治疗躁狂症的电休克疗法(ECT):隐藏在众目睽睽之下。

IF 5.3 2区 医学 Q1 PSYCHIATRY Acta Psychiatrica Scandinavica Pub Date : 2024-05-14 DOI:10.1111/acps.13693
Charles H. Kellner
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When the US Food and Drug Administration reclassified the ECT device in 2018, it was for catatonia and a severe depressive episode in the context of unipolar or bipolar disorder, but there was no mention of mania.<span><sup>5, 6</sup></span> This is an egregious oversight and the work of our Swedish colleagues with their national register data is an extremely helpful way to bolster the evidence base. Although physicians even in the United States are not technically bound by FDA “cleared indications,” (the FDA does not regulate the practice of medicine, and physicians are free to prescribe ECT as they deem indicated, similar to the “off label” use of medications), it is still reassuring to be able to point to high-quality data for the use of ECT in manic episodes.</p><p>Of course, the ECT literature has been replete with such evidence for decades. A PubMed search of “electroconvulsive mania” returns nearly 500 citations; the search “electroconvulsive bipolar” returns nearly 2000. The review article, <i>Electroconvulsive therapy of acute manic episodes: a review of 50 years' experience</i> by Mukerjhee et al. from the <i>American Journal of Psychiatry</i> in 1994 is a classic in the field.<span><sup>7</sup></span> The graphical representation of PubMed citations over time shows a continuously increasing production of articles on ECT for bipolar disorder in recent years. Furthermore, a group of Italian investigators has published data supporting the efficacy and tolerability of ECT for mixed episodes of bipolar disorder, including maintenance ECT.<span><sup>8, 9</sup></span></p><p>Clinically, it is easy to understand why depressive episodes are so much more commonly treated with ECT than manic episodes. Most manic episodes can be successfully managed with adequate mood stabilizing and sedating medications. Typically, ECT is only considered for severe manic episodes, and when multiple medications trials have been inadequately helpful.</p><p>The complicating factor of obtaining fully informed consent from an acutely manic patient only adds to the restricted use of ECT in such situations.<span><sup>10</sup></span> The rare, and most severe, form of mania, delirious mania, is an urgent medical situation, and one in which timely application of ECT may be life-saving.<span><sup>11</sup></span></p><p>What about technical aspects of ECT for manic episodes? Popiolek and colleagues report that about half of the patients in their analysis received right unilateral (RUL) ECT; they noted this as a potential limitation, suggesting that the high ECT response rates they reported might have been even higher, had more patients been treated with bilateral electrode placement. 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On the other hand, the excellent results from the ECT used in Sweden, as well as earlier data in the literature, could be argued as evidence for the suitability of RUL ECT, even for acute mania.<span><sup>12, 13</sup></span> On balance, I believe the clinical wisdom that the more urgent the situation, the more appropriate the use of bilateral ECT is, should still prevail.<span><sup>14</sup></span></p><p>Real-world experience, backed by a very substantial evidence base in the literature, argues for the continued acceptance of ECT as a standard treatment (usually secondary, when medications have failed, but also rarely as a first-line (primary) treatment in urgent situations) for all types of mood episodes in bipolar disorder: depressed, mixed and manic. These new data from the Swedish registries are an important addition to that literature. 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When the US Food and Drug Administration reclassified the ECT device in 2018, it was for catatonia and a severe depressive episode in the context of unipolar or bipolar disorder, but there was no mention of mania.<span><sup>5, 6</sup></span> This is an egregious oversight and the work of our Swedish colleagues with their national register data is an extremely helpful way to bolster the evidence base. Although physicians even in the United States are not technically bound by FDA “cleared indications,” (the FDA does not regulate the practice of medicine, and physicians are free to prescribe ECT as they deem indicated, similar to the “off label” use of medications), it is still reassuring to be able to point to high-quality data for the use of ECT in manic episodes.</p><p>Of course, the ECT literature has been replete with such evidence for decades. A PubMed search of “electroconvulsive mania” returns nearly 500 citations; the search “electroconvulsive bipolar” returns nearly 2000. 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Given that acutely manic patients considered for ECT are typically extremely ill, it seems reasonable to consider offering them the form of ECT that is most likely to be rapidly effective. The treatment of acute mania is often a situation in which considerations of efficacy should take precedence over tolerability concerns about temporary cognitive effects. 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引用次数: 0

摘要

在本期《斯堪的纳维亚精神病学报》(Acta Psychiatrica Scandinavica)上,Popiolek等人发表了电休克疗法(ECT)对因躁狂发作而住院的双相情感障碍患者再入院时间的影响。虽然他们的主要分析并未显示接受和未接受电痉挛疗法治疗的患者在再入院时间上存在差异,但在接受和未接受电痉挛疗法治疗的入院患者子集中,却显示出接受电痉挛疗法治疗的患者再入院时间更长的趋势。正如人们所预料的那样,接受电痉挛疗法治疗的患者终生患有更严重的躁郁症。在12337名入院患者中,有7.3%的患者接受了电痉挛疗法治疗,这个比例其实相当高。我猜想,如果在美国进行类似的研究,这个比例应该会低于1%。在最近的另一份报告中,瑞典研究小组使用了一个基本重叠的临床队列中的CGI数据,结果显示躁狂症患者对ECT的反应率为85%,病情越严重,反应率越高。事实上,从这两份报告中得到的最重要的信息是,电痉挛疗法是治疗急性躁狂症的一种非常有效的方法。3, 4 出于某种原因,尽管有大量的证据支持电痉挛疗法对双相情感障碍所有发作类型的疗效和安全性,但该领域一直难以完全接受这种疗法。美国食品和药物管理局在2018年对电痉挛疗法设备进行重新分类时,将其用于单相或双相情感障碍中的紧张症和严重抑郁发作,但并未提及躁狂症。尽管即使在美国,医生在技术上也不受美国食品及药物管理局 "已批准适应症 "的约束(美国食品及药物管理局并不监管医疗行为,医生可以自由开具他们认为适用的电痉挛疗法处方,类似于 "非标签 "使用药物),但能够指出在躁狂发作中使用电痉挛疗法的高质量数据仍然令人欣慰。在PubMed上搜索 "电休克躁狂症",可以找到近500条引文;搜索 "电休克躁狂症",可以找到近2000条引文。Mukerjhee 等人在 1994 年发表在《美国精神病学杂志》上的综述文章《急性躁狂发作的电休克治疗:50 年经验的回顾》是该领域的经典之作。此外,一组意大利研究人员发表的数据支持电痉挛疗法治疗双相情感障碍混合发作的疗效和耐受性,包括维持性电痉挛疗法。大多数躁狂发作都可以通过适当的情绪稳定和镇静药物得到成功控制。通常情况下,只有在严重的躁狂发作以及多种药物治疗效果不佳的情况下,才会考虑使用电痉挛疗法(ECT)。Popiolek 及其同事报告说,在他们的分析中,约有一半患者接受了右侧单侧(RUL)电痉挛疗法;他们指出这是一个潜在的局限性,并表示如果有更多患者接受了双侧电极置入治疗,他们所报告的高电痉挛反应率可能会更高。鉴于考虑接受电痉挛疗法治疗的急性躁狂症患者通常病情极重,似乎有理由考虑为他们提供最有可能迅速见效的电痉挛疗法。在治疗急性躁狂症的过程中,疗效方面的考虑往往应优先于对暂时性认知影响的耐受性方面的考虑。另一方面,瑞典使用的电痉挛疗法取得了很好的效果,文献中的早期数据也证明了 RUL 电痉挛疗法的适用性,甚至适用于急性躁狂症。
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Electroconvulsive therapy (ECT) for mania: Hiding in plain sight

In this issue of Acta Psychiatrica Scandinavica, Popiolek et al. present data on the effect of effect of electroconvulsive therapy (ECT) on time to readmission in patients with bipolar disorder hospitalized for a manic episode.1 This is yet another high-quality ECT research paper facilitated by the comprehensive patient registries in Sweden, which allow investigation of a myriad of clinical questions at the population level. While their main analysis did not show a difference in time to readmission in patients treated with and without ECT, a subset of patients who had hospital admissions both with ECT and without ECT, showed a trend to longer time to readmission when they had received ECT. As one might expect, patients treated with ECT had more severe lifetime bipolar illness. ECT was administered to patients in 7.3% of 12,337 admissions, which is actually quite a high rate. I suspect that if a similar study was done in the United States, it would be under 1%.

In another recent report using CGI data from a largely overlapping clinical cohort, the Swedish group showed an 85% response rate of mania to ECT, with greater severity of illness associated with higher response.2 Indeed, the most important message from both these reports is that ECT is a very effective treatment for acute mania.

ECT is grossly underutilized overall, and particularly in bipolar disorder.3, 4 For some reason, it has been difficult for the field to fully embrace the use of ECT for all episode types in bipolar disorder, despite a substantial evidence base supporting its efficacy and safety for these clinical situations. When the US Food and Drug Administration reclassified the ECT device in 2018, it was for catatonia and a severe depressive episode in the context of unipolar or bipolar disorder, but there was no mention of mania.5, 6 This is an egregious oversight and the work of our Swedish colleagues with their national register data is an extremely helpful way to bolster the evidence base. Although physicians even in the United States are not technically bound by FDA “cleared indications,” (the FDA does not regulate the practice of medicine, and physicians are free to prescribe ECT as they deem indicated, similar to the “off label” use of medications), it is still reassuring to be able to point to high-quality data for the use of ECT in manic episodes.

Of course, the ECT literature has been replete with such evidence for decades. A PubMed search of “electroconvulsive mania” returns nearly 500 citations; the search “electroconvulsive bipolar” returns nearly 2000. The review article, Electroconvulsive therapy of acute manic episodes: a review of 50 years' experience by Mukerjhee et al. from the American Journal of Psychiatry in 1994 is a classic in the field.7 The graphical representation of PubMed citations over time shows a continuously increasing production of articles on ECT for bipolar disorder in recent years. Furthermore, a group of Italian investigators has published data supporting the efficacy and tolerability of ECT for mixed episodes of bipolar disorder, including maintenance ECT.8, 9

Clinically, it is easy to understand why depressive episodes are so much more commonly treated with ECT than manic episodes. Most manic episodes can be successfully managed with adequate mood stabilizing and sedating medications. Typically, ECT is only considered for severe manic episodes, and when multiple medications trials have been inadequately helpful.

The complicating factor of obtaining fully informed consent from an acutely manic patient only adds to the restricted use of ECT in such situations.10 The rare, and most severe, form of mania, delirious mania, is an urgent medical situation, and one in which timely application of ECT may be life-saving.11

What about technical aspects of ECT for manic episodes? Popiolek and colleagues report that about half of the patients in their analysis received right unilateral (RUL) ECT; they noted this as a potential limitation, suggesting that the high ECT response rates they reported might have been even higher, had more patients been treated with bilateral electrode placement. Given that acutely manic patients considered for ECT are typically extremely ill, it seems reasonable to consider offering them the form of ECT that is most likely to be rapidly effective. The treatment of acute mania is often a situation in which considerations of efficacy should take precedence over tolerability concerns about temporary cognitive effects. On the other hand, the excellent results from the ECT used in Sweden, as well as earlier data in the literature, could be argued as evidence for the suitability of RUL ECT, even for acute mania.12, 13 On balance, I believe the clinical wisdom that the more urgent the situation, the more appropriate the use of bilateral ECT is, should still prevail.14

Real-world experience, backed by a very substantial evidence base in the literature, argues for the continued acceptance of ECT as a standard treatment (usually secondary, when medications have failed, but also rarely as a first-line (primary) treatment in urgent situations) for all types of mood episodes in bipolar disorder: depressed, mixed and manic. These new data from the Swedish registries are an important addition to that literature. That the FDA considered this evidence base, as well as that for ECT in schizophrenia, insufficient to grant an indication, seems like an oversight or outright mistake. No matter, though, clinicians worldwide can reassure their patients that there is plenty of evidence and experience of ECT as an effective and safe treatment for all types of episodes in severe bipolar disorder.

Dr. Kellner receives fees from UpToDate for writing/editing ECT topics, royalties from Cambridge University Press for Handbook of ECT (2019), and fees from Northwell Health for teaching in an ECT course.

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来源期刊
Acta Psychiatrica Scandinavica
Acta Psychiatrica Scandinavica 医学-精神病学
CiteScore
11.20
自引率
3.00%
发文量
135
审稿时长
6-12 weeks
期刊介绍: Acta Psychiatrica Scandinavica acts as an international forum for the dissemination of information advancing the science and practice of psychiatry. In particular we focus on communicating frontline research to clinical psychiatrists and psychiatric researchers. Acta Psychiatrica Scandinavica has traditionally been and remains a journal focusing predominantly on clinical psychiatry, but translational psychiatry is a topic of growing importance to our readers. Therefore, the journal welcomes submission of manuscripts based on both clinical- and more translational (e.g. preclinical and epidemiological) research. When preparing manuscripts based on translational studies for submission to Acta Psychiatrica Scandinavica, the authors should place emphasis on the clinical significance of the research question and the findings. Manuscripts based solely on preclinical research (e.g. animal models) are normally not considered for publication in the Journal.
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