:48:03.410 --> 0:48:05.730 with other departments, with, as I mentioned before, with the ICUs, 0:48:06.610 --> 0:48:09.390 with the pediatrics department who took care of this patient, 0:48:09.790 --> 0:48:12.840 with the medicine department, and try to get them involved 0:48:12.880 --> 0:48:15.580 and show them, you know, what it is we can do, 0:48:16.340 --> 0:48:19.520 because we need as much support as we can get 0:48:19.840 --> 0:48:22.569 to make this treatment available to all the people who 0:48:22.590 --> 0:48:23.310 could benefit from it. 0:48:23.760 --> 0:48:26.190 Kind of along those lines, you know, whether it's sort 0:48:26.210 --> 0:48:30.660 of availability or the procedure itself, what do you see 0:48:30.800 --> 0:48:34.140 as maybe some of the biggest limitations that are facing 0:48:34.160 --> 0:48:35.390 ECT today? 0:48:36.360 --> 0:48:40.609 I think the biggest limitation is access to treatment without question. Obviously, 0:48:42.830 --> 0:48:45.990 maybe that sounds contradictory given the numbers I gave you earlier. 0:48:46.010 --> 0:48:48.790 I think we've worked very hard at our institution to 0:48:48.870 --> 0:48:52.689 establish access to treatment because we really believe in this therapy. 0:48:53.210 --> 0:48:58.160 But nationally, it is not easy to find ECT providers. 0:48:58.860 --> 0:49:02.719 It's not easy if you can find one. To find 0:49:02.880 --> 0:49:05.280 one who can do it at the sort of large 0:49:05.340 --> 0:49:08.739 scale that's sometimes required, given the number of patients that 0:49:08.760 --> 0:49:11.780 can benefit from it. And then there are a variety 0:49:11.820 --> 0:49:15.089 of sort of specialty areas. For example, as we may 0:49:15.110 --> 0:49:17.029 get to down the road, there are more and more 0:49:17.070 --> 0:49:22.160 patients in the pediatric population with osteoporosis. with autoimmune encephalitis 0:49:22.239 --> 0:49:25.530 being identified as catatonic. And there's much less experience even 0:49:25.570 --> 0:49:28.630 in the ECT community treating those patients than there is 0:49:28.690 --> 0:49:33.830 treating adults. So finding someone who can provide this treatment. 0:49:34.840 --> 0:49:35.509 Is very difficult. 0:49:35.550 --> 0:49:38.690 I think the patient with autoimmune encephalitis who may have 0:49:38.710 --> 0:49:41.370 mentioned came from out of state and we've had numerous 0:49:41.410 --> 0:49:46.029 patients come, particularly pediatric patients come to us, although not exclusively, 0:49:46.090 --> 0:49:48.970 also adult patients come to us from out of state 0:49:49.350 --> 0:49:52.819 simply because they could not find the treatment readily available 0:49:52.840 --> 0:49:55.120 in their area or they could not find treaters with 0:49:55.160 --> 0:49:58.319 experience in their area. So to me, that's the biggest barrier. 0:50:00.260 --> 0:50:04.010 And there are a variety of reasons why that's the case, 0:50:04.270 --> 0:50:05.990 but we need to overcome that first. 0:50:07.390 --> 0:50:11.049 So looking to the future now, I'm guessing that one 0:50:11.070 --> 0:50:13.779 of the things you hope to see is increased availability, 0:50:13.840 --> 0:50:16.640 increased access. What are some of your other hopes for 0:50:16.660 --> 0:50:18.989 the future of ECT, say, in the next, you know, 5, 10, 0:50:18.969 --> 0:50:19.320 15 years? 0:50:19.340 --> 0:50:19.410 Yes. 0:50:21.550 --> 0:50:26.049 Oh, I have so many. So, yes, certainly access is 0:50:26.090 --> 0:50:28.870 a big one. And, you know, we take great pride 0:50:29.090 --> 0:50:30.750 in being able to bring patients in from out of 0:50:30.810 --> 0:50:33.509 state and treat them. But of course, it would be 0:50:33.550 --> 0:50:36.110 better if they didn't have to travel for treatment and 0:50:36.130 --> 0:50:38.260 they could just receive treatment at home. So I think 0:50:38.300 --> 0:50:42.020 that's the biggest one. I would like to see more 0:50:42.620 --> 0:50:46.650 acceptance and engagement around the use of ECT. Outside of 0:50:46.670 --> 0:50:52.310 the psychiatric community, the medical, pediatric, critical care communities often 0:50:52.350 --> 0:50:54.870 take care of catatonic patients because they can't be taken 0:50:54.890 --> 0:50:58.030 care of in a psychiatric setting or because their catatonia 0:50:58.070 --> 0:51:02.529 is not due to a psychiatric illness. And those are 0:51:02.570 --> 0:51:05.879 patients that often, even if they're in a place where 0:51:05.910 --> 0:51:09.050 ECT is accessible, do not receive it simply because there's 0:51:09.090 --> 0:51:11.520 not the knowledge or comfort on the part of their 0:51:11.739 --> 0:51:17.600 primary teams taking care of them. More spreading of knowledge 0:51:17.620 --> 0:51:20.680 to those communities and also more spreading of knowledge by 0:51:20.739 --> 0:51:24.440 those communities, more advocacy from those communities, which I think 0:51:24.460 --> 0:51:28.160 we have started to see, particularly in pediatrics in the 0:51:28.180 --> 0:51:30.610 last few years. I'd, of course, like to see a 0:51:30.890 --> 0:51:35.290 greater understanding of mechanism. I think we have a much 0:51:35.350 --> 0:51:39.830 better understanding of what ECT does to the brain than 0:51:39.870 --> 0:51:42.840 we did 10 or 20 years ago at this point. 0:51:43.410 --> 0:51:47.370 But still, we can't say with great certainty why it works. 0:51:47.390 --> 0:51:50.489 And in fact, we can't say that the reason it 0:51:50.510 --> 0:51:52.910 works for depression is the same reason that it works 0:51:52.969 --> 0:51:55.410 for catatonia or the same reason it works for psychosis. 0:51:55.880 --> 0:51:58.620 It's a global treatment, so it may have different effects 0:51:58.840 --> 0:52:02.379 on different illnesses, and we don't understand that. So I'd 0:52:02.400 --> 0:52:06.060 certainly like us to make progress in that area. 0:52:06.800 --> 0:52:10.890 It is such an incredible... therapy to think about this 0:52:10.969 --> 0:52:15.630 is one of our oldest somatic therapies in psychiatry. It's 0:52:15.690 --> 0:52:19.740 still around today and there's so much misinformation surrounding it. 0:52:19.810 --> 0:52:21.890 And so I think that it has been a real 0:52:21.910 --> 0:52:25.660 eye-opening experience to kind of get to research these two episodes, 0:52:25.719 --> 0:52:27.819 to get to chat with you and hear about all 0:52:27.840 --> 0:52:31.719 of the different applications of ECT. So yeah, thank you 0:52:31.780 --> 0:52:34.560 so much for taking the time. Yeah, thank you so much. 0:52:35.110 --> 0:52:37.759 It's my pleasure. I think I appreciate it more than 0:52:38.110 --> 0:52:41.840 you guys do, because we need every outlet we can 0:52:41.900 --> 0:52:47.980 to give real positive and fact-based information to the public, 0:52:48.880 --> 0:52:51.560 because there is so much information given to the public 0:52:51.600 --> 0:52:55.250 that's not reliable. And sometimes that drowns out our voices. 0:52:55.450 --> 0:52:58.049 So very grateful to you guys for having me on. 0:53:21.770 --> 0:53:25.250 That was so great. Thank you so much, Dr. Lopez, 0:53:25.290 --> 0:53:28.430 for taking the time to chat with us. Yeah. So informative. 0:53:28.550 --> 0:53:31.570 And sharing all of your expertise. It really makes a 0:53:31.610 --> 0:53:34.020 huge difference to have someone who really knows. 0:53:34.080 --> 0:53:38.259 We try our best, but let's be honest. We try. 0:53:38.380 --> 0:53:38.739 We try. 0:53:38.780 --> 0:53:42.940 But it really does help. That was fascinating. You know, Erin, 0:53:42.980 --> 0:53:45.410 I had like one last quick question. Of course you do. 0:53:45.420 --> 0:53:49.020 Because I know that ECT is often mentioned alongside other 0:53:49.040 --> 0:53:50.760 therapies that are similar. 0:53:50.780 --> 0:53:50.860 Yeah. 0:53:51.440 --> 0:53:55.160 Like TMS. TMS. Do you have like a brief little 0:53:55.480 --> 0:53:56.230 blurb about it? 0:53:56.239 --> 0:53:58.080 You know I do, Erin, because you know I know 0:53:58.100 --> 0:53:59.299 what questions you're going to ask. 0:53:59.360 --> 0:54:01.259 It's true. It's true. I know your brain. 0:54:01.890 --> 0:54:07.790 So yes, TMS, or transcranial magnetic stimulation... is the other 0:54:07.830 --> 0:54:09.589 thing that people often talk about when they're talking about 0:54:09.670 --> 0:54:14.540 ECT for especially affective disorders like depression. Technically, it's RTMS 0:54:14.560 --> 0:54:18.240 because it's repetitive TMS, but that's neither here nor there. Basically, 0:54:18.320 --> 0:54:23.219 this uses electromagnetic stimulation. So using a really strong magnet 0:54:23.500 --> 0:54:26.830 to generate a magnetic field that's able to then induce 0:54:26.930 --> 0:54:30.470 an electric field in our brains and depolarize our neurons. 0:54:30.790 --> 0:54:33.069 In some way, that's kind of the same thing that 0:54:33.090 --> 0:54:36.069 we're doing with ECT, just using a magnet. Yeah. Which 0:54:36.150 --> 0:54:38.430 means that the electric field that it's generating is not 0:54:38.590 --> 0:54:41.700 nearly as strong as it is in ECT, which means 0:54:41.760 --> 0:54:44.180 it does not stimulate a seizure. 0:54:44.200 --> 0:54:45.719 Okay. 0:54:46.739 --> 0:54:50.460 What's interesting is they usually do it, they stimulate muscle 0:54:50.480 --> 0:54:53.319 contraction of the thumb, and that's how they know that 0:54:53.340 --> 0:54:55.540 they're in the right spot and doing the right thing. 0:54:56.160 --> 0:54:57.220 Isn't that interesting? 0:54:57.360 --> 0:55:00.100 One of the big benefits, though, of TMS compared to 0:55:00.140 --> 0:55:03.040 ECT is that the risk of cognitive effects like memory 0:55:03.080 --> 0:55:05.880 loss is substantially lower. We basically don't see it. We 0:55:05.920 --> 0:55:07.930 don't see the same types of amnesia that we see 0:55:07.950 --> 0:55:11.629 with ECT. However, most of the data does suggest that 0:55:11.690 --> 0:55:15.210 while it is probably effective and more effective than placebo, 0:55:15.330 --> 0:55:19.050 it is still not as effective as ECT in terms 0:55:19.190 --> 0:55:22.969 of remission and response, especially for depressive disorders, which is 0:55:23.030 --> 0:55:26.100 mostly what we're using TMS for. Okay. There's also sometimes 0:55:26.140 --> 0:55:28.540 people will talk about other things like DBS or deep 0:55:28.560 --> 0:55:31.920 brain stimulation or VNS, which is vagal nerve stimulation. These 0:55:31.960 --> 0:55:34.320 are things that we mostly use for either like Parkinson's 0:55:34.340 --> 0:55:36.860 in the case of DBS or refractory epilepsy in the 0:55:36.880 --> 0:55:40.540 case of VNS. But these like require the implantation of devices. 0:55:40.719 --> 0:55:44.319 And so those are kind of different. And then there's 0:55:44.360 --> 0:55:49.500 also interest in actually using magnetic stimulation to induce seizures 0:55:50.239 --> 0:55:54.160 to see if that somehow by using magnets to induce 0:55:54.180 --> 0:55:57.529 the electric field And then also get the seizure, which 0:55:57.570 --> 0:55:59.680 we know is the main thing that's giving us benefit 0:55:59.700 --> 0:56:03.520 in ECT. Does that have less memory effects? But as 0:56:03.540 --> 0:56:04.759 far as I could tell, that's still just in the 0:56:04.800 --> 0:56:07.690 research realm. So we don't have like availability of that yet. 0:56:08.230 --> 0:56:10.089 Okay. It's a great question though. And do you know what? 0:56:10.650 --> 0:56:13.090 People might have so many more questions after this, and 0:56:13.130 --> 0:56:14.529 I can tell you where to learn more. 0:56:14.550 --> 0:56:15.650 Tell us, tell us. 0:56:16.010 --> 0:56:18.529 A book that I actually loved so much, which was 0:56:18.570 --> 0:56:24.100 by Kellner from 2012. It was called Brain Stimulation in Psychiatry, ECT, DBS, TMS, 0:56:24.160 --> 0:56:28.640 and Other Modalities. It was a very comprehensive book. Really 0:56:28.680 --> 0:56:32.930 loved it. There was also, honestly, there was so many papers. 0:56:33.310 --> 0:56:35.150 One by Merkel et al. from 2009 called. 0:56:37.380 --> 0:56:42.320 Antidepressant Electroconvulsive Therapy, Mechanism of Action, Recent Advances and Limitations. 0:56:43.030 --> 0:56:44.750 Another one by Kritzer et al from 2023, so much 0:56:44.770 --> 0:56:49.160 more recent. An Electroconvulsive Therapy Mechanism of Action, Clinical Considerations, 0:56:49.200 --> 0:56:52.180 and Future Directions. Honestly, I have a very, very, very 0:56:52.219 --> 0:56:52.660 long list. 0:56:52.860 --> 0:56:54.739 I'm sure that you do. So I'm not going to 0:56:54.760 --> 0:56:55.020 read them. 0:56:54.980 --> 0:56:57.600 All, but you can find them all on our website, thispodcastwillkillyou.com, 0:56:57.640 --> 0:56:59.120 where you can find the list of sources from this 0:56:59.160 --> 0:57:00.529 episode and every one that we've ever done. 0:57:00.870 --> 0:57:04.430 Yes. A big thank you again to Dr. Leonardo Lopez. 0:57:04.510 --> 0:57:07.670 That was so helpful, so wonderful. And check out the 0:57:07.690 --> 0:57:10.110 Advances in Care episode if you want to hear more 0:57:10.210 --> 0:57:13.560 about that story of the NMDA receptor encephalitis and ECT. 0:57:13.570 --> 0:57:18.750 Yeah. Thank you to Bloodmobile for providing the music for 0:57:18.830 --> 0:57:19.890 this episode and all. 0:57:19.790 --> 0:57:23.950 Of our episodes. Yes, thank you. Thank you to Liana 0:57:24.050 --> 0:57:27.070 and Mark and Jess and Pete and everyone at Exactly 0:57:27.130 --> 0:57:30.580 Right who helps make this podcast happen. We really appreciate it. 0:57:30.580 --> 0:57:32.419 We couldn't do it without you. And we also couldn't 0:57:32.460 --> 0:57:34.280 do it without you, listeners and watchers. 0:57:35.020 --> 0:57:37.340 So thank you. Thank you. Literally, thank you so much. 0:57:37.640 --> 0:57:37.980 Truly. 0:57:38.220 --> 0:57:41.080 Really, truly. It's, yeah, you let us keep making this. 0:57:41.200 --> 0:57:42.760 We'll keep making it as long as we can. 0:57:43.010 --> 0:57:43.230 Yes. 0:57:43.510 --> 0:57:46.410 And thank you to our wonderful, generous patrons. We truly 0:57:46.470 --> 0:57:48.530 appreciate your support. It means everything. 0:57:48.550 --> 0:57:49.010 It does. It does. 0:57:50.060 --> 0:57:52.570 Well, until next time, wash your hands. 0:57:52.690 --> 0:57:53.540 You filthy animals.