Electroconvulsive Therapy-All you should know

Electroconvulsive Therapy in Mental Health

Electroconvulsive therapy (ECT) is one of the most controversial treatments used in mental health. While some psychiatrists believe that ECT is an effective life-saving psychiatric treatment, others have grave concerns about its effectiveness and the associated side effects.

What is Electroconvulsive Therapy?

Electroconvulsive therapy (ECT) is a treatment involving the delivery of a small electrical current to a person’s brain using electrodes. The therapy induces a seizure or a convulsion that lasts for around 15 seconds and is thought to alleviate symptoms in cases of severe depression.

ECT is used to treat refractory clinical depression or depression that has been non-responsive to other methods of treatment such as counselling, cognitive behavioural therapy and medication. In most cases, attempts to improve the patients symptoms using these methods have failed before ECT is advocated. Aside from severe clinical depression, other conditions that may improve with the use of ECT include bipolar disorder and catatonia.

Brief History Of ECT

Methods of inducing seizure or convulsions as a way of treating psychiatric conditions were introduced as early on as the 16th Century. At that time, the conditions were largely untreatable due to medications not being as developed or advanced as they are today. The use convulsive therapy was first documented in the London Medical Journal in 1785.

It was in 1937 that the first international meeting on convulsive therapy took place in Switzerland, under the organization of Swiss psychiatrist Muller. The proceedings from this meeting were published in the American Journal of Psychiatry and within three years, convulsive therapy using cardiazol (metrazol) was being used across the world.

Next, neuropsychiatrist Ugo Cerletti and his colleague Lucio Bini who had been conducting animal experiments using electric shocks, introduced the idea of replacing cardiazol with electroshocks treatment as the method for inducing a convulsion.

The electroshock method was cheaper and more convenient than the metrazol method but it was also less predictable and controllable. Cerletti and Bini were nominated for a Nobel Prize and by the 1940s the use of ECT had become widespread in England and the US. The popularity of the technique also spread throughout the 1950s.

The use of ECT gradually declined over the years, mainly due to poor public perception of the technique, partly as a result of its portrayal in film and media. The therapy became more popular again in the 1980s when the benefits to patients with severe refractory depression became obvious.

In 1978, the first task force report from the The American Psychiatric Association was released introducing new standards for consent and recommending the use of unilateral electrode placement.

In 1985, the NIMH Consensus Conference supported the use of ECT in certain clinical circumstances. In 1990, the American Psychiatric Association released a second report further detailing guidance on the delivery of ECT as well as training and education. The latest task force report from the association in 2001, emphasized the importance of the patient’s informed consent as well as the extended role ECT plays in medicine today.

Electroconvulsive Therapy- What Happens

Informed consent

The term “informed consent” refers to the consent given by a patient to proceed with a therapeutic approach after they have been fully informed of the benefits and risks associated with the therapy. The patient’s written consent is obtained prior to initiation of an ECT treatment plan. A 2005 publication from the World Health Organization entitled “Human Rights and Legislation WHO Resource Book on Mental Health” states that ECT can be administered only after informed consent has been obtained from the patient.

In the United States, any doctor treating a patient is under a legal obligation to ensure that the patient understands the following points before they undergo ECT:

  • The reason for the treatment
  • The risks associated with the ECT treatment plan.
  • The risks and benefits of alternative treatments at the stage of disease concerned
  • The risks and benefits of not receiving any ECT therapy versus receiving therapy

Once these facts are explained, the patient is given the opportunity to reject or accept the treatment. At any time during the course of the treatment plan, the patient retains the right to refuse the treatment and revoke his or her informed consent.

Until 2009, the use of ECT to treat detained patients was allowed in England and Wales under the 1983 Mental Health Act, regardless of whether their consent had been obtained. However, the treatment could only be administered if it was authorized by a psychiatrist from the Mental Health Act Commission’s panel.

After 2009, the law was altered and now ECT cannot be given to any patient who is able to refuse consent. Emergency administration may still be allowed regardless of capacity to consent, if a psychiatrist says the treatment is urgently needed (under Section 62 of the Act).

Anesthesia


Before treatment, the patient is administered a short-acting anesthetic to render them unconscious. Examples of the anesthetics used include methohexital, etomidate and thiopental. A muscle relaxant such as succinylcholine may also be used and sometimes atropine is administered to prevent salivation.

The Process

The application of ECT can differ in the following ways:

  • How the electrodes are placed
  • How frequent the treatments are
  • Which electrical waveform is used

These three factors significantly influence patient outcomes and side effects. In most cases, drug treatment is usually continued after treatment and some patients receive further ECT as a maintenance therapy.

Electrode placement


For unilateral ECT, two electrodes are placed on one side of the patient’s head. The unilateral therapy may be used initially, to limit memory loss. When electrodes are placed on either side of the head, the therapy is called bilateral ECT. Patients in the UK usually receive bilateral ECT.

The ECT treatment


The electrodes deliver an electrical stimulus to the brain that is over the individual’s seizure threshold, usually about one and a half times the threshold in the case of bilateral ECT and up to 12 times the threshold when unilateral ECT is used.

Monitoring


The patient’s blood oxygen level, ECG and EEG are carefully monitored throughout the therapy.

Electroconvulsive Therapy Effectiveness

Opinion is divided over the effectiveness of using electroconvulsive therapy (ECT) to treat severe depression that has not responded to other forms of therapy.

Use of the therapy is controversial mainly due to concerns about its efficacy and side effect profile. ECT alone does not usually provide a sustained benefit and those who remit often suffer a relapse of their condition within six months.

In 1999, a report from the United States Surgeon General on Mental Health summarized the opinion of psychiatrists regarding ECT at that time. This report stated that ECT was an effective treatment for severe depression, mania and some states of psychosis, leading to remission in 60% to 70% of cases.

The therapy was not shown to be effective, however, as a treatment for dysthymia, anxiety disorder, personality disorder or substance abuse. Furthermore, the report said that the therapy has no long-term effect in terms of preventing people form committing suicide and can only offer a short-term benefit for an acute episode of illness. Follow-up therapy would therefore be required in the form of medication of further monthly or weekly ECT.

A 2003 report from the United Kingdom came from the UK ECT Review group who compared literature on the efficacy of ECT versus placebo. This report demonstrated that ECT was significantly more effective than placebo or antidepressant medication.

Another major report followed in 2004. A multicenter follow-up study of New York patients who had undergone ECT showed that only 30% to 47% of individuals remitted. However, when individuals with personality disorders or schizoaffective disorder were omitted from the analysis, the remission rate increased by as much as 70%.

Electroconvulsive therapy appears to fight depression by ‘rebooting’ certain brain networks

Physiologic Mechanism Of ECT

The main mechanism of action in electroconvulsive therapy (ECT) is the induction of a generalized clonic seizure. This seizure is triggered by the delivery of an electric current to the patient’s brain using electrodes placed on the patient’s head.

The nervous system is regulated by electrical currents and disrupting those currents by way of an induced seizure has demonstrated beneficial effects in patients with severe depression and schizophrenia.

Exactly how the induced convulsion achieves this is not clear and many animal models have been studied to try and elucidate the underlying mechanism of the therapy’s effects. However, despite the various similarities between human and animal brains, many dispute the translational value of these studies in terms of understanding depression in humans.

Some of the theories derived from animal research regarding the mechanism of ECT include:

  1. Murine studies have shown that on application of ECT, there is a rise in the level of brain-derived neurotrophic factor (BDNF) and  vascular endothelial growth factor (VEGF) in the hippocampus region of the brain. Evidence shows that rises in blood levels of BDNF and VEGF can increase hippocampal neurogenesis.
  2. Studies have also shown that ECT can increase the BDNF level in people who do not respond to antidepressant drugs.

Electroconvulsive Therapy Side Effects

Results have also shown that ECT may be beneficial in treating some states of psychosis and mania.

Several adverse side effects are associated with the use of ECT. However, the United States Surgeon General’s report states that there are no health contraindications to the use of ECT and that the effects of ECT on the brain are similar to those caused by a brief episode of general anesthesia.

The main side effects associated with ECT are described below:

Muscle soreness

A patient’s muscles may feel sore after they have undergone ECT, although this is usually caused by the administration of muscle relaxants rather than activity in the muscles during therapy.

Effects on memory

One of the main reasons ECT is considered a controversial therapy concerns the purported effects of the therapy on memory. ECT may cause both retrograde amnesia (the loss of memories that existed prior to treatment) and anterograde amnesia (loss of memories formed after treatment).

Memory loss and confusion are more common in cases of bilateral electrode placement rather than unilateral placement. Similarly, these effects are usually seen when the more traditional sine-wave technique is used as opposed to brief-pulse therapy.

Among individuals with retrograde amnesia caused by ECT, the lack of memory is usually most pronounced for events that occurred just weeks or months before the therapy took place. One study showed that in cases where memories are lost from years before treatment, they are almost completely recovered by seven months after the therapy.

Electroconvulsive Therapy Patient Experience

According to the American Psychiatry Association (APA) task force guidelines report, the majority of patients who undergo electroconvulsive therapy (ECT) rate the experience as no more unpleasant than visiting the dentist.

The report states that many patients actually found ECT less distressing than a dental visit and that the majority would be willing to receive ECT again, if required.

According to the NICE guidelines report on ECT, most patients undergoing the therapy have found it beneficial and even life saving. By contrast, other patients felt ashamed, distressed, scared and described the treatment as invasive and abusive, particularly when treatment proceeded without their consent being given.

Informed consent means that the patient is made aware of the benefits and risks associated with the therapy prior to the procedure going ahead. The doctor treating the patient is under a legal obligation to ensure that the patient is informed of the following points prior to treatment with ECT:

  • The reason for the treatment
  • The risks associated with ECT
  • The treatment plan
  • The risks and benefits of alternative treatments at the stage of disease concerned
  • The risks and benefits of not receiving any ECT therapy versus receiving therapy

Once these facts are explained, the patient is given the opportunity to reject or accept the treatment. At any time during the course of the treatment plan, the patient retains the right to refuse the treatment and revoke his or her informed consent.

The NICE report stresses that most people who experience negative feelings associated with ECT are those who have been given ECT without their consent.

One of the main reasons ECT is considered a controversial therapy concerns the purported effects of the therapy on memory. ECT may cause both retrograde amnesia (the loss of memories that existed prior to treatment) and anterograde amnesia (loss of memories formed after treatment).

However, patients may feel that the memory loss associated with ECT is an acceptable price to pay in return for the relief from depression symptoms the therapy can provide. As consent may be withdrawn at any point during the treatment schedule, many patients may well discontinue ECT if they find it uncomfortable or become concerned about the side effects.

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