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Electroconvulsive therapy

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 70150 volts for 0.10.5 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 515 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 1060 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 1530 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.

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Haycock, Dean A.. "Electroconvulsive therapy." Gale Encyclopedia of Mental Disorders. 2003. Encyclopedia.com. (June 29, 2016). http://www.encyclopedia.com/doc/1G2-3405700138.html

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Electroconvulsive Therapy

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 twosix 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.

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Barstow, Donald. "Electroconvulsive Therapy." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. 29 Jun. 2016 <http://www.encyclopedia.com>.

Barstow, Donald. "Electroconvulsive Therapy." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. (June 29, 2016). http://www.encyclopedia.com/doc/1G2-3451600555.html

Barstow, Donald. "Electroconvulsive Therapy." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Retrieved June 29, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3451600555.html

Electroconvulsive Therapy

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 neededfor 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): 2229.

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): 12991307.

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): 425434.

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): 18651870.

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Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT)

The application of a mild electric current to the brain to produce an epileptic-like seizure as a means of treating certain psychological disorders, primarily severe depression.

Electroconvulsive therapy, also known as ECT and electroshock therapy, was developed in the 1930s when various observations led physicians to conclude that epileptic seizures might prevent or relieve the symptoms of schizophrenia . After experiments with insulin and other potentially seizure-inducing drugs, Italian physicians pioneered the use of an electric current to create seizures in schizophrenic patients.

ECT was routinely used to treat schizophrenia, depression , and, in some cases, mania . It eventually became a source of controversy due to misuse and negative side effects. ECT was used indiscriminately and was often prescribed for treating disorders on which it had no real effect, such as alcohol dependence, and was used for punitive reasons. Patients typically experienced confusion and loss of memory after treatments, and even those whose condition improved eventually relapsed. Other side effects of ECT include speech defects, physical injury from the force of the convulsions, and cardiac arrest. Use of electroconvulsive therapy declined after 1960 with the introduction of antidepressant and antipsychotic drugs.

ECT is still used today but with less frequency and with modifications that have made the procedure safer and less unpleasant. Anesthetics and muscle relaxants are usually administered to prevent bone fractures or other injuries from muscle spasms. Patients receive approximately 4 to 10 treatments administered over a period of about two weeks. Confusion and memory loss are minimized by the common practice of applying the current only to the non-dominant brain hemisphere, usually the right-brain hemisphere . Nevertheless, some memory loss still occurs; anterograde memory (the ability to learn new material) returns relatively rapidly following treatment, but retrograde memory (the ability to remember past events) is more strongly affected. There is a marked memory deficit one week after treatment which gradually improves over the next six or seven months. In many cases, however, subtle memory losses persist even beyond this point, and can be serious and debilitating for some patients.

About 100,000 people in the United States receive electroconvulsive therapy annually. ECT can only be administered with the informed consent of the patient and is used primarily for severely depressed patients who have not responded to antidepressant medications or whose suicidal impulses make it dangerous to wait until such medications can take effect. ECT is also administered to patients with bipolar disorder . Contrary to the theories of those who first pioneered its use, ECT is not an effective treatment for schizophrenia unless the patient is also suffering from depression. The rate of relapse after administration of ECT can be greatly diminished when it is accompanied by other forms of treatment.

Researchers are still not sure exactly how electro-convulsive therapy works, although it is known that the seizures rather than the electric current itself are the basis for the treatment's effects, and that seizures can affect the functioning of neurotransmitters in the brain, including norepinephrine and serotonin, which are associated with depression. They also increase the release of pituitary hormones . Because of its possible side effects, as well as the public's level of discomfort with both electrical shock and the idea of inducing seizures, ECT remains a controversial treatment method. In 1982, the city of Berkeley, California, passed a referendum making the administration of ECT a misdemeanor punishable by fines of up to $500 and six months in prison, but the law was later overturned.

Further Reading

Electroconvulsive Therapy: Theory and Practice. New York: Raven Press, 1979.

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electroconvulsive therapy

electroconvulsive therapy in psychiatry, treatment of mood disorders by means of electricity; the broader term "shock therapy" also includes the use of chemical agents. The therapeutic possibilities of these treatments were discovered in the 1930s by Manfred Sakel, a Polish psychiatrist, using insulin; L. J. Meduna, an American psychiatrist, using Metrazol; and Ugo Cerletti and Lucio Bini, Italian psychiatrists, using electric shock. Metrazol and insulin accounted for a very limited number of remissions in cases of schizophrenia. However, the injection of insulin often caused coma, while Metrazol and electric shock resulted in convulsions similar to those of epileptics.

Advances in electroconvulsive therapy (ECT) have made it the standard mechanism of shock therapy. ECT has had unquestionable success with involutional melancholia and other depressive disorders, although it may be ineffective or only temporarily effective. ECT is generally employed only after other therapies for depression, mania, bipolar disorder or schizophrenia have proven ineffective. The administration of anesthetics and muscle relaxants prior to ECT has greatly reduced the risk of injury during the procedure, which is typically administered six to eight times over a period of several weeks. The seizure lasts for up to 20 seconds, and the patient can be up and about in about an hour. Long-term memory loss is the main significant potential side effect; headache, muscle stiffness, and temporary short-term memory loss may occur. Why ECT works, however, is still not understood, but it may be due to changes in brain chemistry caused by procedure, such as neurotransmitters released in the brain, or to a reduction in brain activity in certain areas after the procedure.

See A. S. Hermreck and A. P. Thal, The Adrenergic Drugs and Their Use in Shock Therapy (1968); L. B. Kalinowsky and H. Hippius, Pharmacological, Convulsive, and other Somatic Treatments in Psychiatry (1969).

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Electroconvulsive Therapy

Electroconvulsive Therapy

What Is ECT?

Who Benefits From ECT?

Why Is ECT Controversial?

How Does ECT Work?

What Happens During ECT Treatment?

Resource

Electroconvulsive (e-LEK-tro-kon-VUL-siv) therapy (ECT) is a form of treatment for certain severe psychiatric disorders that involves applying a mild electrical shock to each side of the skull. ECT is performed by a physician while the patient is monitored closely and kept pain-free.

Keywords

for searching the Internet and other reference sources

Convulsions

Tonic-clonic seizure

What Is ECT?

ECT is a form of treatment for certain severe psychiatric disorders that involves using electrical shock. In ECT, a physician applies a mild electrical shock (20 to 30 milliamps) to each side of the patients skull near the area of the temples. The procedure is done under anesthesia*, and the patient is monitored carefully. The shock is applied until the patient experiences a tonic-clonic seizure*. Normally, this would produce strong muscle contractions, causing the body to thrash about. However, the patient also is given a medication to relax the muscles, which prevents this kind of whole-body response. Instead, the seizure occurs just within the brain, where it lasts for a minute or so.

* anesthesia
(an-es-THEE-zha) is a state in which a person is temporarily unable to feel pain while under the influence of a medication.
* tonic-clonic seizure
(TON-ikKLON-ik SEE-zhur) is an episode in which a person usually loses consciousness, stiffens due to muscle contractions, and lets out a loud cry as air is forced through the vocal cords during the tonic phase. In the clonic phase, the muscles of the body contract and relax rhythmically, which causes the body to thrash about.

On the Horizon

Transcranial magnetic stimulation (TMS) is a new, painless treatment that uses magnetic pulses to stimulate brain activity. In some early studies, TMS appeared to work against depression. About one-third of the patients treated with TMS experienced temporary, mild headaches after the treatment, but there seemed to be no other side effects. If TMS is shown to be as effective as ECT, it may become another treatment option for severe depression in the future.

Who Benefits From ECT?

In the United States, about 100,000 people each year receive ECT. The types of mental disorders that are treated with ECT include schizophrenia, severe depression, mania, and delusional states. ECT is particularly effective as a short-term therapy for sudden, severe episodes of depression associated with suicidal tendencies. Because medications take several days or more to have an effect on severe depression, in some cases ECT is a way to provide immediate relief and protection from suicidal intent. About 60 to 70 percent of people who receive ECT experience some benefits. ECT is used with both children and adults.

Why Is ECT Controversial?

Despite its proven benefits, ECT is still somewhat controversial. The debate about its use today is based in part on the treatments history.

Earliest treatments

ECT was first tried in Italy in 1938. It soon was used to treat mental disorders that were resistant to other types of treatment. However, in the early days of ECT, few considerations were given to the patients overall health. In addition, many people experienced pain from the shock itself or injuries from the whole-body seizures that resulted. Nevertheless, ECT was found to be an effective treatment for conditions such as severe depression, acute psychosis, and mania.

Modern treatments

Modern improvements have made ECT a much safer and more comfortable experience for the patient. These improvements include the use of medications to produce a pain-free state and prevent violent muscle contractions. In 1999, the U.S. Surgeon Generals report on mental health concluded that ECT was a safe and effective treatment for certain severe mental disorders when used according to current standards of care. Even so, the states of California, Texas, and Tennessee still prohibit the use of ECT with children and adolescents.

Media portrayals

Some of the lingering debate about ECT is based on its portrayal in movies, television shows, and novels. In the movie One Flew Over the Cuckoos Nest, for example, ECT was used as a punishment for unwanted behavior. Unfortunately, this kind of depiction often frightens people unnecessarily, keeping them from using a treatment that can be highly effective and even lifesaving.

How Does ECT Work?

Scientists do not know for sure how ECT works, although research now is being done to find answers to this question. Most of the research is focused on ECTs effect on part of the brain called the hypothalamus*, which, among its many functions, regulates emotional expression and controls the endocrine glands. Changes in endocrine* function are often seen after ECT treatments.

* hypothalamus
(HY-po-THAL-amus) is part of the brain that controls (among other things) the autonomic nervous system, the endocrine glands, basic drives such as hunger, thirst, and aggressive and sexual drives. The hypothalamus also regulates emotional expression.
* autonomic nervous system
is a branch of the peripheral nervous system that controls various involuntary body activities, such as body temperature, metabolism, heart rate, blood pressure, breathing, and digestion. The autonomic nervous system has two partsthe sympathetic and parasympathetic branches.
* endocrine
(EN-do-krin) refers to a group of glands, such as the thyroid, adrenal, and pituitary glands, and the hormones they produce. The endocrine glands secrete their hormones into the bloodstream, and the hormones travel to the various organs in the body that they affect. Certain hormones have effects on mood and sometimes are involved in symptoms such as irritability, emotional swings, fatigue, insomnia, depression, suspiciousness, and apathy.

Modern electroconvulsive therapy (ECT) is not like the shock treatments depiected in old movies. Patients receive medications to relax and sedate them before treatment begins, and many patients with depression find that ECT is a faster and more effective treatment than medication. Photo Researchers, Inc.

What Happens During ECT Treatment?

ECT is performed in a hospital setting under the careful guidance of a physician. First the patient is given anesthesia and muscle-relaxing medications. Then the patient receives a mild electrical shock to each side of the skull. Thanks to the medications, the patient feels no pain, and the body does not convulse. Once the procedure is over, the patient awakens after 5 to 10 minutes, much as someone would after minor surgery. ECT generally is given in a series of 6 to 12 treatments over a period of a few weeks.

Many people experience some memory loss after ECT. Usually, this loss is temporary, affecting mainly memories of events from the days, weeks, or months just before or during the series of treatments. In most cases, the memories return within several weeks after the completion of ECT.

See also

Bipolar Disorder

Depression

Schizophrenia

Suicide

Resource

Organization

American Psychiatric Association (APA), 1400 K Street Northwest, Washington, DC 20005. A professional organization for psychiatrists, physicians who specialize in treating mental disorders. Psychiatrists perform ECT treatments, and information about the treatments can be found on the APA website. Telephone 888-357-7924 http://www.psych.org

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electroconvulsive therapy

electroconvulsive therapy (ECT) Treatment of mental disturbance by means of an electric current passed via electrodes to one or both sides of the brain to induce convulsions. Given under anaesthesia, it is recommended mainly for depression that has failed to respond to other treatments. It can produce unpleasant side-effects, such as confusion, memory loss and headache. It is a highly controversial form of therapy.

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electroconvulsive therapy

electroconvulsive therapy (ECT, electroplexy) (i-lek-troh-kŏn-vul-siv) n. a treatment for severe depression and occasionally for puerperal psychosis and mania. A convulsion is produced by passing an electric current through the brain; it is modified by giving a muscle relaxant drug and an anaesthetic.

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