A treatment for patients with severe psychiatric disorders, in which a convulsion is produced by passing a low-level electric current through the brain of an anaesthetized patient. The technique is mainly used in severe depression and schizophrenia not treatable by any other means.
Electroconvulsive therapy (ECT), also known as electroshock therapy, is a controversial medical treatment involving the induction of a seizure in a patient by passing electricity through the brain. While the majority of psychiatrists believe that properly administered ECT is a safe and effective treatment for some conditions, a vocal minority of psychiatrists, former patients, antipsychiatry activists, and others strongly criticize the procedure as extremely harmful to patients' subsequent mental state.
ECT was introduced as a treatment for schizophrenia in the 1930s, and soon became a common treatment for neurologically based disorders affecting mood. In the early days of use, ECT was administered without anaesthesia or muscle relaxants. ECT without anaesthesia is referred to as "unmodified ECT", or "direct ECT", and is illegal in most countries. Currently, in most countries, patients are first administered an anaesthetic agent as well as a paralytic agent, significantly reducing the chances of injury seen in unmodified ECT.
ECT was a common psychiatric treatment until the late 20th century, when it fell into disuse as better drug therapies became available for more conditions. When still in common use, ECT was sometimes abused by unethical mental health professionals as a means of punishing and controlling unruly or uncooperative patients. Many people came to view ECT unfavorably after negative depictions of it in several books and films, and the treatment is still controversial.
Overview
The aim of ECT is to induce a bilateral tonic clonic seizure (a seizure where the person loses consciousness and has convulsions) which lasts for at least 60 seconds. Before the discovery of muscle relaxants, ECT was given unmodified. Modern ECT machines regulate the current to keep it constant, and thus the voltage may vary up to a maximum, typically 450 V, but is usually about half that in most cases. The ECT therapist tries to minimize the total energy by restricting the strength and duration of the current.
Electrical current flows between two electrodes placed on the scalp, usually from temple to temple in the past, although now ECT is more often applied to the non-dominant brain hemisphere. With unmodified ECT, the seizure is characteristically more severe than a naturally occurring epileptic seizure. Therapeutic ECT is usually given three times per week for 6 to 12 treatments, on either an inpatient or outpatient basis.
Exactly how ECT exerts its effects is not known, but repeated applications affects several kinds of neurotransmitters in the central nervous system. ECT also decreases the functioning of norepinephrine and dopamine, inhibiting auto-receptors in the locus coeruleus and substantia nigra, respectively, causing more of each to be released. One study suggests that long-term ECT increases the expression of brain-derived neurotrophic factor (BDNF) and its receptor, TrkB, in limbic brain regions.
Techniques and equipment
The original ECT machines used alternating sinusoidal mains current at a frequency of 50 or 60 Hz transformed down to 70-150 volts. A survey of psychiatric facilities in the New York City metropolitan area in 1997 found that approximately 11 per cent of ECT patients received sine-wave stimulation and approximately 75 per cent of patients were treated with bilateral electrode placement. The appropriate levels of stimulation are generally thought to be about one-and-a-half to twice threshold level for bilateral ECT and higher than this for unilateral. Below these levels treatment may not be effective in spite of a seizure, while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe cognitive impairment without additional therapeutic gains.
Side effects and complications
Side-effect profile
Much of the accepted risk of ECT arises from the use of general anesthesia; The most common adverse effects are confusion and retrograde memory loss for events surrounding the period of ECT treatment, and generalised but mild muscle aches after waking. Some of the confusion and disorientation seen on awakening after ECT clears soon after. Most typical with standard, bilateral ECT has been a loss of memories for the time of the ECT series and extending back for an average of 6 months, combined with impairment in learning new information, which continues for perhaps 2 months after ECT. No long-term (six months post-ECT or more) studies of cognition, memory ability, and memory loss have been done in the past two decades, but some long-term studies before this reported permanent amnesia, although others found problems were gone by seven months after ECT. At least a third of ECT patients have some permanent memory loss, according to a systematic review in 2003. Formal neuropsychological testing has documented permanent neuropsychological deficits in ECT patients, including an IQ loss of more than 30 points in one. Critics of ECT believe that there is enough evidence that patients' memories can be permanently and severely damaged to justify a moratorium, at least until more research has been done into its effects on the brain.
Many early studies from the 1940s, 1950s, and early 1960s indicated that ECT was associated with brain abnormalities. However, other authors such as Sackeim (1994) and Weiner (1984) dismiss the work done in the 1940s and 1950s, pointing out that today's ECT is different. Of the case studies which have not found brain changes after ECT, perhaps the most persuasive is a patient who had received more than 1250 bilateral ECT treatments and whose brain was in perfectly good health when she died at 89. Against this is evidence from more sensitive modern imaging studies, and the evidence from those suffering from epileptic fits of comparable duration to those provoked by ECT, who do not suffer hypoxic brain injury. In addition, while early ECT devices were less powerful than those of today, causing opponents of ECT to suggest that today's machines might be more likely to cause brain damage than those used in the early studies, research has shown that the amount of electricity which reaches the brain tissue is significantly below the intensity and duration which would cause damage.
There is more recent work noting brain abnormalities in those who have had ECT. Calloway et al. found an association with frontal lobe atrophy and ECT on a retrospective review of scans , and accordingly did not claim these were caused by ECT (many schizophrenics, for instance, have abnormal brain anatomy as part of their condition, and brain changes have also been found in depressive patients ). Dolan et al. found that a past history of treatment by electroconvulsive therapy was associated with greater sulcal widening in the parietal and occipital areas, although again they did not suggest this was due to ECT. Accordingly, while some practitioners may fail to adhere to accepted guidelines for administering ECT, no studies since anesthesia and oxygenation were introduced as standard practice have shown that they cause any damage, despite the much better imaging currently available.
In addition to the physiological effects, ECT may also have adverse psychological effects, counterproductive to its commonly stated goal.
Psychologist John Breeding has highlighted what he regards as the psychological effects of ECT, particularly:
1) Suppression of emerging distress material 2) Suppression of ability to heal by emotional release;Breeding regards psychiatric illness as the product of unresolved psychic conflict, often due to abuse, and feels that the correct treatment for such problems is to bring out this underlying conflict, and has compared the experience of those who have undergone ECT to that of Holocaust survivors.
The decision to use ECT must be evaluated by each individual, weighing the potential benefits and known risks of all available, appropriate treatments in the context of informed consent, free of coercion and veiled threats. Studies in 2004 and 2005 showed that half of ECT patients did not feel that they could refuse the treatment.
Contraindications
Some psychiatric researchers contend that there are virtually no absolute health contraindications that preclude the use of ECT where warranted, i.e.
Device risk
ECT should be administered under controlled conditions, with appropriate personnel.
The United States Food and Drug Administration has classified the devices used to administer ECT as Class III medical devices. The risks of ECT, according to the FDA, include brain damage and memory loss.
Effectiveness
Some studies—later confirmed in controlled clinical trials which included the use of simulated (placebo) ECT as a control —have shown that ECT is very effective against severe depression, some acute psychotic states, and mania. No controlled study has shown that any other treatment for depression is more effective than ECT. ECT has not been shown to be effective in dysthymia, substance abuse, anxiety, or personality disorders.
Although the average 60-70% response rate seen with ECT is similar to that seen with pharmacotherapy, there is evidence that the antidepressant effect of ECT occurs faster than with medication, which supports the use of ECT when depression is accompanied by potentially uncontrollable suicidal ideas and actions. it is now recognized that a single course of ECT should be regarded as a short-term treatment for acute illness. To sustain the response to ECT, continuation treatment, often in the form of antidepressant and/or mood stabilizer medication, is needed. "Maintenance ECT" refers to indefinite periods of repeated ECT, usually scheduled a few weeks apart. Critics of ECT assert that maintenance ECT is needed because the brain requires approximately four weeks to recover from each closed head injury caused by ECT; thus, when the brain has healed, the temporary euphoric effects are lost and ECT must be given again to attain the previous mood gain. Individuals who repeatedly relapse after ECT despite continuation medication may be candidates for maintenance ECT, delivered on an outpatient basis at a rate of one treatment weekly to as infrequently as monthly.
Current use
There is wide variation in ECT use between different countries, different hospitals and different psychiatrists.
In the United States, a report from the Surgeon General (the chief health educator from the US Department of Health and Human Sciences) endorses ECT as a treatment for depression, mania and catatonia, usually as a second-line treatment if medication fails but in rare circumstances as a first-line treatment. ECT is usually given three times a week in courses of 6-12 treatments (occasionally more or less); maintenance ECT is also sometimes used with patients being given individual treatments at weekly, fortnightly or monthly intervals to prevent recurrence of depression. A survey of psychiatric practice in the late 1980s found that only a small minority (fewer than one in twelve) of psychiatrists performed ECT. An estimated 100,000 people were receiving ECT annually in the United States. Accurate statistics about the frequency, context and circumstances of ECT in the United States are difficult to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information. One such state is Texas, where in the mid-1990s ECT was used in about one third of psychiatric facilities and given to about 1,650 people annually. in 2000-01 ECT was given to about 1,500 people aged from 16 to 97 (in Texas it is illegal to give ECT to anyone under sixteen).
Some psychiatrists have expressed concern that, in some settings, particularly in the public sector and outside major metropolitan areas, ECT may be underutilized. In particular, minority patients tend to be underrepresented among those receiving ECT.
In the United Kingdom, ECT's use has declined in recent years.
Informed consent
Informed consent is an integral part of the ECT process. Prospective candidates for ECT should be informed, for example, that its benefits are short-lived without active continuation treatment, and that there may be some risk of permanent severe memory loss after ECT. Active discussion with the treatment team, possibly supplemented by the growing amount of printed and videotaped information for consumers, is advisable in the decision-making process both prior to and throughout a course of ECT. Care ought to be taken that the informed consent materials originate from objective sources and not, for example, from the manufacturer of ECT devices. Theoretically, in most jurisdictions, consent may be revoked at any time during a series of ECT sessions.
Involuntary ECT
Procedures for involuntary ECT vary from country to country depending on local mental health laws. Legal proceedings are required in some countries, while in others ECT is seen as another form of treatment that may be given involuntarily as long as legal conditions are observed.
The World Health Organization, in its 2005 publication "Human Rights and Legislation WHO Resource Book on Mental Health," specifically states, "ECT should be administered only after obtaining informed consent."
In nearly all states in the United States, involuntary ECT may not be initiated by a physician or family member without a judicial proceeding. In nearly every state, the administration of ECT on an involuntary basis requires such a judicial proceeding at which patients may be represented by legal counsel. As a rule, the law requires that such petitions are granted only where the prompt institution of ECT is regarded as potentially lifesaving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia. In Oregon, an institution may administer involuntary ECT without any judicial proceeding at all through the use of an administrative override that requires, among other things, the review of the case by a physician unaffiliated with the treating facility.
Australian states regard involuntary treatment with ECT in the same light as any other involuntary treatment.
In England and Wales the Mental Health Act 1983 allows the use of ECT on detained patients (with and without capacity), if the treatment is authorised by a psychiatrist from the Mental Health Act Commission's panel. If the treating psychiatrist thinks the need for treatment is urgent they may start a course of ECT before authorisation. In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 gives patients with capacity the right to refuse ECT.
In 2006, the organization Mental Disability Rights International published the results of a two-year investigation in Turkey that found what MDRI termed "widespread" involuntary ECT administered without anesthesia.
Continuation phase therapy
Successful acute phase antidepressant pharmacotherapy or ECT is generally followed by at least 6 months of continued treatment.
Historical usage
ECT was developed in the 1930s by Italian neurologist Ugo Cerletti.
When ECT was first instituted, the procedure was performed on fully conscious patients, without the use of anesthesia or muscle relaxants.
With the development of effective medications for the treatment of major mental disorders a half-century ago, the need for ECT lessened, but did not disappear. Until then, ECT often had been administered for several conditions for which it is now generally regarded as ineffective, for example, for treating schizophrenia.
Advances in treatment technique over the past generation have led to fewer adverse cognitive effects of ECT. Nearly all ECT devices deliver a lower current, brief-pulse electrical stimulation, rather than the original sine wave output; Ultra-brief pulse, higher frequency and longer stimulus duration also contribute to ECT effectiveness while minimizing adverse cognitive effects.
Controversy
As of 2006, most psychiatrists believe that ECT can be beneficial in some circumstances. Though most studies have found that ECT is effective for severe depression and several other conditions (see Effectiveness), opponents claim that the mechanism through which ECT changes mental state is nothing more than the destruction of brain cells, and even proponents are unsure how it works. Many patients who have had ECT claim it caused their mental state to improve; many others think their ECT did more harm than good, and some campaign to have the treatment banned, as it is in the Republic of Slovenia.
Anti-ECT activists allege that patients are rarely told the complete truth about the risks and benefits of ECT. It should be noted that printed or videotaped materials regarding ECT might be commissioned by the manufacturers of the equipment used, and so the possibility of this information leaning towards confirmation bias should be considered.
Fictional and semi-fictional depictions of ECT
Electroconvulsive therapy has been depicted in several fictional and semi-fictional films, books, and songs, almost always in an extremely negative light. It is implied in the film that the hospital staff use ECT to punish uncooperative patients. An episode of Quantum Leap depicts ECT in which the main character, Sam, receives ECT as punishment by a nurse, and the ordeal makes him unable to leap. Order entitled "Cruel and Unusual" also featured negative depictions of ECT. In an episode of The Simpsons entitled "Don't Fear the Roofer," Homer is subjected to ECT after his family mistakenly believes that his friend Ray Magini is imaginary.
In an episode of the sci-fi TV series Stargate SG1, Teal'c's son Rya'c is put under a form of ECT when he has been brainwashed by Apophis. It is about the widespread use of ECT in Ireland's state hospitals in the 1970s, and was reportedly written in response to the treatment's use on one of their close friends. In Elizabeth Flock's novel But Inside I'm Screaming, the main character, Isabel, is initally reluctant to undergo ECT for her severe depression, but the ECT is a major factor in her recovery.
Nonfictional depictions of ECT
Accounts of ECT also abound in popular culture, expressing (much like the scientific literature) tension between ECT's promise of relief and the side effects that often accompany it.
In one example of memory loss and/or resultant trauma, former ECT subject, Bachelor of Science, and Registered Nurse Barbara C. Cody reports negative effects she experienced from ECT, saying:
“I am a former teacher and registered nurse whose life was forever changed by 13 outpatient ECTs I received in 1983. […]”In contrast, Kitty Dukakis reports mostly positive effects from electroconvulsive therapy, saying of her experiences after undergoing ECT:
[For me,] the memory issues are real but manageable. They generally involve things I did two weeks before and two weeks after ECT. I hate losing memories, which means losing control over my past and my mind, but the control ECT gives me over my disabling depression is worth this relatively minor cost.Research into treatments
There is current research in using Magnetic stimulation therapy (MST) as an alternative to ECT although presently it seems to be somewhat less effective. Vagus nerve stimulation therapy is another alternative to ECT.
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