Electroconvulsive therapy

Electroconvulsive therapy (ECT) is a psychiatric treatment that involves inducing a seizure in a patient by passing electricity through the brain. ECT was introduced for treating schizophrenia by the Italian neurologist Ugo Cerletti in the 1930s, and became a common treatment for mood disorders. While many psychiatrists believe that properly administered ECT is a safe and effective treatment for some conditions, some psychiatrists, former patients, antipsychiatry activists, and others warn that ECT might harm the patients' subsequent mental state.

ECT was a common treatment until the late 20th century, when better drug therapies became available for more conditions. It is now reserved for severe cases of clinical depression and bipolar disorder that do not respond to other treatments. When still in common use, ECT was sometimes abused by mental health professionals to punish or control 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.

In its early days, ECT was given without anaesthesia or muscle relaxants, and patients were often injured as a side effect of the seizure. Now, ECT is given under anaesthesia and with muscle relaxants. ECT without anaesthesia is known as "unmodified ECT", or "direct ECT", and is illegal in most countries.

Current use

ECT is mainly used to treat severe depression, particularly if complicated by psychosis. It is also used in cases of severe depression when antidepressant medication, psychotherapy, or both, have been ineffective, when medication cannot be taken, or when other treatments would be too slow (e.g. in a person with delusional depression and intense, unremitting suicidal tendencies). Specific indications include depression accompanied by a physical illness or pregnancy, which makes the usually preferred antidepressants dangerous to the patient or to a developing fetus. It is also sometimes used to treat the manic phase of bipolar disorder and the rare condition of catatonia. In the USA, modern use of ECT is generally limited to evidence-based indications. Accurate statistics about the frequency, context and circumstances of ECT in the USA are hard to obtain, as few states have laws that require this information to be given to state authorities.

Overview

The aim of ECT is to induce a bilateral tonic clonic seizure (where the person loses consciousness and has convulsions) of at least 15 seconds in both motor (convulsive) and EEG manifestations. Before the discovery of muscle relaxants, ECT was given unmodified. Patients were rendered instantly unconscious, but the strength of the muscle contractions and the subsequent fit sometimes led to complications. Muscle relaxants allow a modified fit, where contractions are weak or nonexistent. However, the patient must first be given a general anaesthetic to prevent him or her from experiencing the very uncomfortable state of being paralysed. As a result, the patient drifts off to sleep and wakes up a short time later unable to recall the details of the procedure.

To induce the seizure, short bursts of a fixed current (typically 0.9A) are passed through electrodes applied to the scalp at particular points, using a gel, paste or saline solution. The ECT therapist tries to minimize the total energy by restricting the duration of the current. The seizure is confirmed by observation or by EEG neuromonitoring and/or with the cuff method[4]. The cuff method consists of inflating a blood pressure cuff up to 300mmHg just above the right knee or elbow, after narcosis but before administration of the muscle relaxant (succinylcholine); as there is no muscle block in the lower right arm or leg, the duration of the convuslion can be timed clinically.

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 cerebralhemisphere. Placing both electrodes on one side of the head over the nondominant (usually the right) hemisphere, means that the stimulation is applied away from the main learning and memory centers of the brain. With unmodified ECT, the seizure is usually more severe than a naturally occurring epileptic seizure. The production of an adequate, generalized seizure is required for therapeutic efficacy.. ECT is usually given three times per week for 6 to 12 treatments, on either an inpatient or outpatient basis.

Just how ECT exerts its effects is not known, but repeated application affects several neurotransmitter systems in the brain, including serotonin receptors and pathways that regulate the release and actions of norepinephrine and dopamine. One study suggests that long-term ECT increases the expression of brain-derived neurotrophic factor and its receptor in limbic brain regions. Some studies indicate that ECT is associated with various alterations in brain structure, but it is not clear to what extent these might be caused by ECT, as some brain changes have also been found in depressive patients who have not been treated with ECT..

Types of ECT

There are two basic forms of ECT: bilateral and unilateral, and bilateral ECT can be subdivided into bitemporal and bifrontal ECT. In bitemporal ECT, current is passed across the temporal lobes, between electrodes placed on either side of the head. With unilateral ECT, the electrodes are only on one side, and pass current mainly through one temporal lobe. According to some trials, unilateral ECT is associated with almost no persistent memory loss. Unilateral ECT is less potent and acts more slowly than bilateral ECT, particularly in the most severe cases of depression or mania. An approach that is sometimes used is to begin with unilateral ECT and switch to bilateral ECT after about six treatments if there is no response. Bifrontal ECT is a modified form of bitemporal ECT in which electrodes are placed 2 inches above the lateral angle of each orbit. It appears to have less effect on memory than bitemporal ECT, and it increases the blood flow to the prefrontal cortex.

Side effects and complications

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. ECT should be given under controlled conditions, with appropriate personnel. The risks of ECT, according to the FDA, include brain damage and memory loss. Studies in 2004 and 2005 showed that half of ECT patients did not feel that they could refuse the treatment..

Some psychiatric researchers believe that there are few contraindications that preclude the use of ECT where the psychiatrist, sometimes in consultation with a multidisciplinary team, decides that the potential benefits outweigh the possible risks. The only major contraindication is increased intracranial pressure because of the danger of herniation due to transient further increase in intracranial pressure during the procedure.

Much of the risk of ECT arises from the use of general anesthesia; there is considerable disagreement about other risks. The most common side effects after treatment are muscle aches and headache. Other important side effects are confusion, retrograde memory loss for events surrounding the period of ECT treatment, and anterograde amnesia. Some of the confusion seen on awakening after ECT clears soon after and mainly occurs with treatment of elderly. More persistent memory problems are difficult to quantify; most typical with bilateral ECT has been retrograde amnesia, a loss of memories for the time of the ECT series and extending back for about 6 months. Another memory complaint is anterograde amnesia; difficulty in learning new information. This side effect mainly occurs with bilateral electrode placement and increases with the number of treatments. It disappears during 2 months after ECT. No long-term studies of cognition and memory have been done in the past two decades; some studies before this reported permanent amnesia, while others reported that problems were gone by seven months after ECT. Calev (1994) concluded that patients must be warned of possible non-memory cognitive deficits, as "they are not going to function well on more tasks than they anticipate".. At least a third of ECT patients have some permanent memory loss, according to a systematic review in 2003. The degree of impairment and impact on functioning vary between individuals.

ECT might have some adverse psychological effects. John Breeding, a psychologist at the University of Texas, has highlighted psychological effects of ECT, including suppression of ability to heal by emotional release; emotional distress, with deep feelings of terror and powerlessness; promotion of human beings in the roles of victims and passive dependents of medical professionals, and confirmation of patients' belief that there is something really wrong with them (shame)." Breeding regards psychiatric illness as a product of unresolved psychic conflict, often due to abuse, and feels that the correct treatment is to bring out this underlying conflict.

Effectiveness

Many studies, including some that have used simulated (placebo) ECT as a control, indicate that ECT is effective against severe depression, some acute psychotic states, and mania.

Although the average 60-70% response rate seen with ECT is similar to that seen with pharmacotherapy, the antidepressant effect of ECT might occur faster than with medication, which supports the use of ECT when depression is accompanied by potentially uncontrollable suicidal ideas and actions. However, ECT does not provide long-term protection against the risk of suicide; to attempt to sustain the response to ECT, continuation treatment, often in the form of antidepressant and/or mood stabilizer medication, is used. "Maintenance ECT" refers to indefinite periods of repeated ECT, usually scheduled a few weeks apart. Individuals who repeatedly relapse after ECT despite continuation medication may be candidates for maintenance ECT.

Informed consent

Informed consent is an integral part of the ECT process. [5]. The potential benefits and risks, and those of available alternative interventions, are reviewed carefully, and discussed with patients and, where appropriate, family or friends. Candidates for ECT should be informed that its benefits are short-lived without continuation treatment, and that there is some risk of permanent severe memory loss. 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 before and during a course of ECT. 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, but in others ECT 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," states that "ECT should be administered only after obtaining informed consent."

In nearly all states in the USA, involuntary ECT may not be initiated by a physician or family member without a judicial proceeding at which patients may be represented by legal counsel. As a rule, such petitions are granted only where the prompt institution of ECT is 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 through an administrative override that requires, among other things, review of the case by a physician unaffiliated with the treating facility.

In England and Wales, the Mental Health Act of 1983 allows the use of ECT on detained patients, if authorised by a psychiatrist from the Mental Health Act Commission's panel; if the psychiatrist thinks the treatment is needed urgently they may begin ECT before authorisation. About 2,000 people a year are treated without their consent in this way. In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 2003 gives patients with capacity the right to refuse ECT.

In 2005, the organization Mental Disability Rights International published the results of a two-year investigation in Turkey that found what they termed "widespread" involuntary ECT administered without anesthesia.[6]

Continuation phase therapy

Successful acute phase antidepressant pharmacotherapy or ECT is usually followed by at least 6 months of continued treatment. During this continuation phase, most patients are seen biweekly or monthly. The main goal of continuation pharmacotherapy is to prevent relapse (i.e. exacerbation of symptoms). Continuation pharmacotherapy reduces the risk of relapse from 40-60% to 10-20%. Relapse despite continuation pharmacotherapy might suggest either nonadherence or loss of a placebo response. A second goal of continuation pharmacotherapy is to consolidate a response into complete remission of symptoms, as residual symptoms are associated with increased risk of relapse. Many psychotherapists taper a course of treatment by scheduling several sessions (every other week or monthly) before termination. There is evidence that relapse is less common following successful treatment with one type of psychotherapy, cognitive-behavioral therapy, than with antidepressants.

History

ECT was developed in the 1930s by Italian neurologist Ugo Cerletti. Cerletti saw that electric shocks given to hogs before slaughter rendered them unconscious, but did not kill them. Cerletti found that such electric shocks caused obsessive and difficult mental patients to become meek and manageable. At first, ECT was performed on fully conscious patients, without the use of anesthesia or muscle relaxants. The patient lost consciousness during ECT, and experienced powerful and uncontrolled muscle movement; they would sometimes break bones, and pull muscles from the convulsions induced by the seizure. Patients came to fear ECT, and, in some psychiatric hospitals, it was sometimes used to punish or sedate difficult patients. With the development of better medications for many mental disorders, the need for ECT lessened. Until then, ECT often had been administered for several conditions for which it is now regarded as ineffective, for example, for schizophrenia. Advances in treatment are reported to have led to fewer adverse effects.[7]

Controversy

Many psychiatrists believe that ECT is beneficial in some cases, but others doubt this, and a few regard ECT as inhumane and primitive. Some critics 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. Some patients who have had ECT believe that it caused their mental state to improve; others think it did more harm than good, and some campaign to have the treatment banned, as it is in the Republic of Slovenia. Antipsychiatry believes that there are few "real" mental illnesses, and that ECT is used to suppress certain behaviors which, even if uncommon, are still "normal". Anti-ECT activists allege that patients are rarely told the full truth about the risks and benefits of ECT..

Fictional depictions of ECT

ECT has been depicted in several fictional and semi-fictional films, books, and songs, usually in an very negative light. Considerable anti-ECT sentiment was generated by its depiction in the 1975 movie One Flew Over the Cuckoo's Nest, based on a novel by Ken Kesey, which in turn was based loosely on the author's experiences in mental hospitals during the 1960s. In the film, the hospital staff apparently use ECT to punish uncooperative patients. ECT has occasionally been portrayed in a positive light, however. In Elizabeth Flock's novel But Inside I'm Screaming the main character, Isabel, is at first reluctant to undergo ECT for her severe depression, but the ECT is a major factor in her recovery.

Famous people who have had ECT

• Louis Althusser, French philosopher
• Antonin Artaud, French playwright
• Clara Bow, American actress
• Richard Brautigan, American writer and poet
• Dick Cavett, TV host. In 1992 he wrote in People, "In my case, ECT was miraculous. My wife was dubious, but when she came into my room afterward, I sat up and said, 'Look who's back among the living.' It was like a magic wand."
• Kitty Dukakis, wife of former Massachusetts governor and 1988 Democratic presidential nominee Michael Dukakis and author of Shock, a book chronicling her experiences with ECT.
• Thomas Eagleton, American vice-presidential hopeful who lost the nomination in 1972 when it was discovered he had undergone ECT
• Frances Farmer, American cinema actress
• Janet Frame, New Zealand writer who was wrongly diagnosed with schizophrenia. Many of her works contain semi-autobiographical accounts of her treatment
• Judy Garland, American film actress and singer
• Ernest Hemingway, American author, committed suicide shortly after ECT treatment at the Mayo Clinic in 1961. He is reported to have said to his biographer A.E. Hotchner, Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient....
• Ken Kesey, American author
• Vivien Leigh, British actress
• Robert Lowell, American poet and writer
• Mervyn Peake, English artist and writer
• Sylvia Plath, American poet
• Cole Porter, American composer and musician
• Paul Robeson, American actor
• Yves Saint Laurent, French fashion designer. He underwent treatment after serving in the French military.
• Gene Tierney, American actor

Source note

Sections of this article were adapted from Mental Health: A Report of the Surgeon General.