Electroconvulsive Therapy

Electroconvulsive therapy (ECT) was a common psychiatric treatment until the late 20th century, when it fell into disuse as better drug therapies became available for more conditions.

Electroconvulsive therapy (ECT), also known as Electroshock Therapy is a controversial medical treatment involving the induction of a seizure in a patient by passing electricity through the brain. Patients with any of several conditions often show dramatic short-term improvement after the procedure. While the majority of psychiatrists believe that properly administered ECT is a safe and effective treatment for some conditions, a vocal minority of psychiatrists, former patients, anti-psychiatry activists, and others strongly criticize the procedure as extremely harmful to patients' subsequent mental state.

Electroconvulsive Therapy is performed only under the direct supervision of a psychiatrist. Its effectiveness in treating severe mental illnesses is recognized by the American Psychiatric Association, the American Medical Association, the National Institute of Mental Health, the Food and Drug Administration, the US Surgeon General's office, and similar organizations in Canada, Great Britain and many other countries. Today, the American Psychiatric Association has very strict guidelines for ECT administration. This organization supports use of ECT only to treat severe, disabling mental disorders; never to control behavior.

A course of treatment with ECT usually consists of six to twelve treatments. Treatments are usually 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.

ECT was introduced as a treatment for schizophrenia in the 1930s, and soon became a common treatment for neurologically based disorders affecting mood. In the early days of use, ECT was administered without anesthesia or muscle relaxants. Patients were frequently injured as a side effect of the induced seizure. Currently, in most countries, patients are first administered an anesthetic agent as well as a paralytic agent, significantly reducing the chances of injury seen in unmodified ECT.

ECT was a common psychiatric treatment until the late 20th century, when it fell into disuse as better drug therapies became available for more conditions. It is now reserved for severe cases clinical depression (unipolar depression) and the depression associated with bipolar disorder. Electroconvulsive therapy 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 is the most effective and most rapidly acting treatment available for severe major depression. ECT also helps patients who suffer with most forms of mania (a mood episode which is associated with grandiose, hyperactive, irrational, and destructive behavior), some forms of schizophrenia, and a few other mental and neurological disorders (e.g., bipolar disorder, schizoaffective disorder, catatonia, and Parkinson's disease).

Exactly how ECT exerts its effects is not known.  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.

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 three-tenths of one percent of the 8.6 million who suffer with depression, the 2.1 million who suffer with schizophrenia and the more than one million who suffer with mania during any given year.

The decision to use ECT must be evaluated by each individual, weighing the potential benefits and known risks of all available, appropriate treatments in the context of informed consent, free of coercion and veiled threats. In nearly all states in the United States, involuntary ECT may not be initiated by a physician or family member without a judicial proceeding. In nearly every state, the administration of ECT on an involuntary basis requires such a judicial proceeding at which patients may be represented by legal counsel. As a rule, the law requires that such petitions are granted only where the prompt institution of ECT is regarded as potentially lifesaving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia.

No psychiatrist simply "decides" to treat a patient with ECT. Before he or she can administer ECT, he or she must first obtain written consent from the patient. If the patient is too ill to make decisions for him or herself, in most states a court-appointed guardian (usually one of the patient's family members) can provide consent. Under the APA's recommended "informed consent" protocol, permission to administer ECT comes after a careful review of the treatment.  The patient or family member is informed of when, where, and by whom the treatment will be administered and the number of treatments expected. The person consenting to the procedure is kept informed of progress as the treatment continues, and may withdraw consent at any time.

Informed consent is an integral part of the ECT process.  The potential benefits and risks of this treatment, and of available alternative interventions, should be carefully reviewed and discussed with patients and, where appropriate, family or friends. Prospective candidates for ECT should be informed, for example, that its benefits are short-lived without active continuation treatment, and that there may be some risk of permanent severe memory loss after ECT. Theoretically, in most jurisdictions, consent may be revoked at any time during a series of ECT sessions.  The World Health Organization, in its 2005 publication "Human Rights and Legislation WHO Resource Book on Mental Health," specifically states, "ECT should be administered only after obtaining informed consent."

Much of the accepted risk of ECT arises from the use of general anesthesia; there is considerable disagreement about other risks.  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 treat depression and thereby remove the problems in concentration and memory that depression can cause. The amount and duration of memory problems with ECT vary with the type of ECT that is used.

As of 2006, most psychiatrists believe that ECT can be beneficial in some circumstances. However, ECT remains controversial. Though most studies have found that ECT is effective for severe depression and several other conditions, opponents claim that the mechanism through which ECT changes mental state is nothing more than the destruction of brain cells, and even proponents are unsure how it works. Many patients who have had ECT claim it caused their mental state to improve; many others think their ECT did more harm than good.

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.  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.

The costs for any psychiatric treatment vary widely, depending on the state and the facility administering it. Usually, however, ECT costs roughly $800 to $1000 per treatment, an amount which covers the psychiatrist, anesthetist, and a variety of hospital charges, but this can vary by region, and the average number of treatments is about eight. The cost of ECT is at least partially reimbursed by most insurance plans offering coverage for mental disorders. In cases where the use of ECT shortens the duration of a hospital stay, its net cost may be substantially less.

For more information about Electroconvulsive Therapy (ECT) or Electroshock Therapy and other therapeutic approaches, please click on the linked websites listed below.

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