Bipolar

[istillbelieve]

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How do you find working with Bipolar patients? A resident mentioned that they are a challenge due to their lying and deception. I have never experienced this myself. What do you think about what he said. I think any mental illness is challenging on both sides- the patient and provider.

 

[Zenman1]

Did he mean Borderline?

 

[istillbelieve]

He means Bipolar 1 and 2. Since, bipolar patients can have other diagnoses, I am thinking that it depends on the individual.

 

[whopper]

The main frustration I have with bipolar disordered patients is there is a grey zone where it becomes tough to tell if the patient's problems are from bipolar disorder vs a personality disorder.

It's real easy to tell if someone has bipolar disorder if their drug screen is clean, and they're showing all the classic signs of mania to it's worst extremes. Such is common in a hospital setting. E.g. someone parking their car in the middle of a busy street and dancing on a busy road while screaming.

In an outpatient setting, one will often encounter patients, that while manic, are not involuntarily commitable, nor easily identified as such. For example, I had a guy, that while manic, cheated on his wife, drove his motor cycle for over 5 hours a day, but was still able to go to work and perform well there. He didn't even look manic. His speech, orientation, all the things you look for appeared within a normal range.

Only reason why I knew he had bipolar disorder was because he told me had racing thoughts (though he didn't look like he did), and this problem happened every several months (like every 2-3 years) and lasted about 2-4 months at a time, and were relieved with lithium.

While I could tell that guy had bipolar disorder, you get quite a few people where you can't easily tell, and it's not right medicating a personality disorder. What I do in such cases is I try my darnedest to figure out what is what (they could have bipolar disorder and a PD together vs one or the other), and if I medicate, I tell the patient upfront that this is my best educated guess and I could be wrong. If possible I'll also do psychological testing.

Often times, after a lot of work, the patient and I do figure it out but this process could take several weeks if not even months and the entire process I find frustrating because if I'm wrong and I medicate, I could be causing the person harm without much benefit.

 

[pre med 2014]

For example, I had a guy, that while manic, cheated on his wife, drove his motor cycle for over 5 hours a day, but was still able to go to work and perform well there. He didn't even look manic. His speech, orientation, all the things you look for appeared within a normal range.

LOL For some people riding a motorcycle all day and sleeping with women is a way of life.... joking aside, if he is stuck in a loveless marriage I wouldn't count it as points towards a disorder.

 

[istillbelieve]

I found out today that ECT can be done on Bipolar patients. Obviously, we have to make sure that the person is really Bipolar and not something else. What if a patient had OCD, bipolar, and a personality disorder.

 

[notdeadyet]

How do you find working with Bipolar patients? A resident mentioned that they are a challenge due to their lying and deception.

There may have been a miscommunication between you and the resident. Lying and deception are not traits you would necessarily associate with bipolar patients.

 

[whopper]

There may have been a miscommunication between you and the resident. Lying and deception are not traits you would necessarily associate with bipolar patients.

True, and that's why this case was difficult at first but....
1-He normally didn't do the motorcycle or cheating thing
2-It went away with lithium
3-the behavior had a cyclical nature consistent with bipolar disorder

His case I couldn't figure out what was going on for the first two months.

You sometimes get other hard-to-tell cases. I mentioned this before but I had a guy that during his cycles would think his wife was cheating on him and that was one of the only symptoms. He didn't meet a DSM-IV criteria for mania, and it was relieved with Lamictal. His symptoms were the paranoia with his wife and becoming easily upset. No other signs or symptoms of mania. Only reason why I even considered medication was because he had this occurring with him every several months, when it happened, it lasted weeks, then it would just go away, and he openly said he didn't know why he had a paranoia she was cheating on him and even pointed to it as irrational. Another factor was he already tried pscyhotherapy for it, for over a year, and he wasn't getting anywhere with it. His psychotherapist, a psychologist I highly respected told me he thought this was an oddball case of bipolar disorder. That also cleared it up.

But if I didn't have the psychology-assistance, I would've spent an extra few weeks to possibly even months frustrated and confused on what to do wtih the case.

I've mentioned this before in other threads. From personal experience, I've seen the DSM-IV work about 95% of the time. You do occasionally get odd-ball cases that don't fit the criteria. A problem with deviating from the DSM-IV (or V) is you get doctors claiming psychiatry is an art and start medicating everything, "I gave her Seroquel because I could tell she was blue and I see Seroquel as a warming medication." (I'm not making that up by the way, another psychiatrist did once tell me that, or more like something along the lines of that because it's not like I wrote down her exact words.)

But not everything fits perfectly within the DSM-IV or V either. If you deviate from the DSM IV or V, I recommend you explain why in detail in your notes, and it be mroe comomon sense and evidenced-based than "she's blue."

 

[pre med 2014]

Just for your guys' enlightenment there is no stable pattern for motorcycle riding. For 50% of the jobs out there it's almost impossible to bike to work, and for those office jobs that you can ride too you're at the mercy of the weather. Riding in the rain sucks, its a hassle to stow away/walk around with your helmet/putting away gloves/gear let alone rain gear. If you carry stuff in and out of work its real hard, and work clothes for a lot of jobs are not ideal for motorcycle riding. There is no use for the things except for joyrides. They are not a replacement for a car by any means, it's purely a toy.

"Unusual bouts of motorcycle riding" are really the only kind of bouts when it comes to motorcycle ownership. You can go months without riding it cause its such a pain in the ass. Even in Arizona when weather is good all the time it's a real pain in the ass to deal with all your gear/using for it for work for reasons mentioned above.

Granted your hardcore motorcycle enthusiast will find ways to adapt. But for your average owner it'll be a total crapshoot how often you ride it. You'll find a cyclical bipolar pattern for any motorcyclist.

What I'm trying to say is in no way should a motorcycle riding schedule have any bearing on diagnosing bipolar disorder. The nature of it doesn't lend itself to any regularity, something as little as not being able to get coffee in the morning could change your habits drastically.

 

[whopper]

I think I see your point but my point is several behaviors don't neatly fit into diagnosing and are characterological.

Just to give another example, one patient I had, when she stopped her meds, she teased up her hair. About two weeks from that, she would become violent due to psychosis. These behaviors were consistent over the course of years of observation.

When diagnosing, you have signs and symptoms that apply to entire populations, but you also have ones that are characterological.

What I'm trying to say is in no way should a motorcycle riding schedule have any bearing on diagnosing bipolar disorder.

Disagree. There is a science to diagnosing and characterlogical analsysis that does not conform to the population does play into it. Several tests incorporate and allow for such individualistic evaluations such as the HCR-20.

There's a difference between actuarial diagnosis based on assessments of groups of subjects vs using a combined actuarial and clinical evaluation that utilizes the individual's personal behaviors. By the way, using actuarial in addition to clinical is superior to actuarial alone. Actuarial is superior to clinical alone. If you know Joe Shmoe almost always does Y after X, the pattern has repeated itself several times, even if most people don't do that, it doesn't mean Joe Shmoe will do what the rest of the population does.

This maybe semantics, but you wrote down the words "IN NO WAY," and I'm interpreting your words literally.

This type of understanding of a patient usually only happens after you've had them for at least weeks.

 

[pre med 2014]

If you make millions and you have a black Ducati in the garage there is not going to be any rhyme or reason in terms of your riding pattern, so it is impossible to say the subjects pattern deviates from his normal pattern at the individual level because there is no normal pattern to begin with. It's a toy that doesn't lend itself to be used with any regular pattern.


I suppose if someone left their wife, kids, and work without notice to motorcycle around the country it 'might' be bipolar. But in that case I would argue the motorcycle is irrelevant to the spontaneous behavior.

 

[whopper]

If you make millions and you have a black Ducati in the garage there is not going to be any rhyme or reason in terms of your riding pattern, so it is impossible to say the subjects pattern deviates from his normal pattern at the individual level because there is no normal pattern to begin with. It's a toy that doesn't lend itself to be used with any regular pattern.

I suppose if someone left their wife, kids, and work without notice to motorcycle around the country it 'might' be bipolar. But in that case I would argue the motorcycle is irrelevant to the spontaneous behavior.

Oh well, I think you missed the entire point I was trying to make-that being you're only using the actuarial viewpoint. If one only used that point of view, you'd assume that there's nothing to individual personality traits and behaviors. The DSM IV and V is the foundation but not the end of diagnosis (though as I mentioend before, most cases do nicely work with the DSM IV).

If you ever see an HCR-20, and hold to your line of thinking, you would have to consider that test irrelevant.

Some people do have patterns that the population does not have. It's the entire reason why if you are a good poker player and you know your opponent you can kick their butt, because that person has individualistic behaviors they show in response to what cards are in front of them.

There will often times be a rhyme or reason to a person's driving pattern, if you study them long enough. Such observations have little use in trying to gauge the population as a whole in application to mental illness because in terms of a large group, they don't have much relevance. For individuals it can be different. Don't believe me? Be married for a few years. You start learning things on a level about a person that most people can't figure out in a one-time evaluation. You learn things about the person that don't apply to the population. Same thing goes on with patients after you've interviewed them dozens of times and have gotten to know them after several weeks.

Oops I'm just repeating myself.

I'll just end this here unless there's any new data that can be brought forth. I recommend you get an HCR-20 manual or if there's any psychologists in your program, ask about how individuals can have patterns unique to them that aren't applicable to the rest of the population. This is not an unknown phenomenon. It's quite studied in the field of psychology.

(Not to mention it's a fundamental reason why individuals are unique.)

 

[pre med 2014]

no sense going in circles, I think you are missing my entire point as well.

I do agree in general individuals have their own unique patterns.

 

[whopper]

If you can acknowledge that, then it's not a big leap to then take into consideration that a person's individual patterns do have relevance in diagnosing pathology. That's my entire point.

I brought up this guy's case because he didn't meet a DSM-IV criteria of bipolar disorder but I believed he had it.

I also failed to mention to you that when he drove the motorcycle, he did it in an impulsive manner. When he drove it 5 hours, it was to destinations he did not know where he was going and ended up lost, and sometimes not having his wallet on him. Impulsive yes, but not enough criteria for bipolar disorder in a DSM-IV sense.

 

[pre med 2014]

If somehow someone's motorcycle patterns were erratic (I should say erratic as in random riding schedules not erratic as in reckless riding) and causing them distress I would consider it as a symptom of mental disorder. I just cannot see how someone's riding could bother them since it's an activity quite easily controlled by free will and the necessity of going back to work.

I'm going to call it a night because I'm just going to keep going in circles.

 

[AcronymAllergy]

I agree with whopper that the grey area in differentiating bipolar vs. personality disorder (particularly borderline) can be tough, especially in male patients where the tendency seems to be choosing bipolar. Working with the patient to consistently remain on their medications can also be tough, since quite a few folks report enjoying most of the symptoms that come along with a manic episode (at least until it gets to the point of the sleep deprivation bringing on hallucinations).

As for the aside about motorcycle riding, I can say that using one full-time (i.e., without a car) is great...except when it rains or snows. Then it's horrible. So very, very horrible.

 

[notdeadyet]

As for the aside about motorcycle riding, I can say that using one full-time (i.e., without a car) is great...except when it rains or snows. Then it's horrible. So very, very horrible.

Amen to that one. A motorcycle is a great thing to have for when you want to ride, but can be awful when it's all you have. Bad weather + bad drivers makes for an ugly commute, even when you're young and bulletproof. My ribs still hurt when I see one hurtling by in the rain.

 

[SuperSoccer19]

I agree with whopper that the grey area in differentiating bipolar vs. personality disorder (particularly borderline) can be tough,

I find it especially hard to differentiate because very often a patient comes to you saying he/she has a previous diagnosis of bipolar disorder, but their subjective and objective exam seems to point more towards a cluster b personality disorder. You review the history a little more and you either find substance was involved, no clear manic/hypomanic episode was observed or consistently documented, and the the timing is very off. However, a previous provider called it bipolar or the previous provider called it a PD but the patient still says he/she is bipolar--either self-proclaimed or because another provider told the patient they had this but documented otherwise. In addition, there could have been a true manic episode and the patient lacks insight or cannot give an accurate description.

If a patient is truely bipolar--especially bipolar I, i would not necessarily say he/she lies and is deceitful, but the patient often lacks insight to their mania or does not remember the episode or what their behaviors were like. I had a few patients almost sucessfully convince me I was crazy and delusional when trying to describe their past symptoms when I witnessed their mania with psychotic features. It was different then the typical cluster b deception. The cluster b's I find tend to create their own reality and half the time I wonder if they even know they are FOS, but it seems like a different type of lack of insight and often has a manipulative flavor.

 

[AcronymAllergy]

I find it especially hard to differentiate because very often a patient comes to you saying he/she has a previous diagnosis of bipolar disorder, but their subjective and objective exam seems to point more towards a cluster b personality disorder. You review the history a little more and you either find substance was involved, no clear manic/hypomanic episode was observed or consistently documented, and the the timing is very off. However, a previous provider called it bipolar or the previous provider called it a PD but the patient still says he/she is bipolar--either self-proclaimed or because another provider told the patient they had this but documented otherwise. In addition, there could have been a true manic episode and the patient lacks insight or cannot give an accurate description.

If a patient is truely bipolar--especially bipolar I, i would not necessarily say he/she lies and is deceitful, but the patient often lacks insight to their mania or does not remember the episode or what their behaviors were like. I had a few patients almost sucessfully convince me I was crazy and delusional when trying to describe their past symptoms when I witnessed their mania with psychotic features. It was different then the typical cluster b deception. The cluster b's I find tend to create their own reality and half the time I wonder if they even know they are FOS, but it seems like a different type of lack of insight and often has a manipulative flavor.

Good points. And related to my earlier post, particularly if the recent episode was more on the hypomanic side, the individual really may not have seen it as a problem.

And all of this is not to say that the the two types of diagnoses are mutually exclusive, though, of course. But differentiating between historical report of some manic-like symptoms and issues such as emotional dysregulation and poor distress tolerance can be tough.

 

[shan564]

As somebody has already mentioned, bipolar disorder has nothing to do with deceit/manipulation. There are plenty of borderline patients who get misdiagnosed with bipolar disorder.

 

[istillbelieve]

I sure hope that those who have had ECT done really have bipolar. ECT's side effects are nothing to take lightly. There is a bipolar patient that had ECT recently and can no longer work as an engineer because of the permanent side effect she is having to deal with.

 

[whopper]

One of the only methods I've seen, for myself, aside from trying to see if there's a cyclical pattern corresponding with bipolar disorder and the symptoms (no, daily highs and lows don't count, we need to see symptoms that last weeks, then go away for months, and come back) that comes in differentiating a weak bipolar disorder vs a personality disorder is if meds help, and I'm not talking Ativan. ECT is hardly ever considered for someone that may have bipolar disorder but you're not sure.

When I say "weak" bipolar disorder, I mean cyclothymia or bipolar II disorder. Severe bipolar I disorder can be diagnosed very easily.

I had a patient with both very bad bipolar disorder and a very bad personality disorder. I couldn't make heads or tails what was what, and due to her very severe PD everytime I interviewed her, I couldn't get much out of her in objectively rating her signs and symtpoms. E.g. whenever I asked her a question, she'd only say "please help me!" Her husband had to come into the office and tell me the things such as hours of sleep, appetite, activity level, cause after 3 sessions of "please help me" and only variations of that same statement, I went nowhere fast. She was given ECT, dramatically improved but the severe PD persisted (as expected). That was one of the only ways I could tell where the bipolar disorder ended and the PD began. One of the toughest cases I had yet in outpatient.

 

[pre med 2014]

I sure hope that those who have had ECT done really have bipolar. ECT's side effects are nothing to take lightly. There is a bipolar patient that had ECT recently and can no longer work as an engineer because of the permanent side effect she is having to deal with.

That is scary.

1. Why in the world would someone functional enough to hold an engineering job receive electroshock?

2. Why would someone functional enough to hold an engineering job voluntarily agree to electroshock?

 

[istillbelieve]

That is scary.

1. Why in the world would someone functional enough to hold an engineering job receive electroshock?

2. Why would someone functional enough to hold an engineering job voluntarily agree to electroshock?

Her depression did get in the way of her job. She had many many hospitalizations among other things. But, she did well when she worked. She was good at what she did, and she trusted her doctor. He told her that she should have nothing to worry about, because the side effect was temporary memory loss.

 

[istillbelieve]

One of the only methods I've seen, for myself, aside from trying to see if there's a cyclical pattern corresponding with bipolar disorder and the symptoms (no, daily highs and lows don't count, we need to see symptoms that last weeks, then go away for months, and come back) that comes in differentiating a weak bipolar disorder vs a personality disorder is if meds help, and I'm not talking Ativan. ECT is hardly ever considered for someone that may have bipolar disorder but you're not sure.

When I say "weak" bipolar disorder, I mean cyclothymia or bipolar II disorder. Severe bipolar I disorder can be diagnosed very easily.

I had a patient with both very bad bipolar disorder and a very bad personality disorder. I couldn't make heads or tails what was what, and due to her very severe PD everytime I interviewed her, I couldn't get much out of her in objectively rating her signs and symtpoms. E.g. whenever I asked her a question, she'd only say "please help me!" Her husband had to come into the office and tell me the things such as hours of sleep, appetite, activity level, cause after 3 sessions of "please help me" and only variations of that same statement, I went nowhere fast. She was given ECT, dramatically improved but the severe PD persisted (as expected). That was one of the only ways I could tell where the bipolar disorder ended and the PD began. One of the toughest cases I had yet in outpatient.

It seems that ECT would only help the depression part of the illness. But, it is the mania that can be "worse." They are more of a danger to themselves and others because of the heavy risk taking behavior.

 

[splik]

It seems that ECT would only help the depression part of the illness. But, it is the mania that can be "worse." They are more of a danger to themselves and others because of the heavy risk taking behavior.

ECT is a treatment for both mania and depression (though its effects are shortlived for both). and depressive episodes are by far the worst aspect of bipolar disorder if you ask any patient. historically we have focussed too much on treating mania because it is easier to treat and psychiatry has seen this to be the more serious aspect, but if you ask patients, it is depression that is the most destructive aspect of manic-depressive illness and often the most recalcitrant to treatment.

 

[pre med 2014]

Her depression did get in the way of her job. She had many many hospitalizations among other things. But, she did well when she worked. She was good at what she did, and she trusted her doctor. He told her that she should have nothing to worry about, because the side effect was temporary memory loss.

She had difficulty at work then, but now she cannot work at all. Who will fix her now?

The question in these cases of voluntary ECT is:

1. For those who claim 'but it helped me', do we know if they would have gotten better without the ECT? (That is to say, is ECT more effective than a placebo?)

AND

2. Is it dangerous? (Does it damage brain-blood barrier?, etc...)

 

[istillbelieve]

She had difficulty at work then, but now she cannot work at all. Who will fix her now?

The question in these cases of voluntary ECT is:

1. For those who claim 'but it helped me', do we know if they would have gotten better without the ECT? (That is to say, is ECT more effective than a placebo?)

AND

2. Is it dangerous? (Does it damage brain-blood barrier?, etc...)

I hope there is something that can be done. She may have to go through cognitive rehabilitation. They have neurofeedback that can help with learning disabilities. There is great research on this.

Now, se is very bored and on Social Security disability. She has to ride the handi-Van because she can't drive. She lost a lot of her spatial ability.

I often wonder if ECT is dangerous. Docs seem to only talk about anesthesia. Those are interesting questions. Thanks for bringing them up.

Jack MS3

 

[SuperSoccer19]

Interesting that there seems to be a lot of anti-ECT sentiment in this community. I only did a handful of cases back when I was a resident and spent a week at Duke doing training with their program where there were about 15-20 cases pre day, but the results were pretty awesome. Most of the memory loss was surrounding the time of the ECT, if any, and the improvements were pretty rapid. Most reports suggest relatively high response rates in both unipolar and bipolar depression (then again, with any research there are also reports that its comparable to placebo and "sham" ECT might even offer benefits).

Just wanted to throw out a positive about the subject. Im a believer.

 

[OldPsychDoc]

Interesting that there seems to be a lot of anti-ECT sentiment in this community. I only did a handful of cases back when I was a resident and spent a week at Duke doing training with their program where there were about 15-20 cases pre day, but the results were pretty awesome. Most of the memory loss was surrounding the time of the ECT, if any, and the improvements were pretty rapid. Most reports suggest relatively high response rates in both unipolar and bipolar depression (then again, with any research there are also reports that its comparable to placebo and "sham" ECT might even offer benefits).

Just wanted to throw out a positive about the subject. Im a believer.

I think the "anti-ECT sentiment", such as it is, is coming largely from people like pre-med 2014, who lack the experience that even you have.
I agree, when properly applied, it is pretty awesome. A lot of the negatives I suspect, involve misapplications of ECT for cluster B personality disorders.

 

[pre med 2014]

A lot of the negatives I suspect, involve misapplications of ECT for cluster B personality disorders.

The risk of long term physical disability is the same regardless if ECT is 'misapplied' for a personality disorder OR 'properly' applied for a bipolar disorder. It is not like long term physical disability from ECT ceases to be a negative consequence if the diagnosis was correct.

 

[notdeadyet]

The risk of long term physical disability is the same regardless if ECT is 'misapplied' for a personality disorder OR 'properly' applied for a bipolar disorder. It is not like long term physical disability from ECT ceases to be a negative consequence if the diagnosis was correct.

The rates for long term disability from ECT are much lower than the rates for long term term disability for patients for whom ECT is not given.

I do a fair bit of ECT (my program has it as an option for those who want to get hospital credentials in it). It may vary by institution, but I have yet to have a patient who was not already on disability for mental illness.

And I'm with OPD and the others. ECT is a godsend to the right patients, and the typical appropriate ECT candidate tends to have almost no quality of life due to mental illness that has been refractory to almost every other intervention. In my experience, most ECT patients arrive at the treatment far too late. Many after 15 years of solid depression, anhedonia, amotivation, suicidality, and near total disability. The most common side effect in ECT is anterograde memory loss surrounding the procedure, longer than patients typically have from conscious sedation (if you've ever had an endoscopy, you'll know the drill).

It's hard to be anti-ECT and pro-evidence based, as ECT is about the most evidence-based intervention psychiatry has.

 

[pre med 2014]

It's hard to be anti-ECT and pro-evidence based, as ECT is about the most evidence-based intervention psychiatry has.

blahhh....

It is frustrating to be accused of being anti-evidence when evidence is precisely what I want. Criticizing the practice of neglecting evidence is very pro-evidence.

 

[Armadillos]

Not at the point in my training where I spend much time reading research, but completely anecdotally it wouldn't surprise me if ECT actually improved memory in a substantial subset of patients. Its just incredible when you see these "boulders" on the inpatient unit transform and go home after a week of ECT. In my experience many of these patients were so depressed pre-ECT that their memory/concentration were impaired to the point that they were completely non-functional from a cognitive standpoint. I know there is a ton of research out there showing ECT can have substantial adverse effects, but the people we are treating with it are profoundly sick and in desperate need of something more than alphabet soup therapy and fiddling with meds.

 

[Ceke2002]

ECT is a godsend to the right patients

I do so enjoy reading these discussions.

Just chiming in, with my albeit completely non medical and anecdotal opinion, to agree with this statement. I know a fair few people that ECT has personally helped. There's one case in particular that comes to mind. Female with a history of late onset anorexia and severe, irretractable depression for more than 10 years; repeated hospitalisations; barely able to function on a daily basis let alone work; dependent on disability; little to no hope for the future...And then she agreed to undergo a course of ECT as, what she considered, a desperate last resort. The change in her could not have been more profound. Knowing her when she was ill, and speaking to her now it's like night and day. Her weight is stabilised at a healthy level, she's happily become involved with a variety of social groups and activities, and she's returned to full time work as a pharmacy tech (prior to her illness she was a highly respected physiotherapist, but has now decided on a career change). She now talks about the future as something positive to look forward to, and this was someone who struggled to even get out of bed and attend to their most basic needs. Yes the treatment she's undergone as been nothing short of a miracle. Yes she suffered some cognitive deficits with short term memory, but they weren't permanent and essentially resolved by themselves within 6 months or less. She has stated outright that without ECT she does not think she would have lived another 6 months. As far as I'm concerned (my own personal opinion), this was not only a life changing treatment, it was life saving.

I fully acknowledge that none of the above is in any way evidence based, I'm just saying I've seen first hand the changes ECT can make to a patient's quality of life, and just how positive those changes can be. I don't think it's an entirely black and white issue.

A view point from the other side of the couch, so to speak. Feel free to ignore, dismiss, or take from it what you will.

 

[pre med 2014]

Not at the point in my training where I spend much time reading research, but completely anecdotally it wouldn't surprise me if ECT actually improved memory in a substantial subset of patients. Its just incredible when you see these "boulders" on the inpatient unit transform and go home after a week of ECT. In my experience many of these patients were so depressed pre-ECT that their memory/concentration were impaired to the point that they were completely non-functional from a cognitive standpoint. I know there is a ton of research out there showing ECT can have substantial adverse effects, but the people we are treating with it are profoundly sick and in desperate need of something more than alphabet soup therapy and fiddling with meds.

Just out of curiosity. Do you follow up with these 'boulders'? Do they go back to a severely depressed state? I ask because I have heard of high relapse rates post ECT, close to 100%.

I am truly only "anti-ECT" in terms of involuntary use of ECT but I remain suspicious of the voluntary use of ECT due to supposed high relapse rates, uncertainty in efficacy and unknown/known dangers.

 

[istillbelieve]

I am of course pro-ECT for those that really need it. My sister was given valium and xanax from her psychiatrist for three years. She heard that that could be fatal. She quickly withdrew from all her meds. She got so depressed that she could not function. Meds did not help at all. She had ECT and it really worked. She is no longer on meds, and no longer needs psychotherapy. She would have died without it.

A friend of mine would have killed himself without ECT. He had two attempts on his life. He no longer needs therapy or meds. He sees his psychiatrist every four months for a checkup.

So, I am for it as long as it is used appropriately. That example I gave about the woman is very uncommon.

 

[SuperSoccer19]

Just out of curiosity. Do you follow up with these 'boulders'? Do they go back to a severely depressed state? I ask because I have heard of high relapse rates post ECT, close to 100%.

I am truly only "anti-ECT" in terms of involuntary use of ECT but I remain suspicious of the voluntary use of ECT due to supposed high relapse rates, uncertainty in efficacy and unknown/known dangers.

There are not clear guidelines on this or its frequency, but maintenence ECT is sometimes performed--either if someone has relapsed or even simply based on patient/provider preference. It is also sometimes recommended to continue most medications during and post-ECT to lesson the risk. If there is a relapse, but were significant benefits, you can perform ECT a second or even third time or more if there were minimal side effects. A typical course is only about 8-12 sessions and at least in the places I have been we did it 3 days per week.

Its considered the "gold-standard" for depression in spite of conflicting views on how/why it actually works, but there is a lot of evidence to support its use. Due to media and stigma created by movies like "One Flew Over the Coo-Coo's Nest" are probably the main reasons why it is not used as often as it is. If I remember correctly, Duke's criteria was basically anyone who wanted it and/or had failed 3 medications for depression. There were even some patients who just did not like the idea of taking a medication and considered ECT sooner.

I am not sure if there is a such thing as "involuntary" ECT use unless the patient lacks capacity and a family member is the one obtaining informed consent. I would be surprised if anyone outside of Hollywood or living in the 21st century would be dragged kicking and screaming to a PACU or OR for this procedure. Something about medical ethics and assualt/battery being limiting factors.

 

[pre med 2014]

I am not sure if there is a such thing as "involuntary" ECT use unless the patient lacks capacity and a family member is the one obtaining informed consent. I would be surprised if anyone outside of Hollywood or living in the 21st century would be dragged kicking and screaming to a PACU or OR for this procedure. Something about medical ethics and assualt/battery being limiting factors.

This is a video taken in the 21st century, at about the 2 minute mark you can actually see the child being dragged kicking and screaming into the shock machine. It definitely does happen.

At least after the 'treatment' they were able to get him to take off his damn coat!

 

[notdeadyet]

This is a video taken in the 21st century, at about the 2 minute mark you can actually see the child being dragged kicking and screaming into the shock machine. It definitely does happen.

This is not ECT. Stuff like this unfortunately contributes to all the bad info out there that makes some folks unable to enter rational conversations about what can literally have been a life saving treatment modality.

The person in this video was strapped face down and given electric shocks as punishment. This is NOT electroconvulsive therapy. Please don't confuse the two. It's the equivalent of confusing a surgery with a knife fight.

 

[pre med 2014]

Then I guess I am against involuntary electrocution as a form of punishment. (Actually I am against the electric chair as punishment for crime. Nonetheless I should clarify I am against the use of doctors to administer punishment)

However, the lawyer speaking on behalf of the center referred to it as treatment.

 

[splik]

Then I guess I am against involuntary electrocution as a form of punishment.

you would be in favor of voluntary electrocution?! btw this would be murder as electrocution by definition always results in death.

 

[pre med 2014]

you would be in favor of voluntary electrocution?! btw this would be murder as electrocution by definition always results in death.

No!!! Lol

 

[SuperSoccer19]

This is a video taken in the 21st century, at about the 2 minute mark you can actually see the child being dragged kicking and screaming into the shock machine. It definitely does happen.

At least after the 'treatment' they were able to get him to take off his damn coat!

Yeah, this is totally not ECT. This is claimed to be "aversion therapy" or possibly abuse, but who knows with FOX News. I tend to prefer sources like pubmed, Cockran or UpToDate for evidence based information. If you are interested in learning more about ECT or psychiatry in general, I would recommend pages 1-7698 of Kaplan and Sadock's Comprehensive Textbook of psychiatry. Perhaps consider watching a case if it can be arranged?

In real ECT, the patient is unconscious and given a paralytic. A seizure is induce by applying shocks to his head only. A blood pressure cuff acts as a tourniquet, applied to the leg and the only convulsing one sees is the foot with the cuff (no paralytic) and its merely a rhythmic foot motion and an EEG monitor records seizure activity. A mouth guard and safety devices are worn just in case, since there can be a clenching motion or some movement with the shock. I have seen the paralytic not work or the patient have a mild convulsion, but the patient is still out cold and at most wakes up a little sore. Its very not barberic and patients usually remember being put out and then waking up in the recovery room.

 

[OldPsychDoc]

Involuntary treatment with ECT can occur in some states, but only with a court order as part of a judicial commitment process. Again, the providers need to demonstrate the patient's danger to themselves and inability to give informed consent, and the necessary indication of ECT for the patient's condition. We are usually successful in obtaining these orders in cases of severe catatonia, for example, in which it is thoroughly evidence-based, effective, and life-saving.

 

[pre med 2014]

Involuntary treatment with ECT can occur in some states, but only with a court order as part of a judicial commitment process. Again, the providers need to demonstrate the patient's danger to themselves and inability to give informed consent, and the necessary indication of ECT for the patient's condition. We are usually successful in obtaining these orders in cases of severe catatonia, for example, in which it is thoroughly evidence-based, effective, and life-saving.

That's the most dangerous kind of ECT, when the patient doesn't know its good for them

 

[OldPsychDoc]

That's the most dangerous kind of ECT, when the patient doesn't know its good for them

Read, then post.
You don't even know what you don't know--and THAT'S the most dangerous kind of doctor pre-med.

http://www.amazon.com/Catatonia-Cli...UTF8&qid=1384194929&sr=1-1&keywords=catatonia

http://www.amazon.com/Practice-Elec...087&sr=1-4&keywords=electroconvulsive+therapy

http://www.amazon.com/Electroconvul...087&sr=1-1&keywords=electroconvulsive+therapy

http://www.amazon.com/Shock-Kitty-D...087&sr=1-3&keywords=electroconvulsive+therapy

 

[pre med 2014]

I try to keep an open mind. But my philosophy is a NO means NO. A psychiatric diagnosis can render a patient unable to give consent only in a metaphorical sense.


In the old south one common theme in the master-slave dynamic was the slave never knew he is born brain diseased making him fit only for servitude, and the lashes were good for him if only he could see it. So on and so on. Now it is mental ill who are in denial of their inferiority and instead of lashes they get shocks.

 

[Armadillos]

I try to keep an open mind. But my philosophy is a NO means NO. A psychiatric diagnosis can render a patient unable to give consent only in a metaphorical sense.


In the old south one common theme in the master-slave dynamic was the slave never knew he is born brain diseased making him fit only for servitude, and the lashes were good for him if only he could see it. So on and so on. Now it is mental ill who are in denial of their inferiority and instead of lashes they get shocks.

From seeing that video you posted its very clear to everyone reading this forum that your vastly unfamiliar with ECT (and the practice of medicine in general), and I think you should appreciate the time these MD's are taking to provide you with resources and help you understand the modern practice of psychiatry. If your genuinely interested in learning more I would highly suggest seeing if you can shadow for a general surgical operation requiring general anesthesia and then after seeing that see an ECT treatment so you can compare and understand ECT in its proper context. There are cognitive risks to ECT which can be debated/weighed on a case by case basis, but your understanding of ECT is so far from reality that your not really in a place to have a productive discussion about it right now.

 

[pre med 2014]

I have seen a procedure requiring anesthesia.

I did not know that video showed aversion therapy but incorrectly called it ECT.