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Electroconvulsive therapy

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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. Patients with any of several conditions often show dramatic short-term improvement after the procedure. 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.<ref>For many statements from the latter group, see Frank (2006).</ref>

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. Patients were frequently injured as a side effect of the induced seizure. 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 anesthetic 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. It is now reserved for severe cases of refractory depression in such illnesses as clinical depression (unipolar depression) and the depression associated with bipolar disorder. 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.

Contents

[edit] 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. Patients were rendered instantly unconscious by the electrical current, but the strength of the muscle contractions and the subsequent fit sometimes led to complications, such as compression fractures of the spine or damage to the teeth. Muscle relaxants allow a modified fit, where contractions are weak or nonexistent. However, before using muscle relaxants, the patient must be given a general anesthetic to prevent the patient from experiencing the very uncomfortable state of being paralyzed. The end result is that 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 0.9 A) are passed through electrodes applied to the scalp at specific points using a gel, paste or saline solution to prevent burns to the skin. 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. The existence of the seizure is confirmed by observation or by EEG neuromonitoring[1].

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. Placing both electrodes on one side of the head over the non-dominant (generally right) cerebral hemisphere, results in delivery of the initial stimulation away from the primary learning and memory centers. With unmodified ECT, the seizure is characteristically more severe than a naturally occurring epileptic seizure. The production of an adequate, generalized seizure using the proper amount of stimulation is required for therapeutic efficacy.<ref name="Sackeim1993">Sackeim H, Prudic J, Devanand D, Kiersky J, Fitzsimons L, Moody B, McElhiney M, Coleman E, Settembrino J (1993). "Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy.". N Engl J Med 328 (12): 839-46. PMID 8441428.</ref> Therapeutic ECT is usually given three times per week for 6 to 12 treatments, on either an inpatient or outpatient basis. Studies have shown that each fit must be separated by at least a day.

After the seizure, cortical electrical activity ceases for a short time, during which an EEG reading is 'flat'. After treatment, patients do not remember the seizure or the events immediately before it.

Exactly how ECT exerts its effects is not known, but repeated applications affects several kinds of neurotransmitters in the central nervous system. ECT seems to sensitize two subtypes of serotonin receptor (5-HT receptor), thereby strengthening signaling. 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.<ref>Ishihara & Sasa (1999)</ref> One study suggests that long-term ECT increases the expression of brain-derived neurotrophic factor (BDNF) and its receptor, TrkB, in limbic brain regions.<ref>Duman R, Vaidya V (1998). "Molecular and cellular actions of chronic electroconvulsive seizures.". J ECT 14 (3): 181-93. PMID 9773357.</ref>

[edit] 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. Electrodes were applied bilaterally (one on either side of the head) and stimulus duration was usually 0.1 to 0.5 seconds. The machines were constant voltage and the amount of current delivered depended on the impedance of the patient's head. A current of 300 milliamps was typical. In the early 1940s, in an attempt to reduce the memory disturbance and confusion associated with treatment, two modifications were introduced: the use of unilateral electrode placement (with both electrodes on the non-dominant side of the head) and the replacement of sinusoidal current with brief pulse. It took many years for these modifications to be widely adopted and even today they are not universally used.<ref>Kiloh LG, Smith JS, Johnson GF (1988). Physical Treatments in Psychiatry. Melbourne: Blackwell Scientific Publications. 190-208. ISBN 0867931124</ref> In the USA and the UK for example, bilateral electrode placement is still used more commonly than unilateral, with many psychiatrists finding bilateral more effective and easier to use although there is widespread agreement that it causes more memory loss than unilateral. 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.<ref name="Prudic 01">Prudic J, Olfson M, Sackeim HA (2001). Electroconvulsive therapy practices in the community. Psychological Medicine 31: 929-934. PMID 11459391</ref> Typically, with modern brief-pulse constant current machines a patient may receive a stimulus of 750 milliamps lasting 1-6 seconds. Voltage depends on impedance up to a maximum of 225. Pulsewidth is 2.2 milliseconds, at a frequency of 30-70 Hz.<ref>Parameters are those of the Ectron 5A machine manufactured from 1993 in the UK. Lock, T (1995). "Review of ECT machines", in C Freeman (ed.) The ECT Handbook. London: Royal College of Psychiatrists. 122-148.</ref>

Stimulus dosing, where the stimulus is adjusted to an individual patient's seizure threshold, is a more recent modification.<ref> The information on stimulus dosing comes from Lock T (1995). "Stimulus dosing", in C Freeman (ed.) The ECT Handbook. London: Royal College of Psychiatrists. 72-87</ref> Although the research leading to its development dates back to Sweden in the 1950s and 1960s, its use has only been recommended since 1990 and some clinics still give all their patients the same dose.<ref name="Prudic 01"/> Seizure threshold can only be determined by trial and error ("dose titration"). Some psychiatrists compromise between fixed dose and dose titration by roughly estimating a patient's threshold according to age and sex. 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.

[edit] Side effects and complications

[edit] Side-effect profile

Much of the accepted risk of ECT arises from the use of general anesthesia; there is considerable disagreement about other risks. The most common adverse effects are confusion and retrograde memory loss for events surrounding the period of ECT treatment, and generalized but mild muscle aches after waking. Some of the confusion and disorientation seen on awakening after ECT clears soon after.

More persistent memory problems are variable and difficult to quantify. 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.<ref>NIH & NIMH Consensus Conference, 1985</ref> 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,<ref>Janis IL, Astrachan M (1951). "The effects of electroconvulsive treatments on memory efficiency". J Abnorm Soc Psychol 46 (4): 501-11. PMID 14880367.</ref><ref>Squire L, Slater P (1993). "Electroconvulsive therapy and complaints of memory dysfunction: a prospective three-year follow-up study". Br J Psychiatry 142: 1-8. PMID 6831121.</ref> although others found problems were gone by seven months after ECT.<ref>Squire L, Slater P, Miller P (1981). "Retrograde amnesia and bilateral electroconvulsive therapy. Long-term follow-up.". Arch Gen Psychiatry 38 (1): 89-95. PMID 7458573.</ref> Calev (1994) surveyed the literature and 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".<ref>Calev A (1994). "Neuropsychology and ECT: past and future research trends". Psychopharmacol Bull 30 (3): 461-9. PMID 7878183.</ref> At least a third of ECT patients have some permanent memory loss, according to a systematic review in 2003.<ref>Rose (2003)</ref> Formal neuropsychological testing has documented permanent neuropsychological deficits in ECT patients,<ref>FDA, Docket #82P-0316</ref> including an IQ loss of more than 30 points in one.<ref>Donahue (1999); Andre (2001); Cott (2004)</ref> The degree of impairment and resulting impact on functioning vary between individuals.<ref>NIH & NIMH Consensus Conference (1985); CMHS (1998)</ref> 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.<ref>Alpers (1942); Ebaugh et al. (1942); Faurbye (1942); Neuberger (1942); Heilbrun (1941); Heilbrunn (1942) & (1943); Bjerner (1944); Gralnick (1944); Jetter (1944); Lidbeck (1944); Meyer et al. (1945); Ferraro et al. (1946); Ferraro et al. (1949); Sprague and Taylor (1948); Will and Rehfeldt (1948); Martin (1949); Riese and Fultz (1949); Liban et al (1951); Hartelius (1952); Maclay WS. (1953); Corsellis et al. (1954); McKegney & Panzetta (1963)</ref> However, other authors such as Sackeim (1994) and Weiner (1984)<ref>See Sackeim's 2004 deposition, Weiner's deposition and testimony in the same case, the testimony of Mecta owners and employees, and the credits given to each in the Mecta manuals</ref> dismiss the work done in the 1940s and 1950s, pointing out that today's ECT is different. This is supported by the changes in procedure in the 1960s, by the far more effective imaging techniques used today to assess brain damage, by the fact that very few of the earlier studies were prospective, and by the fact that many were post hoc accounts of single patients rather than clinical trials.<ref>Liban et al. (1951); Maclay (1953); McKegney & Panzetta (1963)</ref> 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.<ref>Abrams, R (2002). Electroconvulsive Therapy, 4th ed, New York: Oxford University Press.</ref> The recent work assessing the consequences of seizures has found no evidence that they cause brain damage,<ref>Meldrum B (1986). "Neuropathological consequences of chemically and electrically induced seizures.". Ann N Y Acad Sci 462: 186-93. PMID 3085568.
Dwork A, Arango V, Underwood M, Ilievski B, Rosoklija G, Sackeim H, Lisanby S (2004). "Absence of histological lesions in primate models of ECT and magnetic seizure therapy". Am J Psychiatry 161 (3): 576-8. PMID 14992989.</ref> with prospective studies appearing to confirm this.<ref>Coffey C, Weiner R, Djang W, Figiel G, Soady S, Patterson L, Holt P, Spritzer C, Wilkinson W (1991). "Brain anatomic effects of electroconvulsive therapy. A prospective magnetic resonance imaging study". Arch Gen Psychiatry 48 (11): 1013-21. PMID 1747016.</ref>

However, critics argue that the differences might make the procedure more damaging, not less. Anesthesia and muscle-paralyzing drugs increase the risks of the procedure and thus its mortality rate.<ref>Barker J, Baker A (1959). "Deaths associated with electroplexy". J Ment Sci 105 (439): 339-48. PMID 13665295.
Impastato D, Berg S, Gabriel A (1957). "Practical elimination of fractures in electroshock therapy by succinylcholine.". NY State J Med 57 (15): 2513-7. PMID 13452099.</ref> The claim that oxygenation prevents brain damage and thus makes some earlier studies irrelevant is disputed, for example, Sackheim<ref>Sackeim (2004)</ref> does not always oxygenate his patients: "They don't turn blue", so earlier studies in which animals are not oxygenated might still be relevant. 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,<ref>Cameron (1994)</ref> 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.<ref>Weiner RD (1984). "Does ECT cause brain damage?". Brain Behav Sci 7: 153.</ref>

There is more recent work noting brain abnormalities in those who have had ECT. Colon & Notermans found changes in nuclear volume in the cortex, but without loss of neurons.<ref>Colon EJ, Notermans SLH (1975) A long-term study of the effects of electro-convulsions on the structure of the cerebral cortex. Acta Neuropathologica (Berlin) 32:21-5 [PMID 1146505]</ref> Calloway et al. found an association with frontal lobe atrophy and ECT on a retrospective review of scans<ref>Colon E, Notermans S (1975). "A long-term study of the effects of electro-convulsions on the structure of the cerebral cortex.". Acta Neuropathol (Berl) 32 (1): 21-25. PMID 1146505.</ref> , and accordingly did not claim these were caused by ECT (many schizophrenics, for instance, have abnormal brain anatomy as part of their condition,<ref>Turner J, Smyth P, Macciardi F, Fallon J, Kennedy J, Potkin S (2006). "Imaging phenotypes and genotypes in schizophrenia.". Neuroinformatics 4 (1): 21-49. PMID 16595857.</ref><ref>Honea R, Crow T, Passingham D, Mackay C (2005). "Regional deficits in brain volume in schizophrenia: a meta-analysis of voxel-based morphometry studies.". Am J Psychiatry 162 (12): 2233-45. PMID 16330585.</ref><ref>Keshavan M, Diwadkar V, Montrose D, Rajarethinam R, Sweeney J (2005). "Premorbid indicators and risk for schizophrenia: a selective review and update.". Schizophr Res 79 (1): 45-57. PMID 16139479.</ref><ref>Tanskanen P, Veijola J, Piippo U, Haapea M, Miettunen J, Pyhtinen J, Bullmore E, Jones P, Isohanni M (2005). "Hippocampus and amygdala volumes in schizophrenia and other psychoses in the Northern Finland 1966 birth cohort.". Schizophr Res 75 (2-3): 283-94. PMID 15885519.</ref> and brain changes have also been found in depressive patients<ref name="Dolan1986">Dolan R, Calloway S, Thacker P, Mann A (1986). "The cerebral cortical appearance in depressed subjects.". Psychol Med 16 (4): 775-9. PMID 3823294.</ref> ). Diehl et al. in a study of six patients found significant post-ECT T2 increases in the right and left thalamus consistent with a post-ECT increase in brain water content.<ref>Diehl DJ, et al. (1994). "Post-ECT increases in MRI regional T2 relaxation times and their relationship to cognitive side effects: a pilot study". Psychiatry Res 54: 177-84. PMID 7761551.</ref> 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.<ref name="Dolan1986"/> 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. These effects may include post-traumatic stress disorder. Instances of such a case have been recorded by David Armstrong.<ref>Armstrong, David (2000-2006). Post Traumatic Stress Disorder (PDF). HealthyPlace.com. Retrieved on 2006-08-24.</ref>

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;
3) Creation of emotional distress, including deep feelings of terror and powerlessness;
4) Promotion of human beings in the roles of victims and passive dependents of medical professionals;
5) Confirmation of patients' belief that there is something really wrong with them (shame)."<ref>Breeding, John (2003). The Necessity of Madness: Explaining How Psychiatry Is a Clinical Construct and Madness Is a Metaphor. Chipmunkapublishing, 460. 0954221877.</ref>

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,<ref>NIH & NIMH Consensus Conference, 1985</ref> 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.<ref>Philpot (2004); Rose (2005)</ref>

[edit] Contraindications

Some psychiatric researchers contend that there are virtually no absolute health contraindications that preclude the use of ECT where warranted,<ref>Potter WZ, Rudorfer MV. Electroconvulsive therapy--a modern medical procedure. N Engl J Med. 1993 Mar 25;328(12):882-3. PMID 8441434</ref>, <ref name="Rudorfer 97">Rudorfer et al. (1997)</ref> i.e. where the treating psychiatrist, often at their sole discretion but frequently in consultation with a multidisciplinary team, decides that the likely benefits outweigh the possible risks. The only major contraindication is increased intracranial pressure, as in cases of recent cerebrovascular accident or known space-occupying lesion such as meningioma, because of the danger of herniation due to transient further increase in intracranial pressure during the procedure.

[edit] Device risk

ECT should be administered under controlled conditions, with appropriate personnel.<ref name="Rudorfer 97"/> Some mental health laws mandate this.[citation needed]

The United States Food and Drug Administration has classified the devices used to administer ECT as Class III medical devices.<ref>Federal Register (1979), p. 51776</ref> Class III is the highest-risk class of medical devices. The risks of ECT, according to the FDA, include brain damage and memory loss.<ref>Federal Register (1978), p. 55729</ref>

[edit] Effectiveness

Some studies—later confirmed in controlled clinical trials which included the use of simulated (placebo) ECT as a control<ref name="Janicak 85a">Janicak PG, Davis JM, Gibbons RD, Ericksen S, Chang S, Gallagher P (1985). "Efficacy of ECT: a meta-analysis." Am J Psychiatry 142: 297-302. PMID 3882006.</ref> —have shown that ECT is very effective against severe depression, some acute psychotic states, and mania.<ref>Small JG, Klapper MH, Kellams JJ, Miller MJ, Milstein V, Sharpley PH, Small IF (1988). "Electroconvulsive treatment compared with lithium in the management of manic states." Arch Gen Psychiatry 45:727-32. PMID 2899425.</ref> No controlled study has shown that any other treatment for depression is more effective than ECT.<ref name="Janicak 85a"/><ref name="Rudorfer 97"/> ECT has not been shown to be effective in dysthymia, substance abuse, anxiety, or personality disorders. These conclusions, and many of those discussed below, are the product of review of extensive research over several decades<ref>Depression Guideline Panel (1993)</ref><ref name="Rudorfer 97"/> as well as by a panel of scientists, practitioners, and consumers.<ref>NIH & NIMH Consensus Conference (1985)</ref>

Although the average 60-70% response rate<ref>Higher response rates have been reported, e.g. 85-90% in Whybrow (1997) and in excess of 90% in Mondimore (1995).</ref> 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.<ref name="Rudorfer 97"/> However, ECT does not provide long-term protection against suicide; 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.<ref name="Sackeim 94a">Sackeim HA (1994). "Continuation therapy following ECT: directions for future research." Psychopharmacol Bull. 30: 501-21. PMID 7878189.</ref> "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.<ref name="Sackeim 94a"/><ref name="Rudorfer 97"/>

[edit] 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 that may be considered 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. Treatment is usually given on an inpatient basis, less commonly as outpatient treatment. A survey of psychiatric practice in the late 1980s found that only a small minority (fewer than one in twelve) of psychiatrists performed ECT. It was not used in one-third of metropolitan statistical areas and its use varied greatly in the remaining areas. An estimated 100,000 people were receiving ECT annually in the United States.<ref name="Hermann 95">Hermann R, Dorwart R, Hoover C, Brody J (1995). "Variation in ECT use in the United States.". Am J Psychiatry 152 (6): 869-75. PMID 7755116.</ref> 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.<ref>Cauchon, Dennis. "Patients often aren't informed of full danger", USA Today, 1995-12-06. (in English)</ref> 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. Seven out of ten patients were women.<ref>Reid WH et al. (1998). "ECT in Texas: 19 months of mandatory reporting." Journal of Clinical Psychiatry 59: 8-13. PMID 9491059.</ref> More recent statistics from Texas show a small decline in use; 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). ECT is more commonly used in private psychiatric hospitals than in public hospitals in the USA; and minority patients are underrepresented in ECT statistics.<ref>Rudorfer MV, Henry ME, Sackeim HA (2003). Electroconvulsive therapy. In A Tasman, J Kay, JA Lieberman (eds), Psychiatry, Second Edition. Chichester: John Wiley & Sons Ltd. 1865-1901.</ref>

In the United Kingdom the use of ECT has been declining steadily over the past three decades (from an estimated 50,000 patients annually<ref>Pippard J and Ellam L (1981), Electroconvulsive treatment in Great Britain, 1980. London: Gaskell.</ref> to about 12,000) although it is still used in nearly all psychiatric hospitals. A survey of ECT use in England in 2002<ref>Electroconvulsive therapy: survey covering the period from January 2002 to March 2002, Statistical Bulletin 2003/08. Department of Health</ref> found that 70 per cent of patients were women and 46 per cent were over 65 years of age. Eighty-one per cent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. ECT is usually given twice a week in courses of 6-12 treatments, although some people have more and some have fewer treatments. About 20 per cent of treatments are given on an outpatient basis. Maintenance ECT is occasionally used, though not as much as in the United States. In 2003 the National Institute for Clinical Excellence, a government body which was set up to standardize treatment throughout the National Health Service, issued guidance on the use of ECT. Its use was recommended "only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode".[2] The guidance got a mixed reception. It was welcomed by an editorial in the British Medical Journal<ref>Carney, S & Geddes, J (2003). "Electroconvulsive therapy: recent recommendations are likely to improve standards and uniformity of use". British Medical Journal 326: 1343-4.</ref> but the Royal College of Psychiatrists launched an appeal, arguing that the recommendation to restrict ECT to the treatment of severe depression was perverse as the evidence base included patients with moderate as well as severe depression. The appeal was not upheld. NICE accepted the point about the evidence base, but argued that ECT could not be recommended as a treatment for moderate depression as there remained uncertainties about both the benefits and adverse effects of treatment.[3] The NICE guidance, as the British Medical Journal editorial points out, is only a policy statement and psychiatrists may deviate from it if they see fit. The latest guidelines on electroconvulsive therapy from the Royal College of Psychiatrists explain how to go about getting round the guidelines.<ref>Scott, AIF (ed.) (2005) The ECT Handbook, Second Edition, London: Royal College of Psychiatrists, p 6-7.</ref> In the UK the use of ECT has traditionally been associated with low standards of care, being carried out by junior doctors, often with minimal training and supervision. Guidelines issued periodically by the Royal College of Psychiatrists have had only partial success at raising standards. The latest initiative by the Royal College is a voluntary accreditation scheme, ECTAS.[4] The scheme was set up in 2004 but, two years on, only a minority of ECT clinics in England, Wales, Northern Ireland and the Irish Republic have signed up.

[edit] Informed consent

Informed consent is an integral part of the ECT process.<ref>NIH & NIMH Consensus Conference (1985)</ref> The potential benefits and risks of this treatment, and of available alternative interventions, should be carefully reviewed and discussed with patients and, where appropriate, family or friends. 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.

[edit] Involuntary ECT

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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. There is an appeal process available for patients and relatives. This position facilitates the expedited use of ECT in emergencies.

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 authorization.<ref>The Mental Health Act 1983, Part 4, sections 58 and 62.</ref> About 2,000 people a year are treated without their consent under the Mental Health Act.<ref>The Mental Health Act Commission: "In Place of Fear? eleventh biennial report, 2003-2005.", page 236. The Stationery Office, 2005.</ref> A small number of informal patients are treated without their consent under common law. In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 gives patients with capacity the right to refuse ECT.<ref>The Mental Health (Care and Treatment)(Scotland) Act 2003, Part 16, sections 237-239</ref>

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.

[edit] Continuation phase therapy

Successful acute phase antidepressant pharmacotherapy or ECT is generally followed by at least 6 months of continued treatment.<ref name="Prien 86">Prien RF, Kupfer DJ. Continuation drug therapy for major depressive episodes: how long should it be maintained? Am J Psychiatry. 1986 Jan;143(1):18-23. PMID 3510571</ref>, <ref>Depression Guideline Panel (1993)</ref>, <ref name="Rudorfer 97"/> During this phase, the 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%.<ref name="Prien 86"/>, <ref>Thase (1993)</ref> Relapse despite continuation pharmacotherapy might suggest either nonadherence<ref>Myers ED & Branthwaithe A. Out-patient compliance with antidepressant medication. Br J Psychiatry. 1992 Jan;160:83-6. PMID 1544017</ref> or loss of a placebo response.<ref>Quitkin et al. (1993a)</ref>

A second goal of continuation pharmacotherapy is to consolidate a response into complete remission (i.e., a 'complete resolution of affective symptoms to a level similar to healthy people').<ref>Frank et al. (1991a)</ref> Residual symptoms are associated with increased risk of relapse.<ref>Keller et al. (1992); Thase et al. (1992)</ref> Many psychotherapists taper a successful 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.<ref>Kovacs et al. (1981); Blackburn et al. (1986); Simons et al. (1986); Evans et al. (1992)</ref>

[edit] Historical usage

ECT was developed in the 1930s by Italian neurologist Ugo Cerletti. Cerletti saw electric shocks given to hogs before slaughter. This rendered them unconscious but did not kill them. Cerletti found that such electric shocks caused his obsessive and difficult mental patients to become meek and manageable.

When ECT was first instituted, the procedure was performed on fully conscious patients, without the use of anesthesia or muscle relaxants. The patient lost consciousness during the application of the current, and experienced powerful and violently uncontrolled muscle movement. Patients would sometimes break bones, especially vertebrae, and pull muscles from the violent convulsions induced by the seizure. Patients came to dread the procedure, and it was sometimes used to punish or sedate difficult patients in psychiatric hospitals.

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.<ref>NIH & NIMH Consensus Conference (1985)</ref>, <ref name="Rudorfer 97"/> Nearly all ECT devices deliver a lower current, brief-pulse electrical stimulation, rather than the original sine wave output; with a brief pulse electrical wave, a therapeutic seizure can be induced with as little as one-third of the electrical power used by the older method, reducing the risk of confusion and memory disturbance.<ref>Andrade et al. (1998)</ref> Ultra-brief pulse, higher frequency and longer stimulus duration also contribute to ECT effectiveness while minimizing adverse cognitive effects.

[edit] Controversy

As of 2006, most psychiatrists believe that ECT can be beneficial in some circumstances. However, ECT remains controversial. 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.[citation needed] 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.<ref>Rose (2005)</ref> To demonstrate what would be required to fully satisfy the legal obligation for 'informed consent', one psychiatrist has formulated his own 'consent form'<ref>Johnson (2003)</ref> using the Texas Legislature<ref>Texas Legislature (2004)</ref> as a model. 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. Some question the effects of drugs on the ability to give informed consent.

[edit] 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.

  • A great deal of 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 the Menlo Park Veterans Hospital during the 1960s. It is implied in the film that the hospital staff use ECT to punish uncooperative patients.
  • In Sylvia Plath's novel The Bell Jar, protagonist, Esther Greenwood, under goes a series of shock therapy treatments while in therapy after a suicide attempt.
  • In the film Girl, Interrupted, Angelina Jolie's character runs away from a mental hospital because she is being given what she calls "shocks."
  • Return to Oz, an unauthorized sequel to the film version of The Wizard of Oz, shows that Dorothy Gale has been diagnosed as mentally ill due to her stories of fantastical adventures in Oz. Early in the film, she is taken to a psychiatrist and given an ECT-like treatment with a machine whose knobs and gauges resemble a face.
  • 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. The episode is concluded when he receives another shock of high voltage, enabling him to complete his leap.
  • An episode of the NBC TV drama Law & 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. This is done by a weapon known in the series as a Zat'nik'tel, which works by shooting a bolt of electricity at its victim.
  • In an episode of the TV series Smallville, Lex Luthor is forced to undergo an ECT-like procedure at the direction of his father, Lionel, with the purpose of erasing his memory for the last 7 weeks and therefore protecting one of Lionel's family secrets.
  • The U2 song "Electric Co." from the album Boy is an anti-ECT anthem. 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.
  • It has occasionally been portrayed in a positive light, however. 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.

[edit] 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. Shock 'therapy' totally and permanently disabled me.
“EEGs [electroencephalograms] verify the extensive damage shock did to my brain. Fifteen to 20 years of my life were simply erased; only small bits and pieces have returned. I was also left with short-term memory impairment and serious cognitive deficits.
“[…]
“Shock ‘therapy’ took my past, my college education, my musical abilities, even the knowledge that my children were, in fact, my children. […]”<ref>Cody, Barbara (Approximately between 1995-2006). Letter. HealthyPlace.com. Retrieved on 2006-09-23.</ref>

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.
Things I lose generally come back. Other memories I prefer to lose, including those about the depression I was suffering. But there are some memories—of meetings I have attended, people's homes I have visited—that I don't want to lose but I can't help it. They generally involve things I did two weeks before and two weeks after ECT. Often they are just wiped out....
I have learned ways to partly compensate for whatever loss I still experience. I call my sister Jinny, Michael and my kids, asking what my niece Betsy's phone number is, what we did yesterday and what we are planning to do tomorrow. I apologize prior to asking. I wonder when they are going to run out of patience with "Kitty being Kitty." 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. It just is.<ref>Dukakis and Tye (2006), excerpt from 'I Feel Good, I Feel Alive' Newsweek Sept. 18, 2006:62-63</ref>

Finally, Martha Manning's autobiographical Undercurrents acknowledges the downside of treatment as well as the upside: "I felt like I'd been hit by a truck for a while, but that was, comparatively speaking, not so bad," while acknowledging that it worked for her: "Afterwards, I thought, do regular people feel this way all the time? It's like you've not been in on a great joke for the whole of your life."

[edit] 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. Dietary omega-3 fatty acids and sleep deprivation are also being researched. Vagus nerve stimulation therapy is another alternative to ECT.

[edit] Famous people who have undergone ECT

[edit] Source note

Sections of this article were copied word for word from the public-domain document Mental Health: a report of the Surgeon General.

The Surgeon General's Report has been criticized; see for instance http://www.ctvip.org/surgeongeneral.html.

[edit] Footnotes

<references/>

[edit] References

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[edit] External links

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