Technical, Clinical Advances Make ECT Safe, More Effective for More Patients

Electroconvulsive therapy (ECT) should be regarded as a valuable treatment for severe major depression based on severity of illness, “not just because all other treatments have failed,” said Charles Kellner, M.D., the chief of electroconvulsive therapy at New York Community Hospital, Brooklyn, during a workshop Saturday at APA’s fall meeting IPS: The Mental Health Services Conference in New Orleans.

Technical and clinical advances have vastly improved the effectiveness and tolerability of ECT for patients with severe depression, and research is now beginning to elucidate how ECT works, he said. Kellner was joined at the session by Robert Greenberg, M.D., chief of geriatric psychiatry at New York University Langone Health, Brooklyn Campus; Adriana Hermida, M.D., of Emory University School of Medicine; and Robert Cotes, M.D., associate director of psychiatry residency education at Emory.

Advances in ECT include technical improvements such as the development of ultra-brief pulse wave ECT. This type of ECT has been shown to substantially diminish the risk of cognitive effects, the biggest fear among patients and family members regarding the treatment. “Modern ECT causes far less retrograde amnesia [than in the past],” Kellner said. “For seriously depressed patients, [concern about this side effect] should not be a deal-breaker.”

Despite improvements in ECT technology and evidence of the effectiveness of the therapy, Kellner told session attendees that the “biggest obstacle to the use of ECT are reservations about the treatment that cannot be explained [rationally].”

Kellner noted that allowing family members to be present for administration of ECT is an important way to diminish stigma about the treatment. “For many family members it is beneficial for them to stay in the treatment suite for the entire procedure,” Kellner said. “Family members are relieved to see that ECT is banal, quick, smooth, and safe.”

Kellner added that there have been new diagnostic indications for ECT, such as for treatment of self-injurious behavior related to autism. He added that the Centers for Medicare and Medicaid Services (CMS) is considering approval of a code for use of ECT in ambulatory surgical centers. “If that becomes available, it will be a major breakthrough for ECT access,” Kellner said.

Look for further coverage of IPS: The Mental Health Services conference in Psychiatric News.

Pfister Award Winner Describes Brief Psychotherapy Modules for Hope in the Midst of Demoralization

Hope is a natural antidote to despair and demoralization experienced by psychiatric patients that can be encouraged and supported through brief “hope” interventions that can be employed in crisis situations, according to James L. Griffith, M.D. Griffith delivered APA’s 2017 Oskar Pfister Award lecture today at IPS: The Mental Health Services Conference in New Orleans.

Griffith, the chair of psychiatry at George Washington University (GWU) School of Medicine, described his work developing brief intervention modules that help patients practice hope in demoralizing life situations and that can be taught to trainees and other mental health clinicians. His work on the subject was published in an article in Academic Psychiatry (July 2017).

“Despair from demoralization is a constant threat to patients with chronic mental illnesses, refugees fleeing persecution, elderly who are socially isolated, the medically disabled, and other marginalized or displaced people,” Griffith said.

Griffith said that he and his colleagues have identified 14 discrete psychotherapeutic practices, or interventions, in the psychotherapy literature that foster hope in patients. These practices correspond to one of four types of coping (problem solving and goal seeking, activating a core identity, emotion regulation, and relational coping) that clinicians can use depending on the strengths of the specific patient. Moreover, they can be employed in a crisis situation without formal psychotherapeutic training.

He described several clinical vignettes in which the “hope” modules were employed to meet and challenge the demoralizing life situations faced by individual patients. For instance, he described a suicidal patient in despair because her house was being foreclosed, and her dog—a companion of many years—had recently died.

A second-year resident at GWU, with no formal training in psychotherapy, asked the patient, “In the past when you faced adversity, what did you do?” The patient recalled when her father, on his deathbed, told her she “was a strong fighter” and the “glue that held the family together.”

These were affirmations that drew on this patient’s strength, activating her core identity. The resident advised the patient to find a picture of her father and look to it whenever she felt despair. The resident also advised the patient to reach out to her children. These actions began a process of rebuilding the patient’s sense of self-efficacy and control over her own fate.

Griffith said that to design psychotherapeutic interventions that help people practice hope, they must be usable in the real-life conditions in which patients find themselves. 

“They must be usable under the often-chaotic conditions of refugee life, homelessness, poverty, or medical or psychiatric illness where a clinician may have only one or two conversations in settings ill-suited for psychotherapy,” he said.

Look for further coverage of IPS: The Mental Health Services conference in upcoming editions of Psychiatric News.

(Image: Ellen M. Dallager)