ect presentation fmp copy

Safety & efficacy of electroconvulsive therapy FOR

patients with depression w/traumatic brain injury

howard realubitpi: david printz, MD

CO-pi: mark Jacobson, phd

Thursday, November 21, 13

overview of ect

• Overall goal: determine if veterans with TBI respond differently to treatment for depression (ECT) compared to those with no TBI

• Why? Very little research completed on the complications of ECT treatment for patients w/TBI

• Why Now? Large numbers of returning veterans with concussions & mental health issues

• How? Compare levels of depression & cognitive performance baseline, mid-treatment phase, after ECT completion to understand group differences

Thursday, November 21, 13

history of electroconvulsive therapy (ect)

• since 1938 - safely used on pregnant women, children, and the elderly

• Mood Disorders (Bipolar, Major Depression), Catatonia

Ugo  Cerle)  (1877-­‐1963)

Thursday, November 21, 13

va & nih endorsement

Thursday, November 21, 13

Text

Thursday, November 21, 13

Study Design

MDD + TBI

MDD w/out TBI

Baseline

= Cognition and Depression Assessments

1 Mos Post ECT

Final ECTECT #63 Mos Post

ECT

ECT Treatments

Thursday, November 21, 13

study design

Depression + TBI

Depression Only

0 20 40

ECT treatments No ECT

Baseline ECT #6 Final ECT1 Mos Post

ECT3 Mos Post

ECT

Thursday, November 21, 13

treatment of depression

Thursday, November 21, 13

treatment of depression

Thursday, November 21, 13

traumatic brain injury (tbi)

• mild to moderate• severe• open vs. closed

Thursday, November 21, 13

ect is underutilized

18# 3#

0.1#

Annual&Prevalence&of&MDD&(in&millions)&

MDD,#Rx#Responsive#

MDD,#Rx#Non4responsive#

ECT#

Thursday, November 21, 13

patient demographic

• influx of veteran population with depression and TBI• VA La Jolla has highest number of

returning veterans with concussion: 20,800 possible TBI <8 years. Confirmed 1200. *Veterans Affairs TBI Screening Data

• {statistical data

Thursday, November 21, 13

ect procedure

• pad placements• anesthesia/muscle relaxant• EEG• seizure duration• recovery

• cognition & mood

Thursday, November 21, 13

ECT Procedure

Thursday, November 21, 13

ect procedure

Thursday, November 21, 13

ect procedure

Thursday, November 21, 13

ect procedure

Thursday, November 21, 13

ect procedure

Thursday, November 21, 13

theory of ect mechanisms

• EEG reading• Ictal

therapeutic seizure reading

Thursday, November 21, 13

ect procedure

Thursday, November 21, 13

theory of ect mechanisms

• “reboot theory”

• neurotransmitters

reference: Electroconvulsive & Modulation Therapies (Swartz)

Thursday, November 21, 13

gathering data

• SLUMS/QIDS test• MOCA test

Thursday, November 21, 13

Thursday, November 21, 13

data interpretation• !!Overall!Design:!2!group,!observa4onal!(correla4onal)!study!with!repeated!measures!(Baseline,!post?ECT,!Follow?up)!• !Step%1:!Comparison!of!group!characteris3cs!to!establish!similari3es/differences!in!demographic!variables!like!gender,!age,!educa3on,!diagnoses,!etc.!!Differences!may!be!used!as!co?variates.!• !!How?!Sta3s3cal!comparison!using!mostly!non?parametric!!!!!!!!!!!2?sample!tests!given!qualita3ve/!ordinal!level!of!data:!!

• !Tested!with!Mann?Whitney!U!test,!or!Chi?Square!tests!for!similarity!of!group!means!or!distribu3on!

• !Step%2:!Comparison!of!�outcome�!variables!like!Depression!Scales,!or!Cogni3ve!Measures!(MoCA)!!!• !How?!Repeated!Measures!Analysis!of!Variance!(ANOVA)!to!iden3fy!if!performance!on!tests!and!ques3onnaires!varies!over!3!3me!points,!and!if!they!differ!between?groups.!!

• !Tested!with!F!sta3s3c;!!Post?Hoc!follow!up!tes3ng!can!iden3fy!group!by!3me!interac3ons,!trends.!

Thursday, November 21, 13

The future

• less reliance on medication• fast outpatient procedures• more options for the veteran• shorter hospital stays

Thursday, November 21, 13

questions?

• Howard Realubit (hrealubi@ucsd.edu)

• David Printz, MD (dprintz@ucsd.edu)

• Mark Jacobson, PhD (mark.jacobson@va.gov)

Thursday, November 21, 13