Aging, Depression, and the Power of ECT: A Conversation with Dr. Joshua Bess - Episode 119
Watching an aging loved one battle severe, treatment-resistant depression can be a painful and isolating experience. When medications and therapies seem to fail, it's easy for caregivers to feel like they're running out of options. But what if there was a powerful, often misunderstood treatment that could offer real hope?
In this crucial episode of the Caregiver Relief Podcast, host Diane Carbo sits down with Dr. Joshua Bess, a nationally respected psychiatrist and the medical director of Seattle NTC. They tackle a topic shrouded in stigma: Electroconvulsive Therapy (ECT).
Dr. Bess dispels the outdated myths, explains what modern ECT is truly like, and shares why it can be an incredibly effective and safe option for older adults when nothing else has worked. This conversation is a must-listen for any caregiver searching for answers and hope.
Here's a look at the essential topics Dr. Bess and Diane cover in their conversation:
- A Journey to Psychiatry 👨⚕️: Dr. Bess shares what drew him from rural Indiana to interventional psychiatry, starting with a desire to offer "human kindness" to those in need.
- Modern ECT vs. The Myths 🎬: Forget the scary scenes from movies! Dr. Bess explains how today's ECT is a safe, routine medical procedure performed under general anesthesia and with muscle paralytics. Family members who observe it for the first time often find it "pretty mundane".
- Why is ECT So Effective in Seniors? 🤔: While the exact reason isn't known, Dr. Bess discusses the leading theories. He notes that certain types of depression common in advanced age, like psychotic depression, are "exquisitely responsive to ECT".
- The Truth About Memory Loss ❓: This is the biggest concern for many families. Dr. Bess breaks down the three main types of memory issues that can occur:
- Temporary Confusion: Lasting for about 15-20 minutes right after the procedure, which happens to everyone.
- Trouble Forming New Memories: Difficulty remembering day-to-day events during the course of treatment. This effect generally goes away once the treatment series is complete.
- Forgetting Past Events: The most feared side effect, known as retrograde amnesia, is not as common as portrayed. It can create "Swiss cheese" gaps in memory but typically doesn't affect core, personal life events or identities.
- When is ECT the Right Choice? ✅: Dr. Bess typically recommends ECT in two main scenarios: for patients who fit a profile known to respond well (like those with psychotic depression or catatonia) or for those who have tried several other interventions without success.
- What a Treatment Course Looks Like 🗓️: An initial "index" course usually involves three treatments per week for about three to four weeks. After a successful course, some patients may continue with "maintenance ECT" (e.g., once a month) to prevent relapse.
- Medical Safety and Clearance ❤️: Learn how doctors determine if a senior is healthy enough for ECT. It involves a process similar to pre-operative clearance for any surgery, focusing on optimizing cardiac, neurologic, and respiratory health.
- Insurance & Medicare Coverage 💵: Good news! Dr. Bess confirms that ECT is "almost universally" covered by insurance and Medicare, having been "grandfathered in" to the system.
- Hope for the Future ☀️: The field of interventional psychiatry is growing, with more options like TMS and ketamine becoming available and ongoing research aimed at making treatments even more effective and less invasive.
This episode is an invaluable resource for understanding a treatment that could change—or save—a life. If you're feeling lost in the face of a loved one's severe depression, Dr. Bess's compassionate and clear explanations will provide both knowledge and hope.
Find out more about Dr. Bess and his work at Seattle NTC.
To our incredible community of caregivers: You are the heart of it all. Please remember to be gentle with yourself and practice self-care every day. You are worth it. ❤️
Podcast Episode Transcript
Diane: Welcome to the Caregiver Relief Podcast, where we support, empower, and inform family caregivers navigating the challenges of caring for aging loved ones. I'm your host, Diane Carbo,
Diane: and today we're Tackling a topic that is often misunderstood, but critically important, ECT electroconvulsive therapy, especially in older adults living with treatment res resistant depression.
Joining me today is Dr. Joshua Best, a nationally respected psychiatrist and medical director of Seattle NTC, one of the busiest ECT and interventional. It's west of the Mississippi. Dr. Bes has extensive experience in treating seniors with depression that doesn't respond to medication, and he's here to clear up, miss, explain modern ECT and offer hope to caregivers who feel like they're running out of options.
Dr. Best thank you so much for joining me here today. I really appreciate you and addressing this difficult topic.
Joshua: Thank you for inviting me, Diane.
Diane: I see you've had an interesting path. You've gone from rural Indiana to interventional psychiatry in Seattle. What drew you to focus on ECT and working with seniors?
What
Joshua: drew me to psychiatry was seeing people who weren't treated very nicely, or at least were upset or anxious about talking to doctors or talking to healthcare professionals. Yeah. Coming out of a small town, I, the only doctor I knew was the family doctor. so when I went to medical school, I thought I would be a family doctor or maybe a pediatrician.
And my first psychiatry rotation, really changed that a hundred, 180 degrees. And I found out that, folks not only were exceedingly, need in a lot of need for, interventions and for treatment, but also just human kindness and. I happened at the time and hopefully still to be good at human kindness and I was able to make connections with people that other, classmates of mine found it difficult to make.
So that's how I jumped over into psychiatry. my training program. My first, the first six months of my training program, was at the Veterans Affairs Hospital in Ann Arbor, Michigan. and that was the ECT Center for the whole vision, the region. within the va,that,referred patients to that hospital.
And we got an earlier exposure to ECT, with a beloved mentor of mine, and it was just off from there. I really enjoyed seeing people get better so quickly, and for people who had been long suffering to, to feel a lot better. In any way, was great. And so I just continued from there and chose, chose my path to, to hang out with the ECT people.
Diane: There's still a lot of fear and misunderstanding about ECT. Can you explain what ECT is today and how it differs from the outdated images people may have?
Joshua: Of course. Yeah. ECT. For both good and bad has been around for a long time. So we have more, more experience with ECT than really almost any other, certainly any other psychiatric treatment.
and it predates almost all the psychiatric medications. It predates all the other interventional, technological things that, that have come about in the last 15 to 20 years. but then it also means it has a bit of a, troubled history as well. And it today is a very, safe, effective, relatively, non-invasive, although there is an IV line and things like that.
treatment for depression and for other, serious issues that we can talk about if you'd like. but for the people going through ECT. It's scary because it's like any other medical procedure, you're gonna be asleep, you're not in control of what's happening for that period of time.
there are potential side effects, which we'll talk about. And, until you do something the first time, it's a scary thing. And what's remarkable is that people who have a series of treatments, 'cause it comes in a series usually, by the second or third treatment, or at least by the second or third week.
It's just. a rote thing for them. it's a inconvenience and something that they don't necessarily look forward to except for feeling better. but it really is routine. And I'll tell you, there are clinics, in the us, unfortunately not ours, where a family member or loved one can observe the procedure.
And there's a family centered ECT movement. and my colleagues who work in those clinics tell me after the first or second time, they don't really bother. They go get a cup of coffee because okay, I've seen it, it's pretty, it's, it is, it's pretty mundane actually.
with all the hype and all the stigma and negative history these days, it's very routine. but yes, it used to be. it used to be done without general anesthesia and without muscle relaxation or, muscle paralytic. so that's where you get the scene from the Cuckoo's Nest.
the other issue is, it, the, forcing people to do it also related to the Cuckoo's Nest. And so those two big,weights, that weights of history that we're carrying still. Are no longer the case. informed consent is exceedingly important and since the sixties really it's been standard of care, at least in, in the West, to use both a paralytic to make the muscles not move, and a general anesthetic to put the person asleep to sleep so that.
They're okay with their muscles not moving. And that's basically it. it hasn't changed a whole lot since then, except for some, finesse and revising of protocols and procedures and frequencies and, there's lots of research ongoing still. but the biggest change has been that, and since then, it's been a, it's a very safe, relatively,I say non-invasive, relatively, straightforward procedure. Yeah.
Diane: I suffer from treatment-resistant depression. I've had it all my life. I tried every single, antidepressant there was, they work for a little bit and then they stop working. And I am actually, excited. I actually go to a Ketamine clinic, and I will tell you right now I have a family, a mother-daughter team that the daughter brings her mom to the ketamine and the daughter.
The mom takes the daughter to her ECT. Yeah. And the daughter is in her fifties, late forties, early fifties. And she says, ketamine's, not for me. I want ECT. And when I heard that, because of my visions of when I was in nursing school, was ECTI was shocked. But she, and they talked about it like, it was just, like you said,it's just nothing bad or big about you.
Terrible about it. So I really got, it, it enlightened me. That's why I was so in, excited about talking to you today because we really do need to dispel people need to find what works for them, right? And they have to get over their fears of the unknown. So that's what we're going to do here today, I hope.
yeah. So why is ECT particularly effective for older adults suffering from severe depression or other psychiatric illnesses?
Joshua: like a lot of things in medicine, including psychiatry, but even in other fields of medicine, the real answer is we don't know. we observe that it is, and we observe that this thing helps and that it especially helps people,in, older people in the later stages of life.
there are lots of theories about why it might be. More effective, in older people and, but we don't really know for sure. I always am a little bit tickled by that. the,I, there aren't many things in life that you can say work better when you're older.
I'm
Diane: I can attest to that.
Joshua: I'm I'm looking forward to, maybe if I am in that position in the future. that I'll have this to fall back on. and my family certainly knows that's what I want,if needed. So it, there, there are theories that involve the type of depression that people have when they're older.
the neurophysiology does change over time. and ECT works. Exquisitesly well in older people who have what's called psychotic depression, where you have some sort of false beliefs or some sort of experiences that aren't real, like a hallucination or a worry that your family's trying to steal your money or that people are trying to harm you in some way.
and that's, that type of depression along with some of the other features that happen in advanced age. they're just exquisitely responsive to ECT.
and so there's a theory that, the type of depression is just more responsive. the,the brain.
Over time as it's developing, gets into certain ruts and certain habits. and maybe by the time we get to our sixties and seventies and eighties, yes, we have some hard hardwired habits, but we're also in a place where we're, More. we're wiser, we're more at peace with things sometimes.
we're not quite as bullheaded, let's say. so that's how I think about it too. I Irish
Diane: girl. Yeah.
the bullheaded is still there,
Joshua: but I, because it, it is a fascinating question. you know why that is? And I, when I'm counseling people about their options I will, if someone's in front of me, this just happened this past week.
If someone's in front of me and they have some of those features, some of those, characteristics that we see since medicine is pattern recognition and we know that things that go together, tell us a story, I'll be very open with them and say, look, this is by far the best chance you have.
we could do other things first. I'm not saying we, we can't, and if you would like to, we should, but to give you the best chance, this is what I recommend. there is that,we do have to be extra careful because people do have other medical problems, more often as we get older.
there is a little bit of a balance there. We're looking more closely at cardiovascular function, neurologic function, respiratory illness, things that you can accumulate over the decades, right? And so while it does work so well in that population, We're also, we're extra careful medically, but also that's just testament to how safe it is.
if you have people who are in their nineties, or even a hundred years old, getting this procedure on some sort of an intermittent or repetitive basis, like it must be safe.
Diane: Oh, it must, absolutely. I agree there, many caregivers worried about memory loss with ECT. Can you tell us about the safety profile of modern ECT, especially for seniors?
Joshua: Yeah, this is really important. and this is the,the avenue that, anti ECT or Antip psychiatry, groups or people will very often try to exploit. and just a quick aside, like what other treatment in all of medicine has a group of people who are. Focused on opposing it, right?
Diane: Yeah.
Joshua: but there are memory problems that can happen with ECT.
Diane: And
Joshua: that's a very important part of the informed consent process. Okay. And what is tricky is the person who's a potentially a good candidate for ECT is also vulnerable. If you're severely depressed, if you have. Worries that bad things are gonna happen, even if that's not realistic.
or that someone's trying to hurt you. If you are, so depressed that you're not eating and you're, you have poor nutrition or you're not sleeping well, that makes you more vulnerable to anything. Yeah. And then we're trying to have an informed consent discussion about the risks and the potential benefits.
But setting that aside for a second, there really are three. Main thinking or memory things that can happen. Okay. Okay. And how I describe it to people is the first one happens to everybody. You're confused, right? Afterward. You, your brain just had a seizure, you've had anesthesia. You're waking up from a procedure.
you're in a strange place. Although it gets to be familiar after a couple of treatments with strange people who then get to be friends. yes, exactly. You're waking up and you're. 15, 20 minutes, it takes for you to be reoriented, right?
and so that happens to everybody no matter what their, pre ECT cognitive function was or what kind of side effects they might have.
and so that's just to be expected. the second is, difficulty forming new memories. So when your brain has a seizure, I think of this as Short term memory or like the,the back in the old days where we had computer discs, right? So not the hard drive, but the disc that you would put in, or maybe the CD rom.
Yeah. So it's temporary, but longer term than just here in the moment. forming new memories is really hard because the way our memory works, we have an experience, it hangs out. For a bit, and then it gets put into more longer term memory. while it's getting processed, if your brain has a seizure, it's disrupted.
That process is disrupted. and so during the course of treatment, if you're getting two or three treatments a week over several weeks, you will have a hard time, remembering things that have happened during that time, maybe a little bit before. often it's mundane things that I have.
Dinner with my friend last night. they mentioned it this morning, but I don't remember, or did I, send that check for whatever I needed to pay, or did that person visit me? some of those things, like those day-to-day life things that we just take for granted that we'll remember, what did I eat yesterday?
So we really counsel people not to make any big decisions during a course of treatment. certainly not to sign any legal documents or do anything like that. Again, the vulnerability, right?
Diane: Yes.
Joshua: but so that forming new memories, what we call, antrograde amnesia, that. As we're going through life now, once the ECT is done or you're coming less often, at least maybe you're doing a maintenance course less often, that pretty much goes away.
Maybe the day of treatment is foggy, but you don't have ongoing. Trouble forming new memories. Okay. Okay. So that's number two. Number three is what people really get,are afraid of and get, very upset by and is a serious situation that you have to make sure that people understand going in and that's forgetting things from the past.
And one of the difficulties is it's very hard to study. I don't know what's in your brain. I can give you a test before and after, right? but I don't know what's in your brain from years and years ago and what your life experiences have been and how you've inter or how you've experienced the world, in different places at different times.
So it is one of those things where you don't know, you don't know you've lost it until you've lost it, right?
Diane: Yes. Yes.
Joshua: and so people do get really worried about that, and it does happen, and we have to be honest about that. It's not common, it's not as common as it is often portrayed to be.
but there are people who have what we call retrograde, autobiographical amnesia, forgetting some things from their past.
By and large as best we can study it. These are usually things that are not personal or not, very, they aren't woven into the fabric necessarily of your.
Of your history, of your life. they may be events, they may be things that are somewhat, tangentially related to you. You're not gonna forget who people are. You're not gonna forget, your huge events in your life. and you may forget a trip that you took or you may forget.
Find details of a trip that you took. and reminders can help. And, talking it over with people can help. But yes, there is this kind of Swiss cheese that can happen where you do forget some of those things. that, so those are the three types of memory impairment, that we talk about. A very recent study also brought up a fourth dimension that's important, which is how you feel about all of that, the subjective.
Memory impairment. So I can give you a test, but the test doesn't, the test can tell us maybe, if you're actually able to pass the test, but it still doesn't have anything to do with how you feel about your memory.
and there are, 25% or so of people, six months after they're done with ECT will have.
Subjectively a feeling that their memory is not as good as it was, for things in the past. And again, mostly those yes, things that happened in your past but weren't intensely personal to you.
and so that's how we've been talking with people about it.
Diane: That's fascinating. As an aging senior myself at 72, I have foggy memories of trips and things that I've took, or have taken it in one time or another.
to me it wouldn't feel like it was anything unusual.
Joshua: and the fun, a funny thing is that people are different too. So yes. my, my wife is. Is the family historian and, she remembers so many developmental things and so many of those little moments with the kids. and not to get the impression that I was some sort of absent, absent father.
But I just, my, my memory doesn't work that way. I have pastiches or, broad brush strokes and Sure. I have.
Diane: Yes. Yeah.
Joshua: And now with social media or everybody has a camera in their pocket. it does help. But those are still reminders. Those are reminders that I need to like, oh, that's what happened.
and some people just are more, more either chronological or detail oriented or more photographic, so there are differences in people to start with. exactly. And so that's one thing that, that we always consider. Something else to keep in mind is, cognitive function. In some ways declines for everybody as we age.
but we do sometimes think about there are differences if someone is,a professor versus say a truck driver or longshoreman, right? So I talk with people from all walks of life, Yep. And I say,if you use your brain for a living, you might notice. You might have a better sense or a more precise or fine tuned sense of when you're having some even relatively minor difficulties.
Whereas if you don't use your brain for a living every day, it's not that you're not smart, you just don't use it like that every day. Yeah, exactly. You might not notice until it's more severe, until there's more impairment. And so that's something also that we have to take into account. So we're, we want to counsel the people who, want to take some time off their job as a teacher or a nurse or a professional.
Have ECT, their depression gets better, go back to their job. We try to be, really, forthright with them about these potential side effects and how that can, not, and the vast majority of them end up going back to work, but it can be, a process.
Diane: So when do you recommend ECT as a treatment option and what has typically already been tried?
Joshua: that's been really cool. a cool evolution over even my lifetime, my career. So when I, was finishing training, so I graduated residency in 2008 if I were in the treatment resistant depression clinic, at University of Michigan. It was basically a question of ECT or not, right? vagus nerve simulators had been approved a couple years previous.
That's a side topic, they were around but not widely adopted. we would sometimes. there were medications that people hadn't tried. and, because,they have more side effects, a little bit older. So we would sometimes recommend that. we would always make sure that they, you were either in a good, situation with psychotherapy or they had a very good trial of psychotherapy.
But really that was the question. That's what we had. The IV ketamine was really just in its infancy. and, TMS was being studied. We, it, it got its FDA approval in 2008, but, it took a long time to be widely adopted as well, yeah. So yeah, that's what we, that's what we talked about.
Now, if you fast forward, almost 20 years later
I have a whole clinic and a whole staff of providers and staff here who, depending on who you count it, are able to offer five or six or seven different things to somebody who comes in and says, I've tried. A bunch of medications and they haven't helped me.
Yeah. and so really it is a nuanced, detailed discussion about,what to do first or what order to do things in, or what characteristics your situation has that makes me think that this might be the most helpful for you. a lot of times it comes down to logistics, for example, so with respect to ECT.
I think about it in two categories. There are people who walk into my office, or who I see them in the hospital, and I think to myself like. This person needs ECT. Okay. So an older person with that psychotic type depression that we talked about, or someone who's not eating very well, someone with, what we call catatonia or catatonic features to their situation, to their mood disorder, or, from another cause.
those are people where most of the time we will at least give serious consideration to do ECT first, right? And there may be other. Roadblocks and maybe other problems that you know, will, that we have to figure out, but that's gonna be at the top of the list. The second category of people who get ECT.
Are the people who have tried everything, quote unquote. Yeah. and so you might do a course of TMS transcranial magnetic stimulation, or you might have like the, person you were talking about, ketamine is not for me. either I tried it and it was not for me, or I don't like the idea of it what, whatever, or I can't afford it.
That's a thing. Exactly. and so that's the,on the monopoly board here, you've been around and you've passed go a couple times and. So then we're talking about ECT as a thing that isn't the last resort. I'm always very careful to not. talk about it as this is it, this is the final station on the train line.
But is the thing that is the most invasive and does carry the most baggage, let's say, and is a big deal as far as getting to the hospital and going through other things. but also has still has the best chance of working. So either you fit the pattern, you fit the characteristics of somebody we know is gonna be a good responder to ECT.
Or you've tried several other things, which fortunately now include. Other interventions, not just medication, but those haven't done the trick. And so then we consider ECT.
Diane: So what does a typical course of ECT look like and how long does it last? And how quickly do patients tend to respond?
Joshua: So in the, in the us or in North America generally.
we do ECT three days a week. For somebody who is in a acute or intensive, or what we call an index course, it's their first, it's their first time. and someplace, many places in Europe, it'll be twice a week. It works the same, it just takes a little bit longer, but usually three times a week for three to four weeks.
It is very purposely wishy-washy and vague. Because we track the response very closely, like daily. Right now, it's excellent to be able to offer a treatment. In psychiatry where you track the response daily because it starts to help in a matter of days, right? but the average, the sort of nu the number that people throw around is 12.
some patients and their families will get a little bit, attached to that number. So we're careful to say you might need more, you might need less, but 12 is a good round number, right? a month off of work or, needing to arrange transportation or something for a month.
and so generally that's how it, that's how it plays out. if, and, I'm a, education co-chair for the ISEN, which is the international ECT organization. and one of the things is the organization. Has always been trying to do and continues to try to do is, really like study and sift out like what's best practices and how,how should we approach certain situations?
'cause there is a wide variety of approaches with even within ECT. but usually we'll start with,a protocol and if somebody's not feeling better by. The end of the second week by around the sixth treatment. We'll switch up the protocol, we'll do the ECTA little differently.
and continue. And then we will keep assessing whether they're responding. People can, I've had people who felt something after the first treatment that's not. Common, but it happens. But definitely by the third, fourth, fifth treatment, if they're gonna be a solid, very straightforward responder, we'll start to get some sort of signal.
that doesn't mean that we stop if it's not there by that time, we keep going. by the 10th or 12th treatment, if we have, no signal at all, if things are just really stuck,we sit down and assess is there something we need to do differently? Did we miss something here?
is this not the condition that we thought it was? the cases I remember from my career are the ones where we did a course of ECT and got nothing, right? And they didn't respond at all. And then down the road we figured out, oh, it was something else. It wasn't, what we thought it was mimicking a severe depression, that sort of thing.
So that's a general course. the, after your first course of ECT. You have a choice to just stop, be done with ECT after that 12 or 14 or something. I'm feeling better. I don't, I wanna go back to work. I wanna go back to my life or I wanna go back to, Arizona, whatever.
Diane: Yeah.
Joshua: and we're very willing to say, okay, great. we're here if you need us, we hope we never see you again. wink. if we're here if you need something. Exactly. where. so there's, so then that clock starts. and if you are doing some sort of maintenance medication.
you probably have about of a two thirds chance that you'll make it six months to a year without any kind of relapse. Oh, wow. if you don't do anything, if you don't do maintenance medication or maintenance, ECT, it's about 50 50. okay. and I say six months to a year, 'cause some studies are six months, some studies are a year, and somewhere in there, if you make it to a year.
you're doing pretty well. if you do both maintenance, ECT and medication That's even better. So certainly by the second time somebody's had a full course of ECT.
Or the third time they've had a full course of ECT because they've relapsed. We'll recommend.
Maintenance, ECT, which is in the weeds as far as how we do that, but it's basically less often, once a month or something like that. I,
Diane: that was gonna be my next question. Yeah. What does maintenance look like?
Joshua: Open-ended, right? So once a month for some people. Forever.
Diane: Yes. For some
Joshua: people, a couple years.
For some people. Six months. And then we give them, let 'em, stop and see how things go. But if you do maintenance and if you do medication. You have, maybe, it's a 25% give or take relapse rate at a year, but, two years, three years, it's the rule rather than the exception.
the mood disorders are episodic. Some, it's gonna come back at some point. Yeah. And it's sad to see, even though, we always explain that to people, but then they, they come back to see me five or six years later. They're like, oh, I thought I was okay. you were okay for six years and we're gonna make you okay again.
But yes, we have to deal with this right now.
Diane: Yeah, that's,
Joshua: yeah.
Diane: it. People don't understand that, your body's always changing and maintenance is not a bad thing. Yeah.
Joshua: it's hard. we, I'm always trying to think of analogies 'cause I'm an analogy thinker and so I want to try to explain it to other people with analogies.
one, one analogy, which I really just think isn't that useful, is dialysis. 'cause dialysis is pretty horrible. Yeah. But it's something that you need and you just go do it, and then you go on with your day.
Diane: Yeah.
Joshua: there are some dermatologic conditions where you have to go get laser treatment once a week.
Diane: Yes. Or,
Joshua: once a month. so somewhere between those two is, is maintenance, ECT, and there I, there are people who, I've been in this job for, going on, 12 years and there are people who are, who I met as maintenance CCT patients who I'm still seeing. they, for them the once a month or once every six weeks, one treatment, couple hours at the hospital, yeah.
Is more than worth it to otherwise be able to not think about or not fear, having that severe relapse. I.
Diane: At a maintenance for my Ketamine right now, and I'm, I go every six to eight weeks and my biggest fear is that I'm going to, Go back to the way I was feeling and, 'cause I don't take any other medication right now.
I have not had to do that, but yes. And I'm very faithful about being aware of how I'm feeling and what I'm doing and, Check the calendar. Go. Yep. It's time to go again.
Joshua: Yep.
Diane: and i think that as we get to older, we also know our bodies better. And if you're aware of what's going on, especially with depression,
it's really challenging. 'cause you notice, you don't want to eat anymore or you just don't wanna get outta bed. And,it, there are so many things and I've seen people in severe depression and it is. Amazing to me the results I've seen with ECT and that was decades ago.
But this, that's the reason why I was so interested in talking to you. When I, this woman was saying that she preferred the ECT to ketamine, I went Really? Yeah. Shocked me. everybody has their needs, but the fact that she knew what she wanted and knew what worked for her was really important.
Yeah. and also she was supportive that her mom preferred the ketamine. Yeah, that was really important. So how do you determine if a senior is medically appropriate for ECT?
Joshua: So we partner with, either their primary care
Physician or if they're in the hospital, there's usually like a internist or a hospitalist team, that will consult on the psychiatric unit.
and really the questions are. it's like any, it's like any, procedure or surgery or operation. the term that gets thrown around, which is a little bit, misleading is clearance, right? So it's preoperative clearance. And, primary care physicians know what to do with that.
Even though they're not giving us permission, like they're not clearing it. They're telling us that things are optimized right. But that just takes a long lot longer to explain. So basically you can have any number of conditions or illnesses or things that you're being treated for as long as your treatment is optimized, that you're doing the best you can and you're physically healthy enough to endure what the physiologic things that are gonna happen during ECT.
The very beginning of the, first of all, anesthesia in general, so can Are you healthy enough for anesthesia?
there's this, when the, when we first give the ECT stimulus, there's an impulse that will slow down your heart.
very temporary, but, young people especially will slow way down.
and then when the seizure starts, your heart speeds up and your blood pressure goes up.
is your heart healthy enough? Basically for exercise, like for a brief slowdown and then exercise. Okay. Okay. So someone who has untreated coronary artery disease or has un who isn't optimally managed with their, say, congestive heart failure, like that needs to be sorted out first.
so cardiac. also along with that blood pressure train, increase intracranial pressure. Up. 'cause the blood is all is going up. Yeah. And the brain's being very active. So things in your brain that are. Already causing problems, like maybe don't want to also add that, something like an aneurysm, let's say that's just being monitored.
We'll really consider that as a risk and we'll wanna really make sure that we're managing their blood pressure exceedingly carefully. because, if that an little aneurysm or that little,blood vessel.
Diane: The
Joshua: goes way up and it pops. That's it. that's bad, right?
Diane: Yeah.
Joshua: and then respiratory function.
So we don't use a breathing tube. You don't get a, you don't get intubated for ECT, right? it's just a mask, that the anesthesiologist use uses to help you breathe because it's, three or four or five minutes that you're out. if your respiratory function is already compromised, and this was the huge thing during COVID, aside from people being,contagious, right?
Which was a problem and we had to manage that. if somebody was recovering from COVID, we really have to make sure that their respiratory function is. Pretty much back to baseline or at least 90% better, just because of that stress that happens during the treatment. So those are the big things.
I had a mentor or supervisor that I really love who, would quip that the only. Absolute contraindication is power failure, right? and that's not quite true. there are some things that somebody, certain, types of tumor or like I said, an aneurysm that's not stable, where we would say that needs to be dealt with first.
not that we can't do ECT down the road. A recent stroke is another example.
Diane: Okay?
Joshua: people who have had a stroke. Several months before.
And it's stable. Yes. and even if they still have deficits, you can have ECT and depression after a stroke is very common.
Diane: I just gonna say that.
Yes. Yeah,
Joshua: a hundred percent. And, ECT can be effective for that, but we're gonna wait until things are stable and that the tissue is not still molding and changing and it's not still an acute thing that's being dealt with. So that's, those are the medical things that we're mostly looking at.
Diane: What advice do you have for family caregivers who are nervous about ECT, but are watching a loved one suffer with debilitating depression or other things like paranoia, or harm, wanting to harm somebody?
How do you address that?
Joshua: it's really hard to see somebody suffer like that. But that, that said ECT, it is anxiety provoking. It's a, like we were talking about the, earlier it's like any procedure you wouldn't, it's not something you do for fun, let's put it that way.
and so I try to lay out for them how things are very likely to improve. And that, A delusion or paranoia or even just the thought that they can't eat for whatever reason, that they're too full even though they haven't eaten all day, that's their brain sort of playing a trick on them, right?
That's their brain misfiring in some way, and we can apply a treatment to the brain that will. Turn that around, right? It doesn't come without risks. There are problems that could arise. They might have, like we said, memory, side effects of various kinds. and it's a lot, it's a hassle, transportation wise, we have people who take, two bridges and a ferry to get here and, it's an all day affair.
and but it's, it can be really worth it for so many people. One thing I forgot to mention when we were talking about memory is that, studies have also shown that,if you test people, before they have the ECT, because depression itself can affect memory, and then you test them two days after.
It's not, it's worse then if you test them 15 days after. It's better than when we started. And there's the acute effect of the ECT, but in general, the memory gets better. So their thinking improves, is more clear. They're more able to take care of themselves. They may be talking about a parent or a sibling or a loved one who lives independently, but there's a question about whether they're gonna be able to, if the illness continues, yes, we can return people to living independently.
Like we've already talked about returning to work, returning to, doing the things they love. So that's how I talk about it with them. And then really it's a matter of fielding questions or addressing their specific concerns. some people say, oh yeah, I know the memory thing is a thing, but my memory's bad anyway.
or, mom can't ever remember, where she put her glasses. That doesn't bother us, but we're concerned about. This or we are worried. We heard about that and so you can really meet them where they are as far as those concerns as well. Yeah.
Diane: I'm one of the seniors that goes looking for my glasses.
They're on my top of my head.
Joshua: Yeah. Uhhuh. Exactly
Diane: That's a senior moment that, yeah, exactly.
Joshua: Yeah.
Diane: Now is ECT typically covered by Medicare or insurance for older adults?
Joshua: almost universally.
Diane: wonderful.
Joshua: Good. I find it, I used to find it humorous. it's definitely odd, it's been around for so long.[00:37:00]
Excuse me. that, it really has been grandfathered or grandmothered in to the system. and. When new things are coming out like TMS or s bravado, s ketamine, nasal spray, we have to jump through all kinds of hoops and there's all these like elaborate policies and we're checking boxes and I have a staff of people here to do that.
Yeah. And then we get to the point where the person needs ECT or if they come in needing ECT. And my administrative staff says, oh yeah, no, we just have to document that they need it. it's, we don't need authorization and we don't need permission. and so especially early on with the other things that we're getting to be more, more prevalent, more popular, I would tell people like, yeah, I can take it to ECT right now and I don't have to get permission from anybody, but I have to get permission to like.
give you this other medication and it's gonna take a week to get that sorted. Yeah. So it's almost always covered. there are like there should be, there are guardrails and you wanna make sure that you have the right diagnosis and that you're not doing it outside of,accepted parameters and accepted practice guidelines and all of that.
but one of the common worries about people, sorry, one of the common worries that people have. When they're in that depressive kind of anxious, ruminating state. Is about their money or their finances. and so it, it can be really challenging to try to convince somebody that, oh yeah, ECT is covered.
It's no problem when they think they're gonna get a large hospital bill. yes. And our system has also, primed them for getting a large hospital bill.
Diane: Absolutely. So
Joshua: it's an interesting kind of, little cul-de-sac that sometimes we get stuck in where we're trying to work with that person to understand that we've done this a lot and it'll be covered.
Diane: And that's nice to hear because, our medical delivery system, the insurance, Medicare is moving to a cost sharing and And the things we need, like skilled care, maybe two to $500 a day copay from some Yeah. Insurance companies. So to hear that this is covered is a good thing. And I hope that continues because we lack so much support for our mental health patients in this country.[00:39:00]
Totally. Yeah. Dr. Bess, what gives you hope about the future of interventional psychiatry for seniors and what message would you give, to leave with caregivers today?
Joshua: we've been talking a lot about ECT, and that's my passion. one of my, one of my passions, but one that I think is important to highlight.
Like I mentioned, there's still ongoing research and all kinds of different parameters of ECT and ways to deliver the ECT that helps, mitigate memory side effects or mitigate other, things that, are problematic with the ECT. and so there are studies going on and people looking into.
Theoretical brain modeling and all kinds of different things where, is there a way that we can deliver this and have it be less invasive or less intrusive into the person's life? Other ways to give the brain a seizure besides electricity has been, looked at for a long time. And is making its way through the scientific, process.
do we even need the seizure in the first place? There's a, studies out there of sub convulsive, ECT, is it the electricity or is it the seizure? So there's that whole thing. And even so setting all of that aside, there's so much promise with. TMS and with these ketamine compounds.
when TMS first came out, many of the private insurances who were at least covering it had an age cap of 65. 'cause the prevailing wisdom was that it didn't work in older people. and it took people treating older people and. getting results that were just as good to break through that.
And now that doesn't exist anymore. It's accepted that it works at, any age, up. those things happen with science and with medical research. the hot thing right now are psychedelics, right? So that's getting a lot of press. and, our clinic is involved in several research studies there.
and I. the hope that I have is that there people are just gonna have more options. Yes. And options that have been, vetted and studied. And I can with, a high degree of confidence, say not only is this safe, but has a good chance of helping. We never have a hundred percent right.
Heart surgery isn't a hundred percent aspirin's, not a hundred percent right. But it's something that, is reasonably safe given the situation. And there's this chance that it will help you, which is much, much better than trying your seventh antidepressant or Right. This other therapy that hasn't been really well vetted.
So that's what gives me hope that there's. Now that I'm in the stage of my career where I know many of the people who are doing this work and who are doing the science and who are running the clinics and just know how committed they are. Yeah. And how they're not in it just to, fool people, right?
They're not selling snake oil. that gives me hope.
Diane: Dr. Bess, thank you so much for spending time with me today. I know you're really busy in your clinic. how can people reach out to you?
Joshua: The easiest way is, to go to our website, which is Seattle, NTC, Nancy Travis, Charlie Seattle n tc.com.
Okay. And so that has then. an array of,options for what treatments we offer, how to get in touch with us. Okay. an email address, a phone number, all the things that you might want.
Diane: and we will have that at the bottom of the page that we create for you as well. Perfect. After this podcast so that my families can reach out or the seniors can reach out.
Yep,
Joshua: absolutely. And We are plugged in, let's say. So if somebody is in a different state, there are resources that we can point them to or people that we know great. who can help them out.
Diane: Great. To my family caregivers out there, you are the most important part of the family caregiving equation.
Without you, it all falls apart. So please learn to be gentle with yourself. Practice self-care every day because you are worth it.
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