Electroconvulsive therapy

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Electroconvulsive therapy
Intervention
ICD-10-PCSGZB
ICD-9-CM94.27
MeSHD004565
OPS-301 code:8-630
MedlinePlus007474
 
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Electroconvulsive therapy
Intervention
ICD-10-PCSGZB
ICD-9-CM94.27
MeSHD004565
OPS-301 code:8-630
MedlinePlus007474

Electroconvulsive therapy (ECT), formerly known as electroshock, is a standard psychiatric treatment in which seizures are electrically induced in patients to provide relief from psychiatric illnesses.[1] ECT is usually used as a last line of intervention for major depressive disorder, schizophrenia, mania and catatonia.[2] A usual course of ECT involves multiple administrations, typically given two or three times per week until the patient is no longer depressed. It was first introduced in 1938 by Italian neuropsychiatrists Ugo Cerletti and Lucio Bini, and gained widespread popularity among psychiatrists as a form of treatment in the 1940s and 1950s.[3][4]

In western fiction, it is usually depicted as a painful procedure, but in western countries ECT is administered under anesthetic with a muscle relaxant.[5]

About 70 percent of ECT patients are women, since they are at twice the risk of depression as men.[1][6][7] Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive, and successful ECT is usually followed by medication treatment. Administration is most commonly bilateral, in which the electrical current is passed across the whole brain, and which seems to have greater efficacy but greater risk of memory loss, or less commonly, unilateral, which has less efficacy but also reduced risk of memory loss.[8][9] The World Health Organization (2005) advises that it should only be used with the informed consent of the patient or their proxy, only with adequate analgesia and muscle relaxants, and never on children.[10] Psychiatrists and other mental health professionals differ on when and if ECT should be used as a first-line treatment or if it should be reserved for patients who have not responded to other interventions such as medication and psychotherapy.[11] ECT is considered one of the least harmful treatment options available for severely depressed pregnant women.[12]

Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and symptom remission. After treatment, drug therapy is usually continued, and some patients receive maintenance ECT. In the United Kingdom and Ireland, drug therapy usually is continued during ECT.[2]

History[edit]

A Bergonic chair "for giving general electric treatment for psychological effect, in psycho-neurotic cases", according to original photo description. World War I era.

As early as the 16th century, agents to induce seizures were used to treat psychiatric conditions. In 1785, the therapeutic use of seizure induction was documented in the London Medical Journal.[1] Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then metrazol (cardiazol).[13][14] Ladislas Meduna is thought to be the father of convulsive therapy.[15] 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.[14] 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. It was known early on that inducing convulsions aided in helping those with severe schizophrenia. Cerletti had noted a shock to the head produced convulsions in dogs. The idea to use electroshock on humans came to Cerletti when he saw how pigs were given an electric shock before being butchered to put them in an anesthetized state.[16] Cerletti and Bini practiced until they felt they had the right parameters needed to have a successful human trial. Once they started trials on patients they found that after 10-20 treatments the results were significant. Patients had much improved. A positive side effect to the treatment was retrograde amnesia. It was because of this side effect that patients could not remember the treatments and had no ill feelings toward it.[16] ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening and more convenient.[17] Cerletti and Bini were nominated for a Nobel Prize but did not receive one. By 1940, the procedure was introduced to both England and the US. In Germany and Austria it was promoted by Friedrich Meggendorfer. Through the 1940s and 1950s, the use of ECT became widespread.

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.[18] 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.[18]

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 1950s to the 1970s. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given, and that "these now-antiquated practices contributed to the negative portrayal of ECT in the popular media."[19] 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".[20]

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 as of 2012 some ECT clinics still were using sine-wave devices.[21] The 1970s saw the publication of the first American Psychiatric Association (APA) 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.[22] 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 1980s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression".[19] In 1985 the National Institute of Mental Health and National Institutes of Health convened a consensus development conference on ECT and concluded that, while 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.[23]

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.

Mechanism of action[edit]

Despite decades of research, the exact mechanism of action of ECT remains elusive. Ladislas J. Meduna believed that chemically induced seizures, brought on by drugs, could change the chemical makeup of the brain of a patient with schizophrenia. Modern electroconvulsive therapy operates under a similar hypothesis, though in modern practice a therapeutic clonic seizure is induced by electrical current via electrodes placed on an anesthetized, unconscious patient. It is known that the central nervous system is regulated by small electrical current; disrupting or "restarting" that current by induced seizure (colloquially, "jumpstarting the brain"), has shown positive effects in patients with severe depression or schizophrenia.[15]

Peter Breggin, an outspoken and controversial critic of evidence-based psychiatry, claims that ECT induces "a closed-head injury caused by an overwhelming current of electricity sufficient to cause a grand mal seizure" and that the improvements in mood seen in patients receiving ECT are resultant from brain damage.[24] Such claims are rejected as wholly unsubstantiated by the consensus of the scientific and medical community.[25][26][27]

There is a vast body of literature on the effects of ECT in animals; however, though human and animal brains are very similar, animal models of depression are widely acknowledged to parallel only limited aspects of depressive illness, a uniquely human disease. Some suggest pruning of normally dense synaptic connections in the hippocampus, a richly connected area deep in the temporal lobe vital in controlling both mood and memory, seen in animal studies may play a role in its effectiveness.[28]

Selection of patients for ECT[edit]

Experts disagree on whether ECT is an appropriate first-line treatment or if it should be reserved for patients who have not responded to other interventions such as medication and psychotherapy.[11]

The American Psychiatric Association 2001 guidelines give the primary indications for ECT among patients with depression as a lack of response to, or intolerance of, antidepressant medications; a good response to previous ECT; and the need for a rapid and definitive response (e.g. because of psychosis or a risk of suicide). The decision to use ECT depends on several factors, including the severity and chronicity of the depression, the likelihood that alternative treatments would be effective, the patient's preference and capacity to consent, and a weighing of the risks and benefits.[29]

Some guidelines[which?] recommend cognitive behavioral therapy or other psychotherapy before ECT is used. However, treatment resistance is widely defined as lack of therapeutic response to two antidepressants at adequate doses for an adequate duration and with good compliance. The APA states that at times patients will prefer to receive ECT over alternative treatments, but commonly the opposite will be the case.

The APA ECT guidelines state that severe major depression with psychotic features, manic delirium, or catatonia are conditions where there is a clear consensus favoring early ECT. The UK's National Institute for Health and Clinical Excellence 2003 (NICE) guidelines recommended ECT for patients with severe depression, catatonia, or prolonged or severe mania. It did not recommend the use of ECT as a maintenance therapy in depressive illness as "the long-term benefits and risks ... had not been clearly established"[25]:5–6 and those recommendations were unchanged in the 2010 update.[30]:526 The 2001 APA guidelines support the use of ECT for relapse prevention.

The 2001 APA ECT guidelines say that ECT is rarely used as a first-line treatment for schizophrenia, but is considered after unsuccessful treatment with antipsychotic medication, and may also be considered in the treatment of patients with schizoaffective or schizophreniform disorder. The 2003 NICE ECT guidelines do not recommend ECT for schizophrenia, and this has been supported by meta-analytic evidence showing no or little benefit versus placebo, or in combination with antipsychotic drugs, including Clozapine.[31]

The NICE 2003 guidelines state that doctors should be particularly cautious when considering ECT treatment for women who are pregnant and for older or younger people, because they may be at higher risk of complications with ECT. The 2001 APA ECT guidelines say that ECT may be safer than alternative treatments in the infirm elderly and during pregnancy, and the 2000 APA depression guidelines stated that the literature supports the safety for mother and fetus, as well as the efficacy during pregnancy.

ECT has been used in selected cases of depression occurring in the setting of multiple sclerosis, Parkinson's disease, Huntington's chorea, developmental delay, brain arteriovenous malformations and hydrocephalus.[32]

Efficacy[edit]

Non-clinical patient characteristics[edit]

About 70 percent of ECT patients are women.[1] This may be due to the fact that women are more likely to be diagnosed with depression.[1][6] Older and more affluent patients are also more likely to receive ECT. The use of ECT is not as common in ethnic minorities.[6][33]

Degree of effectiveness and risks[edit]

Scientific papers and articles reviewing studies of ECT effectiveness have reached conflicting conclusions.

A meta-analysis done on the effectiveness of ECT in unipolar and bipolar depression was conducted in 2012. Findings showed that although patients with unipolar depression and bipolar depression responded very differently to other medical treatments both groups responded equally as well to ECT. Overall remission rate for patients with unipolar depression was 51.5% and 50.9% in those with bipolar depression. The severity of each patient’s depression was assessed at the same baseline in each group.[34]

In 2003, The UK ECT Review group published a systematic review and meta-analysis comparing ECT to placebo and antidepressant drugs. This meta-analysis demonstrated a large effect size (high efficacy relative to the mean in terms of the standard deviation) for ECT versus placebo, and versus antidepressant drugs.[35]

In 2006, a research article by Dr. Colin A. Ross found that no studies had ever shown that ECT was more effective than a placebo (sham ECT) treatment as of 1 month posttreatment.[36]

In 2008, a meta-analytic review paper found in terms of efficacy, "a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus TCAs and ECT versus MAOIs."[37]

In 2010, a paper by Dr. John Reed and Dr. Richard Bentall found that ECT was only minimally more effective than a placebo during the treatment period, and that there was no difference in effect after the treatment period. In light of this finding, and the risk of side-effects, the authors concluded that the use of ECT "cannot be scientifically justified".[9]

A 2011 paper in the Journal of Psychiatric Nurses Association reported that ECT was effective.[38]

Surveys of public opinion, the testimony of former patients, legal restrictions on its use and disputes as to the efficacy, ethics and adverse effects of ECT within the psychiatric and wider medical community indicate that the use of ECT remains controversial.[39][40][41][42][43][44] This is reflected in the recent vote by the United States Food and Drug Administration's (FDA's) Neurological Devices Advisory Panel to recommend that FDA maintain ECT devices in the Class III device category for high risk devices except for patients suffering from catatonia. This may result in the manufacturers of such devices having to do controlled trials on their safety and efficacy for the first time.[45][46][47] In justifying their position, panelists referred to the memory loss associated with ECT and the lack of long-term data.[48]

Duration of effect[edit]

ECT on its own does not usually have a sustained benefit. Half those who remit then relapse within six months. This is similar to the rate of relapse after discontinuing antidepressant medication, and it has been suggested that it is due to the severity and chronicity of pre-existing illness for which ECT is generally used.[49] The relapse rate in the first six months is reduced by the use of psychiatric medications or further ECT, but remains high.[50][51]

Probability of remission[edit]

The 1999 U.S. Surgeon General's Report on Mental Health summarized psychiatric opinion at the time about the effectiveness of ECT. It stated that both clinical experience and published studies had determined ECT to be effective (with an average 60 to 70 percent remission 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.[52]

A 2004 large multicentre clinical follow-up study of ECT patients in New York — describing itself as the first systematic documentation of the effectiveness of ECT in community practice in the 65 years of its use — found remission rates of only 30 to 47 percent, with 64 percent of those relapsing within six months.[53] However, when patients with co-morbid personality disorders or who were suffering from schizoaffective disorder were removed from the analysis, the remission rates climbed to 60-70%.[53]

Related experimental therapeutics[edit]

Recent research has investigated whether implantable devices such as those used in DBS (deep brain stimulation) could result in clinical improvements for patients with treatment-resistant depression. However, in North America, DBS has not been authorized as an approved, effective therapy for treatment-resistant depression.

Adverse effects[edit]

Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia; the U.S. Surgeon General's report says that there are "no absolute health contraindications" to its use.[52]:259 Immediately following treatment, the most common adverse effects are confusion and memory loss. The state of confusion usually disappears after a few hours. It can be tolerated by pregnant women who are not suffering major complications. It can be used with diabetic or obese patients, and with caution in those whose cancers are in remission or under control. It can be used in some immunocompromised patients. It must be used very cautiously in people with epilepsy or other neurological disorders because by its nature it provokes small tonic-clonic seizures, and so would likely not be given to a person whose epilepsy is not well controlled.[54][55] Some patients experience muscle soreness after ECT. This is due to the muscle relaxants given during the procedure and rarely due to muscle activity. ECT, especially if combined with deep sleep therapy, may lead to brain damage if administered in such a way as to lead to hypoxia or anoxia in the patient.[56][57][58] The death rate due to ECT is around 4 per 100,000 procedures.[59] There is evidence and rationale to support giving low doses of benzodiazepines or else low doses of general anesthetics which induce sedation but not anesthesia to patients to reduce adverse effects of ECT.[60]

Effects on memory[edit]

It is the purported effects of ECT on long-term memory that give rise to much of the concern surrounding its use.[61] The acute effects of ECT can include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment).[62] Memory loss and confusion are more pronounced with bilateral electrode placement rather than unilateral, and with outdated sine-wave rather than brief-pulse currents. The use of either constant or pulsing electrical impulses also varied the memory loss results in patients. Patients who received pulsing electrical impulses as opposed to a steady flow seemed to incur less memory loss. The vast majority of modern treatment uses brief pulse currents.[62]

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 memories in the weeks and months prior to the treatment.[63][64] 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.[1][62] One published review summarizing the results of questionnaires about subjective memory loss found that between 29% and 55% of respondents believed they experienced long-lasting or permanent memory changes.[65] In 2000, American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with more persistently impaired memory of public events as compared to RUL ECT.[61]

Controversy over long-term effects on general cognition[edit]

According to prominent ECT researcher Harold Sackeim, "despite over fifty years of clinical use and ongoing controversy", until 2007 there had "never been a large-scale, prospective study of the cognitive effects of ECT."[66] In this first-ever large-scale study (347 subjects), Sackeim and colleagues found that at least some forms (namely bilateral application and outdated sine-wave currents) of ECT "routine[ly]" lead to "adverse cognitive effects," including global cognitive deficits and memory loss, that persist for up to six months after treatment, suggesting that the induced deficits may be permanent.[66][67] The authors also warned that their findings did not suggest that right-unilateral ECT did not also lead to chronic cognitive deficits.

Harold Sackeim can be seen in a videotaped deposition briefly discussing the findings of this study and why, in his opinion, earlier studies had failed to find evidence of long-term harm from ECT.[68] Despite over fifty years of clinical use, Sackeim states that prior to 2001, "the field itself never really had an opportunity to have a discussion about patients who have complaints about long-term memory loss." In this video clip, Sackeim also reveals that at a California ECT conference with 200 practitioners present, when polled as to whether they think ECT can lead to chronic cognitive deficits, two-thirds raised their hands. Sackeim says this was "almost a watershed moment for the field", and was the "first time publicly that the field itself said 'no' to the position that it can't happen."[68][69]

In July 2007, a second study was published concluding that ECT routinely leads to chronic, substantial cognitive deficits, and the findings were not limited to any particular forms of ECT.[70] The study, led by psychiatrist Glenda MacQueen and colleagues, found that patients treated with ECT for bipolar disorder show marked deficits across multiple cognitive domains. According to the researchers, "Subjects who had received remote ECT had further impairment on a variety of learning and memory tests when compared with patients with no past ECT. This degree of impairment could not be accounted for by illness state at the time of assessment or by differential past illness burden between patient groups." Despite the findings of chronic, global cognitive deficits in post-ECT patients, MacQueen and colleagues suggest that it is "unlikely that such findings, even if confirmed, would significantly change the risk–benefit ratio of this notably effective treatment."[70]

Six months after the publication of the Sackeim study[66] documenting routine, long-term memory loss after ECT, prominent ECT researcher Max Fink published a review in the journal Psychosomatics concluding that patient complaints of memory loss after ECT are "rare" and should be "characterized as somatoform disorders, rather than as evidence of brain damage, thus warranting psychological treatment for such disorders."[71] Based on his findings, Fink suggests that, "Instead of endorsing these reports as the direct consequence of ECT, especially in patients who have recovered from their depressive illness, lost their suicidal drive, and have improved social functioning, is it not more useful to accept the complaint as a somatoform disorder, explore the basis in the individual's history and experience, and offer appropriate supportive treatment?"[71]

A number of reviews of the literature and other articles continue to characterize ECT as safe and effective.[72][73][74][75][76][77][78][79] For example, in June 2009, Portuguese researchers published a review on the safety and efficacy of ECT in an article entitled, Electroconvulsive Therapy: Myths and Evidences.[72] In their review, the researchers conclude that ECT is an "efficient, safe and even life saving treatment for several psychiatric disorders." In 2008, Yale researchers published a review on the safety and efficacy of ECT in elderly patients.[79] According to the authors, "ECT is well established as a safe and effective treatment for several psychiatric disorders." And in a June 2009 article published in the Journal of ECT, Iranian researchers observe that, "Despite the wide consensus over the safety and efficacy of electroconvulsive therapy (ECT), it still faces negative publicity and unfavorable attitudes of patients and families."[78]

Breggin, chief editor of the journal Ethical Human Psychology and Psychiatry, is a leading critic of ECT who believes the procedure is neither safe nor effective. In a published article reviewing the findings of Harold Sackeim's 2007 study[66] on the cognitive effects of ECT, Breggin accuses Max Fink and other pro-ECT researchers of having a history of "systematically covering up damage done to millions of [ECT] patients throughout the world."[67] He disagrees with the position that findings of chronic, global cognitive deficits should have no bearing on the risk-benefit ratio of ECT, and he believes it's important to address the "actual impact of these losses on the lives of individual patients." In his 2007 paper, a section is entitled Destroying Lives, and in it, Breggin writes, "Even when these injured people can continue to function on a superficial social basis, they nonetheless suffer devastation of their identities due to the obliteration of key aspects of their personal lives. The loss of the ability to retain and learn new material is not only humiliating and depressing but also disabling. Even when relatively subtle, these activities can disrupt routine activities of living."[67]

Effects on brain structure[edit]

Considerable controversy exists over the effects of ECT on brain tissue, although a number of mental health associations — including the American Psychiatric Association — have concluded that there is no evidence that ECT causes structural brain damage.[25][26][27] A 1999 report by the U.S. 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".[80] However, not all experts agree that ECT does not cause brain damage, and two studies have been published since 2007 finding that at least some forms of ECT may result in widespread, persisting, generalized cognitive dysfunction, which might support claims that ECT causes brain damage.[66][70][81]

Peter Breggin, a psychiatrist, has published books and journal reviews of the literature purporting to show that ECT routinely causes brain damage as evidenced by a considerable list of studies in humans and animals.[82] In particular, Breggin asserts that animal and human autopsy studies have shown that ECT routinely causes 'widespread pinpoint hemorrhages and scattered cell death.'[81] According to Breggin, the 1990 APA task force report on ECT ignored much of the scientific literature pointing out the negative effects of electroshock therapy. For example, in 1952 Hans Hartelius conducted and published an animal study on cats entitled Cerebral Changes Following Electrically Induced Convulsions in which a double-blind microscopic pathology examination showed that it was possible to distinguish the 8 shocked animals from the 8 non-shocked animals with remarkable accuracy based on statistically significant structural changes to the brain, including vessel wall changes, gliosis, and nerve cell changes. Based on the detection of shadow cells and neuronophagia, Hartelius determined that there was irreversible damage to neurons associated with electroshock.[81]

Proponents argue that the addition of hyperoxygenation and refinement in technique in the last thirty years has made ECT safe, and a majority of published reviews in recent decades have reflected this position.[83] A 2004 study was designed to evaluate whether modern ECT techniques lead to identifiable brain damage, In the study: "Twelve adolescent Macaca mulatta, the initial subjects in an ongoing study of the cognitive and anatomic effects of ECT and magnetic seizure therapy, were divided into cohorts of three and matched for age, weight, and sex. Each cohort was housed in a group. Within each cohort, the monkeys were randomly assigned to ECT, magnetic seizure therapy, or sham. All staff not involved in the delivery of the interventions were masked to group assignment. This study was approved by the Institutional Animal Care and Use Committee of New York State Psychiatric Institute. Interventions were performed 4 days per week for 6 weeks. A 5-week recovery period was interposed before the last intervention week to permit maturation of possible neuropathological effects. Animals were euthanized 3 days after the last intervention." Their brains were compared to monkeys undergoing anesthesia alone. According to the researchers, "None of the ECT-treated monkeys showed pathological findings."[84]

Many expert proponents of ECT maintain that the procedure is safe and does not cause brain damage. Dr. Charles Kellner, a prominent ECT researcher and former chief editor of the Journal of ECT, stated in a 2007 interview[85] that, "There are a number of well-designed studies that show ECT does not cause brain damage and numerous reports of patients who have received a large number of treatments over their lifetime and have suffered no significant problems due to ECT." Dr. Kellner cites a study[86] purporting to show an absence of cognitive impairment in eight subjects after more than 100 lifetime ECT treatments. Dr. Kellner stated "Rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness."

Effects in pregnancy[edit]

If steps are taken to decrease potential risks, ECT is generally accepted to be relatively safe during all trimesters of pregnancy, particularly when compared to pharmacological treatments.[87][88][89] Suggested preparation for ECT during pregnancy includes a pelvic examination, discontinuation of nonessential anticholinergic medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate antacid. During ECT, elevation of the pregnant woman's right hip, external fetal cardiac monitoring, intubation, and avoidance of excessive hyperventilation are recommended.[87] Much of the medical literature in this area is composed of case studies of single or twin pregnancies, and although some have reported serious complications,[90][91] the majority have found ECT to be safe.[92]

Administration[edit]

ECT is selected as a therapy as described above, and normally requires the informed consent of the patient.[1]:1880

Whether psychiatric medications are terminated prior to treatment or maintained, varies.[1]:1885[93] However, drugs that are known to cause toxicity in combination with ECT, such as lithium, are discontinued, and benzodiazepines, which increase seizure thresholds, are either discontinued, a benzodiazepine antagonist is administered at each ECT session, or the ECT treatment is adjusted accordingly.[1]:1879:1875

The placement of electrodes, as well as the dose and duration of the stimulation is determined on a per-patient basis.[1]:1881

In unilateral ECT, both electrodes are placed on the same side of the patient's head. Unilateral ECT may be used first to minimize side effects (memory loss). When electrodes are placed on both sides of the head, this is known as bilateral 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 if the dose administered is close to the seizure threshold.[1]:1881 In the USA most patients receive bilateral ECT.[94] In the UK almost all patients receive bilateral ECT.[8][95]

The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT.[1]:1881 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.[96] 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.[94] 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.

Immediately prior to treatment, a patient is given a short-acting anesthetic such as methohexital, etomidate, or thiopental,[1] a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation. The patient's EEG, ECG, and blood oxygen levels are monitored during treatment.[1]:1882

ECT is usually administered three times a week, on alternate days, over a course of two to four weeks.[1]:1882–1883

ECT devices[edit]

ECT machine from ca 1960.

Most modern ECT devices deliver a brief-pulse current, which is thought to cause fewer cognitive effects than the sine-wave currents which were originally used in ECT.[1] A small minority of psychiatrists in the USA still use sine-wave stimuli.[94] Sine-wave is no longer used in the UK or Ireland.[95] Typically, the electrical stimulus used in ECT is about 800 milliamps and has up to several hundred watts, and the current flows for between one and 6 seconds.[96] In the USA, ECT devices 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.[97] Class III is the highest-risk class of medical devices. In the UK, the market for ECT devices was long monopolized by Ectron Ltd, although in recent years some hospitals have started using American devices. 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.

Variations in international practice[edit]

There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists.[1] 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.[98] 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,[99] India,[100] and Nigeria,[101] ECT may be used without anesthesia. WHO has called for a worldwide 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 hospital.[102] A major difficulty for developing countries in eliminating unmodified ECT is a lack of trained anesthesiologists available to administer the procedure.[103] 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.

Sarah Hall reports, "ECT has been dogged by conflict between psychiatrists who swear by it, and some patients and families of patients who say that their lives have been ruined by it. It is controversial in some European countries such as the Netherlands and Italy, where its use is severely restricted".[104]

United States[edit]

ECT became popular in the United States in the 1940s. At this time psychiatric hospitals were overrun with patients whom doctors were desperate to treat and cure. The practices of ECT and lobotomies became popular because they held some promise of addressing the overpopulation problem. Whereas lobotomies would reduce a patient to a more manageable submissive state ECT helped to improve mood in those with severe depression. In the United States, 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.[105] 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.[106] 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.[6] Usage of ECT has since declined slightly; in 2000–01 ECT was given to about 1500 people aged from 16 to 97 (in Texas it is illegal to give ECT to anyone under sixteen).[107] ECT is more commonly used in private psychiatric hospitals than in public hospitals, and minority patients are underrepresented in the ECT statistics.[1] In the United States, ECT is usually given three times a week; in the UK, it is usually given twice a week.[1] Occasionally it is given on a daily basis.[1] 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.[1] A few psychiatrists in the USA use multiple-monitored ECT (MMECT) where patients receive more than one treatment per anesthetic.[1] Electroconvulsive therapy is not a required subject in US medical schools and not a required skill in psychiatric residency training. Privileging for ECT practice at institutions is a local option: no national certification standards are established, and no ECT-specific continuing training experiences are required of ECT practitioners.[108]

United Kingdom[edit]

In the United Kingdom in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then[109] to about 12,000 per annum in 2002.[110] It is still used in nearly all psychiatric hospitals, with a survey of ECT use from 2002 finding that 71 percent of patients were women and 46 percent were over 65 years of age. Eighty-one percent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. Sixteen percent were treated without their consent.[110] In 2003, the National Institute for Clinical Excellence, a government body which was set up to standardize treatment throughout the National Health Service in England and Wales, 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".[111]

The guidance received a mixed reception. It was welcomed by an editorial in the British Medical Journal[112] but the Royal College of Psychiatrists launched an unsuccessful appeal.[113] 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.[114] 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 Republic of Ireland have signed up.[115]

India[edit]

The Union Health Ministry of India has decided in the Mental Health Care Bill of 2010 that they will no longer use direct ECT. The Health Ministry recommended a ban on the whole procedure.[116]

Legal status[edit]

Informed consent[edit]

The World Health Organization (2005) advises that ECT should only be used with the informed consent of the patient (or their guardian if their incapacity to consent has been established).[10]

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 consent may be revoked and treatment discontinued at anytime during a course of ECT.[52] The Surgeon General's Report on Mental Health states 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.[52] The report advises 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 he believes should be required to fully satisfy the legal obligation for informed consent, one psychiatrist, working for an anti-psychiatry organisation, has formulated his own consent form[117] using the consent form developed and enacted by the Texas Legislature[118] as a model.

According to the Surgeon General, involuntary treatment is uncommon in the United States and is typically used only in cases of great extremity, and only when all other treatment options have been exhausted. The use of ECT is believed to be a potentially life-saving treatment.[80]

In one of the few jurisdictions where recent statistics on ECT usage are available, a national audit of ECT by the Scottish ECT Accreditation Network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent.[119]

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.[120] One review from 2005 found that only about half of patients felt they were given sufficient information about ECT and its adverse effects[121] and another survey found that about fifty percent of psychiatrists and nurses agreed with them.[122]

A 2005 study published in the British Journal of Psychiatry described patients' perspectives on the adequacy of informed consent before ECT.[121] The study found that, "About half (45–55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not." The authors also stated:

"Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form. The proportion who feel they did not freely choose the treatment has actually increased over time. The same themes arise whether the patient had received treatment a year ago or 30 years ago. Neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ECT, at least in England and Wales."[121]

Involuntary ECT[edit]

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. Involuntary electroshock contravenes the principle of autonomy in medical ethics. The maxim of autonomy is "Voluntas aegroti suprema lex." This rule states that the will of the patient is supreme. It implies that a patient has the right to consent to, or to refuse a medical treatment, such as ECT. Persons considered not to be of sound mind are in many jurisdictions considered incapable of giving true consent. In such a case, the patient's "assent" may be sought; opinions are divided as to whether this should be routinely done, or whether a patient who is not competent to consent to therapy should retain the right to refuse it.

Citizens in western societies often undergo emergency medical procedures when they have lost the capacity to consent (such as neurosurgery after head injury). Under these circumstances, the principles of beneficence and non-maleficence must be adhered to.

United States[edit]

In most states in the USA, a judicial order following a formal hearing is needed before a patient can be forced to undergo involuntary ECT. Patients may be represented by legal counsel at the hearing. According to the Surgeon General's Report on Mental Health, "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."[52] However, ECT can also be involuntarily administered in situations with less immediate danger. Suicidal intent is a common justification for its involuntary use, especially when other treatments are ineffective.

United Kingdom[edit]

Until 2009 in England and Wales, the Mental Health Act 1983 allowed the use of ECT on detained patients whether or not they had capacity to consent to it. However, following amendments which took effect in 2009, ECT may not generally be given to a patient who has capacity and refuses it, irrespective of his or her detention under the Act.[123] In fact, even if a patient is deemed to lack capacity, if they made a valid advance decision refusing ECT then they should not be given it; and even if they do not have an advance decision, the psychiatrist must obtain an independent second opinion (which is also the case if the patient is under age of consent).[124] However, there is an exception regardless of consent and capacity; under Section 62 of the Act, if the treating psychiatrist says the need for treatment is urgent they may start a course of ECT without authorization.[125] About 2,000 people a year in England and Wales are treated without their consent under the Mental Health Act.[126] Concerns have been raised by the official regulator that psychiatrists are too readily assuming that patients have the capacity to consent to their treatments, and that there is a worrying lack of independent advocacy.[127] In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 also gives patients with capacity the right to refuse ECT.[128]

Patient experience[edit]

NICE ECT guidelines report that some individuals consider ECT to have been a beneficial and lifesaving treatment, while others reported feelings of terror, shame and distress, and found it positively harmful and an abusive invasion of personal autonomy, especially when administered without their consent.

Individual positive depictions[edit]

Kitty Dukakis, wife of politician 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.[129]

American psychotherapist Martha Manning's autobiographical Undercurrents[130] 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 writer 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."[131]

Curtis Hartmann, a lawyer in western Massachusetts, stated: "ECT, a treatment of last resort for severe, debilitating depression, is all that has ever worked for me. I awaken about 20 minutes later, and although I am still groggy with anesthesia, much of the hellish depression is gone. It is a disease that for me, literally steals me from myself—a disease that executes me and then forces me to stand and look down at my corpse. Thankfully, ECT has kept my monster at bay, my hope intact".[132]

Beverley Callard is a British actress, best known for her role as Liz McDonald in Coronation Street. In her recently published autobiography titled "Unbroken", she describes her experience with ECT for severe depression, stating that the treatment was in part responsible for her recovery.[133]

Carrie Fisher, an American actress and author best known for her role as Princess Leia in Star Wars, praises ECT as an ongoing treatment for her bipolar disorder in her autobiographical books Wishful Drinking and Shockaholic.

Kay Redfield Jamieson also wrote about the experience of having ECT as a positive experience, that relieved her from the crushing pain of untreatable depression.

Individual negative accounts[edit]

Accounts of severe long-term, permanent memory loss[edit]

In a letter to the editor published in the Washington Post in December, 2000, registered nurse Barbara C. Cody wrote that her life was forever changed by 13 outpatient ECTs she received in 1983. She wrote,

"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. I call ECT a rape of the soul."[134]

Similarly, writer Johnanton Cott claims to have completely lost 15 years of memory in On the Sea of Memory: A Journey from Forgetting to Remembering.[135]

Despite former patients having reported devastating, permanent amnesia and cognitive impairment since ECT was first invented, the first lawsuit for ECT amnesia, Marilyn Rice v. John Nardini, was not brought until 1975; dozens of suits followed. While there have been a few settlements, including one for half a million dollars, no former patient had won a case until 2005. In a 2005 South Carolina court proceeding, Peggy S. Salters became the first ECT survivor to win a jury verdict and compensation. Ms. Salters sued Palmetto Baptist Medical Center in Columbia, as well as the three doctors responsible for her care, for an intensive course of outpatient ECT that she received in 2000, at age 55 years old, that caused her to lose all memories of the past 30 years of her life, including all memories of her husband of three decades, then deceased, and the births of her three children. She held a Masters of Science in nursing and, prior to the ECT, had a long career as a psychiatric nurse; but, as a result of the ECT, lost her knowledge of nursing skills and was unable to return to work. The jury awarded Salters $635,177 in compensation for her inability to work.[136] The judgement was upheld upon appeal in an unpublished opinion.[137]

Accounts of severe cognitive diminishment[edit]

Liz Spikol, the senior contributing editor of Philadelphia Weekly, wrote of her ECT in 1996,

"Not only was the ECT ineffective, it was incredibly damaging to my cognitive functioning and memory. But sometimes it's hard to be sure of yourself when everyone 'credible' — scientists, ECT docs, researchers — are telling you that your reality isn't real. How many times have I been told my memory loss wasn't due to ECT but to depression? How many times have I been told that, like a lot of other consumers, I must be perceiving this incorrectly? How many times have people told me that my feelings of trauma related to the ECT are misplaced and unusual? It's as if I was raped and people kept telling me not to be upset—that it wasn't that bad."[138]

Involuntary or other problems in administrating ECT[edit]

ECT received a lot of bad press much like psychosurgery did. There were cases publicized of it being administered improperly. The news would boast examples of ECT being used as a means of punishment for patients in mental institutions with chronic behavior problems. At times these treatments were even administered without proper anesthetics or restraints.[16] In 2007, a judge canceled a two-year-old court order that allowed the involuntary electroshock of Simone D., a psychiatric patient at Creedmoor Psychiatric Center in the state of New York.[139] Although Simone spoke only Spanish, she rarely received access to staff fluent in her language.[139][140] Simone previously had 200 electroshocks.[139][140] However, she communicated that she did not want more electroshock.[139][140] Simone stated, "Electroshock causes more pain. I suffer more from shock treatment![139] "

In 2008, David Tarloff, a psychiatric patient who had received electroshock, assaulted two therapists in the city of New York. Tarloff injured one therapist and killed the other. One of the therapists was Kent Shinbach, a psychiatrist who had an interest in electroconvulsive therapy. "It is not clear whether Dr. Shinbach played any role in Mr. Tarloff's shock therapy".[141] However, Tarloff told investigators that Shinbach had given Tarloff psychiatric treatment at a psychiatric facility initially in 1991.[142]

Other descriptions[edit]

In an interview with Houston Chronicle in 1996, Melissa Holliday, a former extra on Baywatch and model for Playboy stated the ECT she received in 1995, "ruined her life." She went on to state, "I've been through a rape, and electroshock therapy is worse. If you haven't gone through it, I can't explain it."[143]

Historical accounts[edit]

Ernest Hemingway, American author, committed suicide shortly after ECT at the Mayo Clinic in 1961. He is reported to have said to his biographer, "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...."[144]

In a poem, The Hanging Man, by Sylvia Plath ECT is described:

By the roots of my hair some god got hold of me.
I sizzled in his blue volts like a desert prophet.
The nights snapped out of sight like a lizard's eyelid:
A world of bald white days in a shadeless socket.
A vulturous boredom pinned me in this tree.
If he were I, he would do what I did.

Public perception and mass media[edit]

A questionnaire survey of 379 members of the general public in Australia indicated that more than 60% of respondents had some knowledge about the main aspects of ECT. Participants were generally opposed to the use of ECT on depressed individuals with psychosocial issues, on children, and on involuntary patients. Public perceptions of ECT were found to be mainly negative.[44]

Fictional examples[edit]

Electroconvulsive therapy has been depicted in fiction and works based on true experiences. These include A Clockwork Orange and Requiem for a Dream.

See also[edit]

References[edit]

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