Hi all,

I continue to look into ECT (electroconvulsive therapy). Just posted the piece below to my blog, which I would appreciate folks visiting at http://parkinsense.blogspot.com. If you go there it'll help the post get noticed by search engines, which leads to reaching more readers. I think that's how it goes. Anyway, there's a striking photo of lightning over the bayou to make it worth your while!

I see the neglect of research on the effects of ECT on motor impairments of PD as a major dropped ball...I am stunned that so little is known about an intervention observed by many to show promise.

I will be posting more on ECT, its cousin TMS (transcranial magnetic stimulation), and related therapies.

Kathleen

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Shocked

A couple of weeks ago, I read an article in the Huffington Post by Dr. Mark Goulston.1 Dr. Goulston described his work in 1986 with a suicidal, late-stage Parkinson’s patient who stepped back off the ledge after receiving electroconvulsive therapy (ECT).

Because I have Parkinson’s disease, I read this post with particular interest. Near the end of the article, my interest turned to shock. Dr. Goulston noted, almost as an aside, that with ECT, not only did the patient’s depression lift—his motor functioning improved as well.

I was diagnosed in 1997. Since then, I have become a Parkinson’s news and information addict. Yet never before had I heard that ECT might be effective in treating motor symptoms of Parkinson’s. How could I have missed this?

I dove into the Internet and discovered that over the last 50 years or so, psychiatrists reported cases in which ECT helped Parkinson’s sufferers not only with depression, but also with motor symptoms. Some of these psychiatrists called for controlled studies to learn more about the effects of ECT on PD, what risks ECT would pose, and what conditions and practices would maximize ECT’s benefits and minimize risks.

Where, then, were the controlled studies?

Hunting for research on ECT, I discovered there is shockingly little to be found. In 2003, authors of a review of articles on ECT and PD (1990-2000)2 concluded:

“ Overall, a substantial amount of data support the positive effects of ECT on the motor symptoms of Parkinson’s disease. However, almost all of these data are from case reports or cases series, with only one randomized controlled trial in the literature. This, together with concerns over side effects, may raise doubts among neurologists. Further research in collaboration with neurological colleagues should be encouraged to address these concerns, as ECT may be a viable option that is acceptable to many patients.” [emphasis mine]

Authors of a meta-analysis of the literature (1980-2005)3 on ECT stated:

“…ECT can produce statistically significant effects on motor function in PD….. For ECT, although there was a relatively large and significant effect size, we considered the low number of studies to be a limiting factor, and therefore avoid any definite conclusions about this method of brain stimulation in PD.”

So 20-plus years after Dr. Goulston’s patient picked up his life again, PD patients are not equipped to weigh the risks and benefits of ECT. In fact, neurologists aren’t even talking about it. The research is insufficient. Why is that? Because not enough studies have been done to make anyone want to do further studies. The evidence on ECT is largely anecdotal and that simply isn’t enough.

It’s a perfect circle, a Catch-22. And it leaves patients with only one option when, inevitably, medications fail and symptoms worsen – DBS surgery, which involves drilling holes in the skull, pushing wires through the brain, and depending on batteries to keep a constant current pulsing through wires inserted under the skin. If it comes to the point that I need that, I’ll do it. But why has this procedure been deemed worthy of risk, worthy of study, worthy of being paid for by Medicare, while ECT, simpler, noninvasive, and far less expensive, has been shunted aside?

Two weeks’ worth of reading has not turned me into an expert on ECT. But what I learned convinces me that there is a very good chance that ECT offers another choice, an additional station along the way where patients can stave off, for a little while longer, the ravages of this disease.

Only research will tell us if this choice pans out.

This research is long overdue.



References

1. Goulston, M. Living through wanting to die. The Huffington Post, July 9, 2009. http://www.huffingtonpost.com/mark-g..._b_228811.html

2. Kennedy R, Mittal D, and O’Jile J. Electroconvulsive therapy in movement disorders: an update. J Neuropsychiatry Clin Newurosci 2003; 15:407-421.

3. Fregni F, Simon DK, Wu A, and Pascal-Leone A. Non-invasive brain stimulation for Parkinson’s disease: a systematic review and meta-analysis of the literature. J Neural Neurosurg Psychiatry 2005; 76:1614-1623.

ECT has such a stigma attached to it. Many, including Psychiatrist, still consider it archaic.

I agree Kathleen...why not? Right, NO ONE talks about ECT. Even patients who have received ECT are hesitant to speak of it publicly. The stigma is that pervasive!

For those who don't know much about ECT: Common Questions about ECT Also, Wikipedia on ECT

Abtract summary/Springlink:
Journal of Neural Transmission: Parkinson's Disease and Dementia Section
Volume 10, Numbers 2-3 / June, 1995, Sweden
P. -A. Fall1, R. Ekman3, A. -K. Granérus1, L. -H. Thorell2 and J. Wålinder2

ECT in Parkinson's disease. Changes in motor symptoms, monoamine metabolites and neuropeptides
Summary Electroconvulsive therapy (ECT) was given to 16 non-depressed, non-demented patients with advanced Parkinson's disease (PD). In all the patients an antiparkinsonian effect was seen, lasting for 18 months in one patient, 3–5 months in seven patients, and a few days to four weeks in eight patients. After ECT the levels of homovanillic acid and neuropeptide Y in cerebrospinal fluid (CSF) were significantly increased. The eight patients with long lasting motor improvement after ECT had significantly lower CSF-3-methoxy-4-hydroxyphenylglycol compared to the group with short lasting improvement.

Five patients developed transitory mental confusion after ECT. In these patients, and in no others, a high albumin-ratio was found already before ECT was given-an indication of blood CSF barrier damage.

Our results suggest that ECT is valuable in patients with drug refractory PD or PD with intolerance to antiparkinsonian drugs.

Thanks so much for your reply! I continue to research ECT and I saw the Swedish study you posted. It is the only place I have seen mention of blood-CSF barrier damage. I want to find out more about that.

One paper by Max Fink and colleagues (Electroconvulsive Therapy: Evidence and Challenges, JAMA.2007; 298: 330-332) notes that ECT is more widely used and accepted in Canada and Europe than in the U.S. Interesting.

Kathleen

My father had PD and had ECT several times over a short period. He did improve for a few weeks. Apparently some doctors give maintenance ECT:

Titre du document / Document title
Maintenance electroconvulsive therapy for Parkinson's disease
Auteur(s) / Author(s)
AARSLAND D. (1) ; LARSEN J. P. (2) ; WAAGE Ø. (1) ; LANGEVELD J. H. (1) ;
Affiliation(s) du ou des auteurs / Author(s) Affiliation(s)
(1) Section of Geriatric Psychiatry, Psychiatric Hospital of Rogaland, Stavanger, NORVEGE
(2) Department of Neurology, Central Hospital of Rogafand, Stavanger, NORVEGE
Résumé / Abstract

In two patients with severe Parkinson's disease (PD) whose response to levodopa had decreased the parkinsonian motor symptoms responded to acute and maintenance unilateral electroconvulsive therapy (ECT). Case 1 relapsed while taking antiparkinsonian medication 2 and 3 months after two brief courses of ECT. After another relapse, he received maintenance ECT and stayed well for 13 months.

Case 2 relapsed 4 months after a course of ECT. Acute and maintenance ECT induced improvement for 14 months. Further relapses were treated with brief courses of ECT followed by maintenance ECT. Three and 4 years after their first ECT, the parkinsonian motor symptoms in these two patients are still markedly improved.

Neuropsychological assessments did not suggest ECT-induced long-term cognitive impairment. We conclude that maintenance ECT should be considered in PD patients who relapse after having responded to an initial course of ECT. There is an urgent need for controlled studies.

http://cat.inist.fr/?aModele=afficheN&cpsidt=2107607

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I love how the following research included only one type of PD patient:

"Eighteen patients with the predominantly akinetic rigid form of idiopathic PD"

"To assess gait, the time to walk a 10-meter distance was recorded. The time to perform a complex hand and arm movement test was used to measure upper limb bradykinesia. For the walk test, patients were instructed to walk as quickly as they could. For the complex movement test, patients were instructed to perform 10 flexion-extension movements in the elbow joint while simultaneously squeezing a rubber bulb twice during each flexion-extension cycle. "


Research Article
Placebo-controlled study of rTMS for the treatment of Parkinson's disease:

http://www3.interscience.wiley.com/c...0637/HTMLSTART

"The objective of this study is to assess the safety and efficacy of repetitive transcranial magnetic stimulation (rTMS) for gait and bradykinesia in patients with Parkinson's disease (PD). In a double-blind placebo-controlled study, we evaluated the effects of 25 Hz rTMS in 18 PD patients. Eight rTMS sessions were performed over a 4-week period. Four cortical targets (left and right motor and dorsolateral prefrontal cortex) were stimulated in each session, with 300 pulses each, 100% of motor threshold intensity. Left motor cortex (MC) excitability was assessed using motor evoked potentials (MEPs) from the abductor pollicis brevis.

During the 4 weeks, times for executing walking and complex hand movements tests gradually decreased. The therapeutic rTMS effect lasted for at least 1 month after treatment ended. Right-hand bradykinesia improvement correlated with increased MEP amplitude evoked by left MC rTMS after individual sessions, but improvement overall did not correlate with MC excitability. rTMS sessions appear to have a cumulative benefit for improving gait, as well as reducing upper limb bradykinesia in PD patients. Although short-term benefit may be due to MC excitability enhancement, the mechanism of cumulative benefit must have another explanation"

It's funny to me that the above study said this:

"For the complex movement test, patients were instructed to perform 10 flexion-extension movements in the elbow joint while simultaneously squeezing a rubber bulb twice during each flexion-extension cycle. "

I tried to show old neuros how I could not extend my arm and bend it towards me, reaching my hand toward my face, while my hand was squeezed in a fist. They didn't care. I get a strange ratcheting effect combined with a strong action tremor.

Anyone else have a problem doing that, or the test in the article?

I also can't trace a picture with my right hand while the left one is merely squeezing something. I slow down the moment my left hand starts to squeeze.

More on ECT

"ECT for Parkinson's disease." (an editorial)
Popeo D, Kellner CH
in Medical Hypotheses. 2009 Aug 4;
http://www.hubmed.org/display.cgi?uids=19660875

Abstract:

Parkinson's disease (PD) is a chronic, progressive, degenerative disorder that affects over five million people worldwide. Pharmacotherapy with dopamine enhancing medications is the mainstay of treatment. Neurosurgical techniques, ranging from pallidotomy to deep brain stimulation (DBS) are used in refractory patients. Another treatment, electroconvulsive therapy (ECT), has repeatedly been shown to have beneficial effects in PD, but has never gained acceptance as a clinical treatment option. We review the literature on the use of ECT in PD, pointing out that ECT has beneficial effects on both the core motor symptoms of PD as well as the commonly occurring psychiatric co-morbidities. ECT is hypothesized to act in PD by enhancing dopamine neurotransmission, including increasing sensitivity of dopamine receptors. The beneficial effects of ECT in PD persist for variable periods. Maintenance ECT has been used to increase the length of benefit. The stigma surrounding ECT has likely been responsible for its lack of use in PD. We suggest that ECT has a role in the treatment of PD, both in patients with PD alone, or PD with co-occurring depression

Here are some excerpts from the full article :

A number of small studies performed in the 1970's-90's showing improvement of motor symptons, are described. (my notes)

Excerpt:
"Since Wengel’s report was published in 1998, several other cases and reviews have appeared, showing the favorable effect of ECT in the treatment of PD and Parkinsonism, both in individuals with and without concomitant psychiatric illness. In recent reviews of the treatment of PD, however, ECT is rarely mentioned.

In a recent search of the practice guidelines in the American Academy of Neurology website, the only guideline that resulted from a search of ECT that related to PD was a slide presentation on ‘‘Evaluation and Treatment of Depression, Psychosis, and Dementia in Parkinson Disease.”" It does not recommend ECT as a non-pharmacological treatment, due to lack of good evidence [14]. A current review of the treatment of PD by a neurologist at our own institution (Mt. Sinai) does not mention ECT as a possible treatment at all [15].

It is unfortunate that ECT has never gained favor with neurologists in the treatment of PD In fact, the treatment is not even mentioned in any current treatment guidelines or exhaustive reviews on the subject. Perhaps this is because there is so much excitement in the possibilities of Deep Brain Stimulation (DBS) for those with medication resistant or intractable disease. ..."

" Unfortunately, it is a likely reality that the stigma surrounding ECT is the main reason for its lack of use in PD. Such stigma persists, despite some encouraging signs that it is decreasing and that ECT is being considered a more ‘‘mainstream’ treatment in Psychiatry [17]. One of the reasons for ongoing stigma is our lack of knowledge of the antidepressant mechanism of action of ECT. Interestingly, we believe we understand that it is the dopamine enhancing effect of ECT that leads to its effectiveness in PD [18].

On balance, we feel that ECT has a role in the treatment of PD, particularly in those patients with coexisting severe depression and PD. While we recognize that it will never be a widely used treatment for PD, it may have a larger role than currently practiced.."

So more research is needed, but who would sponsor such studies? Doesn't seem like there would be much money to be made in developing ECT treatments for PD. (my interpretation )

Are we missing out on what could be an effective and safe treatment for at least some advanced patients? Due to a stigma? A too-close connection with mental illness ? What do the neurologists think about this?

Some questions for the doctors would be :

Which procedure is more invasive?

which is potentially more dangerous in terms of memory loss, personality change, other complications?

Which delivers more total current to the brain over time?

What are the possible side effects of ECT, and how do they compare with DBS?

For how long is ECT expectected to continue working? How long are follow up treatments needed and at what frequency?

Who are the best candidates for ECT for Parkinson's

Hi, ZucchiniFlower--

In Sweden, where it appears to me the approach to health care is more wholistic and collaborative than it is here in the U.S., there seems to be a fair amount of work being done on ECT for motor symptoms of PD.

A proponent of rTMS is Dr. Mark George, who directs the Center for Advanced Imaging Research and the Brain Imaging Center of Excellence at the Medical University of South Carolina in Charleston. More about him at: http://health.usnews.com/articles/he...tromagnet.html

I have trouble reading about doing this, much less doing it!

Kathleen

I realize that we are talking about ECT (electroconvulsive therapy), and that this is barbaric to some people. I can tell you that the effect of ECT, especially the loss of some memory, is not all that bad. The loss usually includes the days during which the patient was given the ECT treatment. It is not usually that you forget where you worked or who you children are.

But is it not worthy of at least some serious discussion on this board. Is it so distasteful to just discuss this concept as a therapy or to even believe that it could be helpful to some PWPs? I hear all the times, "we want a cure or at a minimum better and effective thearpy." Is it just a new pill everyone wants?

If you have had ECT in the past, I am not asking anyone to divulge that since those who have had the therapy for depression don't even like to admit it. That is how unsettling the stigma is.

To begin with:
Is this because DBS makes LOTS of money and so many researchers as monetarily invested, while ECT would not make money. We have discussed this, the financial investment, before. Is ECT so much more scary than having holes drilled in your head and metal rods permanently inserted? Is there no one who would have ECT before having DBS in the off chance that it MAY be helpful. I ask these questions in both veins; 1) for discussion, since the science is not there and 2) in somewhat of a rhetorical nature.

And this quote from the post Linda (the PPP has done considerable research into ECT for PD since Dr. Mark Goulston's article appeared in The Huffington Post a week or so ago) made is simply the manner in which the result of the ECT was measured. It has nothing to do with what any PWP can or cannot do in ones current state of PD.

Hi,

The more I read and learn about this, the more it seems to me that a treatment highly likely to help many PwPs has been left unexplored because the psychiatrists won't encroach on the territory of movement disorder neuros, and the neuros won't, for whatever reason, follow up on what is staring them in the face.

I think the game is changing. DBS is being pushed for earlier stages of PD. Research studies are trying to find evicence supporting DBS as an alternative to ECT.

Who isn't in the game—yet? The patients, of course. We MUST make our voices heard about this. We must demand research on ECT and PD with and without concomitant depression.

The research must be done.

And to answer the question Sticher asks—"Is there no one who would have ECT before having DBS in the off chance that it MAY be helpful"—I would...and I'd regard that choice as offering better than an off chance.

Kathleen