Electroconvulsive therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]

Overview

Electroconvulsive therapy (ECT), also known as electroshock, is a controversial psychiatric treatment in which seizures are induced with electricity for therapeutic effect. Today, ECT is most often used as a treatment for severe major depression which has not responded to other treatment, and is also used in the treatment of mania, catatonia, schizophrenia and other disorders. It first gained widespread use as a form of treatment in the 1940s and 50s; today, an estimated 1 million people worldwide receive ECT every year, usually in a course of 6-12 treatments administered 2 or 3 times a week. Electroconvulsive therapy can differ in its application in three ways; electrode placement, length of time that the stimulus is given, and the property of the stimulus. The variance of these three forms of application have significant differences in both adverse side effects and positive outcomes. ECT has been shown clinically to be the most effective treatment for severe depression, and to result in improved quality of life in both short- and long-term. For at least half of the patients, the benefits of the initial treatment are short-lived. After treatment, drug therapy can be continued, and some patients receive continuation/maintenance ECT. Side-effects include confusion and memory loss for events around the time period of treatment. It is widely accepted that ECT does not cause brain damage. Certain types of ECT have been shown to cause persistent memory loss, whereas confusion usually clears within hours of treatment. Informed consent is a standard of modern electroconvulsive therapy. Involuntary treatment is uncommon in countries that follow contemporary standards and is typically only used when the use of ECT is considered potentially life saving.

Indications

ECT is used predominantly as a treatment for severe depression. It is generally reserved for use as a second-line treatment for patients who have not responded to drugs. The first-line use of treatment is for situations where immediate clinical intervention is needed or alternative treatments are not advisable. About seventy percent of ECT patients are women.This is largely, but not entirely, due to the fact that women are more likely to receive treatment for depression. Older and more affluent patients are also more likely to receive ECT. The use of ECT treatment is "markedly reduced for ethnic minorities." ECT is also sometimes used in the treatment of other disorders, for example, schizophrenia, mania, and catatonia.

In the US the Surgeon General's report on mental health summarised current psychiatric opinion about the effectiveness of ECT. It stated that both clinical experience and controlled trials had determined ECT to be effective (with an average 60 to 70 per cent response rate) in the treatment of severe depression, some acute psychotic states, and mania. Its effectiveness had not been demonstrated in dysthymia, substance abuse, anxiety, or personality disorder. The report stated that ECT does not have a long-term protective effect against suicide and should be regarded as a short-term treatment for an acute episode of illness, to be followed by continuation therapy in the form of drug treatment or further ECT at weekly to monthly intervals. A large multicentre clinical follow-up study of ECT patients in New York found response rates of 30-47 per cent (depending on criteria), with 64 per cent of those relapsing within six months. A survey of New York psychiatrists found that they thought that 85 per cent of their patients benefited from ECT.

In the UK in 2003 the UK ECT Review Group, led by Professor Geddes of Oxford University, reviewed the evidence and concluded that ECT had been shown to be an effective short-term treatment for depression (as measured by symptom rating scales) in physically healthy adults, and that it was probably more effective than drug treatment. Bilateral ECT was more effective than unilateral, and high-dose was more effective than low-dose. Their conclusions were qualified: most of the trials were old and conducted on small numbers of patients; some groups (for example, elderly people, women with postpartum depression and people with treatment-resistant depression) were under-represented in the trials even though ECT is believed to be especially effective for them.

Contraindicated medications

Electroconvulsive therapy is considered an absolute contraindication to the use of the following medications:

• Reserpine

Administration

Once the decision has been made for a patient to have ECT there is usually a pretreatment evaluation that determines what factors will allow for maximum benefits and minimize risk. Informed consent is also sought before treatment. Patients are informed about the risks and benefits of the procedure. Patients are also made aware of risks and benefits of other treatments and of not having the procedure done at all. Depending on the jurisdiction the need for further inputs from other medical professionals or legal professionals may be required. ECT is usually given on an in-patient basis, although it may also be given on an out-patient basis. Prior to treatment a patient is given a short-acting anesthetic such as methohexital, propofol, etomidate and thiopental, a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation.

Electrodes are usually placed one on either side of the patient's head. This is known as bilateral ECT. Less frequently both electrodes are placed on one side of the head. This is known as unilateral ECT. In bifrontal ECT, an uncommon variation, the electrode position is somewhere between bilateral and unilateral. Unilateral is thought to cause fewer cognitive effects than bilateral but is considered less effective. In the USA most patients receive bilateral ECT. In the UK almost all patients receive bilateral ECT. Stimulus levels in excess of an individual's seizure threshold are therefore recommended: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT. 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. Seizure threshold is determined by trial and error ("dose titration"). Some psychiatrists use dose titration, some still use "fixed dose" (that is, all patients are given the same dose) and others compromise by roughly estimating a patient's threshold according to age and sex. Older men tend to have higher thresholds than younger women, but it is not a hard and fast rule, and other factors, for example drugs, affect seizure threshold.

There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists. International practice varies considerably from widespread use of the therapy in many western countries to a small minority of countries that do not use ECT at all such as Slovenia. Guidelines on the use of ECT are stringent in the USA and the UK. Modern standards are not always followed throughout the world and not all countries that use ECT have written technical standards. The use of both anesthesia and muscle relaxants is universally recommended in the administration of ECT. If anesthesia and muscle relaxants are not used the procedure is called unmodified ECT. In a minority of countries such as Japan, India, and Nigeria, ECT may be used without anesthesia. WHO has called for a world wide ban on unmodified ECT and the topic is currently being debated in countries like India. The practice has been recently abolished in Turkey's largest psychiatric hospitial. A major difficulty for developing countries in eliminating unmodified ECT is a lack of trained anesthetists available to administer the procedure. A small minority of countries never seek consent before administering ECT. This significantly uneven application of ECT around the world continues to make ECT a controversial procedure.

In the USA, a survey of psychiatric practice in the late 1980s found that an estimated 100,000 people received ECT annually, with wide variation between metropolitan statistical areas. 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 state which does report such data 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. Usage of ECT has since declined slightly; 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 and minority patients are underrepresented in the ECT statistics. In the United States ECT is usually given three times a week; in the UK it is usually given twice a week. Occasionally it is given on a daily basis. A course usually consists of 6-12 treatments, but may be more or fewer. Following a course of ECT some patients may be given continuation or maintenance ECT with further treatments at weekly, fortnightly or monthly intervals. A few psychiatrists in the USA use multiple-monitored ECT (MMECT) where patients receive more than one treatment per anesthetic.

In the United Kingdom in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then to about 12,000 per annum. It is still used in nearly all psychiatric hospitals, with a survey of ECT use from 2002 finding that 71 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. Sixteen per cent were treated without their consent. 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". The guidance got a mixed reception. It was welcomed by an editorial in the British Medical Journal but the Royal College of Psychiatrists launched an unsuccessful appeal. 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. Adherence to standards has not been universal in the past. A survey of ECT use in 1980 found that more than half of ECT clinics failed to meet minimum standards set by the Royal College of Psychiatrists, with a later survey in 1998 finding that minimum standards were largely adhered to, but that two-thirds of clinics still fell short of current guidelines, particularly in the training and supervision of junior doctors involved in the procedure. A voluntary accreditation scheme, ECTAS, was set up in 2004 by the Royal College, but as of 2006 only a minority of ECT clinics in England, Wales, Northern Ireland and the Irish Republic have signed up.

Most modern ECT machines deliver a brief-pulse current, which is thought to cause fewer cognitive effects than the sine-wave currents which were originally used in ECT. A small minority of psychiatrists in the USA still use sine-wave stimuli. Sine-wave is no longer used in the UK. Typically, the electrical stimulus used in ECT is about 800 milliamps, and the current flows for between one and 6 seconds. In the USA, ECT machines are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and MECTA. The Food and Drug Administration has classified the devices used to administer ECT as Class III medical devices. Class III is the highest-risk class of medical devices. In the UK the market for ECT machines was long monopolised by Ectron Ltd, although in recent years some hospitals have started using American machines. Ectron Ltd was set up by psychiatrist Robert Russell, who together with a colleague from the Three Counties Asylum, Bedfordshire, invented the Page-Russell technique of intensive ECT.

Adverse effects

The physical risks of ECT are similar to those of brief general anesthesia; the United States' Surgeon General's report says that there are "no absolute health contraindications" to its use. Immediately following treatment the most common side effects are confusion and memory loss. The state of confusion usually disappears after an hour.

It is the effects of ECT on long-term memory, that give rise to much of the concern surrounding its use.The acute effects of ECT include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment). Memory loss and confusion are more pronounced with bilateral electrode placement rather than unilateral, and with sine-wave rather than brief-pulse currents. The vast majority of modern treatment uses brief pulse currents. Retrograde amnesia is most marked for events occurring in the weeks or months before treatment, with one study showing that although some people lose memories from years prior to treatment, recovery of such memories was "virtually complete" by seven months post-treatment, with the only enduring loss being of memories in the weeks prior to the treatment. Later research by the same author suggested memory of events in the months prior to treatment might be lost, as well as suggesting that self-report of memory loss was in fact a problem before treatment which patients associated with it. Further reviews have supported the idea that reports of memory loss are due to somatoform disorders and not to brain damage. Anterograde memory loss is usually limited to the time of treatment itself or shortly afterwards. In the weeks and months following ECT these memory problems gradually improve, but some people have persistent losses, especially with bilateral ECT. One review of paitent self-reporting found that between 29 percent and 55 percent (depending on the study) of people who had undergone ECT reported persistent memory loss.. In 2000 American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with persistent impairment for memory of public events" as compared to RUL ECT. A large study (250 subjects), published January 2007 by Harold Sackeim and colleagues found that some forms of ECT "routine[ly]" causes "adverse cognitive effects," including cognitive dysfunction and memory loss, that can persist for an extended period. Formal neuropsychological testing has documented permanent neuropsychological deficits in patients who receive certain types of ECT treatment, A recent article by a neuropsychologist and a psychiatrist in Dublin suggests that ECT patients who experience cognitive problems following ECT should be offered some form of cognitive rehabilitation. The authors say that the failure to attempt to rehabilitate patients may be partly responsible for the negative public image of ECT.

A number of national mental health institutions have concluded that there is no evidence that ECT causes structural brain damage. A report of the United States Surgeon General states, "The fears that ECT causes gross structural brain pathology have not been supported by decades of methodologically sound research in both humans and animals". All of the recent scientific reviews on this topic which reviewed the body of ECT research using autopsies, brain imaging, and animal studies of electroconvulsive therapy, have also concluded that there is no evidence that ECT causes brain damage. Current research is examining the possibility that, "...rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness"

Mechanism of action

The aim of ECT is to induce a therapeutic clonic seizure (a seizure where the person loses consciousness and has convulsions) lasting for at least 15 seconds. Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive. The main reasons for this are the difficulty of isolating the therapeutic effect from the plethora of effects that accompany the anesthetic, electric shock and seizure; the differences between human and animal brains; and the lack of satisfactory animal models of mental illness.

Legal status

Informed consent

It is widely acknowledged internationally that written informed consent is as important in ECT as other medical treatments. 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 the US, this doctrine places a legal obligation on a doctor to make a patient aware of: the reason for treatment, the risks and benefits of a proposed treatment, the risks and benefits of alternative treatment, and the risks and benefits of receiving no treatment. The patient is then given the opportunity to accept or reject the treatment. The form states how many treatments are recommended and also makes the patient aware that the treatment may be revoked at anytime during a course of ECT. The Surgeon General's report on mental health said that patients should be warned that the benefits of ECT are short-lived without active continuation treatment in the form of drugs or further ECT and that there may be some risk of permanent severe memory loss after ECT. The report advised psychiatrists to involve patients in discussion, possibly with the aid of leaflets or videos, both before and during a course of ECT.

To demonstrate what would be required to fully satisfy the legal obligation for 'informed consent', one psychiatrist has formulated his own 'consent form' using the Texas Legislature 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.

In the UK in order for consent to be valid it requires an explanation in "broad terms" of the nature of the procedure and its likely effects. One review from 2005 found that only about half of patients felt they were given sufficient information about ECT and its side effectsand another survey found that about fifty per cent of psychiatrists and nurses agreed with them.

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.

In the USA, the Surgeon General's report on mental health requires a judicial proceeding, at which patients may be represented by legal counsel, prior to initiation of involuntary ECT, stating: "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 England and Wales the Mental Health Act 1983 allows the use of ECT on detained patients (with and without capacity) if the treatment is likely to alleviate or prevent deterioration in a condition and is authorized 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. About 2,000 people a year in England and Wales are treated without their consent under the Mental Health Act, with a small number of informal patients treated in this way under common law. In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 gives patients with capacity the right to refuse ECT.

Duress in involuntary ECT makes reports about its effects, by patients while under duress, uncertain in their validity.

History

As early as the 16th century, agents to produce seizures were used to treat psychiatric conditions. In 1785 the therapeutic use of seizure induction was documented in the London Medical Journal. Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures with first camphor and then metrazol (cardiazol). Within three years metrazol convulsive therapy was being used worldwide. In 1937, the first international meeting on convulsive therapy was held in Switzerland by the Swiss psychiatrist Muller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide. Italian Professor of neuropsychiatry Ugo Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his colleague Lucio Bini developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1937, experimented for the first time on a person. ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening and more convenient. Cerletti and Bini were nominated for a Nobel Prize but didn't get one. By 1940, the procedure was introduced to both England and the US. Through the 40's and 50's the use of ECT became widespread. ECT is the only form of shock treatment still performed by modern medicine.

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 and the replacement of sinusoidal current with brief pulse. It took many years for brief-pulse equipment to be widely adopted Unilateral ECT has never been popular with psychiatrists and is still only given to a minority of ECT patients.. In the 1940s and early 1950s ECT was usually given in "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones. In the 1940s psychiatrists began to experiment with curare, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction of suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to the more widespread use of "modified" ECT. A short-acting anesthetic was usually given in addition to the muscle relaxant in order to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants.

The steady growth of antidepressant use along with negative depictions of ECT in the mass media led to a marked decline in the use of ECT during the 50's to the 70's. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given and, these now antiquated practices contributed to the negative portrayal of ECT in the popular media. The New York Times described the public's negative perception of ECT as being caused mainly by one movie,"For Big Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and in the public mind shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".

In 1976 Dr. Blatchley demonstrated the effectiveness of his constant current, brief pulse device ECT. This device eventually largely replaced earlier devices because of the reduction in cognitive side effects, although some ECT clinics in the US still use sine-wave devices. The 1970s saw the publication of the first American Psychiatric Association task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001). The report endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT. Specifically critics pointed to shortcomings such as noted side effects, the procedure being used as a form of abuse, and uneven application of ECT. The use of ECT declined until the 1980's, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression". In 1985 the National Institute of Mental Health and National Institutes of Health convened a consensus development conference on ECT and concluded that, whilst ECT was the most controversial treatment in psychiatry and had significant side-effects, it had been shown to be effective for a narrow range of severe psychiatric disorders.

Due to the backlash noted previously, national institutions reviewed past practices and set new standards. In 1978 The American Psychiatric Association released its first task force report in which new standards for consent were introduced and the use of unilateral electrode placement was recommended. The 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task force report in 1990 where specific details on the delivery, education, and training of ECT were documented. Finally in 2001 the American Psychiatric Association released its latest task force report. This report emphasizes the importance of informed consent, and the expanded role that the procedure has in modern medicine.

Role in mass media

Fictional and semi-fictional depictions of ECT

Main article: 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.

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.

Registered nurse Barbara C. Cody reports in a letter to the Washington Post that her 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. […]"

In contrast, Kitty Dukakis, wife of political figure Michael Dukakis, reports in a Newsweek article mostly positive effects from electroconvulsive therapy, and regards memory loss as an acceptable price to pay for relief from depression,"[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.

American psychotherapist Martha Manning's autobiographical Undercurrents acknowledges the downside of treatment: "I felt like I'd been hit by a truck for a while, but that was, comparatively speaking, not so bad," as well as the upside: "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."

In his autobiographical book Electroboy, American fraudster Andy Behrman describes undergoing ECT as a treatment for bipolar disorder while under house-arrest: "I wake up thirty minutes later and think I am in a hotel in Acapulco. My head feels as if I have just downed a frozen margarita too quickly. My jaws and limbs ache. But I am elated."

In his Zen and the Art of Motorcycle Maintenance, Robert Pirsig gives several references to psychiatric treatments he received. In particular, he describes how Phaedrus (Pirsig's alter-ego) underwent destruction ECT to erase any personality whatsoever. Despite this treatment Pirsig describes how he retains some of Phaedrus' memory.

Famous people who have undergone ECT

• Antonin Artaud, French playwright
• 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.
• Actress Frances Farmer
• Harold Gimblett, British cricketer. "Rita [his wife] came to see me and couldn't believe the difference. I had some colour back in my cheeks..."
• 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...."
• Roky Erickson, American singer, songwriter, harmonica player and guitarist.
• John Forbes Nash, American mathematician, Nobel laureate
• Peter Green, English blues guitarist, founding member of Fleetwood Mac
• Sylvia Plath, American writer and poet.
• Lou Reed, The Velvet Underground

See also

• DSM-IV Codes
• Harold A. Sackeim