CVMC seeks OK for shock therapy

CVMC seeks OK for shock therapy

November 5, 2007

BERLIN – Central Vermont Medical Center is seeking state approval to provide electroconvulsive therapy to a small number of psychiatric patients so they can receive treatment closer to home.

“On the average, CVMC has been treating six to 12 patients a year who are subsequently sent to Dartmouth or Fletcher Allen for electroconvulsive therapy, so the ability to have this in the community is important,” said Dr. Peter Thomashow, CVMC’s medical director of inpatient psychiatry.

Once referred to as electroshock, the treatment now called ECT has changed substantially and been refined since it was first introduced in the early 1940s.

“Generally, this is a treatment reserved for patients with severe depression, depression with psychotic features and sometimes for very agitated depressions. It is rarely used first-line,” Thomashow said, explaining that in most cases psychiatrists turn to it only after drug therapy has proven unsuccessful or in situations where the depression is life-threatening.

No patients from Vermont State Hospital or the Vermont Department of Corrections will be treated if approval is granted for CVMC, Thomashow said.

Thomashow cited “lethal catatonia” as an example of a life-threatening condition where electroconvulsive therapy might be used as a first-line treatment. “Someone in severe catatonia can be so impaired that they don’t eat or drink, they don’t move,” he said. “ECT is the most effective treatment for this kind of catatonia.”

All patients who come to the unit for care will get a comprehensive screening, including “a full battery of blood tests to rule out any possible medical causes for their depression. Sometimes, patients will get a CT scan or an MRI of the brain to rule out any medical condition such as a brain tumor that could cause their depression,” he said.

For many, the public image of ECT comes from the movie of Ken Kesey’s “One Flew Over the Cuckoo’s Nest,” in which actor Jack Nicholson undergoes the process. But both the equipment and the sophistication of its use have changed considerably.

Thomashow and the other two psychiatrists at CVMC, Dr. Kenneth Adler and Dr. Paul Cameron, had a weeklong fellowship at Columbia University School of Medicine, where much of the research in ultra-brief unilateral electroconvulsive therapy – the kind that CVMC plans to use – has been done. The nursing staff has also gone through training.

“The ultra-brief unilateral ETC is a fairly recent development,” Thomashow said, explaining that the machine CVMC purchased is able to deliver stimulus to just one side of the brain, which “has far less side effects and is much better tolerated than bilateral (both sides of the brain) ETC.”

Jim Tautfest, the nurse director of inpatient psychiatry, noted that the new machines can be adjusted to a variety of pulse-widths, frequencies and durations of stimulus. This flexibility enables the psychiatrist to provide effective treatment with fewer side effects.

The most common side effect is short-term, and in some cases also long-term, memory loss. The degree of memory loss is the subject of substantial debate.

The decision to use electroconvulsive therapy will be made by a treatment team, Thomashow said, and will include extensive records reviews, consultation with the primary care physician and interviews with the patient and his family, along with a full medical work-up.

With a patient who presents special concerns, Thomashow said, tests will be done to determine if electroconvulsive therapy will work or pose problems. Elderly patients will get cardiograms, and patients over 50 will get chest X-rays. A patient who has had a recent heart attack would not receive electroconvulsive therapy, Thomashow noted.

He added that “there’s a very detailed informed consent process that is supervised by the state of Vermont. There’s quite a lot of oversight and regulation.” Patients and families will be shown an informational videotape produced by Dartmouth Hitchcock Medical Center and will discuss the risks and benefits of electroconvulsive therapy before consenting to the treatment.

“There’s no question that it’s a very effective treatment in the right individual,” Thomashow said, offering benefits to some “individuals who have suffered for prolonged periods of time, whose lives have changed and who have not been able to function.”

CVMC’s application is the first the Department of Mental Health will act on since the Legislature charged it in 2000 with oversight. Fletcher Allen Health Care, White River Junction VA Medical Center and Retreat Healthcare in Brattleboro are already providing ECT.

Dr. Bill McMains, the medical director of the Department of Mental Health, said officials will conduct a review to make sure that the hospital’s standards for ECT comply with national standards, as well as meet extra state requirements to ensure “the safety of the person and making sure that people are adequately educated about what they’re doing.”

Vermont has “a very in-depth consent form” that hospitals must agree to use in order to get certified, he added. The form was developed through two years of negotiations with treatment experts and hospitals that were delivering electroconvulsive therapy at the time. McMains noted that Rep. Anne Donahue, R-Northfield, who follows mental health issues closes, was “very much a party” to developing the document.

The form, which all Vermont hospitals must use, requires that hospitals obtain the patient’s consent after every 12 treatments. “So a person doesn’t give ‘forever’ consent,” McMains observed. “It’s only good for 12 treatments, and then you have to go over it and get consent for any more.”

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