INDICATIONS AND PROCEDURES

Electroconvulsive therapy (ECT), also known as “shock therapy,” is a somatic, or physical, form of therapy that is used for some individuals who suffer from severe mental disorders. It involves the direct application of an electric current to the brain. Typically, this current lasts for up to one second at a rate of 140 to 170 volts. The purpose of this electrical charge is to induce a grand mal seizure that will usually last for thirty to sixty seconds. The seizure that is induced is similar to those experienced in some types of epilepsy. It is through this grand mal seizure that ECT has its beneficial effect in reducing the symptoms of the patient.

The use of electrical charges as a medical treatment has been reported for centuries. As early as 47 CE, Scribonius Largus used an electric eel to treat headaches. During the sixteenth century, Ethiopians were reported to have used electric catfish to expel evil spirits from the bodies of the mentally ill. Direct electric charges for the treatment of nervous complaints were also reported during the eighteenth century in Europe.

The modern application of electric current for the treatment of individuals with mental disorders began in 1938. It was at this time that two Italians, Ugo Cerletti, a psychiatrist, and Lucio Bini, a neuropathologist, invented the first ECT machine for use on humans. Cerletti and Bini first used their newly developed ECT machine to induce convulsions for the treatment of schizophrenic patients, and they reported that the treatment was a success.

ECT was introduced into the United States in 1940, at which time it quickly became the major somatic treatment for all severely disturbed individuals, regardless of mental disorder. By the mid-1950s, its use began to decline rapidly for several reasons, including the introduction of psychotropic medications, increasing demands for civil rights for the mentally ill, and concerns about potential adverse effects of ECT. Subsequently, however, a growing body of research has indicated that ECT is an effective treatment for some severe mental disorders. This research has led to a gradual increase in the acceptance of its use, particularly in the treatment of severely depressed individuals.

When ECT was first used for the treatment of mental disorders, the patient would be strapped to a table and, without any medications or other medical safeguards, would be administered the electrical current and sent into a convulsion. During this convulsion, the patient would thrash around on the table, often being left with broken limbs and other physical complications. In its later use, prior to administration of the ECT, the patient is given a muscle relaxant, which completely immobilizes the body, and anesthesia, which makes the patient completely unconscious. The result of these safeguards has been a much safer treatment of the patient.

THEORIES OF EFFICACY

Although ECT has been demonstrated to be an effective treatment, it is not known how and why ECT works. The theoretical basis of the original use of ECT had to do with the observation that schizophrenia and epilepsy rarely occur together, suggesting that the two are mutually exclusive. Based on this observation, it was hypothesized that, if a seizure could be induced in a schizophrenic, the schizophrenic symptoms could be eliminated. Physicians had tried previously to induce such seizures by means of injections of insulin, camphor, and other chemicals, but these approaches proved to have more disadvantages relative to ECT.

Although this early theory of the mechanics of ECT has been refuted, there still is little knowledge of how and why ECT actually works. The only fact that has been firmly established is that it is the seizure that ECT induces that creates any positive changes in the patient’s symptoms. There is no clear-cut explanation, however, of how the seizure creates the changes. Several theories have been developed to explain the process, most of which center on ECT’s effect on neurotransmitters.Neurotransmitters are chemicals that are used in the brain to transmit messages from one cell to another. One well-accepted theory holds that abnormalities in the level and utilization of certain neurotransmitters lead to the development of mental disorders such as depression, schizophrenia, and mania. Consequently, it is thought that ECT, through the creation of a seizure, somehow affects the level and utilization of some of these neurotransmitters, and that it is this process that reduces the patient’s symptoms of mental disorder. While research to investigate how ECT works continues, it is important to remember that, as with all somatic treatments, ECT does not cure the disorder; it provides only temporary relief from the symptoms.Despite its reported effectiveness, ECT remains a controversial treatment for mental disorders. Opponents point to potential adverse effects that ECT can cause, particularly the possibility of permanent brain damage resulting from the induced seizure. These opponents, who highlight the negative effects that ECT can have on a patient’s memory, prefer the use of alternative treatment methods. The public media have served to exacerbate negative perceptions of ECT by depicting it as an inhumane treatment that is used only to control and punish malcontents, not to help the severely disturbed. There is perhaps no better example of the media’s distorted depiction of ECT than that found in the film One Flew Over the Cuckoo’s Nest (1975), in which ECT was used as a brutal method to control and manage the main character. As a result of these misunderstandings and distorted perceptions, ECT is often not used when it might be helpful.

USES AND COMPLICATIONS

It has been estimated that each year 60,000 to 100,000 people in the United States receive electroconvulsive therapy. This form of treatment has been used to treat a variety of mental disorders, including severe major depression, schizophrenia, and mania. Several surveys have indicated that more than three-fourths of individuals who receive ECT have been diagnosed as suffering from severe major depression. The second-largest group of individuals receiving ECT consists of those who have been diagnosed as schizophrenic. While there is substantial evidence that ECT is effective in the treatment of severe major depression, the evidence supporting the use of ECT to treat other disorders is not as strong.

Generally speaking, ECT is not seen as a treatment of choice. It will most likely not be the first treatment given to someone suffering from a severe mental disorder. Instead, it is typically viewed as the treatment of last resort and is used primarily to treat individuals who do not respond to any other treatments. For example, a typical course of treatment for an individual suffering from debilitating severe major depression would be talking therapy and one of the many antidepressant medications. For most people, it takes two to four weeks to respond to such medications. If the patient does not respond to the medication, another antidepressant medication may be tried. If, after several trials of medication, the patient still does not respond and continues to be severely depressed, ECT might be considered a viable option.

There are a few individuals for whom ECT might be considered the treatment of choice. These individuals include those who are in life-threatening situations, such as those who show symptoms of severe anorexia or strong suicidal tendencies, or those for whom medications would be damaging. ECT might be used to treat pregnant women, for example, since it presents fewer risks for a fetus than medication does, or individuals with heart disease, for whom medications can cause severe complications.

Because of the stigma attached to ECT as a result of its historical misuse and its characterization in the popular media, many physicians believe that ECT is not used as widely as it could and should be. Often, ECT is suggested as the treatment of choice, but because of its stigma, other approaches are tried first. The effect of this decision is to deprive the patient of an effective treatment and delay or prevent remission.

TECHNIQUES AND EFFECTS

When ECT is indicated for the treatment of a mental disorder, it usually involves five to ten applications of ECT administered at a rate of two or three per week. The number of ECT treatments given, however, will vary depending on the individual’s medical history and the severity of the presenting symptoms. ECT is always administered by a physician; it cannot be ordered by a psychologist. When ECT is applied, many medical safeguards are used to prevent or minimize adverse effects. They include the use of a muscle relaxant, anesthesia, and oxygen. These medical procedures have made the use of ECT much safer than it was during the days when the patient would thrash about the table, breaking bones.

Additional refinements in the use of ECT have made it even safer. One such refinement is the application of unilateral, rather than bilateral, ECT. In unilateral ECT, the electric shock is sent through only one of the brain’s two hemispheres. Usually, the shock is sent through the right hemisphere, which controls abstract thinking and creativity, rather than the left hemisphere, which controls language and rational thinking. While usually as effective as bilateral ECT, in which the shock goes through the entire brain, unilateral ECT has been shown to cause fewer adverse side effects.

Despite the refinements in ECT and the caution exercised in its use, there are several documented potential adverse side effects. Although most research indicates that these effects are temporary, some researchers suggest that ECT can cause permanent brain damage. The major adverse effects of ECT relate to how well the patient’s brain functions after the treatment. The most common effect is extreme confusion and disorientation in the patient on awakening after an ECT treatment. Generally, this confusion will last for only a few minutes to a few hours.

Another serious concern about ECT’s effects on the cognitive functioning of the patient has to do with the patient’s memory. ECT can cause retrograde amnesia, the inability to remember things from the past, and anterograde amnesia, the inability to memorize new material. Both forms of amnesia are most noticeable in the first days and weeks after the ECT treatments have stopped. With the passage of time, the patient will slowly remember more from the past and will regain or strengthen the ability to remember new material. In most patients, this recovery of memory will take no more than two to six months. The patient may, however, permanently lose memories of events that occurred immediately before the ECT treatments or while the patient was hospitalized for the treatments. The degree of memory loss appears to be related to the number of ECT treatments the patient received.

Research investigating permanent brain damage from the use of ECT has been mixed. Some research has indicated that any application of ECT will cause brain damage and that more brain damage will occur as more treatments are applied. Long-term impairment in the patient’s memory is one effect that has thus been identified as permanent. Other researchers, however, have reported that ECT does not cause permanent brain damage. In the meantime, ECT is used cautiously, and research continues into its potential adverse effects.

CHANGING ATTITUDES

Before the advent of psychotropic medications, there were few effective treatments for the severely mentally ill. Numerous treatment methods were attempted to help relieve the symptoms of mental illness. Among these methods were bloodletting, the use of leeches, and immersion in water. Perhaps the most common approach was the permanent institutionalization of severely mentally ill individuals. This was done not only to control patients but also to protect others, since patients were viewed as a threat to others and themselves.

As a result of the ineffectiveness of these treatments and the growing concern about the institutionalization of the mentally ill, a number of new treatment approaches were developed and applied. Among these new approaches was electroconvulsive therapy. Electroconvulsive shock therapy was first used on schizophrenic patients, and the treatment met with some success. It was also tried on depressed and manic patients, with even greater success. As a result of these successes and the lack of other effective treatment approaches, ECT quickly came to be a commonly used treatment for individuals who suffered from a variety of mental disorders.

Many factors caused ECT to fall out of favor during the late 1950s. First, the earlier applications of ECT held significant dangers for the patient. The risk of death was approximately one in one thousand, and the risk of physical damage, such as broken bones, was even greater—in fact, such damage was noted in up to 40 percent of the patients. Concerns about complications continue today, and their focus is the impact of ECT on cognitive functioning.

Another factor that led to the decline in the use of ECT was the development and introduction of psychotropic shock therapy versus medications. These medications revolutionized the treatment of the mentally ill and led to thousands of patients being deinstitutionalized. In terms of both effectiveness and safety, it soon became evident that the use of these medications was substantially preferable to the use of ECT.

A third major influence on the decline of ECT’s use was the growing civil rights movement for the mentally ill. Many community and religious leaders began to advocate the fair and humane treatment of the seriously mentally ill. These individuals saw ECT as an undesirable treatment method, used as an instrument for controlling and punishing individuals who could not defend themselves. This view of ECT as inhumane soon came to be widely held. ECT was perceived as a method to control, rather than help, patients—as a punishment rather than a therapy.

These and other factors led to the substantially decreased use of ECT. Subsequently, however, well-designed research has begun to define ECT as a relatively safe treatment method that may be the best therapy in certain situations. Additionally, refinements in the application of ECT have increased its effectiveness and reduced its complications. As a result of not only the ambiguity about its potential adverse effects but also the emotional issues related to its use, the controversy about ECT and its relative risks and benefits is likely to continue for many years.