What is Electro-Convulsive Therapy (ECT)?
ECT is short for 'Electro-Convulsive Therapy'. It is also known as electro-shock and shock therapy for obvious reasons because it is an electrocusion process to the brain and body. ECT has been in use as a 'therapy' for about sixty years although it's use in psychiatry dates back much further.
ECT is a highly controversial procedure. There is an argument relates to its actual effectiveness as well as the potential benefit it provides as a 'treatment'. Arguably, some people do seem to gain benefit from the procedure whilst others suffer debilitating injuries.
ECT is quite complicated to administer. The person being treated has to be given a short general anesthetic of a type that, besides causing loss of consciousness, also produces complete muscle relaxation. Once this has been achieved, the patient receives a brief intense, sometimes prolonged series of electric shocks delivered to the brain via electrodes placed on the head. This causes a seizure (or fit).
It must be understood that ECT is not the same everywhere. The equipment may be different, the drugs administered during the procedure will vary and of course the subjective experience of the administering clinician will be inconsistent.
A depressed person for example, might receive at least six such treatments of this type, given every second day. The anesthesia is the responsibility of a specialist medical clinician, although this is rarely an aneasthetist. It would usually be a mental health professional trained specifically to administer ECT according to a certain procedure.
How was ECT developed?
In 1934, a neuropsychiatrist named Dr Meduna commenced clinical trials with patients. After careful observations of patients, Meduna believed in the benefits that seemed to accrue when a patient sustained a spontaneous epileptic seizure. He then attempted to induce such seizures in patients with schizophrenia and observed whether they might have a therapeutic effect on their psychotic symptoms.
Seizure induction was initially produced by use of chemical agents, but the use of such pharmacological methods was complicated by side effects and a lack of reliability in inducing seizures. A further advance occurred when an Italian psychiatrist, Dr Cerletti, made use of electricity to induce the seizures. This soon replaced chemical methods of induction because electricity proved to be more efficient, reliable and controllable.
By the 1940s, ECT had become a well-established treatment for schizophrenia and also for the major mood disorders, including major depression. However, by the 1950s, with the advent of the first effective drug treatments (antidepressants, lithium, antipsychotics, etc.) the clinical use of ECT began to reduce.
The drug treatments were viewed as less intrusive options. In developing countries however, unable to afford the cost of these many drugs, ECT has continued to be used extensively and still with good results. Over the ensuing decades ECT, unfortunately, became increasingly stigmatized as a treatment that was inhumane and authoritarian. Although it is now recognized that these impressions were inaccurate, media portrayal of ECT was extremely negative.
The media implied that ECT was given without anesthetic, and far from being used as an effective treatment for serious illness, was used rather as a punishment to keep difficult patients 'in line'. Graphic portrayals of patients thrashing around during an untreated fit, engendered fear and dismay. During the 1990s, painstaking research contributed to a more accurate understanding of ECT.
At the same time, methods of anesthesia and of administering the treatment became increasingly sophisticated. Improved anesthetic methods and the use of muscle relaxing drugs have made the procedure safer and less confronting. Nevertheless, the past stigmatization of the procedure, with its undertones of fear, punishment and barbarism, can still have an impact on the use of ECT.
When is ECT used?
Research has demonstrated that ECT is most effective in the treatment the following conditions.
Major depression with psychotic features, e.g. delusions.
Psychotic depression refers to a depressive illness where these more severe features of psychosis are present. Psychotic features include fixed and false beliefs such as the overwhelming belief that one is rotting away, that one is being punished for some past act; paranoid ideas may also be present and also auditory hallucinations.
Major depression with melancholic features (diurnal mood variation, terminal insomnia, and psychomotor disturbance). Other indications for using ECT in depression include:
- high suicidal risk;
- treatment resistance (i.e. failure to respond to anti-depressant medication); and
- a previous positive response to ECT.
What are the possible long term effects of ECT?
Neuropsychological tests (tests of intellectual function) demonstrate that there are no ongoing impairments in thinking following ECT. There is no formal evidence of persisting dysfunction of memory, concentration, or calculation ability.
On the contrary, because depressive illness itself causes impairment in these functions, most studies have shown that ECT produces recovery of these impaired functions. Neuropathological effects (structural damage to underlying tissues) have been seen only where there have been prolonged epileptic seizures with failure to breathe during these prolonged fits.
With the abandonment of chemical methods of inducing seizures and the use of modern anesthetic techniques in the hands of specialist anesthetists, these states no longer occur.
In some circumstances, in the early days of ECT, situations arose where unmodified ECT was administered using electrical doses far in excess of the safety limits of good practice.
This can no longer arise because of the design constraints of modern ECT devices. In summary, there is controversial evidence as to whether or not permanent damage is sustained to the brain structure or its function after 'properly' administered ECT.
What are the possible side effects of ECT?
Headaches, drowsiness, nausea and muscle pain may occur immediately after ECT, but usually only last a few hours. People do have varied experienced and some people will say that they have major problems for weeks, months or years after having electro-shock therapy.
There is a debate as to whether side effects in the short term are due to the effects of the anesthetic rather than the treatment itself. There is also a debate as to whether longer-term problems are due to mental illness itself or the effects of ECT.
How does ECT affect memory and thinking?
Amnesia (memory loss), both retrograde and anterograde can occur but this often mild. Retrograde refers to memory for matters experienced just before the ECT and anterograde refers to memory for events just after the treatment.
Some people have profound memory loss and testify that 'chunks' of memory may have disappeared or that several life events seem to have vanished or never have occured.
Both anterograde and retrograde amnesia usually improves within weeks following completion of the ECT. Some confusion is common after an anesthetic and ECT.
The confusion can sometimes be quite severe and is related to several factors such as:
- electrode placement;
- age of patient;
- frequency and number of treatments; and
- pre-existing disturbances of intellectual function, e.g. patients with a pre-existing mild dementia may become more confused for a short period after the treatment.
Is ECT safe?
ECT is a safe procedure, but caution may be needed in patients with the following conditions.
Brain disorders: A patient with a condition associated with raised intracranial pressure (e.g. a brain tumor) should not have ECT.
High blood pressure: High blood pressure should be stabilized prior to ECT. It may be necessary to modify medication to decrease the likelihood of a dangerous increase in blood pressure during the procedure.
Coronary artery disease: A heart attack within the last three months is considered potentially high risk as there is the chance of further heart damage with ECT. Angina must also be stabilized prior to a course of ECT. Consultation with a cardiologist is recommended. * Osteoporosis: Fractures may occur if there is inadequate muscle relaxation, however this is extremely unlikely with properly administered and supervised anesthetic.
People at risk of retinal detachment: Control of blood pressure is essential because the risk of this complication increases if blood pressure rises too high, as may occur with ECT.
Epilepsy: Anticonvulsant therapy can interfere with the effectiveness of the ECT in causing a seizure. Usually the dose of any anticonvulsant is reduced and the morning dose withheld before the treatment is given.
Diabetes: Insulin must be reduced because the patient will be fasting prior to the ECT. Blood glucose monitoring is also necessary because hypoglycaemia may increase the risk of seizures.
