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Advancements Aim to Build Trust in ECT

August 08, 2019

Developments Seek to Demonstrate Safety and Efficacy

A series of advances in electroconvulsive therapy (ECT) have been made recently, with the aim of facilitating safe and effective use of the treatment for patients with certain severe mental health disorders.

During a session at the upcoming Psych Congress conference, C. Edward Coffey, MD, affiliate professor of psychiatry and behavioral sciences at the Medical University of South Carolina, Charleston, will bring attendees up to speed on several developments in the field.

ECT, as defined by the American Psychiatric Association (APA), “involves a brief electrical stimulation of the brain while the patient is under anesthesia” and is typically administered by a team that includes a psychiatrist, an anesthesiologist, and a nurse or physician’s assistant. It has been found to be “highly effective for the relief of major depression,” per the APA. Most commonly, it is used for mood disorders that are severe or have not responded to other treatments.

ECT has been shown to significantly reduce symptoms in between 70% and 90% of patients, according to Duke Health in North Carolina. It is estimated that approximately 100,000 people in the United States and more than 1 million worldwide are treated with the procedure each year.

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ECT is an area to which Dr. Coffey has dedicated more than 35 years of work. Upon completing his residency in psychiatry and neurology at Duke University in Durham, North Carolina, Dr. Coffey started an ECT service at the university medical center in collaboration with his colleague Richard Weiner, MD, in 1984. The program became a model for organizing clinical and research activities around a subspecialty such as brain stimulation, Dr. Coffey says.

From there, he went on to partner with other colleagues to launch ECT services at Allegheny Health System in Pittsburgh, Pennsylvania, Henry Ford Health System in Detroit, Michigan, and Menninger Clinic in Houston, Texas. Dr. Coffey developed the Menninger program in collaboration with his son, Justin, a board-certified psychiatrist and behavioral neurologist.

In addition to his work at the Medical University of South Carolina, Dr. Coffey currently serves as a member of the ECT certificate course faculty of the International Society for ECT and Neurostimulation, an organization for which he also previously served as president.

Three recent developments in the area of ECT, which he will discuss at length at Psych Congress, will be of interest to general mental health practitioners, he says.

FDA reclassification: In December, the US Food and Drug Administration (FDA) issued a ruling to reclassify ECT devices for “the treatment of catatonia or a severe major depressive episode associated with major depressive disorder or bipolar disorder in patients age 13 years and older who are treatment-resistant or who require a rapid response treatment due to the severity of their psychiatric or medical condition” to Class II (moderate risk). Previously, the devices were part of Class III (higher risk).

The move to Class II, a division which also encompasses devices such as electrocardiogram (EKG) machines for reading heart rhythms, is significant in changing the way ECT devices are perceived, Dr. Coffey said.

“This reclassification adds further evidence to the conclusion that ECT remains an extraordinarily safe medical procedure, among the safest in all of general medicine,” he added.

Safety and effectiveness: As with any procedure in medicine, Dr. Coffey said, the safety and effectiveness of an ECT procedure depends critically on how it is done.

“We now know there is an important relationship between the effectiveness of ECT and how we go about inducing the brain seizure with our electrical stimulation,” he said.

The nature of the stimulus—its waveform, intensity, and location—all factor into the success of the highly complex procedure, said Dr. Coffey, who adds that a significant amount of decision-making goes into the design of the stimulus that brings about the brain seizure in ECT.

Family-centered approach: Placing patients and their families/significant others at the center of their ECT care, including having them present for the entirety of the treatment, is a concept Dr. Coffey said he and his team have worked on extensively in the past 20 years. Getting family involved is “a very exciting development,” he said, because it has a profound effect on both the patient’s and family’s understanding and acceptance of the procedure, helping to foster a sense of safety and security. Moreover, he added, strong family involvement benefits the clinical team as well, as it helps to ensure practitioners are adequately addressing patient and family needs.

“It’s very rewarding to understand what the patient and family really need and to be able to deliver on those expectations,” he said.

Overall, Dr. Coffey said, recent advancements around ECT are about building trust with patients and families, as well as within the treatment community, through transparency and by placing families and patients at the center of care.

Dr. Coffey said he and his team have not formally measured trust in ECT, but they have observed improved patient and family satisfaction with the procedure when it is provided using the patient/family-centered approach.

“As physicians, we can talk about this until we’re blue in the face, but there is no substitute for the family and patient seeing what’s going on in real time,” he said. “That speaks volumes.”

—Tom Valentino

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