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'''Electroconvulsive therapy''' ('''ECT''') is a controversial [[psychiatry|psychiatric]] therapy involving the induction of a [[seizure]] in a patient by passing [[electricity]] through the [[brain]]. Patients with several conditions sometimes show dramatic short-term improvement after ECT. While many [[psychiatrist]]s believe that properly administered ECT is a safe and effective treatment for some conditions, a vocal minority of psychiatrists, former patients, [[antipsychiatry]] activists, and others strongly criticize the procedure as harmful to patients' subsequent mental state.<ref>see Frank (2006)</ref>
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ECT was introduced for treating [[schizophrenia]] in the [[1930s]], and became a common treatment for [[mood disorder]]s. In its early days, ECT was given without [[anaesthesia]] or [[muscle relaxant]]s. Patients were often injured as a side effect of the seizure. Currently, ECT is administered under [[anaesthesia]] and [[muscle relaxants]], which limit the effects of the procedure to the [[brain]] itself. ECT without anaesthesia is known as "unmodified ECT", or "direct ECT", and is illegal in most countries.
'''Electroconvulsive therapy''' ('''ECT''') is a [[psychiatry|psychiatric]] treatment that involves inducing a seizure in a patient by passing electricity through the brain. ECT was introduced for treating [[schizophrenia]] by the Italian neurologist [[Ugo Cerletti]] in the 1930s, and became a common treatment for mood disorders. While many psychiatrists believe that properly administered ECT is a safe and effective treatment for some conditions, some psychiatrists, former patients, [[antipsychiatry]] activists, and others warn that ECT might harm the patients' subsequent mental state.


ECT was a common psychiatric treatment until the late [[20th century]], when better drug therapies became available for more conditions. It is now reserved for severe cases of [[clinical depression]] and [[bipolar disorder]] that do not respond to other treatments. When still in common use, ECT was sometimes abused by mental health professionals to punish or control uncooperative patients. Many people came to view ECT unfavorably after negative depictions of it in several books and films, and the treatment is still controversial.
ECT was a common treatment until the late 20th century, when better drug therapies became available for more conditions. It is now reserved for severe cases of clinical [[depression]] and [[bipolar disorder]] that do not respond to other treatments. When still in common use, ECT was sometimes abused by mental health professionals to punish or control uncooperative patients. Many people came to view ECT unfavorably after negative depictions of it in several books and films, and the treatment is still controversial.
 
In its early days, ECT was given without anaesthesia or muscle relaxants, and patients were often injured as a side effect of the seizure. Now, ECT is given under anaesthesia and with muscle relaxants. ECT without anaesthesia is known as "unmodified ECT", or "direct ECT", and is illegal in most countries.


==Current use==  
==Current use==  
Currently, ECT is mainly used to treat severe [[Clinical depression|depression]], particularly if complicated by [[psychosis]].<ref>NIH & NIMH Consensus Conference, 1985; Depression Guideline Panel (1993)</ref>. It is also used in cases of severe depression where [[antidepressant]] medication (sometimes in multiple courses), [[psychotherapy]], or both, have been ineffective ([[refractory depression]]),when medication cannot be taken, or when other treatments would be too slow (for example, in a person with delusional depression and intense, unremitting [[suicide|suicidal]] tendencies). Specific indications include depression accompanied by a physical illness or [[pregnancy]], which renders the use of the usually preferred antidepressants dangerous to the patient or to a developing [[fetus]]. Under such circumstances, some psychiatrists consider ECT to be the safest treatment option. It is also sometimes used to treat the [[mania|manic phase]] of [[bipolar disorder]] and the rare condition of [[catatonia]].  
ECT is mainly used to treat severe depression, particularly if complicated by psychosis<ref>{{cite journal | author=Potter WZ, Rudorfer MV | title=Electroconvulsive therapy--a modern medical procedure | journal=N Engl J Med | volume=328 | issue=12 | pages=839–46 | year=1993 | id=PMID 8441434}}; see also [http://consensus.nih.gov/1985/1985ElectroconvulsiveTherapy051html.htm]</ref>. It is also used in cases of severe depression when antidepressant medication, psychotherapy, or both, have been ineffective, when medication cannot be taken, or when other treatments would be too slow (e.g. in a person with delusional depression and intense, unremitting suicidal tendencies). Specific indications include depression accompanied by a physical illness or pregnancy, which makes the usually preferred antidepressants dangerous to the patient or to a developing fetus. It is also sometimes used to treat the manic phase of bipolar disorder and the rare condition of catatonia. In the USA, modern use of ECT is generally limited to evidence-based indications. <ref>{{cite journal | author=Hermann R ''et al.'' | title=Diagnoses of patients treated with ECT: a comparison of evidence-based standards with reported use. | journal=Psychiatr Serv | volume=50 | pages=1059-65 | year=1999 | id=PMID 10445655}}</ref> Accurate statistics about the frequency, context and circumstances of ECT in the USA are hard to obtain, as few states have laws that require this information to be given to state authorities. <ref>{{cite news | first = Dennis | last = Cauchon | title = Controversy and Questions Shock Therapy: Patients often aren't informed of full danger | publisher = USA Today | date = 1995-12-06 }}</ref>
 
Recent [[epidemiology|epidemiological]] surveys in the [[United States]] show that modern use of ECT is generally limited to evidence-based indications.<ref>{{cite journal | author=Hermann R ''et al.'' | title=Diagnoses of patients treated with ECT: a comparison of evidence-based standards with reported use. | journal=Psychiatr Serv | volume=50 | pages=1059-65 | year=1999 | id=PMID 10445655}}</ref> Indeed, concern has been raised that, in some settings, particularly in the public sector and outside major metropolitan areas, ECT may be underutilized.<ref>{{cite journal | author=Hermann R, ''et al.''| title=Variation in ECT use in the United States. | journal=Am J Psychiatry | volume=152 | pages=869-75 | year=1995 | id=PMID 7755116}}</ref>
In particular, minority patients tend to be underrepresented among those receiving ECT.<ref>Rudorfer ''et al.'' (1997)</ref> Accurate statistics about the frequency, context and circumstances of ECT in the USA are hard to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information. <ref>{{cite news | first = Dennis | last = Cauchon | title = Controversy and Questions Shock Therapy: Patients often aren't informed of full danger | publisher = USA Today | date = 1995-12-06 | language = English}}</ref>


==Overview==   
==Overview==   
The aim of ECT is to induce a bilateral tonic clonic [[seizure]] (a seizure where the person loses consciousness and has convulsions) which lasts for at least 60 seconds. Before the discovery of [[muscle relaxants]], ECT was given unmodified. Patients were rendered instantly unconscious by the electrical current, but the strength of the muscle contractions and the subsequent fit sometimes led to complications. Muscle relaxants allow a modified fit, where contractions are weak or nonexistent. However, before using muscle relaxants, the patient must be given a general anaesthetic to prevent the patient from experiencing the very uncomfortable state of being paralysed. The end result is that the patient drifts off to sleep and wakes up a short time later unable to recall the details of the procedure.
The aim of ECT is to induce a bilateral tonic clonic seizure (where the person loses consciousness and has convulsions) of at least 15 seconds in both motor (convulsive) and EEG manifestations. Before the discovery of muscle relaxants, ECT was given unmodified. Patients were rendered instantly unconscious, but the strength of the muscle contractions and the subsequent fit sometimes led to complications. Muscle relaxants allow a modified fit, where contractions are weak or nonexistent. However, the patient must first be given a general anaesthetic to prevent him or her from experiencing the very uncomfortable state of being paralysed. As a result, the patient drifts off to sleep and wakes up a short time later unable to recall the details of the procedure.


To induce the seizure, short bursts of a fixed current (typically 0.9 [[Ampere|A]]) are passed through electrodes applied to the [[scalp]] at specific points using a gel, paste or saline solution to prevent burns to the skin. Modern ECT machines regulate the current to keep it constant, and thus the voltage may vary up to a maximum, typically 450 [[Volt|V]], but is usually about half that. The ECT therapist tries to minimize the total energy by restricting the strength and duration of the current. The existence of the seizure is confirmed by observation or by [[Electroencephalography|EEG]] [[neuromonitoring]][http://www.psychiatrictimes.com/p980570.html].  
To induce the seizure, short bursts of a fixed current (typically 0.9A) are passed through electrodes applied to the scalp at particular points, using a gel, paste or saline solution. The ECT therapist tries to minimize the total energy by restricting the duration of the current. The seizure is confirmed by observation or by EEG neuromonitoring and/or with the cuff method[http://www.psychiatrictimes.com/p980570.html]. The cuff method consists of inflating a blood pressure cuff up to 300mmHg just above the right knee or elbow, after narcosis but before administration of the muscle relaxant (succinylcholine); as there is no muscle block in the lower right arm or leg, the duration of the convuslion can be timed clinically. 


[[Electricity|Electrical]] current flows between two [[electrode]]s placed on the scalp, usually from temple to temple in the past, although now ECT is more often applied to the non-dominant brain hemisphere. Placing both electrodes on one side of the head over the nondominant (generally right) [[cerebral hemisphere]], results in delivery of the initial stimulation away from the primary learning and memory centers. With unmodified ECT, the seizure is characteristically more severe than a naturally occurring [[epilepsy|epileptic]] seizure. The production of an adequate, generalized seizure using the proper amount of stimulation is required for therapeutic efficacy.<ref name="Sackeim1993">{{cite journal | author=Sackeim H ''et al.'' | title=Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. | journal=N Engl J Med | volume=328 | pages=839-46 | year=1993 | id=PMID 8441428}}</ref>. Therapeutic ECT is usually given three times per week for 6 to 12 treatments, on either an inpatient or outpatient basis. Studies have shown that each fit must be separated by at least a day.
Electrical current flows between two electrodes placed on the scalp, usually from temple to temple in the past, although now ECT is more often applied to the non-dominant cerebralhemisphere. Placing both electrodes on one side of the head over the nondominant (usually the right) hemisphere, means that  the stimulation is applied away from the main learning and memory centers of the brain. With unmodified ECT, the seizure is usually more severe than a naturally occurring epileptic seizure. The production of an adequate, generalized seizure is required for therapeutic efficacy.<ref name="Sackeim1993">{{cite journal | author=Sackeim H ''et al.'' | title=Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. | journal=N Engl J Med | volume=328 | pages=839-46 | year=1993 | id=PMID 8441428}}</ref>. ECT is usually given three times per week for 6 to 12 treatments, on either an inpatient or outpatient basis.


Exactly how ECT exerts its effects is not known, but repeated application affects several kinds of [[neurotransmitter]]s in the [[central nervous system]]. ECT seems to sensitize two subtypes of [[5-HT receptor|serotonin receptor]] (5-HT receptor), thereby strengthening signaling. ECT also decreases the functioning of [[norepinephrine]] and [[dopamine]], inhibiting auto-receptors in the [[locus coeruleus]] and [[substantia nigra]], respectively, causing more of each to be released.<ref>Ishihara & Sasa (1999)</ref> One study suggests that long-term ECT increases the expression of brain-derived neurotrophic factor ([[BDNF]]) and its receptor in limbic brain regions.<ref>{{cite journal | author=Duman R, Vaidya V | title=Molecular and cellular actions of chronic electroconvulsive seizures. | journal=J ECT | volume=14 |  pages=181-93 | year=1998 | id=PMID 9773357}}</ref>
Just how ECT exerts its effects is not known, but repeated application affects several neurotransmitter systems in the brain, including serotonin receptors  and pathways that regulate the release and actions of norepinephrine and dopamine.<ref>Ishihara & Sasa (1999)</ref> One study suggests that long-term ECT increases the expression of brain-derived neurotrophic factor and its receptor in limbic brain regions.<ref>{{cite journal | author=Duman R, Vaidya V | title=Molecular and cellular actions of chronic electroconvulsive seizures. | journal=J ECT | volume=14 |  pages=181-93 | year=1998 | id=PMID 9773357}}</ref> Some studies indicate that ECT is associated with various alterations in brain structure, but it is not clear to what extent these might be caused by ECT, as some brain changes have also been found in depressive patients who have not been treated with ECT.<ref >{{cite journal | author=Dwork A ''et al.''| title=Absence of histological lesions in primate models of ECT and magnetic seizure therapy. | journal=Am J Psychiatry | volume=161 | pages=576-8 | year=2004 | id=PMID 14992989}}
{{cite journal | author=Coffey C, ''et al.'' | title=Brain anatomic effects of electroconvulsive therapy. A prospective magnetic resonance imaging study. | journal=Arch Gen Psychiatry | volume=48 | pages=1013-21 | year=1991 | id=PMID 1747016}}</ref>.


===Types of ECT===   
===Types of ECT===   
There are two basic forms of ECT: ''bilateral'' and ''unilateral'', and bilateral ECT can be subdivided into ''bitemporal'' and ''bifrontal'' ECT. In bitemporal ECT, current is passed across the temporal lobes, between electrodes placed on either side of the head. With unilateral, the electrodes are only on the right side, and pass current mainly through the right temporal lobe. According to several trials, unilateral ECT is associated with almost no detectable, persistent memory loss.<ref>{{cite journal | author=Horne R, ''et al.'' | title=Comparing bilateral to unilateral electroconvulsive therapy in a randomized study with EEG monitoring. | journal=Arch Gen Psychiatry | volume=42 | pages=1087-92 | year=1985 | id=PMID 3901956}}</ref> <ref>NIH Consensus Conference (1985); Rudorfer ''et al.'' (1997)</ref> However, unilateral ECT is less potent and acts more slowly than bilateral ECT, particularly in the most severe cases of depression or mania. An approach that is sometimes used is to begin with unilateral ECT and switch to bilateral ECT after about six treatments if there is no response.
There are two basic forms of ECT: ''bilateral'' and ''unilateral'', and bilateral ECT can be subdivided into ''bitemporal'' and ''bifrontal'' ECT. In bitemporal ECT, current is passed across the temporal lobes, between electrodes placed on either side of the head. With unilateral ECT, the electrodes are only on one side, and pass current mainly through one temporal lobe. According to some trials, unilateral ECT is associated with almost no persistent memory loss.<ref>{{cite journal | author=Horne R, ''et al.'' | title=Comparing bilateral to unilateral electroconvulsive therapy in a randomized study with EEG monitoring. | journal=Arch Gen Psychiatry | volume=42 | pages=1087-92 | year=1985 | id=PMID 3901956}};  [http://consensus.nih.gov/1985/1985ElectroconvulsiveTherapy051html.htm] </ref> Unilateral ECT is less potent and acts more slowly than bilateral ECT, particularly in the most severe cases of depression or mania. An approach that is sometimes used is to begin with unilateral ECT and switch to bilateral ECT after about six treatments if there is no response. Bifrontal ECT is a modified form of bitemporal ECT in which electrodes are placed 2 inches above the lateral angle of each orbit. It appears to have less effect on memory than bitemporal ECT, and it increases the blood flow to the prefrontal cortex.<ref>{{cite journal| author=Blumenfeld H ''et al.''|title=Targeted prefrontal cortical activation with bifrontal ECT| journal=Psychiatry Res| year=2003| volume=123| pages=165–70| id=PMID 12928104}}</ref>
 
The relationship of electrical dose to clinical response depends on the electrode placement; for bilateral ECT, as long as an adequate seizure is obtained, any higher dose will merely add to the cognitive toxicity, whereas for unilateral ECT, a therapeutic effect will not be achieved unless the electrical stimulus is more than minimally above the seizure threshold.<ref name="Sackeim1993"/>
 
Even a moderately high electrical dosage in unilateral ECT has fewer cognitive adverse effects than bilateral ECT. On the other hand, high-dose bilateral ECT might be an avoidable cause of severe memory impairment. Bifrontal ECT is a modified form of bitemporal ECT in which electrodes are placed 2 inches above the lateral angle of each orbit. It has fewer adverse effects on memory than bitemporal ECT, and it increases the blood flow to the prefrontal cortex.<ref>Blumenfeld ''et al.'' (2003)</ref>


==Side effects and complications==
==Side effects and complications==
Much of the risk of ECT arises from the use of [[general anesthesia]]; there is considerable disagreement about other risks. The most common adverse effects are confusion and retrograde memory loss for events surrounding the period of ECT treatment, and generalised but mild muscle aches after waking. Some of the confusion seen on awakening after ECT clears soon after. More persistent memory problems are difficult to quantify. Most typical with standard, bilateral ECT has been a loss of memories for the time of the ECT series and extending back for an average of 6 months, combined with impairment in learning new information, which continues for perhaps 2 months after ECT.<ref>NIH & NIMH Consensus Conference, 1985</ref> No long-term studies of cognition, memory ability, and memory loss have been done in the past two decades, but some long-term studies before this reported permanent amnesia,<ref>Janis IL, Astrachan M. The effects of electroconvulsive treatments on memory efficiency. ''J Abnorm Soc Psychol''. 1951 46:501-11 [PMID 14880367]</ref> <ref>{{cite journal | author=Squire L, Slater P | title=Electroconvulsive therapy and complaints of memory dysfunction: a prospective three-year follow-up study. | journal=Br J Psychiatry | year=1993 | volume=142 | pages=1-8 | id=PMID 6831121}}</ref> although others found problems were gone by seven months after ECT.<ref>{{cite journal | author=Squire L, Slater P, Miller P | title=Retrograde amnesia and bilateral electroconvulsive therapy. Long-term follow-up. | journal=Arch Gen Psychiatry | volume=38 | pages=89-95 | year=1981 | id=PMID 7458573}}</ref> Calev (1994) concluded that patients must be warned of possible non-memory cognitive deficits, as "they are not going to function well on more tasks than they anticipate".<ref>{{cite journal | author=Calev A | title=Neuropsychology and ECT: past and future research trends. | journal=Psychopharmacol Bull | volume=30 |  pages=461-9 | year=1994 | id=PMID 7878183}}</ref>. At least a third of ECT patients have some permanent memory loss, according to a systematic review in 2003.<ref>Rose (2003)</ref> Formal neuropsychological testing has documented permanent neuropsychological deficits in ECT patients<ref>FDA, Docket #82P-0316</ref>. The degree of impairment and resulting impact on functioning vary between individuals.<ref>NIH & NIMH Consensus Conference (1985); CMHS (1998)</ref> Critics of ECT believe that there is enough evidence that patients' memories can be permanently and severely damaged to justify a moratorium, at least until more research has been done.
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]] <ref>NIH & NIMH Consensus Conference, 1985</ref> free of coercion and veiled threats. ECT should be given under controlled conditions, with appropriate personnel. The risks of ECT, according to the FDA, include brain damage and memory loss.<ref>Federal Register (1978) p 55729</ref> Studies in 2004 and 2005 showed that half of ECT patients did not feel that they could refuse the treatment.<ref>{{cite journal| author=Philpot M ''et al''| year=2004| title=Eliciting users' views of ECT in two mental health trusts with a user-designed questionnaire| journal=J Mental Health| volume=14| pages=403–13}}
 
{{cite journal|author=Rose D ''et al''| year=2005)|title=Information, consent and perceived coercion: patients' perspectives on electroconvulsive therapy| journal=Br J Psychiatry| volume=186| pages=54-9| url=http://bjp.rcpsych.org/cgi/content/full/186/1/54}})</ref>.  
Many studies from the [[1940s]], [[1950s]], and early [[1960s]] indicated that ECT was associated with brain abnormalities However, other authors point out that today's ECT is different, and recent work has found no evidence that the seizures cause brain damage <ref> {{cite journal | author=Dwork A ''et al.''| title=Absence of histological lesions in primate models of ECT and magnetic seizure therapy. | journal=Am J Psychiatry | volume=161 | issue=3 | pages=576-8 | year=2004 | id=PMID 14992989}}</ref> with prospective studies appearing to confirm this <ref>{{cite journal | author=Coffey C, ''et al.'' | title=Brain anatomic effects of electroconvulsive therapy. A prospective magnetic resonance imaging study. | journal=Arch Gen Psychiatry | volume=48 | pages=1013-21 | year=1991 | id=PMID 1747016}}</ref>.
 
There is more recent work noting brain abnormalities in those who have had ECT. Colon & Notermans found changes in nuclear volume in the cortex, but without loss of neurons.<ref>Colon EJ, Notermans SLH (1975) A long-term study of the effects of electro-convulsions on the structure of the cerebral cortex. ''Acta Neuropathologica (Berlin)'' 32:21-5 [PMID 1146505]</ref> Calloway ''et al.'' found an association with frontal lobe atrophy and ECT on a retrospective review of scans <ref>{{cite journal | author=Colon E, Notermans S | title=A long-term study of the effects of electro-convulsions on the structure of the cerebral cortex. | journal=Acta Neuropathol (Berl) | volume=32 | pages=21-5 | year=1975 | id=PMID 1146505}}</ref>, but did not claim these were caused by ECT (many schizophrenics, for instance, have abnormal brain anatomy as part of their condition and brain changes have also been found in depressive patients.
 
ECT may have adverse psychological effects. John Breeding, a psychologist at the [[University of Texas]], has highlighted what he regards as psychological effects of ECT, including suppression of ability to heal by emotional release; emotional distress, with deep feelings of terror and powerlessness; promotion of human beings in the roles of victims and passive dependents of medical professionals, and confirmation of patients' belief that there is something really wrong with them (shame)." <ref>{{cite book | last = Breeding | first = John | title = The Necessity of Madness: Explaining How Psychiatry Is a Clinical Construct and Madness Is a Metaphor | publisher = Chipmunkapublishing | date = 2003 | pages = 460 | doi = 2003-01-03 | id = 0954221877 }}</ref> Breeding regards psychiatric illness as the product of unresolved psychic conflict, often due to abuse, and feels that the correct treatment for such problems is to bring out this underlying conflict.


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]] <ref>NIH & NIMH Consensus Conference, 1985</ref> free of coercion and veiled threats. Studies in 2004 and 2005 showed that half of ECT patients did not feel that they could refuse the treatment.<ref>Philpot (2004); Rose (2005)</ref>
Some psychiatric researchers believe that there are few contraindications that preclude the use of ECT where the psychiatrist, sometimes in consultation with a multidisciplinary team, decides that the potential benefits outweigh the possible risks. The only major contraindication is increased intracranial pressure because of the danger of herniation due to transient further increase in intracranial pressure during the procedure.


Some psychiatric researchers contend that there are virtually no absolute health contraindications that preclude the use of ECT where warranted <ref>Potter & Rudorfer (1993); Rudorfer ''et al.'' (1997)</ref> i.e. where the treating psychiatrist, sometimes in consultation with a multidisciplinary team, decides that the likely benefits outweigh the possible risks. The only major contraindication is increased intracranial pressure, as in cases of recent [[cerebrovascular accident]] or [[meningioma]], because of the danger of [[herniation]] due to transient further increase in intracranial pressure during the procedure.
Much of the risk of ECT arises from the use of general anesthesia; there is considerable disagreement about other risks. The most common side effects after treatment are muscle aches and headache. Other important side effects are confusion, retrograde memory loss for events surrounding the period of ECT treatment, and [[anterograde amnesia]]. Some of the confusion seen on awakening after ECT clears soon after and mainly occurs with treatment of elderly. More persistent memory problems are difficult to quantify; most typical with bilateral ECT has been [[retrograde amnesia]], a loss of memories for the time of the ECT series and extending back for about 6 months. Another memory complaint is anterograde amnesia; difficulty in learning new information. This side effect mainly occurs with bilateral electrode placement and increases with the number of treatments. It disappears during 2 months after ECT.<ref>NIH & NIMH Consensus Conference 1985</ref> No long-term studies of cognition and memory have been done in the past two decades; some studies before this reported permanent amnesia, while others reported that problems were gone by seven months after ECT.<ref>{{cite journal | author=Squire L, Slater P | title=Electroconvulsive therapy and complaints of memory dysfunction: a prospective three-year follow-up study. | journal=Br J Psychiatry | year=1993 | volume=142 | pages=1-8 | id=PMID 6831121}}
{{cite journal | author=Squire L, Slater P, Miller P | title=Retrograde amnesia and bilateral electroconvulsive therapy. Long-term follow-up. | journal=Arch Gen Psychiatry | volume=38 | pages=89-95 | year=1981 | id=PMID 7458573}}</ref> Calev (1994) concluded that patients must be warned of possible non-memory cognitive deficits, as "they are not going to function well on more tasks than they anticipate".<ref>{{cite journal | author=Calev A | title=Neuropsychology and ECT: past and future research trends. | journal=Psychopharmacol Bull | volume=30 |  pages=461-9 | year=1994 | id=PMID 7878183}}</ref>. At least a third of ECT patients have some permanent memory loss, according to a systematic review in 2003.<ref>{{cite journal| author=Rose D ''et al.''|year=2003| title=Patients' perspectives on electroconvulsive therapy: systematic review| journal=Br Med J| volume=326| pages=1323–67 | id=PMID 12816822}}</ref> The degree of impairment and impact on functioning vary between individuals.


ECT should be administered under controlled conditions, with appropriate personnel.<ref>Rudorfer ''et al.'' (1997)</ref>. The United States [[Food and Drug Administration]] has classified the devices used to administer ECT as [[Medical devices#Class III: General Controls and Premarket Approval|Class III medical devices]]. <ref>Federal Register (1979), p. 51776</ref>
ECT might have some adverse psychological effects. John Breeding, a psychologist at the [[University of Texas]], has highlighted psychological effects of ECT, including suppression of ability to heal by emotional release; emotional distress, with deep feelings of terror and powerlessness; promotion of human beings in the roles of victims and passive dependents of medical professionals, and confirmation of patients' belief that there is something really wrong with them (shame)." <ref>{{cite book | last = Breeding | first = John | title = ''The Necessity of Madness: Explaining How Psychiatry Is a Clinical Construct and Madness Is a Metaphor'' | publisher = Chipmunkapublishing | date = 2003 | pages = 460 | id = 0954221877 }}</ref> Breeding regards psychiatric illness as a product of unresolved psychic conflict, often due to abuse, and feels that the correct treatment is to bring out this underlying conflict.
Class III is the highest-risk class of medical devices. The risks of ECT, according to the FDA, include brain damage and memory loss.<ref>Federal Register (1978), p. 55729</ref>


==Effectiveness==   
==Effectiveness==   
Some studies, later confirmed in trials which included the use of simulated ([[placebo]]) ECT as a control,<ref>Janicak ''et al.'' (1985)</ref> have shown that ECT is very effective against severe depression, some acute [[psychotic]] states, and [[mania]].<ref>Small ''et al.'' (1988)</ref>. No controlled study has shown that any other treatment for depression is more effective than ECT. <ref>Janicak ''et al.'' (1985); Rudorfer ''et al.'' (1997)</ref>. These conclusions, and many of those discussed below, are the product of review of extensive research <ref>Depression Guideline Panel (1993); Rudorfer ''et al.'' (1997)</ref> as well as by a panel of scientists, practitioners, and consumers.<ref>NIH & NIMH Consensus Conference (1985)</ref>
Many studies, including some that have used simulated (placebo) ECT as a control, <ref>Janicak ''et al.'' (1985)</ref> indicate that ECT is effective against severe depression, some acute psychotic states, and mania.<ref>Depression Guideline Panel (1993); [http://consensus.nih.gov/1985/1985ElectroconvulsiveTherapy051html.htm]</ref>


Although the average 60-70% response rate seen with ECT is similar to that seen with pharmacotherapy, there is evidence that the antidepressant effect of ECT occurs faster than with medication, which supports the use of ECT when depression is accompanied by potentially uncontrollable suicidal ideas and actions <ref>Rudorfer ''et al.'' (1997)</ref> However, ECT does not provide long-term protection against suicide; it is now recognized that a single course of ECT should be regarded as a short-term treatment for acute illness. To sustain the response to ECT, continuation treatment, often in the form of antidepressant and/or [[mood stabilizer]] medication, is needed. <ref>Sackeim (1994)</ref>
Although the average 60-70% response rate seen with ECT is similar to that seen with pharmacotherapy, the antidepressant effect of ECT might occur faster than with medication, which supports the use of ECT when depression is accompanied by potentially uncontrollable suicidal ideas and actions. However, ECT does not provide long-term protection against the risk of suicide; to attempt to sustain the response to ECT, continuation treatment, often in the form of antidepressant and/or mood stabilizer medication, is used. "Maintenance ECT" refers to indefinite periods of repeated ECT, usually scheduled a few weeks apart. Individuals who repeatedly relapse after ECT despite continuation medication may be candidates for maintenance ECT.
"Maintenance ECT" refers to indefinite periods of repeated ECT, usually scheduled a few weeks apart. Critics of ECT assert that maintenance ECT is needed because the brain requires approximately four weeks to recover from each closed head injury caused by ECT; thus, when the brain has healed, the temporary euphoric effects are lost and ECT must be given again to attain the previous mood gain. Individuals who repeatedly [[relapse]] after ECT despite continuation medication may be candidates for maintenance ECT, delivered on an outpatient basis at a rate of one treatment weekly to as infrequently as monthly <ref>Rudorfer ''et al.'' (1997)</ref>


==Informed consent==   
==Informed consent==   
[[Informed consent]] is an integral part of the ECT process. <ref>NIH & NIMH Consensus Conference (1985)</ref>. The potential benefits and risks, and those of available alternative interventions, should be reviewed carefully, and discussed with patients and, where appropriate, family or friends. Candidates for ECT should be informed that its benefits are short-lived without continuation treatment, and that there is some risk of permanent severe memory loss. Active discussion with the treatment team, possibly supplemented by the growing amount of printed and videotaped information for consumers, is advisable in the decision-making process before and during a course of ECT. Care should be taken that the informed consent materials come from objective sources and not, for example, from the manufacturer of ECT devices. In most jurisdictions, consent may be revoked at any time during a series of ECT sessions.
[[Informed consent]] is an integral part of the ECT process. [http://consensus.nih.gov/1985/1985ElectroconvulsiveTherapy051html.htm]. The potential benefits and risks, and those of available alternative interventions, are reviewed carefully, and discussed with patients and, where appropriate, family or friends. Candidates for ECT should be informed that its benefits are short-lived without continuation treatment, and that there is some risk of permanent severe memory loss. Active discussion with the treatment team, possibly supplemented by the growing amount of printed and videotaped information for consumers, is advisable in the decision-making process before and during a course of ECT. In most jurisdictions, consent may be revoked at any time during a series of ECT sessions.


==Involuntary ECT==   
==Involuntary ECT==   
Procedures for involuntary ECT vary from country to country depending on local [[mental health law]]s. Legal proceedings are required in some countries, while in others ECT is seen as another form of treatment that may be given involuntarily as long as legal conditions are observed. 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."
Procedures for involuntary ECT vary from country to country depending on local mental health laws. Legal proceedings are required in some countries, but in others ECT may be given involuntarily as long as legal conditions are observed. The World Health Organization, in its 2005 publication "Human Rights and Legislation WHO Resource Book on Mental Health," states that "ECT should be administered only after obtaining informed consent."
 
In nearly all states in the USA, 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]]. In Oregon, an institution may administer involuntary ECT without any judicial proceeding at all through the use of an administrative override that requires, among other things, the review of the case by a physician unaffiliated with the treating facility.


Australian states regard involuntary treatment with ECT in the same light as any other involuntary treatment. There is an appeal process available for patients and relatives. This position facilitates the expedited use of ECT in emergencies.
In nearly all states in the USA, involuntary ECT may not be initiated by a physician or family member without a judicial proceeding at which patients may be represented by legal counsel. As a rule, such petitions are granted only where the prompt institution of ECT is potentially lifesaving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia. In Oregon, an institution may administer involuntary ECT without any judicial proceeding through an administrative override that requires, among other things, review of the case by a physician unaffiliated with the treating facility.  


In England and Wales, the Mental Health Act 1983 allows the use of ECT on detained patients (with and without capacity), if the treatment is authorised by a psychiatrist from the Mental Health Act Commission's panel. If the treating psychiatrist thinks the need for treatment is urgent they may start a course of ECT before authorisation. About 2,000 people a year are treated without their consent under the Mental Health Act.<ref>The Mental Health Act Commission: "In Place of Fear? eleventh biennial report, 2003-2005.", page 236. The Stationery Office, 2005.</ref> A small number of informal patients are treated without their consent under common law. In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 gives patients with capacity the right to refuse ECT.
In England and Wales, the Mental Health Act of 1983 allows the use of ECT on detained patients, if authorised by a psychiatrist from the Mental Health Act Commission's panel; if the psychiatrist thinks the treatment is needed urgently they may begin ECT before authorisation. About 2,000 people a year are treated without their consent in this way.<ref>The Mental Health Act Commission: "In Place of Fear? eleventh biennial report, 2003-2005" p 236. The Stationery Office, 2005</ref> In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 2003 gives patients with capacity the right to refuse ECT.


In 2006, the organization Mental Disability Rights International published the results of a two-year investigation in Turkey that found what MDRI termed "widespread" involuntary ECT administered without anesthesia.{{fact}}
In 2005, the organization ''Mental Disability Rights International'' published the results of a two-year investigation in Turkey that found what they termed "widespread" involuntary ECT administered without anesthesia.[http://www.mdri.org/projects/turkey/turkey%20final%209-26-05.pdf]


==Continuation phase therapy==   
==Continuation phase therapy==   
Successful acute phase antidepressant pharmacotherapy or ECT is generally followed by at least 6 months of continued treatment.<ref> Depression Guideline Panel (1993)</ref> During this ''continuation phase'', most patients are seen biweekly or monthly. The main goal of continuation pharmacotherapy is to prevent [[relapse]] (i.e. exacerbation of symptoms). Continuation pharmacotherapy reduces the risk of relapse from 40-60% to 10-20%.<ref>Prien & Kupfer (1986); Thase (1993)</ref> Relapse despite continuation pharmacotherapy might suggest either nonadherence or loss of a placebo response.  
Successful acute phase antidepressant pharmacotherapy or ECT is usually followed by at least 6 months of continued treatment. During this ''continuation phase'', most patients are seen biweekly or monthly. The main goal of continuation pharmacotherapy is to prevent relapse (i.e. exacerbation of symptoms). Continuation pharmacotherapy reduces the risk of relapse from 40-60% to 10-20%.<ref>Prien & Kupfer (1986); Thase (1993)</ref> Relapse despite continuation pharmacotherapy might suggest either nonadherence or loss of a placebo response. A second goal of continuation pharmacotherapy is to consolidate a response into complete remission of symptoms, as residual symptoms are associated with increased risk of relapse. Many psychotherapists taper a course of treatment by scheduling several sessions (every other week or monthly) before termination. There is evidence that relapse is less common following successful treatment with one type of psychotherapy, cognitive-behavioral therapy, than with antidepressants.<ref>Evans ''et al'' (1992)</ref>
 
A second goal of continuation pharmacotherapy is to consolidate a response into complete remission of symptoms, as residual symptoms are associated with increased risk of relapse. Many psychotherapists taper a successful course of treatment by scheduling several sessions (every other week or monthly) before termination. There is evidence that relapse is less common following successful treatment with one type of psychotherapy&mdash;[[Cognitive therapy|cognitive-behavioral therapy]]&mdash;than with antidepressants.<ref>Kovacs ''et al.'' (1981); Blackburn ''et al.'' (1986); Simons ''et al.'' (1986); Evans ''et al.'' (1992)</ref>


==History==   
==History==   
ECT was developed in the [[1930s]] by [[Italy|Italian]] [[neurologist]] [[Ugo Cerletti]]. Cerletti saw [[electric shock]]s given to hogs before [[Slaughter (livestock)|slaughter]]. This rendered them unconscious but did not [[kill]] them. Cerletti found that such electric shocks caused his obsessive and difficult mental patients to become meek and manageable. At first, ECT was performed on fully conscious patients, without the use of anesthesia or muscle relaxants. The patient lost consciousness during the application of the current, and experienced powerful and violently uncontrolled muscle movement. Patients would sometimes break bones, especially [[vertebra]]e, and pull muscles from the violent convulsions induced by the seizure. Patients came to fear the procedure, and it was sometimes used to punish or sedate difficult patients in [[psychiatric hospital]]s.  
ECT was developed in the 1930s by Italian neurologist [[Ugo Cerletti]]<ref>{{cite journal|author=Cerletti U, Bini L| title=L'Elettroshock| journal=Arch Gen Neurol Psychiat Psycoanal| year=1938| volume=19| pages=266–8}}</ref>. Cerletti saw that electric shocks given to hogs before slaughter rendered them unconscious, but did not kill them. Cerletti found that such electric shocks caused obsessive and difficult mental patients to become meek and manageable. At first, ECT was performed on fully conscious patients, without the use of anesthesia or muscle relaxants. The patient lost consciousness during ECT, and experienced powerful and uncontrolled muscle movement; they would sometimes break bones, and pull muscles from the convulsions induced by the seizure. Patients came to fear ECT, and, in some psychiatric hospitals, it was sometimes used to punish or sedate difficult patients. With the development of better medications for many mental disorders, the need for ECT lessened. Until then, ECT often had been administered for several conditions for which it is now regarded as ineffective, for example, for schizophrenia. Advances in treatment are reported to have led to fewer adverse effects.[http://consensus.nih.gov/1985/1985ElectroconvulsiveTherapy051html.htm]
 
With the development of effective medications for major mental disorders, the need for ECT lessened, but did not disappear. Until then, ECT often had been administered for several conditions for which it is now generally regarded as ineffective, for example, for treating [[schizophrenia]].  
 
Advances in treatment technique have led to fewer adverse cognitive effects of ECT.<ref>NIH & NIMH Consensus Conference (1985); Rudorfer ''et al.'' (1997)</ref> Nearly all ECT devices deliver a lower current, brief-pulse electrical stimulation, rather than the original [[sine wave]] output; with a brief pulse electrical wave, a therapeutic seizure can be induced with as little as one-third of the electrical power used by the older method, reducing the risk of confusion and memory disturbance.<ref>Andrade ''et al.'' (1998)</ref>
Ultra-brief pulse, higher frequency and longer stimulus duration also contribute to ECT effectiveness while minimizing  adverse cognitive effects.


==Controversy==   
==Controversy==   
[[As of 2006]], most [[psychiatry|psychiatrists]] believe that ECT can be beneficial in some circumstances. However, ECT remains controversial, and a vocal minority of psychiatrists oppose it; some regard it as inhumane and primitive. 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 it did more harm than good, and some campaign to have the treatment banned, as it is in the [[Republic of Slovenia]].
Many psychiatrists believe that ECT is beneficial in some cases, but others doubt this<ref>{{cite journal| author=Cameron DG| title=ECT: sham statistics, the myth of convulsive therapy, and the case for consumer misinformation| journal=J Mind Behav| year=1994| volume=15| pages=177–98}}</ref>, and a few regard ECT as inhumane and primitive. Some critics 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. Some patients who have had ECT believe that it caused their mental state to improve; others think it did more harm than good, and some campaign to have the treatment banned, as it is in the Republic of Slovenia.
[[Antipsychiatry]] believes that, for the most part, there are no real [[mental illness]]es, and that ECT is used to suppress certain behaviors which, although perhaps uncommon, are still within the normal range. Anti-ECT activists allege that patients are rarely told the full truth about the risks and benefits of ECT.<ref>Rose (2005)</ref>.
[[Antipsychiatry]] believes that there are few "real" mental illnesses, and that ECT is used to suppress certain behaviors which, even if uncommon, are still "normal". Anti-ECT activists allege that patients are rarely told the full truth about the risks and benefits of ECT.<ref>Rose (2005)</ref>.  
 
==Fictional and semi-fictional depictions of ECT==
ECT has been depicted in several fictional and semi-fictional films, books, and songs, almost always in an extremely negative light. A great deal of anti-ECT sentiment was generated by its depiction in the [[1975]] movie ''[[One Flew Over the Cuckoo's Nest (film)|One Flew Over the Cuckoo's Nest]]'', based on a novel by [[Ken Kesey]], which in turn was based loosely on the author's experiences in various mental hospitals during the [[1960s]]. It is implied in the film that the hospital staff use ECT to punish uncooperative patients. ECT has occasionally been portrayed in a positive light, however. In [[Elizabeth Flock]]'s novel ''But Inside I'm Screaming'', the main character, Isabel, is initally reluctant to undergo ECT for her severe depression, but the ECT is a major factor in her recovery.


==Fictional depictions of ECT==
ECT has been depicted in several fictional and semi-fictional films, books, and songs, usually in an very negative light. Considerable anti-ECT sentiment was generated by its depiction in the 1975 movie [[One Flew Over the Cuckoo's Nest (film)|''One Flew Over the Cuckoo's Nest'']], based on a novel by [[Ken Kesey]], which in turn was based loosely on the author's experiences in mental hospitals during the 1960s. In the film, the hospital staff apparently use ECT to punish uncooperative patients. ECT has occasionally been portrayed in a positive light, however. In Elizabeth Flock's novel ''But Inside I'm Screaming'' the main character, Isabel, is at first reluctant to undergo ECT for her severe depression, but the ECT is a major factor in her recovery.


==Famous people who have had ECT==
==Famous people who have had ECT==
* [[Louis Althusser]], French philosopher
* [[Louis Althusser]], French philosopher
* [[Peter Green (musician)|Peter Green]], British blues guitarist
* [[Antonin Artaud]], French playwright
* [[Antonin Artaud]], French playwriter 
* [[Clara Bow]], American actress
* [[Clara Bow]], American actress
* [[Richard Brautigan]], American writer and poet
* [[Richard Brautigan]], American writer and poet
* [[Dick Cavett]], TV host. In 1992 he wrote in ''[[People (magazine)|People]],'' "In my case, ECT was miraculous. My wife was dubious, but when she came into my room afterward, I sat up and said, 'Look who's back among the living.' It was like a magic wand."
* [[Dick Cavett]], TV host. In 1992 he wrote in ''[[People (magazine)|People]],'' "In my case, ECT was miraculous. My wife was dubious, but when she came into my room afterward, I sat up and said, 'Look who's back among the living.' It was like a magic wand."
* [[Kitty Dukakis]], wife of former Massachusetts governor and 1988 Democratic presidential nominee Michael Dukakis and author of ''Shock'', a book chronicling her experiences with ECT.
* [[Kitty Dukakis]], wife of former Massachusetts governor and 1988 Democratic presidential nominee Michael Dukakis and author of ''Shock'', a book chronicling her experiences with ECT.<ref>{{cite book | title=Shock: The healing power of electroconvulsive therapy|last=Dukakis|first=K|authorlink=Kitty Dukakis|coauthors=Tye L|date=2006|publisher=Avery/Penguin}}</ref>
* [[Thomas Eagleton]], American vice-presidential hopeful who lost the nomination in 1972 when it was discovered he had undergone ECT
* [[Thomas Eagleton]], American vice-presidential hopeful who lost the nomination in 1972 when it was discovered he had undergone ECT
* [[Frances Farmer]], American cinema actress
* [[Frances Farmer]], American cinema actress
* [[Janet Frame]], New Zealand writer who was wrongly diagnosed with schizophrenia. Many of her works contain semi-autobiographical accounts of her treatment
* [[Janet Frame]], New Zealand writer who was wrongly diagnosed with schizophrenia. Many of her works contain semi-autobiographical accounts of her treatment
* [[Judy Garland]], American film actress and singer
* [[Judy Garland]], American film actress and singer
* [[David Helfgott]], Australian pianist
* [[Ernest Hemingway]], American author, committed suicide shortly after ECT treatment at the Mayo Clinic in 1961. He is reported to have said to his biographer A.E. Hotchner, ''Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient....''
* [[Ernest Hemingway]], American author, committed suicide shortly after ECT treatment at the Mayo Clinic in 1961. He is reported to have said to his biographer [[A.E. Hotchner]], "Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient...."
* [[Vladimir Horowitz]], pianist 
* [[Pat Ingoldsby]], Irish poet
* [[Ken Kesey]], American author
* [[Ken Kesey]], American author
* [[Vivien Leigh]], British actress
* [[Vivien Leigh]], British actress
* [[Oscar Levant]], pianist
* [[Robert Lowell]], American poet and writer
* [[Robert Lowell]], American poet and writer
* [[Mervyn Peake]], English artist and writer
* [[Mervyn Peake]], English artist and writer
* [[Robert Pirsig]]. His experiences, somewhat fictionalized, are mentioned in his ''[[Zen and the Art of Motorcycle Maintenance: An Inquiry into Values]]''
* [[Sylvia Plath]], American poet
* [[Sylvia Plath]], American poet
* [[Cole Porter]], American composer and musician
* [[Cole Porter]], American composer and musician
* [[Dory Previn]], American poet, writer and lyricist
* [[Paul Robeson]], American actor
* [[Paul Robeson]], American actor
* [[Lou Reed]], rock musician
* [[Yves Saint Laurent]], French fashion designer. He underwent treatment after serving in the French military.
* [[Yves Saint Laurent]], French fashion designer. He underwent treatment after serving in the French military.
* [[Gene Tierney]], American actor
* [[Gene Tierney]], American actor


==Source note==   
==Source note==   
Sections of this article were adapted from the public-domain document ''[http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec3_1.html#treatment Mental Health: a report of the Surgeon General]''.
Sections of this article were adapted from ''[http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec3_1.html#treatment Mental Health: A Report of the Surgeon General]''.


==Footnotes==
==Footnotes==
<!--See http://en.wikipedia.org/wiki/Wikipedia:Footnotes for an explanation of how to generate footnotes using the <ref(erences/)> tags-->
<div class="references-small"><references/></div>[[Category:Suggestion Bot Tag]]
<div class="references-small"><references/></div>
 
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</div>
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== External links ==
* [http://consensus.nih.gov/1985/1985ElectroconvulsiveTherapy051html.htm Consensus Development Conference Statement] - [[National Institutes of Health]] (June 10-12, 1985)
* [http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec3_1.html#treatment Surgeon General.gov] - Mental Health: a report of the Surgeon General:  Treatment of Mood Disorders, [[Surgeon General of the United States]]
* [http://www.psych.org/research/apire/training_fund/clin_res/index.cfm Psych.org] - Electroconvulsive Therapy (ECT), [[American Psychiatric Association]]
* [http://www.ect.org/effects.shtml ECT.org] - Effects of ECT (criticism)
* [http://www.cchr.org/index.cfm/6608 CCHR.org] - Electroshock (ECT) and [[Psychosurgery]], by [[Citizens Commission on Human Rights]] (a [[Scientology]]-controlled group)
* Frank, Leonard R. (June 2006). [http://www.endofshock.com/102C_ECT.PDF Electroshock Quotationary]. Retrieved July 23, 2006, from [http://www.endofshock.com The Coalition for the Abolition of Electroshock in Texas] website.
 
[[Category:Psychiatric treatments]]
[[Category:Devices to alter consciousness]]
 
[[da:ECT]]
[[de:Elektrokrampftherapie]]
[[fr:Sismothérapie]]
[[he:נזעי חשמל]]
[[it:Terapia elettroconvulsivante]]
[[nl:Elektroconvulsietherapie]]
[[no:Elektrokonvulsiv terapi]]
[[pl:Terapia elektrowstrząsowa]]
[[fi:Sähköhoito]]
[[sv:ECT]]

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Electroconvulsive therapy (ECT) is a psychiatric treatment that involves inducing a seizure in a patient by passing electricity through the brain. ECT was introduced for treating schizophrenia by the Italian neurologist Ugo Cerletti in the 1930s, and became a common treatment for mood disorders. While many psychiatrists believe that properly administered ECT is a safe and effective treatment for some conditions, some psychiatrists, former patients, antipsychiatry activists, and others warn that ECT might harm the patients' subsequent mental state.

ECT was a common treatment until the late 20th century, when better drug therapies became available for more conditions. It is now reserved for severe cases of clinical depression and bipolar disorder that do not respond to other treatments. When still in common use, ECT was sometimes abused by mental health professionals to punish or control uncooperative patients. Many people came to view ECT unfavorably after negative depictions of it in several books and films, and the treatment is still controversial.

In its early days, ECT was given without anaesthesia or muscle relaxants, and patients were often injured as a side effect of the seizure. Now, ECT is given under anaesthesia and with muscle relaxants. ECT without anaesthesia is known as "unmodified ECT", or "direct ECT", and is illegal in most countries.

Current use

ECT is mainly used to treat severe depression, particularly if complicated by psychosis[1]. It is also used in cases of severe depression when antidepressant medication, psychotherapy, or both, have been ineffective, when medication cannot be taken, or when other treatments would be too slow (e.g. in a person with delusional depression and intense, unremitting suicidal tendencies). Specific indications include depression accompanied by a physical illness or pregnancy, which makes the usually preferred antidepressants dangerous to the patient or to a developing fetus. It is also sometimes used to treat the manic phase of bipolar disorder and the rare condition of catatonia. In the USA, modern use of ECT is generally limited to evidence-based indications. [2] Accurate statistics about the frequency, context and circumstances of ECT in the USA are hard to obtain, as few states have laws that require this information to be given to state authorities. [3]

Overview

The aim of ECT is to induce a bilateral tonic clonic seizure (where the person loses consciousness and has convulsions) of at least 15 seconds in both motor (convulsive) and EEG manifestations. Before the discovery of muscle relaxants, ECT was given unmodified. Patients were rendered instantly unconscious, but the strength of the muscle contractions and the subsequent fit sometimes led to complications. Muscle relaxants allow a modified fit, where contractions are weak or nonexistent. However, the patient must first be given a general anaesthetic to prevent him or her from experiencing the very uncomfortable state of being paralysed. As a result, the patient drifts off to sleep and wakes up a short time later unable to recall the details of the procedure.

To induce the seizure, short bursts of a fixed current (typically 0.9A) are passed through electrodes applied to the scalp at particular points, using a gel, paste or saline solution. The ECT therapist tries to minimize the total energy by restricting the duration of the current. The seizure is confirmed by observation or by EEG neuromonitoring and/or with the cuff method[4]. The cuff method consists of inflating a blood pressure cuff up to 300mmHg just above the right knee or elbow, after narcosis but before administration of the muscle relaxant (succinylcholine); as there is no muscle block in the lower right arm or leg, the duration of the convuslion can be timed clinically.

Electrical current flows between two electrodes placed on the scalp, usually from temple to temple in the past, although now ECT is more often applied to the non-dominant cerebralhemisphere. Placing both electrodes on one side of the head over the nondominant (usually the right) hemisphere, means that the stimulation is applied away from the main learning and memory centers of the brain. With unmodified ECT, the seizure is usually more severe than a naturally occurring epileptic seizure. The production of an adequate, generalized seizure is required for therapeutic efficacy.[4]. ECT is usually given three times per week for 6 to 12 treatments, on either an inpatient or outpatient basis.

Just how ECT exerts its effects is not known, but repeated application affects several neurotransmitter systems in the brain, including serotonin receptors and pathways that regulate the release and actions of norepinephrine and dopamine.[5] One study suggests that long-term ECT increases the expression of brain-derived neurotrophic factor and its receptor in limbic brain regions.[6] Some studies indicate that ECT is associated with various alterations in brain structure, but it is not clear to what extent these might be caused by ECT, as some brain changes have also been found in depressive patients who have not been treated with ECT.[7].

Types of ECT

There are two basic forms of ECT: bilateral and unilateral, and bilateral ECT can be subdivided into bitemporal and bifrontal ECT. In bitemporal ECT, current is passed across the temporal lobes, between electrodes placed on either side of the head. With unilateral ECT, the electrodes are only on one side, and pass current mainly through one temporal lobe. According to some trials, unilateral ECT is associated with almost no persistent memory loss.[8] Unilateral ECT is less potent and acts more slowly than bilateral ECT, particularly in the most severe cases of depression or mania. An approach that is sometimes used is to begin with unilateral ECT and switch to bilateral ECT after about six treatments if there is no response. Bifrontal ECT is a modified form of bitemporal ECT in which electrodes are placed 2 inches above the lateral angle of each orbit. It appears to have less effect on memory than bitemporal ECT, and it increases the blood flow to the prefrontal cortex.[9]

Side effects and complications

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 [10] free of coercion and veiled threats. ECT should be given under controlled conditions, with appropriate personnel. The risks of ECT, according to the FDA, include brain damage and memory loss.[11] Studies in 2004 and 2005 showed that half of ECT patients did not feel that they could refuse the treatment.[12].

Some psychiatric researchers believe that there are few contraindications that preclude the use of ECT where the psychiatrist, sometimes in consultation with a multidisciplinary team, decides that the potential benefits outweigh the possible risks. The only major contraindication is increased intracranial pressure because of the danger of herniation due to transient further increase in intracranial pressure during the procedure.

Much of the risk of ECT arises from the use of general anesthesia; there is considerable disagreement about other risks. The most common side effects after treatment are muscle aches and headache. Other important side effects are confusion, retrograde memory loss for events surrounding the period of ECT treatment, and anterograde amnesia. Some of the confusion seen on awakening after ECT clears soon after and mainly occurs with treatment of elderly. More persistent memory problems are difficult to quantify; most typical with bilateral ECT has been retrograde amnesia, a loss of memories for the time of the ECT series and extending back for about 6 months. Another memory complaint is anterograde amnesia; difficulty in learning new information. This side effect mainly occurs with bilateral electrode placement and increases with the number of treatments. It disappears during 2 months after ECT.[13] No long-term studies of cognition and memory have been done in the past two decades; some studies before this reported permanent amnesia, while others reported that problems were gone by seven months after ECT.[14] Calev (1994) concluded that patients must be warned of possible non-memory cognitive deficits, as "they are not going to function well on more tasks than they anticipate".[15]. At least a third of ECT patients have some permanent memory loss, according to a systematic review in 2003.[16] The degree of impairment and impact on functioning vary between individuals.

ECT might have some adverse psychological effects. John Breeding, a psychologist at the University of Texas, has highlighted psychological effects of ECT, including suppression of ability to heal by emotional release; emotional distress, with deep feelings of terror and powerlessness; promotion of human beings in the roles of victims and passive dependents of medical professionals, and confirmation of patients' belief that there is something really wrong with them (shame)." [17] Breeding regards psychiatric illness as a product of unresolved psychic conflict, often due to abuse, and feels that the correct treatment is to bring out this underlying conflict.

Effectiveness

Many studies, including some that have used simulated (placebo) ECT as a control, [18] indicate that ECT is effective against severe depression, some acute psychotic states, and mania.[19]

Although the average 60-70% response rate seen with ECT is similar to that seen with pharmacotherapy, the antidepressant effect of ECT might occur faster than with medication, which supports the use of ECT when depression is accompanied by potentially uncontrollable suicidal ideas and actions. However, ECT does not provide long-term protection against the risk of suicide; to attempt to sustain the response to ECT, continuation treatment, often in the form of antidepressant and/or mood stabilizer medication, is used. "Maintenance ECT" refers to indefinite periods of repeated ECT, usually scheduled a few weeks apart. Individuals who repeatedly relapse after ECT despite continuation medication may be candidates for maintenance ECT.

Informed consent

Informed consent is an integral part of the ECT process. [5]. The potential benefits and risks, and those of available alternative interventions, are reviewed carefully, and discussed with patients and, where appropriate, family or friends. Candidates for ECT should be informed that its benefits are short-lived without continuation treatment, and that there is some risk of permanent severe memory loss. Active discussion with the treatment team, possibly supplemented by the growing amount of printed and videotaped information for consumers, is advisable in the decision-making process before and during a course of ECT. In most jurisdictions, consent may be revoked at any time during a series of ECT sessions.

Involuntary ECT

Procedures for involuntary ECT vary from country to country depending on local mental health laws. Legal proceedings are required in some countries, but in others ECT may be given involuntarily as long as legal conditions are observed. The World Health Organization, in its 2005 publication "Human Rights and Legislation WHO Resource Book on Mental Health," states that "ECT should be administered only after obtaining informed consent."

In nearly all states in the USA, involuntary ECT may not be initiated by a physician or family member without a judicial proceeding at which patients may be represented by legal counsel. As a rule, such petitions are granted only where the prompt institution of ECT is potentially lifesaving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia. In Oregon, an institution may administer involuntary ECT without any judicial proceeding through an administrative override that requires, among other things, review of the case by a physician unaffiliated with the treating facility.

In England and Wales, the Mental Health Act of 1983 allows the use of ECT on detained patients, if authorised by a psychiatrist from the Mental Health Act Commission's panel; if the psychiatrist thinks the treatment is needed urgently they may begin ECT before authorisation. About 2,000 people a year are treated without their consent in this way.[20] In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 2003 gives patients with capacity the right to refuse ECT.

In 2005, the organization Mental Disability Rights International published the results of a two-year investigation in Turkey that found what they termed "widespread" involuntary ECT administered without anesthesia.[6]

Continuation phase therapy

Successful acute phase antidepressant pharmacotherapy or ECT is usually followed by at least 6 months of continued treatment. During this continuation phase, most patients are seen biweekly or monthly. The main goal of continuation pharmacotherapy is to prevent relapse (i.e. exacerbation of symptoms). Continuation pharmacotherapy reduces the risk of relapse from 40-60% to 10-20%.[21] Relapse despite continuation pharmacotherapy might suggest either nonadherence or loss of a placebo response. A second goal of continuation pharmacotherapy is to consolidate a response into complete remission of symptoms, as residual symptoms are associated with increased risk of relapse. Many psychotherapists taper a course of treatment by scheduling several sessions (every other week or monthly) before termination. There is evidence that relapse is less common following successful treatment with one type of psychotherapy, cognitive-behavioral therapy, than with antidepressants.[22]

History

ECT was developed in the 1930s by Italian neurologist Ugo Cerletti[23]. Cerletti saw that electric shocks given to hogs before slaughter rendered them unconscious, but did not kill them. Cerletti found that such electric shocks caused obsessive and difficult mental patients to become meek and manageable. At first, ECT was performed on fully conscious patients, without the use of anesthesia or muscle relaxants. The patient lost consciousness during ECT, and experienced powerful and uncontrolled muscle movement; they would sometimes break bones, and pull muscles from the convulsions induced by the seizure. Patients came to fear ECT, and, in some psychiatric hospitals, it was sometimes used to punish or sedate difficult patients. With the development of better medications for many mental disorders, the need for ECT lessened. Until then, ECT often had been administered for several conditions for which it is now regarded as ineffective, for example, for schizophrenia. Advances in treatment are reported to have led to fewer adverse effects.[7]

Controversy

Many psychiatrists believe that ECT is beneficial in some cases, but others doubt this[24], and a few regard ECT as inhumane and primitive. Some critics 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. Some patients who have had ECT believe that it caused their mental state to improve; others think it did more harm than good, and some campaign to have the treatment banned, as it is in the Republic of Slovenia. Antipsychiatry believes that there are few "real" mental illnesses, and that ECT is used to suppress certain behaviors which, even if uncommon, are still "normal". Anti-ECT activists allege that patients are rarely told the full truth about the risks and benefits of ECT.[25].

Fictional depictions of ECT

ECT has been depicted in several fictional and semi-fictional films, books, and songs, usually in an very negative light. Considerable anti-ECT sentiment was generated by its depiction in the 1975 movie One Flew Over the Cuckoo's Nest, based on a novel by Ken Kesey, which in turn was based loosely on the author's experiences in mental hospitals during the 1960s. In the film, the hospital staff apparently use ECT to punish uncooperative patients. ECT has occasionally been portrayed in a positive light, however. In Elizabeth Flock's novel But Inside I'm Screaming the main character, Isabel, is at first reluctant to undergo ECT for her severe depression, but the ECT is a major factor in her recovery.

Famous people who have had ECT

  • Louis Althusser, French philosopher
  • Antonin Artaud, French playwright
  • Clara Bow, American actress
  • Richard Brautigan, American writer and poet
  • Dick Cavett, TV host. In 1992 he wrote in People, "In my case, ECT was miraculous. My wife was dubious, but when she came into my room afterward, I sat up and said, 'Look who's back among the living.' It was like a magic wand."
  • Kitty Dukakis, wife of former Massachusetts governor and 1988 Democratic presidential nominee Michael Dukakis and author of Shock, a book chronicling her experiences with ECT.[26]
  • Thomas Eagleton, American vice-presidential hopeful who lost the nomination in 1972 when it was discovered he had undergone ECT
  • Frances Farmer, American cinema actress
  • Janet Frame, New Zealand writer who was wrongly diagnosed with schizophrenia. Many of her works contain semi-autobiographical accounts of her treatment
  • Judy Garland, American film actress and singer
  • Ernest Hemingway, American author, committed suicide shortly after ECT treatment at the Mayo Clinic in 1961. He is reported to have said to his biographer A.E. Hotchner, Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient....
  • Ken Kesey, American author
  • Vivien Leigh, British actress
  • Robert Lowell, American poet and writer
  • Mervyn Peake, English artist and writer
  • Sylvia Plath, American poet
  • Cole Porter, American composer and musician
  • Paul Robeson, American actor
  • Yves Saint Laurent, French fashion designer. He underwent treatment after serving in the French military.
  • Gene Tierney, American actor

Source note

Sections of this article were adapted from Mental Health: A Report of the Surgeon General.

Footnotes

  1. ↑ Potter WZ, Rudorfer MV (1993). "Electroconvulsive therapy--a modern medical procedure". N Engl J Med 328 (12): 839–46. PMID 8441434.
    see also [1]
  2. ↑ Hermann R et al. (1999). "Diagnoses of patients treated with ECT: a comparison of evidence-based standards with reported use.". Psychiatr Serv 50: 1059-65. PMID 10445655.
  3. ↑ Cauchon, Dennis. "Controversy and Questions Shock Therapy: Patients often aren't informed of full danger", USA Today, 1995-12-06.
  4. ↑ Sackeim H et al. (1993). "Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy.". N Engl J Med 328: 839-46. PMID 8441428.
  5. ↑ Ishihara & Sasa (1999)
  6. ↑ Duman R, Vaidya V (1998). "Molecular and cellular actions of chronic electroconvulsive seizures.". J ECT 14: 181-93. PMID 9773357.
  7. ↑ Dwork A et al. (2004). "Absence of histological lesions in primate models of ECT and magnetic seizure therapy.". Am J Psychiatry 161: 576-8. PMID 14992989. Coffey C, et al. (1991). "Brain anatomic effects of electroconvulsive therapy. A prospective magnetic resonance imaging study.". Arch Gen Psychiatry 48: 1013-21. PMID 1747016.
  8. ↑ Horne R, et al. (1985). "Comparing bilateral to unilateral electroconvulsive therapy in a randomized study with EEG monitoring.". Arch Gen Psychiatry 42: 1087-92. PMID 3901956.
    [2]
  9. ↑ Blumenfeld H et al. (2003). "Targeted prefrontal cortical activation with bifrontal ECT". Psychiatry Res 123: 165–70. PMID 12928104.
  10. ↑ NIH & NIMH Consensus Conference, 1985
  11. ↑ Federal Register (1978) p 55729
  12. ↑ Philpot M et al (2004). "Eliciting users' views of ECT in two mental health trusts with a user-designed questionnaire". J Mental Health 14: 403–13. Rose D et al (2005)). "Information, consent and perceived coercion: patients' perspectives on electroconvulsive therapy". Br J Psychiatry 186: 54-9. )
  13. ↑ NIH & NIMH Consensus Conference 1985
  14. ↑ Squire L, Slater P (1993). "Electroconvulsive therapy and complaints of memory dysfunction: a prospective three-year follow-up study.". Br J Psychiatry 142: 1-8. PMID 6831121. Squire L, Slater P, Miller P (1981). "Retrograde amnesia and bilateral electroconvulsive therapy. Long-term follow-up.". Arch Gen Psychiatry 38: 89-95. PMID 7458573.
  15. ↑ Calev A (1994). "Neuropsychology and ECT: past and future research trends.". Psychopharmacol Bull 30: 461-9. PMID 7878183.
  16. ↑ Rose D et al. (2003). "Patients' perspectives on electroconvulsive therapy: systematic review". Br Med J 326: 1323–67. PMID 12816822.
  17. ↑ Breeding, John (2003). The Necessity of Madness: Explaining How Psychiatry Is a Clinical Construct and Madness Is a Metaphor. Chipmunkapublishing, 460. 0954221877. 
  18. ↑ Janicak et al. (1985)
  19. ↑ Depression Guideline Panel (1993); [3]
  20. ↑ The Mental Health Act Commission: "In Place of Fear? eleventh biennial report, 2003-2005" p 236. The Stationery Office, 2005
  21. ↑ Prien & Kupfer (1986); Thase (1993)
  22. ↑ Evans et al (1992)
  23. ↑ Cerletti U, Bini L (1938). "L'Elettroshock". Arch Gen Neurol Psychiat Psycoanal 19: 266–8.
  24. ↑ Cameron DG (1994). "ECT: sham statistics, the myth of convulsive therapy, and the case for consumer misinformation". J Mind Behav 15: 177–98.
  25. ↑ Rose (2005)
  26. ↑ Dukakis, K; Tye L (2006). Shock: The healing power of electroconvulsive therapy. Avery/Penguin. 
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