ECT to control behaviour in the US

In a post a couple of months ago I wrote about an article in the Dutch Psychiatric Journal, Tijdschrift voor Psychiatrie (Electro-convulsive treatment of elderly patients with both behavioural problems and dementia” by B.L.I.A.M. Kramer, T. Albronda and D.L. Clarenbach-wierda) which described how three women in their eighties had been given ECT to control their behaviour.

This use of ECT to control behaviour in people with dementia has apparently been going on for some time in the United States.

Last week the Clinical Neurology News website reported on a presentation given by Dr Yilang Tang at the annual meeting of the American Association for Geriatric Psychiatry.

“He presented a retrospective chart review of the 38 patients with dementia who received ECT for agitation at Emory University’s Wesley Woods Geriatric Hospital in Atlanta during 2012.”

The patients’ agitation was measured on the Pittsburgh Agitation Scale. This scale measures four groups of behaviours: aberrant vocalisation; motor agitation; agressiveness; resisting care (washing, dressing, etc). Each group is measured on a scale of 0 to 4. For example someone whose rater ticked the boxes “louder than conversational, mildly disruptive, redirectable”, “increased rate of movements, mildly intrusive, easily redirectable”, “threatening gestures, no attempt to strike”, and “pushing away to avoid task”, would score 9. The mean pre-treatment average score of the people in this research was 9.2. Their scores saw a median decrease of 8 points with ECT, and there was a reduction from an average of 6 psychotropic drugs per person to 5. I have only read the first page of the article.

The McLean Hospital has been carrying out similar experiments: An article published in 2012 in the American Journal of Geriatric Psychiatry (“Safety and efficacy of electroconvulsive therapy for the treatment of agitation and aggression in patients with dementia” by M. Ujkaj et al.) described how the Pittsburgh Agitation Scale scores of 16 patients were reduced. A more recent trial, carried out together with Pine Rest Christian Mental Health Services, uses the Cohen-Mansfield Agitation Inventory Short Version. This inventory is more detailed than the Pittsburgh Scale and includes such behaviours as complaining (“whining, complaining about self, somatic complaints, personal gripes or complaining about physical environment or other people”) and negativism (“bad attitude, doesn’t like anything, nothing is right”).

In 2010 the journal Medical Hypotheses published an editorial with the title “ECT for agitation in dementia: is it appropriate?” by F. Tuna Burgut, Dennis Popeo and Charles H Kellner. The authors conclude that “maintenance ECT may also be necessary and appropriate to sustain the benefit of ECT in the treatment of agitation in dementia”. However they see a possible drawback:

“The use of ECT to treat agitation in dementia is controversial because it is not a mainstream use of ECT. If ECT were a medication, this would be an “off label” indication… Even if ECT does have beneficial effects in dementia patients with prominent agitation as a major symptom, it may not be prudent to recommend its use in this situation, because this may be miscontrued as a form of “behavior control” in non-consenting subjects”.

The solution they suggest is to only use ECT to treat agitation in dementia “when all other treatment options had been exhausted, when the patient’s family were fully informed of the potential risks and the family were requesting that the healthcare team proceed with a trial of ECT”.

ECT, in particular continuation ECT, is also used to control the behaviour of young people with autism.