Safety and effectiveness of electroconvulsive therapy in psychiatry

Psychiatry

Electroconvulsive Therapy

Electroconvulsive therapy (ECT), also known as shock treatment, is an extremely safe and effective medical treatment for certain psychiatric disorders. With this treatment, a small quantity of electricity is applied to the scalp, producing a seizure in the brain. The process is painless because the patient is asleep under general anesthesia. ECT has a tremendously high success rate for the treatment of major depressive disorder, catatonia, mania and various psychotic symptoms. While ECT has been in use for more than sixty years, the way it is administered and the conditions under which it is used to treat patients has changed radically in recent years. Currently, about one hundred thousand individuals are thought to receive ECT every year in the United States (History and use, n.d.).

Although ECT has been used since the 1940's and 1950's, it remains misunderstood by the general public. A lot of the procedure's risks and side effects are connected to the misuse of equipment, incorrect administration, or inappropriately trained staff. It is also a misconception that ECT is used as a quick fix in place of long-term therapy or hospitalization. It is also not true that patients are painfully shocked out of the depression. Adverse news reports and media coverage have contributed to the controversy surrounding this treatment (Electroconvulsive Therapy and Other Depression Treatments, 2011).

Mechanism of Action

Electroconvulsive therapy (ECT) is a procedure in which electric currents are passed through the brain, intentionally activating a brief seizure. Electroconvulsive therapy appears to cause alterations in brain chemistry that can instantly reverse symptoms of certain mental illnesses. It frequently works when other treatments are ineffective (Electroconvulsive therapy (ECT), 2011).

With ECT, electrodes are put on the patient's scalp and a finely controlled electric current is applied. The current causes a short seizure in the brain. ECT is one of the quickest ways to relieve symptoms in severely depressed or suicidal people. It's also very effective for those who suffer from mania or other mental illnesses. ECT is normally used when severe depression is unresponsive to other forms of therapy. Or it might be used when patients pose a severe threat to themselves or others and it is unsafe to wait until medications take effect (Electroconvulsive Therapy and Other Depression Treatments, 2011).

ECT treatments typically begin by having an IV line started and sensors for recording brain activity are placed on the head. Other sensors are placed on the chest for monitoring the heart and a cuff is wrapped around the arm for blood pressure. When everything is connected and in order, a medication is injected through the IV line that will cause the patient to sleep for five to ten minutes. Once asleep, another medication is given to relax the patient's muscles. This medication will prevent the patient's muscles from moving throughout the treatment and will decrease the possibility of injury. This same medication also relaxes the muscles that help a patient breathe, so oxygen will be provided through a mask until the medication wears off and the patient recommences breathing on their own (History and use, n.d.).

Once the patient is entirely asleep and the muscles are well relaxed, the treatment is administered. A brief electrical charge is applied to electrodes that have been placed on the scalp. This stimulates the brain and produces a seizure, which lasts for about one minute.

During the seizure, the patient may experience an elevated heart rate, the patient's toes may twitch, fists may clench or chest may heave. The patient's body will not convulse and they will not feel any pain (History and use, n.d.).

When the treatment is completed, the patient will be brought to the recovery area. Typically, patients will wake up about ten to fifteen minutes later and in many cases will be able to go home within an hour. Once the patient wakes up, they may experience headache, nausea, and temporary confusion and muscle stiffness. These symptoms normally go away in a matter of about sixty minutes (History and use, n.d.).

Efficacy

According to Reisner (2003), evidence seems strongest for the effectiveness of ECT in severely depressed, and even psychotically depressed, patients. Evidence has been cited suggesting that ECT is particularly efficacious with psychotic depression. Experimental research and reviews of the literature tend to conclude that ECT is either equal or superior to antidepressant medication in the treatment of severe depression. In one study both depressed men and women were helped by ECT, but women tended to improve more with ECT than with imipramine, a tricyclic antidepressant. Men tended to improve more with imipramine. Both men and women improved more with ECT than with phenalzine, a monoamine oxidase inhibitor (MAOI). It has been suggested that MAOIs and serotonin-specific reuptake inhibitors (SSRIs) may be less clinically effective than heterocyclic antidepressants for severe depression. Thus, ECT's favorable comparison with imipramine is a strong endorsement.

Adverse Effects

The side effect of ECT that has received the most attention is memory loss. ECT results in two kinds of memory loss. The first involves quick forgetting of new information. For instance, shortly after the treatment, patients often have trouble remembering conversations or things they have recently read. This kind of memory loss is short lived and has not been shown to last for more than a few weeks after the completion of ECT (Side effects and risks, n.d.).

The second kind of memory loss concerns events from the past. Some patients will have gaps in their memory of events that took place in the weeks to months and, less frequently, years before the treatment took place. This memory problem also gets better after the completion of ECT. Nevertheless, permanent gaps in memory may exist for some events; predominantly those that took place close in time to the treatment. As with any treatment, patients differ in the degree to which they experience side effects, and more extensive memory loss has been reported. It's important to note that the benefits of ECT are not related to memory loss, that is, patients don't feel better just because they can't remember something. In addition, relief through ECT of a psychiatric disorder can result in improved intelligence, attention and learning ability (Side effects and risks, n.d.).

As for other side effects and risks, scientific evidence strongly speaks against the possibility of ECT causing brain damage. Careful studies in animals have shown no evidence of brain damage from brief seizures such as those given with ECT. In an adult, seizures must go on for hours before brain damage takes place, while, the ECT seizure lasts only about one minute. Brain scans after ECT have shown no injury to the brain. During ECT, the amount of electricity that reaches the brain is too small to cause electrical injury. It is estimated that death associated with ECT occurs in one out of ten thousand patients. This rate may be higher in patients with severe medical conditions and is most strongly associated with the use of anesthesia, just as it would be with any medical procedure (Side effects and risks, n.d.).

Administration

Informed consent is obtained before treatment is give. Patients are informed about the risks and benefits of the procedure. Patients are also made aware of risks and benefits of other treatments and of not having the procedure done at all. Depending on the jurisdiction the need for further inputs from other medical professionals or legal professionals may be required. ECT is typically given on an in-patient basis. Prior to treatment a patient is given a short-acting anesthetic such as methohexital, etomidate, or thiopental, a muscle relaxant such as suxamethonium (succinylcholine), and sometimes atropine to inhibit salivation. Both electrodes can be placed one on the same side of the patient's head. This is known as unilateral ECT. Unilateral ECT is used first to minimize the side effects of memory loss. When electrodes are placed on both sides of the head, this is known as bilateral ECT. In bifrontal ECT, an unusual variation, the electrode position is somewhere between bilateral and unilateral (Electroconvulsive therapy administration, n.d.).

Legal Status

It is widely acknowledged internationally that obtaining the written, informed consent of the patient is important before ECT is administered. In the U.S., 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 chance to accept or reject the treatment. The form states how many treatments are recommended and also makes the patient aware that the treatment may be revoked at anytime during a course of ECT (Electroconvulsive therapy legal status, n.d.).

Public Perception

Despite years of social, political, and legal attacks and lack of acceptance by the general public, approximately one hundred thousand people in the United States and over one million worldwide receive ECT every year (Payne, 2009). But still Electroconvulsive therapy continues to be a treatment of last resort. Until psychiatric professionals develop a more complete understanding of ECT, patients and families are likely to persist to resist ECT as a viable treatment alternative. Well-informed clinicians should be comfortable presenting ECT as a safe, effective, and potentially life-saving therapy for patients who desperately need relief (Keltner & Boschini, 2009).

Even though ECT has been used since the 1940's and 1950's, it remains misunderstood by the general public Many of the procedure's risks and side effects are related to the misuse of equipment, incorrect administration, or improperly trained staff. It is also a misconception that ECT is used as a quick fix in place of long-term therapy or hospitalization. It is also not correct that patients are painfully shocked out of the depression. Unfavorable news reports and media coverage have contributed to the controversy surrounding this treatment (Electroconvulsive therapy and other depression treatments, 2011). Much of the public stigma attached to ECT is based on lurid media depictions of early treatments in which high doses of electricity were administered without anesthesia for any number of psychiatric problems or simply for punishment. Modern ECT is nothing like these accounts (Narrow, 2011).

Social Issues and Controversy

Much of the stigma attached to electroconvulsive therapy is based on early treatments in which high doses of electricity were administered without anesthesia, leading to memory loss, fractured bones and other serious side effects (Electroconvulsive therapy (ECT), 2011). Although ECT is widely used in depression and some other conditions, it continues to attract controversy. Disagreement mainly centers on the possibility of memory loss and intellectual impairment. Even though the debate about cognitive impairment has received much attention, the question of possible unwanted psychological effects has, until recently, been almost totally ignored. The ECT handbook contains a single paragraph referring briefly to pretreatment anxiety. This omission has been commented on in that doctors who give ECT have shown remarkably little interest in their patients' views of the procedure and its effects on them and only recently has this topic received any consideration in the literature' and by service users. What are never discussed in the literature are the profoundly damaging psychological effects ECT can have on people long-term (Johnstone, 1999).

Original Positive Perception

Since its development in 1938 it has proven effective for the treatment of depression with psychotic features and suicidal ideation (Leinbaugh, 2001). In the beginning this treatment was seen as a good one. It was responsible for saving many peoples lives who suffered from depression and other mental illnesses when no other treatment was available or worked. It wasn't until the discovery of unethical practices being used in regards to the therapy that its positive perception changed.

Unethical Practices

Electroconvulsive therapy has been a highly troublesome therapy. First, there were many examples of ECT being used to subdue and to control patients in psychiatric hospitals. Troublesome patients received several shocks a day, many times without proper restraint or sedation. It has been said that ECT stands practically alone among the medical/surgical interventions in that misuse was not the goal of curing but of controlling the patients for the benefits of the hospital staff (Sabbatini, n.d.).

Replacement with Pharmaceuticals

The introduction of psychoactive drugs quickly replaced these treatments and by the mid-1960s, fever therapy, insulin coma, leucotomy, and electroconvulsive therapy (ECT) disappeared, a fortunate change in the eyes of many critics who firmly believed that the patients had been abused by these interventions. By the late 1970s, however, as increasing numbers of patients with severe illness failed to improve, even with the cornucopia of new chemical elements and imaginative psychotherapies, experienced clinicians resurrected ECT and found it still effective (Fink, 2011).

Safety and Ethical Developments

Patients in the 1950's sometimes received more than one hundred treatments. The amount of electricity used was also greater, and the waveform and the stimulus were different. Anesthetics and muscle relaxants were not used. Patients were typically shackled to the gurney which often led to broken bones and vertebrae. People were not closely monitored during the treatment process. ECT today is different than it was fifty years ago. How ECT works, with minimal damage to the patient, has a lot to do with how it is currently administered. There are two advances that have improved the procedure. The first is non-dominant unilateral ECT, which is the use of electrodes only to the right side of the patient's head as opposed to bilateral, protecting the left side of the brain, the site of language and auditory memory. The other advance has been the introduction of brief-pulse stimulus which is a quick jolt of electricity instead of a steady stream, making it less likely that the patient will later suffer serious problems with memory (Electroshock therapy, 2005).

Electroconvulsive therapy is much safer today. Although electroconvulsive therapy still causes some side effects, it now uses electrical currents given in a controlled setting to achieve the most benefit with the fewest possible risks (Electroconvulsive therapy (ECT), 2011). 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 (Electroconvulsive therapy, 2011).

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

cannot stand, or receive no noteworthy 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 (Electroconvulsive therapy, 2011).

The controversy surrounding ECT in the United States led to three institutional responses that have affected the future of ECT throughout the world. First, in 1985 the National Institute of Mental Health (NIMH) and the National Institutes of Health (NIH) held a joint Consensus Conference aimed at setting up some agreement among mainstream professionals about the status of ECT. Second, in 1990 the Food and Drug Administration (FDA) decided for the first time to review the safety of ECT machines. Third, still in 1990, the American Psychiatric Association (APA) issued a lengthy report aimed at convincing the FDA not to require the testing of ECT machines. The APA report was successful in this regard and became the basis for the FDA's final report. The APA's report was also aimed at oppressing controversy surrounding the treatment and protecting psychiatrists from lawsuits being brought by patients claiming they had suffered brain injury from ECT (Breggin, n.d.).

The clinical experience with ECT has improved the delivery of care so that no complete contraindication for the treatment is known and the efficacy for the principal psychopathologies is well established with greater than eighty five percent remission rates. Despite its poor optics, despite its public and professional stigmatization and despite universal contempt, the treatment continues to survive. It does so because it is effective and safe even in people who are the most severely and desperately ill and who have failed all other treatments. ECT deserves greater attention to its mechanism of action, offering the prospective for greater understanding of the treatment and its underlying pathophysiology, and the best opportunities to understand the abnormal brain processes that underlie major psychiatric disorders and their remarkable resolution by inducing seizures (Fink, 2011).

Electroconvulsive therapy has had a very checked past. When it was first introduced it was used to treat mental illnesses in people who had no other treatment options. This helped led to a lot of lives being saved. It was only after it was discovered that some people were using the treatment unethically that it began to have a bad reputation. Because of the continued misunderstanding surrounding the treatment it has still not managed to shake the bad stigma that it has gotten over the years. There have been many developments in the administration of the treatment and the rules and regulations surrounding its administration that it is now thought to be a very safe and effective treatment for certain mental illnesses by experts today.

It appears that more research needs to be done in regards to the current procedures surrounding ECT and the results published so that current information can be given to the public as to the current state of this treatment. It is a shame that some people do not get the help that they need because they have an erroneous view of this treatment based on past events.