The original use of electricity as a cure for "insanity" dates back to the beginning of the 16th century when electric fish were used to treat headaches. ECT originates from research in the 1930's into the effects of camphor-induced seizures in people with schizophrenia. In 1938, two Italian researchers, Ugo Cerletti and Lucio Bini, were the first to use an electric current to induce a seizure in a delusional, hallucinating, schizophrenic man. The man fully recovered after 11 treatments, which led to a rapid spread of the use of ECT as a way to induce therapeutic convulsions in the mentally ill.
A course of treatment with ECT usually consists of six to twelve treatments given three times a week for a month or less. The patient is given general anesthesia and a muscle relaxant. When these have taken full effect, the patient's brain is stimulated, using electrodes placed at precise locations on the patient's head, with a brief controlled series of electrical pulses. This stimulus causes a seizure within the brain, which lasts for approximately a minute. Because of the muscle relaxants and anesthesia, the patient's body does not convulse and the patient feels no pain. The patient awakens after five to ten minutes, much as he or she would from minor surgery.
It is generally used with severely depressed patients when other forms of therapy (such as medications or psychotherapy) have not been effective, cannot be tolerated, or (in life-threatening cases) will not help the patient quickly enough. ECT also helps patients who suffer with most forms of mania (a mood disorder which is associated with grandiose, hyperactive, irrational and destructive behavior), some forms of schizophrenia, and a few other mental and neurological disorders. ECT is also useful in treating these mental illnesses in older patients for whom a particular medication may be inadvisable.
Psychiatrists are very selective in their use of electroconvulsive therapy. According to the National Institute of Mental Health, approximately 33,000 hospitalized Americans received ECT in 1980, the last year for which NIMH has figures. That comes out to only about two tenths of one percent of the 9.4 million who suffer with depression, the four million who suffer with schizophrenia and the more than one million who suffer with mania during any given year. Some patients (a minority) also undergo ECT as an outpatient procedure.
Improvements in 4 out of 5 patients
Numerous studies since the 1940s have demonstrated ECT's effectiveness. Clinical evidence indicates that for uncomplicated cases of severe major depression, ECT will produce a substantial improvement in at least 80 percent of patients. ECT has also been shown to be effective in depressed patients who do not respond to other forms of treatment. Medication is usually the treatment of choice for mania, but here too certain patients don't respond. Many of these patients have been successfully treated with ECT.
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 50's to the 70's. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given and, these now antiquated practices contributed to the negative portrayal of ECT in the popular media. 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".
Due to the backlash, 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.
The brain is an organ that functions through complex electrochemical processes, which may be impaired by certain types of mental illnesses. Scientists believe ECT acts by temporarily altering some of these processes.
Electroconvulsive Therapy, more commonly known as "ECT," is a medical treatment performed only by highly skilled health professionals, including doctors and nurses, under the direct supervision of a psychiatrist, who is a medical doctor trained in diagnosing and treating mental illnesses.
Its effectiveness in treating severe mental illnesses is recognized by the American Psychiatric Association, the American Medical Association, the National Institute of Mental Health and similar organizations in Canada, Great Britain and many other countries.
The Thymatron ECT
- Stimulus Output Current: 0.9 A constant, isolated from line current
- Frequency: 10 to 70 Hz in 10 Hz increments (to 140 Hz for 0.25 ms pulse)
- Pulsewidth: 0.25 to 1.5 ms in 0.25 ms increments
- Duration: 0.14 to 8.0 s in increments of equal charge
- Maximum: 504 mC (99.4 J @ 220 ohm); 1008 mC (188.8 J @220 ohm) with double-dose option (where available)
- Recording 8 user-selectable gain positions (10, 20, 50, 100, 200, 500, and 2000 microvolts/cm)
Risks and side effects
Any medical procedure entails a certain amount of risk. However ECT is no more dangerous than minor surgery under general anesthesia, and may at times be less dangerous than treatment with antidepressant medications. Patients are carefully screened before a psychiatrist will recommend them for the treatment. Immediate side effects from ECT are rare except for headaches, muscle ache or soreness, nausea and confusion, usually occurring during the first few hours following the procedure. Over the course of ECT, it may be more difficult for patients to remember newly learned information, though this difficulty disappears over the days and weeks following completion of the ECT course. Some patients also report a partial loss of memory for events that occurred during the days, weeks, and months preceding ECT. While most of these memories typically return over a period of days to months following ECT, some patients have reported longer-lasting problems with recall of these memories. However, other individuals actually report improved memory ability following ECT, because of its ability to remove the amnesia that is sometimes associated with severe depression. The amount and duration of memory problems with ECT vary with the type of ECT that is used and are less a concern with unilateral ECT (where one side of the head is stimulated electrically) than with bilateral ECT.
No evidence of brain damage
Researchers have found no evidence that ECT damages the brain. There are medical conditions (such as epilepsy), that cause spontaneous seizures which, unless prolonged or otherwise complicated, do not harm the brain. ECT artificially stimulates a seizure; but ECT-induced seizures occur under much more controlled conditions than those that are "naturally occurring" and are safe. A recent study found no changes in brain anatomy with ECT, as measured by very sensitive scans of the brain using magnetic resonance imaging (MRI) equipment. Other research has established that the amount of electricity which actually enters the brain, (only a small fraction of what is applied to the scalp) is much lower in intensity and shorter in duration than that which would be necessary to damage brain tissue.
Some people who advocate legislative bans against ECT are former psychiatric patients who have undergone the procedure and believe they have been harmed by it and that the treatment is used to punish patients' misbehavior and make them more docile. This is untrue.
Braking bones when administered without anaesthesia
It is true that many years ago, when psychiatric knowledge was less advanced, ECT was used for a wide range of psychiatric problems, sometimes even to control troublesome patients. The procedure was frightening for patients because it was then administered without anesthesia or muscle relaxants, and the uncontrolled seizures sometimes broke bones.
Changes in Brain waves
Today, the There are very strict guidelines for ECT administration. Use of ECT is only to treat severe, disabling mental disorders, never to control behavior. ECT is generally used in severely depressed patients for whom psychotherapy and medication are proving ineffective. It may also be considered when there is an imminent risk of suicide because ECT often has much quicker results than antidepressant remedies. Clinically effective seizures generally last from about 30 seconds to just over a minute. The patient's body does not convulse and the patient feels no pain. During the seizure there are a series of changes in brain waves on an electroencephalogram (EEG) and when the EEG tracing levels off this is an indication that the seizure is over. As the patient awakens there may be headache, nausea, temporary confusion and muscle stiffness.
There are varying opinions as to how the memory is affected by ECT. Many patients report loss of memory for events that occurred in the days, weeks or months surrounding the ECT. Many of these memories may return, although not always. Some patients have also reported that their short-term memory continues for months to be affected by ECT although there is the argument that this may be the type of amnesia that is sometimes associated with severe depression.
In the first few decades of ECT's use, death occurred in 1 in 1,000 patients. Current studies report a very low mortality rate of 2.9 deaths per 10,000 patients or, in another study, 4.5 deaths per 100,000 treatments. Much of this risk is due to the anesthetic although the risk is no greater than the use of anesthetic for any minor surgical procedure.
There is no doubt that, properly used, ECT can be an effective procedure in the treatment of severe depression. Surprisingly, experts are still uncertain as to why it works. It is thought that ECT acts by temporarily altering some of the brain's electrochemical processes.
ECT machine are a high-risk class of medical device. In the UK the market, ECT machines were long monopolised by Ectron Ltd, although in recent years some hospitals have started using American machines. In 1948, two English Surgeons, L.G.M. Page and R.J. Russell, wrote the benchmark article on ECT. The Page-Russell technique used powerful multiple shocks, but no more than five in one treatment. Ectron Ltd was set up by psychiatrist Robert Russell, who together with his colleague from the Three Counties Asylum, Bedfordshire, invented the Page-Russell technique of intensive ECT.
NICE (National Institute for Clinical Excellence) guidance
In the United Kingdom, NICE has looked carefully at the evidence and has recommended that ECT should only be used for the treatment of severe depressive illness, a prolonged or severe episode of mania, or catatonia. ECT should be used to gain fast and short-term improvement of severe symptoms after all other treatment options have failed, or when the situation is thought to be life-threatening.
Compiled and edited by JD Sandham