Ep 221 Electroconvulsive Therapy Part 2: A current conversation
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What is the focus of this episode and why is electroconvulsive therapy being revisited?
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So this patient was actually five at the time that she was diagnosed. She presented initially with seizures, was diagnosed with epilepsy, was sent home from a hospital, and then came back with unusual movements and mutism. And was diagnosed by the team there with catatonia, which is a psychiatric syndrome that we see across a variety of illnesses, both psychiatric and medical. That provoked a further medical workup, including uh lumbar punctures, spinal taps. And she was found to have what is known as anti-NMDA receptor encephalitis. This condition is frequently characterized by the things I just mentioned: seizures, ketonia, other psychiatric symptoms, and is treated with a combination of immunotherapies to deal with the overactivity of the immune system, and also sort of conventional treatments to manage seizures, ketotonia, etcetera.
This patient received immunotherapy, many immunotherapies actually, and received Lurazepam or Adiban, which is the standard medication that we give for ketotonia, to very, very high doses. And continue to receive these treatments over the course. Of about nine months. And after that nine month period, she remained very catatonic. She could not speak. She could not dress herself what she'd been able to do previously. She could not feed herself. She required a gastrostomy tube or a a feeding tube for all her feeding. She required total care from her family and from the nursing staff. And so at that time, the team at the hospital where she was a patient at the time started discussing the possibility of treating her with ECT.
ECT is a gold standard treatment for catatonia, has very high response rates across all causes of catatonia, both psychiatric and medical. However, It's not typical to treat ECT in patients so young, in part because it's not typical to see catatonia in patients so young, or anyway, it has not been recognized in patients so young historically. It's almost certainly been underrecognized. So it would have been unusual to treat a patient this age with ECT. But they had sort of run out of options. They had given her many, many doses of immunotherapies that are also used as chemotherapeutic agents that have their own side effects, that had treated her with very high dose larazipam, as I said.
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Chapters
8 chapters
1
What is the focus of this episode and why is electroconvulsive therapy being revisited?
0:01–8:08
2
How is electroconvulsive therapy administered step by step, from consent to recovery?
8:08–17:55
3
Why are electrodes placed on specific head locations and the right foot during ECT, and how is seizure threshold determined?
17:55–27:19
4
What are the leading hypotheses for how ECT produces its therapeutic effects in the brain?
27:19–36:26
5
Which psychiatric and neurological conditions are most effectively treated with ECT and what are the remission rates?
36:26–45:07
6
What cognitive side effects, especially memory loss, can occur after ECT and how long do they last?
45:07–59:35
7
What barriers limit wider access to ECT in the United States and how can they be addressed?
59:35–1:03:49
8
How does ECT compare to other brain‑stimulation therapies like TMS, and what are the future directions for ECT?
1:03:49–1:06:00