Electroconvulsive Therapy

Definition

Purpose

Precautions

Description

Preparation

Aftercare

Risks

Normal results

Abnormal results

Resources

Definition

Electroconvulsive therapy (ECT) is a controversial procedure in which a patient is treated by using controlled, low-dose electric currents to induce a seizure. The electric current produces a convulsion that may relieve symptoms associated with such mental illnesses as major depressive disorder, bipolar disorder , acute psychosis , and catatonia. Symptom relief, however, is often temporary.

Purpose

Also known as electroconvulsive shock therapy or electroshock therapy, ECT uses low-dose electric currents together with anesthesia, muscle relaxants, and oxygen to produce a mild generalized seizure or convulsion. With repeated administration, usually over a period of weeks, ECT may be effective in relieving symptoms of several mental illnesses.

The American Psychiatric Association’s Practice Guidelines for the Treatment of Psychiatric Disorders discusses the use of ECT in the treatment of major depressive disorder, bipolar disorder, and schizophrenia. It is most closely associated with the treatment of severe depression. Historically, ECT was the treatment of choice for depression if a patient with severe depression or psychotic symptoms was at increased risk of committing suicide and had not responded to other treatments. In addition, patients with catatonia, neuroleptic malignant syndrome, and parkinsonism may also benefit from the procedure.

Although antidepressant medications are effective in many cases, they may take two to six weeks to begin to work. In addition, some patients with mania and schizophrenia may not be able to tolerate the side effects of the antipsychotic medications used to treat these disorders. For these individuals, ECT is an option. ECT is also indicated when patients need a treatment that brings about rapid improvement because they are refusing to eat or drink, or presenting some other danger to themselves.

ECT is also recommended for certain subgroups of patients diagnosed with depression. Many elderly patients, for example, respond better to ECT than to antidepressant medications. Pregnant women are another subgroup that may benefit from ECT. Because ECT does not harm a fetus as some medications might, pregnant women with severe depression can choose ECT for relief of their depressive symptoms.

Today, however, other treatments such as transcranial magnetic stimulation (TMS) are becoming available and replacing ECT in such cases. TMS has also been found to be more effective than ECT in many of the more difficult cases. The literature to date on TMS reports few side effects such as those resulting from ECT.

Precautions

Candidates for ECT must be carefully screened. Prior to receiving this treatment, patients receive a thorough evaluation to identify any medical conditions they may have that might complicate their responses to the procedure. This evaluation includes a complete medical history, a physical examination, and routine laboratory tests. In addition to standard blood tests, the patient should receive an electrocardiogram (EKG) to test for heart abnormalities. Evidence of a recent heart attack would disqualify a patient from receiving ECT. Spinal and chest x rays can identify other physical conditions that might complicate a patient’s response. Finally, a computed tomography (CT) scan

should be performed to rule out any structural abnormalities in the brain that might be made worse by the electrical stimulation and resulting convulsions associated with ECT. Signs of a recent stroke or a tumor in the brain, for instance, would disqualify a patient as a candidate for ECT therapy.

The doctors who are administering the procedure must receive the signed informed consent of the patient a day before the first treatment is given. In addition, at least two psychiatrists should confirm that ECT is the proper treatment for a specific patient. One of these physicians should serve as the source of a “second opinion” and not be actively involved in treating the patient on a daily basis. This second, or outside, medical consultant should independently determine that ECT is appropriate for a particular patient after conducting a physical examination. The second physician should also confirm that the patient is mentally sound enough to give informed consent to the procedure.

Patients in any age group are eligible for treatment with ECT. However, informed consent for patients under 18 must be given by a parent or legal guardian.

Description

Early history of ECT

Ugo Cerletti and Lucio Bini, who were two Italian physicians working in the 1930s, were the first to use ECT to treat patients with severe mental illnesses. Their first patient was a 39-year-old unidentifiable homeless man who had been found wandering through the railroad station in Rome, mumbling incoherently. The doctors were inspired to try the new method by a notion that intrigued psychiatrists in this period, who were desperate for useful therapies—namely, that epilepsy and schizophrenia never appeared in the same person at the same time. (It was later shown, however, that it is possible for the same individual to have both disorders at the same time.) Because epilepsy causes seizures , psychiatrists in the 1930s reasoned that artificially induced seizures might cure schizophrenia. Some in the medical community were receptive to this approach because physicians were already using a variety of chemicals to produce seizures in patients. Unfortunately, many of their patients died or suffered severe injuries because the strength of the convulsions could not be well controlled.

As ECT became more widely used, many members of the general public and some in the psychiatric profession were opposed to its use. To them it seemed barbaric and crude. ECT joined psychosurgery as one of the most intensely distrusted psychiatric and neurological practices. Many people were frightened simply because ECT was called “shock treatment.” Many assumed the procedure would be painful; others thought it was a form of electrocution; and still others believed it would cause brain damage. Unfavorable publicity in newspapers, magazines, and movies added to these fears. Indeed, from the 1930s up through the 1960s, doctors and nurses did not explain either ECT or other forms of psychiatric treatment to patients and their families very often. Moreover, many critics had good reasons for opposing the procedure before it was refined. Neither anesthesia nor muscle relaxants were used in the early days of ECT. As a result, patients had violent seizures, and even though they did not remember them, the thought of the procedure itself seemed frightening. Even more unfortunately, this crude, early version of ECT was applied sometimes to patients who could never have benefited from ECT under any conditions.

As the procedures used with ECT became more refined, psychiatrists found that ECT could be an effective treatment for schizophrenia, depression, and bipolar disorder. The use of ECT, however, was phased out when antipsychotic and antidepressant drugs were introduced during the 1950s and 1960s. The psychiatric community reintroduced ECT several years later when patients who did not respond to the new drugs stimulated a search by mental health professionals for effective, and if necessary, non-drug treatments. While the new psychotropic medications provided relief for untold thousands of patients who suffered greatly from their illnesses and would otherwise have been condemned to mental hospitals, the drugs unfortunately produced a number of side effects, some irreversible. Another drawback is that some medications do not have a noticeable effect on the patient’s mood for two to six weeks. During this time, the patient may be at risk for suicide. In addition, there are patients who do not respond to any medications or who have severe allergic reactions to them.

ECT in contemporary practice

ECT is performed in both inpatient and outpatient facilities in specially equipped rooms with oxygen, suction, and cardiopulmonary resuscitation equipment readily available to deal with the rare emergency. A team of health care professionals, including a psychiatrist , an anesthesiologist, a respiratory therapist, and other assistants, is present throughout the entire procedure.

As of 2000, the American Psychiatric Association has renewed its set of guidelines, first published in 1990, for determining the appropriate use of ECT in patients with depression. They state that patients qualify for ECT if they meet these conditions

• cannot tolerate, or receive no significant benefit from, antidepressant medications
• have responded well to ECT treatments during past depressive episodes
• face a greater risk from taking antidepressant drugs than from undergoing ECT
• need treatment without delay to avoid suicide or other self-destructive acts

Administration of ECT

ECT is performed while the patient is unconscious. Unconsciousness is induced by a short-acting barbiturate such as methohexital (Brevital Sodium), or another appropriate anesthetic drug. The drug is given intravenously. To prevent the patient from harming themselves during the convulsions or seizures induced by ECT, he or she is given succinylcholine (Anectine) or a similar drug that temporarily paralyzes the muscles. Because the patient’s muscles are relaxed, the seizures will not produce any violent contractions of the limbs and torso. Instead, the patient lies quietly on the operating table. One of the patient’s hands or feet, however, is tied off with a tourniquet before the muscle relaxant is given. The tourniquet prevents the muscles in this limb from being paralyzed like the muscles in other parts of the patient’s body. The hand or foot is used to monitor muscle movement induced by the electrical current applied to the brain.

A breathing tube is then inserted into the unconscious patient’s airway and a rubber mouthpiece is inserted into the mouth to prevent him or her from biting down on teeth or tongue during the electrically induced convulsion. As the current is applied, brain activity is monitored using electroencephalography. These brain wave tracings tell the medical team exactly how long the seizure lasts. The contraction of muscles in the arm or leg not affected by the muscle relaxant also provides an indication of the seizure’s duration.

The electrodes for ECT may be placed on both sides of the head (bilateral) or one side (unilateral). Physicians often use bilateral electrode placement during the first week or so of treatments. An electric current is passed through the brain by means of a machine specifically designed for this purpose. The usual dose of electricity is 70-150 volts for 0.1-0.5 seconds. In the first stage of the seizure (tonic phase), the muscles in the body that have not been paralyzed by medication contract for a period of 5-15 seconds. This is followed by the second stage of the seizure (clonic phase) that is characterized by twitching movements, usually visible only in the toes or in a non-paralyzed arm or leg. These are caused by alternating contraction and relaxation of these same muscles. This stage lasts approximately 10-60 seconds. The physician in charge will try to induce a seizure that lasts between one half minute and two minutes. If the first application of electricity fails to produce a seizure lasting at least 25 seconds, another attempt is made 60 seconds later. The session is stopped if the patient has no seizures after three attempts. The entire procedure, from beginning to end, lasts about 30 minutes.

The absence of seizures is most commonly caused either by the patient’s physical condition at the time of treatment or by the individual nature of human responses to drugs and other treatment procedures. Just as there are some patients who do not respond to one type of anti-depressant medication but do respond to others, some patients do not respond to ECT.

The total number of ECT treatments that will be given depends on such factors as the patient’s age, diagnosis , the history of illness, family support, and response to therapy. Treatments are normally given every other day at a rate of two to three per week. The ECT treatments are stopped when the patient’s psychiatric symptoms show significant signs of improvement. Depending on the patient’s condition, this improvement may happen in a few weeks or, rarely, over a six-month period. In most cases, patients with depression require between six and twelve ECT sessions.

Only rarely is ECT treatment extended beyond six months. In such infrequent cases, treatments are decreased from two to four per week after the first month to one treatment every month or so.

No one knows for certain why ECT is effective. Because the treatment involves passing an electric current through the brain, which is electrically excitable tissue, it is not surprising that ECT has been shown to affect many neurotransmitter systems. Neurotransmitters are chemical messengers in the nervous system that carry signals from nerve cell to nerve cell. The neurotransmitters affected by ECT include dopamine , norepinephrine, serotonin, and gamma-aminobutyric acid (GABA).

Preparation

Patients and their relatives are typically prepared for ECT by viewing a videotape that explains both the procedure and the risks involved. The physician then answers any questions these individuals might have, and the patient is asked to sign an informed consent form. This form gives the doctor and the hospital legal permission to administer the treatment.

After the form has been signed, the doctor performs a complete physical examination and orders a number of tests that can help identify any potential problem. These tests may include a chest x ray, electrocardiogram (EKG), CT scan, urinalysis, spinal x ray, electroencephalogram (EEG), and complete blood count (CBC).

Some medications, such as lithium and a class of antidepressants known as monoamine oxidase inhibitors (MAOIs), should be discontinued for some time before ECT administration. Patients are instructed not to eat or drink for at least eight hours prior to the procedure to reduce the possibility of vomiting and choking. During the procedure itself, the members of the health care team closely monitor the patient’s vital signs, including blood pressure, heart rate, and oxygen content.

Aftercare

The patient is moved to a recovery area after an ECT treatment. Vital signs are recorded every five minutes until the patient is fully awake, which may take 15-30 minutes. The patient may experience some initial confusion, but this feeling usually disappears in a matter of minutes. The patient may complain of headache, muscle pain, or back pain, which can be relieved by aspirin or another mild medication.

Following successful ECT treatments, patients with bipolar disorder may be given maintenance doses of lithium. Similarly, patients with depression may be given antidepressant drugs. These medications are intended to reduce the chance of relapse or the recurrence of symptoms. Some studies have estimated that approximately one-third to one-half of patients treated with ECT relapse within 12 months of treatment. After three years, this figure may increase to two-thirds. Follow-up care with medications for bipolar disorder or depression can reduce the relapse rate in the year following ECT treatment from 50% to 20%. Some patients might relapse because they do not respond well to the medications they take after their ECT sessions are completed. In some cases, patients who relapse may have severe forms of depression that are especially difficult to treat by any method.

KEY TERMS

Acute psychosis —A severe mental disorder marked by delusions, hallucinations, and other symptoms that indicate that the patient is not in contact with reality.

Catatonia —Disturbance of motor behavior with either extreme stupor or random, purposeless activity.

Electroencephalography —The measurement and recording of the brain’s electrical activity.

Informed consent —A person’s agreement to undergo a medical or surgical procedure, or to participate in a clinical study, after being properly advised of the medical facts related to the procedure or study and the risks involved.

Mania —An elevated or euphoric mood or irritable state that is characteristic of bipolar I disorder. This state is characterized by mental and physical hyper-activity, disorganization of behavior, and inappropriate elevation of mood.

Neuroleptic —Another name for the older antipsychotic medications, such as haloperidol (Haldol) and chlorpromazine (Thorazine).

Neuroleptic malignant syndrome (NMS) —An unusual but potentially serious complication that develops in some patients who have been treated with antipsychotic medications. NMS is characterized by changes in blood pressure, altered states of consciousness, rigid muscles, and fever. Untreated NMS can result in coma and death.

Parkinsonism —A condition caused by the destruction of the brain cells that produce dopamine (a neurotransmitter), and characterized by tremors of the fingers and hands, a shuffling gait, and muscular rigidity.

Psychomotor —Referring to a response or reaction that involves both the brain and muscular movements.

Psychotropic —Having an effect on the mind, brain, behavior, perceptions, or emotions. Psychotropic medications are used to treat mental illnesses because they affect a patient’s moods and perceptions.

Relapse —A person experiences a relapse when he or she re-engages in a behavior that is harmful and that he or she was trying to change or eliminate. Relapse is a common occurrence after treatment for many disorders, including addictions and eating disorders.

Schizophrenia —A severe mental illness in which a person has difficulty distinguishing what is real from what is not real. It is often characterized by hallucinations, delusions, language and communication disturbances, and withdrawal from people and social activities.

Tourniquet —A rubber tube or length of cloth that is used to compress a blood vessel in order to stop bleeding or to shut off circulation in a part of the body. The tourniquet is wrapped around the arm (or other limb) and tightened by twisting.

Risks

Recent advances in medical technology have substantially reduced the complications associated with ECT. These include memory loss and confusion. Persons at high risk of having complications following ECT include those with a recent heart attack, uncontrolled high blood pressure, brain tumors, and previous spinal injuries.

One of the most common side effects of electro-convulsive therapy is memory loss. Patients may be unable to recall events that occurred before and after treatment. Elderly patients, for example, may become increasingly confused and forgetful as the treatments continue. In a minority of individuals, memory loss may last for months. For the majority of patients, however, recent memories return in a few days or weeks.

Elderly patients receiving ECT may experience disturbances in heart rhythm, slow heartbeat (bradycardia) or rapid heartbeat (tachycardia), and an increased number of falls. As many as one-third of elderly patients may experience such complications following the procedure.

Normal results

Post-treatment confusion and forgetfulness are common, though disturbing, symptoms associated with ECT. Doctors and nurses must be patient and supportive by providing patients and their families with factual information about the nature and time-frame of the patient’s recovery.

A few patients are placed on maintenance ECT. This term means that they must return to the hospital every one to two months as needed for an additional treatment. These persons are thus able to keep their illness under control and lead normal and productive lives.

Abnormal results

If an ECT-induced seizure lasts too long (more than two minutes) during the procedure, physicians will control it with an intravenous infusion of an anti-convulsant drug, usually diazepam (Valium).

Overall, ECT is a very safe procedure. There is no convincing evidence of long-term harmful effects from ECT. Researchers are continuing to explore its potential in treating other disorders as well as other methods to replace ECT.

See alsoCatatonic disorder; Neurotransmitters.

Resources

BOOKS

American Psychiatric Association. Practice Guidelines for the Treatment of Psychiatric Disorders. 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Fink, Max. Electroshock. New York: Oxford University Press, 2005.

VandenBos, Gary R., ed. APA Dictionary of Psychology. Washington, D.C.: American Psychological Association, 2007.

PERIODICALS

Loo, Colleen K., Isaac Schweitzer, and Chris Pratt. “Recent Advances in Optimizing Electroconvulsive Therapy.” Australian and New Zealand Journal of Psychiatry 40.8 (2006): 632–38.

Munk-Olsen, T., and others. “Electroconvulsive Therapy: Predictors and Trends in Utilization from 1976 to 2000.” Journal of ECT 22.2 (2006): 127–32.

Stein, Daniel, Abraham Weizman, and Yuval Bloch. “Electroconvulsive Therapy and Transcranial Magnetic Stimulation: Can They Be Considered Valid Modalities in the Treatment of Pediatric Mood Disorders?” Child and Adolescent Psychiatric Clinics of North America 15.4 (2006): 1035–56.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. <http://www.psych.org>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA 22021. <http://www.nami.org/index.html>.

Dean A. Haycock, PhD
Ruth A. Wienclaw, PhD

Electroconvulsive therapy

Eating disorders see Anorexia nervosa and Bulimia nervosa

EEG see Electroencephalography

Effexor see Venlafaxine

Elavil see Amitriptyline

Definition

Electroconvulsive therapy (ECT) is a medical procedure in which a small, carefully controlled amount of electric current is passed through the brain to treat symptoms associated with certain mental disorders. The electric current produces a convulsion for the relief of symptoms associated with such mental illnesses as major depressive disorder , bipolar disorder , acute psychosis , and catatonia .

Purpose

Also known as electroconvulsive shock therapy or electroshock therapy, ECT is used together with anesthesia, muscle relaxants and oxygen to produce a mild generalized seizure or convulsion. With repeated administration, usually over a period of weeks, ECT is highly effective in relieving symptoms of several mental illnesses.

The American Psychiatric Association's Practice Guidelines for the Treatment of Psychiatric Disorders discusses the use of ECT in the treatment of major depressive disorder, bipolar disorder and schizophrenia . Electroconvulsive therapy is administered to provide relief from the signs and symptoms of these and occasionally other mental illnesses. ECT is used routinely to treat patients with major depression, delusional depression, mania, and depression associated with bipolar disorder and schizophrenia. It is most closely associated with the treatment of severe depression, for which it provides the most rapid relief available as of 2002. In addition, patients suffering from catatonia, neuroleptic malignant syndrome, and parkinsonism may also benefit from the procedure.

ECT may become the treatment of first choice for depression if a patient with severe depression or psychotic symptoms is at increased risk of committing suicide and has not responded to other treatments. Although antidepressant medications are effective in many cases, they may take two to six weeks to begin to work. Some patients with mania and schizophrenia may not be able to tolerate the side effects of the antipsychotic medications used to treat these disorders. In addition, some patients may be unable to take their prescribed medications. For these individuals, ECT is an important option. ECT is also indicated when patients need a treatment that brings about rapid improvement because they are refusing to eat or drink, or presenting some other danger to themselves.

ECT is also recommended for certain subgroups of patients diagnosed with depression. Many elderly patients, for example, respond better to ECT than to antidepressant medications. Pregnant women are another subgroup that may benefit from ECT. Because ECT does not harm a fetus as some medications might, pregnant women suffering from severe depression can safely choose ECT for relief of their depressive symptoms.

Precautions

Candidates for ECT must be carefully screened. Prior to receiving this treatment, patients receive a thorough evaluation to identify any medical conditions they may have that might complicate their response to the procedure. This evaluation includes a complete medical history, a physical examination, and routine laboratory tests. In addition to standard blood tests, the patient should receive an electrocardiogram (EKG) to test for heart abnormalities. Evidence of a recent heart attack would disqualify a patient from receiving ECT. Spinal and chest x rays can identify other physical conditions that might complicate a patient's response. Finally, a computed tomography (CT) scan should be performed to rule out any structural abnormalities in the brain that might be made worse by the electrical stimulation and resulting convulsions associated with ECT. Signs of a recent stroke or a tumor in the brain, for instance, would disqualify a patient as a candidate for ECT therapy.

The doctors who are administering the procedure must receive the informed consent of the patient a day before the first treatment is given. In addition, at least two psychiatrists should confirm that ECT is the proper treatment for a specific patient. One of these physicians should serve as the source of a "second opinion" and not be actively involved in treating the patient on a daily basis. This second, or outside, medical consultant should independently determine that ECT is appropriate for a particular patient after conducting a physical examination. The second physician should also confirm that the patient is mentally sound enough to give informed consent to the procedure.

Patients in any age group are eligible for treatment with ECT; however, informed consent for patients under 18 must be given by a parent or legal guardian.

Description

Early history of ECT

Ugo Cerletti and Lucio Bini, who were two Italian physicians working in the 1930s, were the first to use electroconvulsive therapy to treat patients with severe mental illnesses. Their first patient was a 39-year-old unidentifiable homeless man who had been found wandering through the railroad station in Rome, mumbling incoherently. The doctors were inspired to try the new method by a notion that intrigued psychiatrists in this period, who were desperate for useful therapies— namely, that epilepsy and schizophrenia never appeared in the same person at the same time. (It was later shown, however, that it is possible for the same individual to suffer from both disorders at the same time.) Since epilepsy causes seizures , psychiatrists in the 1930s reasoned that artificially induced seizures might cure schizophrenia. Some in the medical community were receptive to this approach because physicians were already using a variety of chemicals to produce seizures in patients. Unfortunately, many of their patients died or suffered severe injuries because the strength of the convulsions could not be well controlled.

As ECT became more widely used, many members of the general public and some in the psychiatric profession were opposed to its use. To them it seemed barbaric and crude. ECT joined psychosurgery as one of the most intensely distrusted psychiatric and neurological practices. Many people were frightened simply because ECT was called "shock treatment." Many assumed the procedure would be painful; others thought it was a form of electrocution; and still others believed it would cause brain damage. Unfavorable publicity in newspapers, magazines and movies added to these fears. Indeed, from the 1930s up through the 1960s, doctors and nurses did not explain either ECT or other forms of psychiatric treatment to patients and their families very often. Moreover, many critics had good reasons for opposing the procedure before it was refined. Neither anesthesia nor muscle relaxants were used in the early days of ECT. As a result, patients had violent seizures, and even though they did not remember them, the thought of the procedure itself seemed frightening. Even more unfortunately, this crude, early version of ECT was applied sometimes to patients who could never have benefited from ECT under any conditions.

As the procedures used with ECT became more refined, psychiatrists found that ECT was an effective treatment for schizophrenia and soon after, depression and bipolar disorder. The use of ECT, however, was phased out when antipsychotic and antidepressant drugs were introduced during the 1950s and 1960s. The psychiatric community reintroduced ECT several years later when patients who didn't respond to the new drugs stimulated a search by mental health professionals for effective, and if necessary, non-drug treatments. While the new psychotropic medications provided relief for untold thousands of patients who suffered greatly from their illnesses and would otherwise have been condemned to mental hospitals, the drugs unfortunately produced a number of side effects, some of which are irreversible. Another drawback is that some medications do not have a noticeable effect on the patient's mood for two to six weeks. During this time, the patient may be at risk for suicide. In addition, there are patients who do not respond to any medications or who have severe allergic reactions to them. For these individuals, ECT may be the only treatment that will help.

ECT in contemporary practice

Today, with the introduction of improved safety procedures, ECT is a remarkably safe and highly effective procedure. It is performed in both inpatient and outpatient facilities in specially equipped rooms with oxygen, suction, and cardiopulmonary resuscitation equipment readily available to deal with the rare emergency. A team of health care professionals, including a psychiatrist , an anesthesiologist, a respiratory therapist, and other assistants, is present throughout the entire procedure.

As of 2000, the American Psychiatric Association has renewed its set of guidelines, first published in 1990, for determining the appropriate use of ECT in patients suffering from depression. They state that patients qualify for ECT if they:

• cannot tolerate, or receive no significant benefit from, antidepressant medications
• have responded well to ECT treatments during past depressive episodes
• face a greater risk from taking antidepressant drugs than from undergoing ECT
• need treatment without delay to avoid suicide or other self-destructive acts

Administration of ECT

ECT is performed while the patient is unconscious. Unconsciousness is induced by a short-acting barbiturate such as methohexital (Brevital sodium), or another appropriate anesthetic drug. The drug is given intravenously. To prevent the patient from harming themselves during the convulsions or seizures induced by ECT, he or she is given succinylcholine (Anectine) or a similar drug that temporarily paralyzes the muscles. Because the patient's muscles are relaxed, the seizures will not produce any violent contractions of the limbs and torso. Instead, the patient lies quietly on the operating table. One of the patient's hands or feet, however, is tied off with a tourniquet before the muscle relaxant is given. The tourniquet prevents the muscles in this limb from being paralyzed like the muscles in other parts of the patient's body. The hand or foot is used to monitor muscle movement induced by the electrical current applied to the brain.

A breathing tube is then inserted into the unconscious patient's airway and a rubber mouthpiece is inserted into the mouth to prevent him or her from biting down on teeth or tongue during the electrically induced convulsion. As the current is applied, brain activity is monitored using electroencephalography . These brain wave tracings tell the medical team exactly how long the seizure lasts. The contraction of muscles in the arm or leg not affected by the muscle relaxant also provides an indication of the seizure's duration.

The electrodes for ECT may be placed on both sides of the head (bilateral) or one side (unilateral). Physicians often use bilateral electrode placement during the first week or so of treatments. An electric current is passed through the brain by means of a machine specifically designed for this purpose. The usual dose of electricity is 70–150 volts for 0.1–0.5 seconds. In the first stage of the seizure (tonic phase), the muscles in the body that have not been paralyzed by medication contract for a period of 5–15 seconds. This is followed by the second stage of the seizure (clonic phase) that is characterized by twitching movements, usually visible only in the toes or in a nonparalyzed arm or leg. These are caused by alternating contraction and relaxation of these same muscles. This stage lasts approximately 10–60 seconds. The physician in charge will try to induce a seizure that lasts between one-half and two minutes. If the first application of electricity fails to produce a seizure lasting at least 25 seconds, another attempt is made 60 seconds later. The session is stopped if the patient has no seizures after three attempts. The entire procedure, from beginning to end, lasts about 30 minutes.

The absence of seizures is most commonly caused either by the patient's physical condition at the time of treatment or by the individual nature of human responses to drugs and other treatment procedures. Just as there are some patients who do not respond to one type of antidepressant medication but do respond to others, some patients do not respond to ECT.

The total number of ECT treatments that will be given depends on such factors as the patient's age, diagnosis , the history of illness, family support and response to therapy. Treatments are normally given every other day with a total of two to three per week. The ECT treatments are stopped when the patient's psychiatric symptoms show significant signs of improvement. Depending on the patient's condition, this improvement may happen in a few weeks or, rarely, over a six-month period. In most cases, patients with depression require between six and twelve ECT sessions.

Only rarely is ECT treatment extended beyond six months. In such infrequent cases, treatments are decreased from two to four per week after the first month to one treatment every month or so.

No one knows for certain why ECT is effective. Because the treatment involves passing an electric current through the brain, which is electrically excitable tissue, it is not surprising that ECT has been shown to affect many neurotransmitter systems. Neurotransmitters are chemical messengers in the nervous system that carry signals from nerve cell to nerve cell. The neurotransmitters affected by ECT include dopamine, norepinephrine, serotonin and GABA (gamma-aminobutyric acid).

Preparation

Patients and their relatives are prepared for ECT by viewing a videotape that explains both the procedure and the risks involved. The physician then answers any questions these individuals might have, and the patient is asked to sign an informed consent form. This form gives the doctor and the hospital legal permission to administer the treatment.

After the form has been signed, the doctor performs a complete physical examination and orders a number of tests that can help identify any potential problem. These tests may include a chest x ray; an electrocardiogram (EKG); a CT scan; a urinalysis; a spinal x ray; a brain wave tracing (EEG); and a complete blood count (CBC).

Some medications, such as lithium and a class of antidepressants known as monoamine oxidase inhibitors (MAOIs), should be discontinued for some time before ECT administration. Patients are instructed not to eat or drink for at least eight hours prior to the procedure in order to reduce the possibility of vomiting and choking. During the procedure itself, the members of the health care team closely monitor the patient's vital signs, including blood pressure, heart rate and oxygen content.

Aftercare

The patient is moved to a recovery area after an ECT treatment. Vital signs are recorded every five minutes until the patient is fully awake, which may take 15–30 minutes. The patient may experience some initial confusion, but this feeling usually disappears in a matter of minutes. The patient may complain of headache, muscle pain, or back pain, which can be quickly relieved by aspirin or another mild medication.

Following successful ECT treatments, patients with bipolar disorder may be given maintenance doses of lithium. Similarly, patients with depression may be given antidepressant drugs. These medications are intended to reduce the chance of relapse or the recurrence of symptoms. Some studies have estimated that approximately one-third to one-half of patients treated with ECT relapse within 12 months of treatment. After three years, this figure may increase to two-thirds. Follow-up care with medications for bipolar disorder or depression can reduce the relapse rate in the year following ECT treatment from 50% to 20%. Some patients might relapse because they do not respond well to the medications they take after their ECT sessions are completed. In some cases, patients who relapse may suffer from severe forms of depression that are especially difficult to treat by any method.

Risks

Recent advances in medical technology have substantially reduced the complications associated with ECT. These include memory loss and confusion. Persons at high risk of having complications following ECT include those with a recent heart attack, uncontrolled high blood pressure, brain tumors, and previous spinal injuries.

One of the most common side effects of electroconvulsive therapy is memory loss. Patients may be unable to recall events that occurred before and after treatment. Elderly patients, for example, may become increasingly confused and forgetful as the treatments continue. In a minority of individuals, memory loss may last for months. For the majority of patients, however, recent memories return in a few days or weeks.

Elderly patients receiving ECT may experience disturbances in heart rhythm; slow heartbeat (bradycardia); or rapid heartbeat (tachycardia); and an increased number of falls. As many as one-third of elderly patients may experience such complications following the procedure.

Normal results

ECT often produces dramatic improvement in the signs and symptoms of major depression, especially in elderly patients. Sometimes the benefits are evident even during the first week of treatment.

A remarkable 90% of patients who receive ECT for depression respond positively. By contrast, only 70% respond as well when treated with antidepressant medications alone. While it is estimated that as many as 50% of successfully treated patients will have future episodes of depression, the prognosis for each episode of illness is good. Mania also often responds well to treatment with ECT. The picture is not as bright for schizophrenia, which is more difficult to treat and is characterized by frequent relapses.

Post-treatment confusion and forgetfulness are common, though disturbing, symptoms associated with ECT. Doctors and nurses must be patient and supportive by providing patients and their families with factual information about the nature and timeframe of the patient's recovery.

A few patients are placed on maintenance ECT. This term means that they must return to the hospital every one to two months as needed for an additional treatment. These persons are thus able to keep their illness under control and lead normal and productive lives.

Abnormal results

If an ECT-induced seizure lasts too long (more than two minutes) during the procedure, physicians will control it with an intravenous infusion of an anticonvulsant drug, usually diazepam (Valium).

Overall, ECT is a very safe procedure. The complications encountered are no different from those that may occur with the administration of anesthesia without ECT. There is no convincing evidence of long-term harmful effects from ECT. Researchers are continuing to explore its potential in treating other disorders.

See also Catatonic disorder; Neurotransmitters

Resources

BOOKS

American Psychiatric Association. Practice Guidelines for the Treatment of Psychiatric Disorders. Fourth edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Mondimore, Francis Mark. Depression, The Mood Disease. Baltimore, MD: The Johns Hopkins University Press, 1995.

Nathan, Peter, E. and Jack M. Gorman, eds. A Guide to Treatments that Work. New York, NY: Oxford University Press, 1998.

Zarit, Steven H. and Judy M. Zarit. Mental Disorder in Older Adults, Fundamentals of Assessment and Treatment. New York, NY: The Guilford Press, 1998.

PERIODICALS

Fink, M. "Convulsive therapy: a review of the first 55 years." Journal of Affective Disorders 63, no. 1-3 (March 2001): 1-15.

Grant, M. M. and J. M. Weiss. "Effects of chronic antidepressant drug administration and electroconvulsive shock on locus coeruleus electrophysiologic activity." Biological Psychiatry 49, no. 2 (January 2001): 117-129.

Nuland, Sherwin B., M.D. "The Uncertain Art: Lightning On My Mind." The American Scholar 71 (Spring 2002): 127-131.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. <http://www.psych.org>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington,VA 22021. <http://www.nami.org/index.html>.

OTHER

Sabbatini, Renato M. E. "The History of Shock Therapy in Psychiatry." Brain & Mind Magazine June 1997/February 1998 [cited 20 April 2002]. <http://www.epub.org.br/cm/n04/historia/shock_i.htm#cerletti>.

Sackeim, Harold A. "ECT Effective for Many." NAMI-NYC Metro. [cited 21 April 2002]. <http://nyc.nami.org/askthedoctor/ask9.htm>.

Dean A. Haycock, Ph.D.

ELECTROCONVULSIVE THERAPY

Electroconvulsive therapy (ECT) is a highly efficacious treatment in psychiatry (Crowe, Abrams), and yet there is ethical controversy about its use. Some have claimed that ECT should be outlawed because it seriously impairs memory; others, that ECT is best viewed as a crude form of behavior control that psychiatrists frequently coerce patients to accept. Still others claim that, even if coercion is not employed, depressed patients are rarely, if ever, competent to give valid consent to the treatment (Breggin). The complaint is also sometimes voiced that ECT is given more frequently to women patients than to men. There is also ample evidence that, in earlier years, ECT was given in ways that are not used today: higher amounts of electrical current, and sometimes daily or several-times-daily treatments. Undoubtedly, this harmed some patients (Breggin). Probably because of concerns like these, one state, California, has passed legislation making it difficult for psychiatrists to employ ECT without satisfying many administrative regulations (California Welfare and Institutions Code). There also exist several activist groups that are opposed to all ECT and have even tried to criminalize the administration of ECT. Daniel Smith provides an excellent summary of these groups's arguments and activities in his 2001 article "Shock and Disbelief."

The nature of the treatment itself understandably frightens some persons, and there have been gruesome depictions of it in popular films and novels (Kesey). The notion of passing an electrical current through the brain, stimulating a cerebral seizure and causing unconsciousness, may seem forbidding, particularly in view of the fact that ECT's therapeutic mechanism of action remains largely unknown. There are, however, many effective treatments in medicine whose mechanisms are unknown, and there are probably many surgical treatments that would seem equally forbidding if they were observed by a layperson. In appraising the ethical legitimacy of ECT as a treatment, it is important to ask the same questions about ECT that are asked about any treatment: Of what does it consist, what is the likelihood that it will help, what kinds of harm can it cause; and how does its spectrum of benefits and harms compare with those of alternative plausible treatments?

ECT Treatment

There are several excellent reviews of the history, clinical indications, and likely harms and benefits of ECT (Abrams; American Psychiatric Association Task Force on Electroconvulsive Therapy (APA Task Force); Crowe; Ottosson). The essential feature of the treatment is the induction of a cerebral seizure (which is easily measured via concomitant electroencephalography) by means of electrodes attached to the scalp. Current is applied through the electrodes for a fraction of a second. The two electrodes may be attached to the right and left temples (bilateral ECT), inducing a seizure in both hemispheres of the brain, or to anterior and posterior placements on only one side (unilateral ECT), limiting the seizure to that side. Patients are premedicated with a muscle relaxant and anesthetized with a short-acting barbiturate general anesthetic. Patients remain unconscious after the treatment for about five minutes and are usually mildly confused for an hour or so after they awaken. They have no memory of the treatment itself. Treatments are usually given two or three times weekly for two to four weeks.

ECT was used originally as a treatment for schizophrenia on the basis of the now-discredited belief that epilepsy, which ECT was thought to mimic, and schizophrenia did not occur in the same persons. It is used chiefly with patients suffering from severe depression; most psychiatrists suggest its use to patients only when drug treatment and/or psychotherapy have not helped. ECT is also used occasionally with bipolar patients suffering from a life-threatening degree of manic excitement, or to schizophrenic patients suffering from a catatonic stupor, when these conditions do not improve with drug therapy.

Efficacy and Side Effects

The effectiveness of ECT in reversing severe depression seems beyond dispute (Abrams; Crowe; APA Task Force): Many large studies show a significant recovery from depression in 80 to 90 percent of patients who receive ECT, as compared with 50 to 60 percent of depressed patients who respond to antidepressant medication. Patients who do not respond to drugs show a high response rate to ECT: about 50 to 60 percent recover. No study comparing the differential effects of drugs and ECT has ever found that drugs have a greater therapeutic effect. ECT also works more quickly than drugs: Patients who improve typically begin to do so after about one week; drugs, if they work, typically take three to four weeks, sometimes longer, to have a significant effect. Many studies have shown that unilateral and bilateral ECT are equally effective treatments, although a minority have found unilateral ECT to be on average less effective. However unilateral ECT also causes, on average, less cognitive confusion during treatment and less residual memory impairment afterward.

Although ECT can cause death, it does so infrequently that it is difficult to reliably estimate a mortality rate. The largest modern report (Heshe and Roeder) studied 3,438 courses of treatment (22,210 ECTs), and only one death occurred. The APA Task Force estimates a death rate of 1 in 10,000 patients and 1 in 80,000 treatments. When ECT does cause death, it is usually cardiovascular in origin and is related to the use of a general barbiturate anesthesia.

The principal adverse effect of ECT on some patients is to cause one or another kind of memory impairment. Two of these kinds of memory impairment are limited. During the two to three weeks that treatments are given, memory and other cognitive functions are usually mildly to moderately impaired because of the ongoing seizures. Moreover in later years patients are often unable to recall many events that took place shortly before, during, and shortly after the two- to three-week course of treatment. Neither of these effects bothers most patients, as long as they understand ahead of time that they will occur.

The more important and controversial question is how often ECT causes an ongoing, permanent deficit in memory function (an anterograde amnesia). If and when it does, it is possible that the treatment has damaged parts of the brain underlying memory function. This has proven to be an elusive research problem, despite dozens of studies, many quite sophisticated, that have been carried out (Taylor et al., Abrams). Among the many methodological problems involved in doing this research (Strayhorn) is the fact that depression itself often causes cognitive impairment, including memory dysfunction. In fact studies of the effect of ECT on memory have repeatedly shown that the majority of patients actually report improved memory function after ECT, probably due to the diminution of their depression (APA Task Force).

A small minority of patients—the exact percentage seems unknown—do report mild, ongoing, permanent memory problems after ECT; nearly all of them rate the memory problem as annoying but not serious. However, when patients treated with ECT are compared with appropriate control groups, no deterioration in performance on objective tests of memory ability has ever been found. Nonetheless a very small number of patients, perhaps 1 to 2 percent, complain of serious ongoing memory problems. Memory complaints occur more frequently after bilateral than unilateral ECT, which has led many commentators to recommend that unilateral treatment generally be given, and that bilateral treatment be used only in serious conditions and after unilateral ECT has failed.

Ethical Issues

Is ECT so harmful that it should be outlawed? Very few persons maintain this position. ECT has an extremely small risk of causing death. It probably also has a small risk of causing chronic mild memory impairment, and a very small risk of causing chronic serious memory impairment. It is frequently used, however, in clinical settings where other treatments have failed and where the patient is suffering intensely and may be at risk of dying. Severe depression is a miserable and a serious illness: The three-year death rate in untreated or undertreated patients is about 10 percent, while in treated patients, it is about 2 percent (Avery and Winokur). Even if the risks of ECT were substantially greater than they are, it would still be rational in the clinical setting of severe depression for patients to consent to receiving ECT.

As with all other treatments in medicine, the possible harms and benefits of ECT should be explained to the patient during the consent process. The risk of death and of chronic memory dysfunction should be mentioned specifically. The APA Task Force also stipulates that a discussion should be included, during the consent process, "of the relative merits and risks of the different stimulus electrode placements and the specific choice that has been made for the patient. The patient's understanding of the data presented should be appraised, questions should be encouraged, and ample time for decision making should be allowed. Patients should be free to change their minds about receiving ECT, either before the treatments start or once they are under way" (pp. 5–6).

ECT is often suggested to patients only after other treatments have failed. However, although it has slight risks, ECT has several advantages over other treatments: It works more quickly, in a higher percentage of cases, and it does not have the annoying and, for some cardiac patients, possibly dangerous side effects of many antidepressant drugs. Following the general notion that part of an adequate valid consent process is to inform patients of any available rational treatment options (Gert et al.), a strong argument can be made that, from the outset of treatment, seriously depressed patients should be offered ECT as one therapeutic option (Culver et al.). The APA Task Force states: "As a major treatment in psychiatry with well-defined indications, ECT should not be reserved for use only as a last resort."

Do psychiatrists often coerce patients into receiving ECT? This seems doubtful, but there are no data addressing this question. In the overwhelming majority of cases, psychiatrists should not force any treatment on a patient. Nonetheless there are very rare clinical situations in which it is ethically justified to give ECT to patients who refuse it (Group for the Advancement of Psychiatry): for example, patients in danger of dying from a severe depression that has not been responsive to other forms of treatment (Merskey). But this is a special instance of the general ethical issue of justified paternalistic treatment, and no special rules should apply to psychiatric patients or to ECT (Gert et al.).

There seems no reason to believe that the consent or the refusal depressed patients give to undergo ECT is not in most cases valid. If a patient is given adequate information about the treatment, if he or she understands and appreciates this information, and if the patient's choice is not forced, then the decision is valid and, in almost all cases, should be respected. Most psychiatrists would assert that the great majority of depressed patients are like the great majority of all patients: They feel bad, they would like to feel better, and if presented with information about available treatment options, they try to make a rational choice.

Is ECT disproportionally and unjustly given to women patients? There are no data that address this question, and it would be useful to obtain them. However, given the fact that women suffer from clinically significant depression two to three times more frequently than men (Willner), the critical question is not whether more women in total receive ECT, as would be expected, but whether ECT is given at a higher rate to women than to equally depressed men.

charles m. culver (1995)

revised by author

SEE ALSO: Behaviorism; Behavior Modification Therapies; Electrical Stimulation of the Brain; Emotions; Freedom and Free Will; Human Dignity; Informed Consent: Issues of Consent in Mental Healthcare; Mental Health Therapies; Mental Illness: Issues in Diagnosis; Neuroethics; Psychiatry, Abuses of; Psychosurgery, Ethical Aspects of; Psychosurgery, Medical and Historical Aspects of; Research Policy: Risk and Vulnerable Groups; Technology

BIBLIOGRAPHY

Abrams, Richard. 2002. Electroconvulsive Therapy, 4th edition. New York: Oxford.

American Psychiatric Association. Task Force on Electroconvulsive Therapy. 2001. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging, 2nd edition. Washington, D.C.: Author.

Avery, David, and Winokur, George. 1976. "Mortality in Depressed Patients Treated with Electroconvulsive Therapy and Antidepressants." Archives of General Psychiatry 33(9): 1029–1037.

Breggin, Peter Roger. 1979. Electroshock: Its Brain-Disabling Effects. New York: Springer.

California Welfare and Institutions Code. 1979. §§5325.1, 5326.7, 5326.8, 5434.2.

Crowe, Raymond R. 1984. "Electroconvulsive Therapy—A Current Perspective." New England Journal of Medicine 311(3): 163–167.

Culver, Charles M.; Ferrell, Richard B.; and Green, Ronald M. 1980. "ECT and Special Problems of Informed Consent." American Journal of Psychiatry 137: 586–591.

Gert, Bernard; Culver, Charles M.; and Clouser, K. Danner. 1997. Bioethics: A Return to Fundamentals. New York: Oxford.

Group for the Advancement of Psychiatry. Committee on Medical Education. 1990. A Casebook in Psychiatric Ethics. New York: Brunner/Mazel.

Heshe, Joergen, and Roeder, Erick. 1976. "Electroconvulsive Therapy in Denmark." British Journal of Psychiatry 128: 241–245.

Kesey, Ken. 1962. One Flew over the Cuckoo's Nest. New York: New American Library.

Merskey, Harold. 1991. "Ethical Aspects of the Physical Manipulation of the Brain." In Psychiatric Ethics, 3rd edition, ed. Sidney Bloch and Paul Chodoff. Oxford: Oxford University Press.

Ottosson, Jan-Otto. 1985. "Use and Misuse of Electroconvulsive Treatment." Biological Psychiatry 20(9): 933–946.

Smith, Daniel. 2001. "Shock and Disbelief." Atlantic 287(2): 79–90.

Strayhorn, Joseph M., Jr. 1982. Foundations of Clinical Psychiatry. Chicago: Year Book Medical Publishers.

Taylor, John R.; Tompkins, Rachel; Demers, Renée; and Anderson, Dale. 1982. "Electroconvulsive Therapy and Memory Dysfunction: Is There Evidence for Prolonged Defects?" Biological Psychiatry 17(10): 1169–1193.

Willner, Paul. 1985. Depression: A Psychobiological Synthesis. New York: Wiley.

ELECTROCONVULSIVE THERAPY

Electroconvulsive therapy (ECT) involves the use of a brief electrical current to produce a seizure in the brain. Many studies have shown ECT to be an effective treatment for severe psychiatric disorders, particularly major depressive disorders. ECT is believed to work by regulating neurotransmitter systems in the brain, the same way other somatic (physical) psychiatric treatments (including medications) work.

Historical origins

ECT was discovered in Europe in the first part of the twentieth century. In 1934, a Hungarian psychiatrist, Ladislas von Meduna reported on the successful use of a chemical product, camphor, to induce epileptic seizures (convulsions) in a series of patients with schizophrenia. This form of convulsive therapy was found to be efficacious but extremely unpleasant. Four years later, the Italians Ugo Cerletti and Luigi Bini used electricity to induce seizures.

ECT was first used in the United States in 1940, and within a few years it became widely used. Following the development of effective psychiatric medications in the 1950s, the use of ECT and other somatic psychiatric treatments, such as psychosurgery, decreased markedly. However, a number of studies have shown that some patients who do not respond to medications can be treated successfully with ECT. As of 2000, it was estimated that about 100,000 American patients with severe psychiatric disorders were treated annually with ECT.

Indications

Over the years, ECT equipment and techniques have been perfected, and recent scientific studies have confirmed that ECT is an extremely safe and effective treatment. However, in large part due to its negative and sensational portrayal in the media, ECT remains a controversial treatment. As a result, it is usually used when pharmacotherapy (drug treatment) has been ineffective or poorly tolerated. Nevertheless, ECT can be used as a first-line treatment when a rapid response is needed—for instance to treat an actively suicidal patient; a depressed patient refusing fluids, food, or medications; a patient that presents with a recurrence of a disorder that has responded to ECT but not to medications in the past; or a patient that requests to be treated with ECT rather than medications.

ECT is mostly used to treat severe depressive episodes associated with recurrent depression, bipolar disorder (manic-depressive illness), or due to general medical conditions. ECT can also be used to treat other conditions when they have not responded to pharmacotherapy or when rapid treatment is needed; such conditions include manic episodes; schizophrenia and other psychotic disorders; catatonic states of any cause; or prominent depressive symptoms associated with Alzheimer's disease and other dementias. In rare instances, ECT has been used to treat other psychiatric disorders and some physical disorders (e.g., treatment-resistant Parkinson's disease). Older patients with severe depression often present with psychosis, suicidal thoughts, or refusal of food and fluid requiring rapid treatment. Thus, while age does not constitute an indication for, or a predictor of, favorable response to ECT, older patients are particularly likely to meet the current indications for ECT.

Risks

While there are no absolute contraindications to ECT, it should not be used when its associated risks outweigh its potential benefits. During the ECT procedure, intracranial pressure, heart rate, and blood pressure (and thus myocardial demand in oxygen) are increased. As a result, ECT should be avoided in patients with brain tumors, vascular aneurysms, recent myocardial or cerebral infarction, and severe pulmonary disease. Poor health status, rather than advancing age, increases the risk for the rare but potentially severe physical complications associated with general anesthesia and ECT, such as cardiac arrhythmias, aspiration pneumonia, spinal compression fractures, or mouth injury.

ECT does not appear to impair the ability to learn and retain new information and it is usually associated with subjective cognitive improvement. However, ECT may cause some objective cognitive impairment. This impairment typically consists of a transient inability to retrieve some memories, in particular for events occurring during the few months preceding or following the ECT course. In addition to these transient memory deficits, many patients also experience permanent memory loss for events occurring during the course of treatment, particularly events on treatment days. Cognitive impairment can be minimized with the use of the proper ECT techniques.

Elderly patients are at greater risks for prolonged confusion and even delirium, particularly when they suffer from a degenerative or vascular dementia. However, elderly patients presenting with a dementia syndrome associated with depression may experience a dramatic improvement in cognition when they are treated with ECT. Thus, cognitive impairment should not constitute by itself a contraindication to ECT.

Procedures

Typically, a course of ECT consists of a total of six to twelve treatments given over two to four weeks, with two or three treatments per week. All treatments are given under general anesthesia with patients being oxygenated and closely monitored. Once patients are asleep, they are given a paralyzing agent so that they can experience a seizure in their brain without motor convulsions. Two electrodes are then applied to the scalp and a brief controlled current is circulated from one electrode to the other through the patient's skull and brain. To minimize risks of confusion, treatment is usually initiated in older patients with unilateral ECT (i.e., with placement of both electrodes over the right-sided nondominant hemisphere). Regardless of electrode placement, a brief-pulse, square-wave current is now routinely used, since its efficacy is similar to a sine-wave current but it is less likely to induce significant adverse cognitive effects. Similarly, optimization of current intensity, based on a systematic determination of each patient's seizure threshold, has been shown to improve efficacy and to decrease cognitive impairment. ECT is typically discontinued once a patient's mood is back to baseline or when it reaches a plateau after two consecutive treatments. Once the acute course of ECT is completed, the majority of patients are given psychiatric medications to maintain their improvement and prevent relapses. In a small number of selected patients who exhibit a good response to ECT but relapse rapidly despite adequate continuation pharmacotherapy, the use of ECT can be continued. Typically, this consists of ECT given on an outpatient basis every two to four weeks for several months or years.

Benoit H. Mulsant, M. D.

See also Antidepressants; Depression.

BIBLIOGRAPHY

Abrams, R. Electroconvulsive Therapy, 3d. ed. New York: Oxford University Press, 1997.

American Psychiatric Association Committee on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging, 2d ed. Washington, D.C.: American Psychiatric Association, 2001.

Olfson, M.; Marcus, S.; Sackeim, H. A.; Thompson, J.; and Pincus, H. A. "Use of ECT for the Inpatient Treatment of Recurrent Major Depression." American Journal of Psychiatry 155 (1998): 22–29.

Sackeim, H. A.; Haskett, R. F.; Mulsant, B. H.; Thase, M. E.; Mann, J. J.; Pettinati, H. M.; Greenberg, R. M.; Crowe, R. R.; Cooper, T. B.; and Prudic, J. "Continuation Pharmacotherapy in the Prevention of Relapse Following Electroconvulsive Therapy." Journal of the American Medical Association 285, no. 10 (2001): 1299–1307.

Sackeim, H. A.; Prudic, J.; Devanand, D. P.; Nobler, M. S.; Lisansby, S. H.; Peyser, S.; Fitzsimmons, L.; Moody, B. J.; and Clark, J. "A Prospective, Randomized, Double-Blind Comparison of Bilateral and Right Unilateral Electroconvulsive Therapy at Different Stimulus Intensities." Archives of General Psychiatry 57 (2000): 425–434.

Tew, J. D.; Mulsant, B. H.; Haskett, R. F.; Prudic, J.; Thase, M. E.; Crowe, R.; Dolata, D.; Begley, A. E.; Reynolds, C. F.; and Sackeim, H. A. "Acute Efficacy of ECT in the Treatment of Major Depression in the Old-Old." American Journal of Psychiatry 156 (1999): 1865–1870.

Electroconvulsive Therapy

Definition

Electroconvulsive therapy (ECT) is a medical treatment for severe mental illness in which a small, carefully controlled amount of electricity is introduced into the brain. This electrical stimulation, used in conjunction with anesthesia and muscle relaxant medications, produces a mild generalized seizure or convulsion. While used to treat a variety of psychiatric disorders, it is most effective in the treatment of severe depression, and provides the most rapid relief currently available for this illness.

Purpose

The purpose of electroconvulsive therapy is to provide relief from the signs and symptoms of mental illnesses such as severe depression, mania, and schizophrenia. ECT is indicated when patients need rapid improvement because they are suicidal, self-injurious, refuse to eat or drink, cannot or will not take medication as prescribed, or present some other danger to themselves. Antidepressant medications, while effective in many cases, may take two-six weeks to produce a therapeutic effect. Antipsychotic medications used to treat mania and schizophrenia have many uncomfortable and sometimes dangerous side effects, limiting their use. In addition, some patients develop allergies and therefore are unable to take their medicine.

Precautions

The most common risks associated with ECT are disturbances in heart rhythm. Broken or dislocated bones occur very rarely.

Description

The treatment of severe mental illness, such as schizophrenia, using electroconvulsive therapy was introduced in 1938 by two Italian doctors named Cerletti and Bini. In those days many doctors believed that convulsions were incompatible with schizophrenia since, according to their obervations, this disease rarely occurred in individuals suffering from epilepsy. They concluded, therefore, that if convulsions could be artifically produced in patients with schizophrenia, the illness could be cured. Some doctors were already using a variety of chemicals to produce seizures, but many of their patients died or suffered severe injuries because the strength of the convulsions could not be well controlled.

Electroconvulsive therapy is among the most controversial of all procedures used to treat mental illness. When it was first introduced, many people were frightened simply because it was called "shock treatment." Many assumed the procedure would be painful, others thought it was a form of electrocution, and still others believed it would cause brain damage. Unfortunately, unfavorable publicity in newspapers, magazines, and movies added to these fears.

Indeed, in those early years, patients and families were rarely educated by doctors and nurses regarding this or other forms of psychiatric treatment. In addition, no anesthesia or muscle relaxants were used. As a result, patients had violent seizures, and even though they did not remember them, the procedure itself was frightening.

The way these treatments are given today is very different from the procedures used in the past. Currently, ECT is offered on both an inpatient and outpatient basis. Hospitals have specially equipped rooms with oxygen, suction, and cardiopulmonary resuscitation (CPR ) in order to deal with the rare emergency.

The treatment is carried out as follows: approximately 30 minutes before the scheduled treatment time, the patient may receive an injection of a medication (such as atropine) that keeps the pulse rate from decreasing too much during the convulsion. Next, the patient is placed on a cot and hooked up to a machine that automatically takes and displays vital signs (temperature, pulse, respiration, and blood pressure) on a television-like monitor. A mild anesthetic is then injected into a vein, followed by a medication (such a Anectine) that relaxes all of the muscles in the body so that the seizure is mild, and the risk of broken bones is virtually eliminated.

When the patient is both relaxed and asleep, an airway is placed in the mouth to aid with breathing. Electrodes are placed on the sides of the head in the temple areas. An electric current is passed through the brain by means of a machine specifically designed for this purpose. The usual dose of electricity is 70-150 volts for 0.1-0.5 seconds. In the first stage of the seizure (tonic phase), the muscles in the body that have not been paralyzed by medication contract for a period of five to 15 seconds. This is followed by the second stage (clonic phase) that is characterized by twitching movements, usually visible only in the toes or in a non-paralyzed arm or leg. These are caused by alternating contraction and relaxation of these same muscles. This stage lasts approximately 10-60 seconds. The entire procedure, from beginning to end, lasts about 30 minutes.

The total number of treatments a patient will receive depends upon many factors such as age, diagnosis, the history of illness, family support, and response to therapy. Patients with depression, for example, usually require six to 12 treatments. Treatments are usually administered every other day, three times a week.

The electrodes may be placed on both sides of the head (bilateral) or one side (unilateral). While bilateral ECT appears to be somewhat more effective, unilateral ECT is preferred for individuals who experience prolonged confusion or forgetfulness following treatment. Many doctors begin treatment with unilateral ECT, then change to bilateral if the patient is not improving.

Post-treatment confusion and forgetfulness are common, though disturbing symptoms associated with ECT. Doctors and nurses must be patient and supportive by providing patients with factual information about recovery. Elderly patients, for example, may become increasingly confused and forgetful as the treatments continue. These symptoms usually subside with time, but a small minority of patients state that they have never fully recovered from these effects.

With the introduction of antipsychotics in the 1950s, the use of ECT became less frequent. These new medications provided relief for untold thousands of patients who suffered greatly from their illness. However, there are a number of side effects associated with these drugs, some of which are irreversible. Another drawback is that some medications do not produce a therapeutic effect for two—six weeks. During this time the patient may present a danger to himself or others. In addition, there are patients who do not respond to medicine or who have severe allergic reactions. For these individuals, ECT may be the only treatment that will help.

Preparation

Patients and relatives are prepared for ECT by being shown video tapes that explain both the procedure and the risks involved. The physician then answers any questions these individuals may have, and the patient is asked to sign an "Informed Consent Form." This gives the doctor and the hospital permission to administer the treatment.

Once the form is signed, the doctor performs a complete physical examination, and orders a number of tests that can help identify any potential problem. These tests may include a chest x ray, an electrocardiogram (ECG), urinalysis, spinal x ray, brain wave (EEG), and complete blood count (CBC).

Some medications, such as lithium and a type of antidepressant known as monoamine oxidase inhibitors, should be discontinued for some time before treatment. Patients are instructed not to eat or drink for at least eight hours prior to the procedure in order to reduce the possibility of vomiting and choking.

Aftercare

After the treatment, patients are moved to a recovery area. Vital signs are recorded every five minutes until the patient is fully awake, which may take 15-30 minutes. Some initial confusion may be present but usually disappears in a matter of minutes. There may be complaints of headache, muscle pain, or back pain. Such discomfort is quickly relieved by mild medications such as aspirin.

Risks

Advanced medical technology has substantially reduced the complications associated with ECT. These include slow heart beat (bradycardia), rapid heart beat (tachycardia), memory loss, and confusion. Persons at high risk for ECT include those with recent heart attack, uncontrolled blood pressure, brain tumors, and previous spinal injuries.

Normal results

ECT often produces dramatic improvement in the signs and symptoms of major depression, especially in elderly individuals, sometimes during the first week of treatment. While it is estimated that 50% of these patients will experience a future return of symptoms, the prognosis for each episode of illness is good. Mania also often responds well to treatment. The picture is not as bright for schizophrenia, which is more difficult to treat and is characterized by frequent relapses.

A few patients are placed on maintenance ECT. This means they return to the hospital every one-two months, as needed, for an additional treatment. These individuals are thus able to keep their illness under control and lead a normal and productive life.

Resources

BOOKS

Stuart, Gail W., and Michele T. Laraia. Principles and Practice of Psychiatric Nursing. St. Louis: Mosby-Year Book, Inc., 1998.

ORGANIZATIONS

National Institutes of Health. 5600 Fishers Lane. Room 7CO2, Rockville, MD 20857. (301) 496-4000. 〈http://www.nih.gov〉.

KEY TERMS

Mania— A mood disorder in which a person experiences prolonged elation or irritability characterized by overactivity that can lead to exhaustion and medical emergencies.

Relapse— A return of the signs and symptoms of an illness.

Schizophrenia— A severe mental illness in which a person has difficulty distinguishing what is real from what is not real. It is often characterized by hallucinations, delusions, and withdrawal from people and social activities.