From the Editor
He has tried different medications, and yet he continues to struggle. The months have turned into years. When he was last well, he worked two jobs and was physically active, hoping to run the Boston marathon one day. When I saw him, he explained that he has difficulty following the plot of a TV show. Asked if he had ever considered ECT, his eyes widened. “They still do that?”
In the first selection, we look at a new review paper on ECT from The New England Journal of Medicine. Drs. Randall T. Espinoza (of the University of California, Los Angeles) and Charles H. Kellner (of the Medical University of South Carolina) provide a concise summary of the latest evidence. They conclude: “ECT is a valuable treatment for several severe psychiatric illnesses, particularly when a rapid response is critical and when other treatments have failed.” We consider the paper and the ongoing stigma associated with the treatment.
In the second selection, Joseph R. Friedman and Dr. Helena Hansen (both of the University of California, Los Angeles) draw on American data to consider overdose deaths and ethnicity. The JAMA Psychiatry paper concludes: “In this cross-sectional study, we observed that Black individuals had the largest percentage increase in overdose mortality rates in 2020, overtaking the rate among White individuals for the first time since 1999, and American Indian or Alaska Native individuals experienced the highest rate of overdose mortality in 2020 of any group observed.”
And in the third selection, Neil Seeman (of the University of Toronto) considers the life and death of his father, Dr. Philip Seeman, the celebrated scientist who studied schizophrenia. In this CMAJ essay, he comments on dopamine and his father’s life work. And he also writes about his relationship and dying. “It was that giving ice chips to my father will forever remind me of how the sensation of touch can stir love, fetch memories, and offer solace.”
Selection 1: “Electroconvulsive Therapy”
Randall T. Espinoza and Charles H. Kellner
The New England Journal of Medicine, 17 February 2022
Electroconvulsive therapy (ECT) has been an essential treatment for severe mood and psychotic disorders for many decades, and its use is supported by evidence of efficacy and safety. This brief review discusses current indications for ECT and recent advances in treatment. Over the past 15 years, new treatments – for example, vagus-nerve stimulation, transcranial magnetic stimulation, and intranasal administration of esketamine – have been approved for use in depression. Trials comparing new treatments directly with ECT have been inadequate, and none of these approaches have been considered a replacement for ECT in severely depressed and certain psychotic patients.
So begins a paper by Drs. Espinoza and Kellner.
Here are five key take-aways.
“Studies have indicated that the use of ECT results in a decreased risk of suicide, improved functional outcomes and quality of life, and decreased rates of rehospitalization. In specific populations, ECT can rapidly ameliorate depressive, psychotic, and catatonic symptoms and can decrease suicidal drive. Trials of ECT for major depressive disorder in patients with treatment-resistant depression have shown pooled response rates of 60 to 80% and pooled remission rates of 50 to 60%. High rates of response to ECT have been reported in patients with psychotic depression or catatonia. In a study involving patients with treatment-resistant schizophrenia, ECT efficacy rates ranged from 40 to 70%, and in some Asian countries, the primary indication for ECT is schizophrenia.”
“A study has shown that ECT has been underused. Furthermore, ECT is less accessible to uninsured or underinsured patients and those receiving care in public hospitals than to other patient populations, it has been underused in some large health care systems, it has been limited to inpatient settings, and it is less accessible to minority racial or ethnic groups than to other groups.”
“The estimated mortality with ECT is approximately 2.1 deaths per 100,000 treatments. The most frequent complications are acute cardiopulmonary events, which have been estimated to occur in less than 1% of treatments… Serious adverse events associated with ECT, which are rare, include cardiac arrhythmias with or without hemodynamic changes, respiratory distress, prolonged apnea, aspiration, prolonged paralysis, and prolonged seizures. Common but minor side effects include headache, jaw soreness, myalgias, postprocedure nausea and vomiting, and fatigue, all of which are self-limited or require only symptomatic treatment.”
On Cognitive Effects
“Greater cognitive impairment has been associated with bilateral electrode placement, a larger number of treatments, and a higher stimulus charge, and less impairment has been associated with right unilateral electrode placement, ultrabrief pulse widths, and shorter treatment courses. It has not been possible to predict how an individual patient may be affected, but most patients have mild or moderate cognitive side effects, which usually resolve within days to weeks after the completion of the ECT course.”
They also comment on dementia: “In a Danish National Patient Registry cohort study involving 168,015 patients with depression, of whom 3.1% had at least one ECT treatment, over a median follow-up of 4.9 years, ECT was not associated with an increased risk of incident dementia.”
“Sensationalist media portrayals, lack of knowledge among physicians about contemporary techniques of ECT, fear of electricity, and concern about memory effects have all contributed to the stigmatization of ECT.”
This review is excellently written and worth reading even for physicians who don’t generally prescribe the treatment.
The British Journal of Psychiatry has a paper and a commentary on ECT in the March issue. Dr. Joel Paris (of McGill University) notes the ongoing stigma and urges us to address it: “For now, psychiatrists will bear the responsibility to educate patients who suffer from severe forms of depression, as well as their family members, about a full range of options for managing their illness.”
The analysis paper is written by a person with lived experience. Tania Gergel (of King’s College London) takes on the case against ECT, but notes: “it remains arguably the most stigmatised, misunderstood, contested and feared psychiatric or perhaps even medical treatment.”
The BJP papers can be found here:
Clinically, this NEJM paper shows what we already know: ECT is an underutilized tool. Because of stigma, patients and their families often hesitate. Starting a conversation about ECT requires us then to discuss the stigma.
The full NEJM paper can be found here:
Selection 2: “Evaluation of Increases in Drug Overdose Mortality Rates in the US by Race and Ethnicity Before and During the COVID-19 Pandemic”
Joseph R. Friedman and Helena Hansen
JAMA Psychiatry, 3 March 2022 Online First
Drug overdose mortality rates have increased sharply in the US since the COVID-19 pandemic began in 2020. Since 2015, overdose deaths have been rising most rapidly among Black and Hispanic and Latino communities. The pandemic has since disproportionately worsened a wide range of health, social, and economic outcomes among racial and ethnic minoritized communities. Careful attention to examining these trends by race and ethnicity is therefore warranted.
So begins a research letter by Friedman and Dr. Hansen.
Here’s what they did: “We used data from the Centers for Disease Control and Prevention WONDER (Wide-Ranging Online Data for Epidemiologic Research) platform and the National Center for Health Statistics (NCHS) to calculate drug overdose death rates per 100 000 population by race and ethnicity for 1999 to 2020.”
Here’s what they found:
- “Overdose death rates per 100 000 among Black individuals increased from 24.7 in 2019 to 36.8 in 2020, which was 16.3% higher than that for White individuals (31.6) in 2020.”
- “Thus, the 2020 overdose mortality rate among Black individuals was higher than that among White individuals for the first time since 1999.”
- “The results also showed that American Indian or Alaska Native individuals experienced the highest rate of overdose mortality in 2020 (41.4 per 100 000), which was 30.8% higher than that for White individuals.”
This is a good and important research letter, bringing data to a larger discussion. As the authors write: “Drug overdose mortality is increasingly becoming a racial justice issue in the US.”
How to proceed? They forward a thoughtful agenda: “Providing individuals with a safer supply of drugs, closing gaps in health care access (eg, harm reduction services and medications for opioid use disorder), ending routine incarceration of individuals with substance use disorders, and addressing the social conditions of people who use drugs represent urgently needed, evidence-based strategies that can be used to reduce increasing inequalities in overdose rates.”
The full JAMA Psych research letter can be found here:
Selection 3: “Ice chips, death and calm”
CMAJ, 28 February 2022 Online First
Only now, almost a year later, am I able to separate my grief over the death of my father from how important it was for me to be there and to care for him at the end.
‘More ice chips, please,’ was his repeated request to me in his last days.
My late father, Philip Seeman – a pharmacologist who dedicated his scientific career to investigating how the molecular structure and function of dopamine receptors were involved in the pathogenesis of schizophrenia – survived on ice chips and teaspoonfuls of ice cream during the final days of his life. He had been in hospital, with family visits forbidden because of COVID-19, but was mercifully permitted to die at home.
So begins a paper by Seeman.
He describes his father’s research: “My father’s laboratory had isolated and cloned several of the receptors for dopamine. That was his life’s work.”
The essay, though, is very personal. “I have suffered from anxiety all my life and, even as my dad was dying, as he lay in bed in probable pain, unable to swallow regular food or even nod his head, he touched my hand again and again to calm me as I sought to care for him.”
He notes the role of dopamine in his father’s research. And he writes about his father’s dying. “On reflection, I suspect my father did find that ice chips brought him calm. They boosted his dopamine levels directly and likely through happy memories: his early years in east-end Montreal, when ice was delivered every week in large blocks for the ice box; of freezing Montreal winters when long icicles, reflecting the sunlight, hung from metal staircases outside; of our family skating on makeshift backyard ice rinks; and of the dry ice that kept postmortem brain slices viable for his beloved dopamine experiments.”
He concludes: “Ice chips have offered me another window into the wonder of my father’s discoveries, a personal portal.”
This is a moving essay.
For a consideration of the dopamine hypothesis (and Dr. Seeman’s contributions), this World Journal of Psychiatry paper by Dr. Mary Seeman is a must read:
And the Globe obituary for Dr. Seeman was considered in a past Reading. It opens with this wonderful sentence: “Through hard work and inventiveness, molecular neuropharmacologist Philip Seeman transformed medical science’s understanding of schizophrenia and other brain conditions.” See:
The full CMAJ paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.