Defining Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is a treatment method that is sometimes used to treat psychiatric disorders, such as major depression, that do not respond to other forms of treatment (psychotherapy or pharmacological treatments).
During treatment, a convulsion, or seizure, is induced by the application of electrical current to the brain. It is unclear exactly how ECT works, but research suggests that it helps by shocking the brain and reducing the number of neural connections involved in depression or other illnesses, thereby stimulating the creation of new connections in other areas of the brain. Some research suggests that ECT may stimulate an increased production of neurotrophic growth factors such as the brain derived neurotrophic factor (BDNF), causing migration and proliferation of progenitor cells and growth of new neurons in the hippocampus. The average treatment requires 2–3 sessions a week. The total number of treatments may vary, but generally between 6 and 12 total treatments are recommended.
ECT machine
The Thymatron IV is a machine used for electroconvulsive therapy.
History of Electroconvulsive Therapy
Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna, who is widely considered to be the father of convulsive therapy. However, Meduna used camphor, and later metrazol, rather than electricity, to induce seizures. Italian professor of neuropsychiatry Ugo Cerletti, who had been experimenting with using electric shocks to produce seizures in animals, developed the idea of using electricity as a substitute for metrazol in convulsive therapy. In 1937, he and his colleagues tested electroconvulsive therapy for the first time on a person. Once they started trials on patients they found that after 10 to 20 treatments patients had improved greatly, though they experienced memory loss. This had benefits, however, as patients could not remember the treatments and had no ill feelings toward them. ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening, and more convenient.
The steady growth of antidepressant use along with negative depictions of ECT in the mass media led to a marked decline in the use of ECT, or "shock therapy" as it was sometimes called, during the 1950s to the 1970s. The U.S. surgeon general stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given, and that these (now obsolete) practices were causing misperceptions about the way ECT was used.
Because of this backlash, national institutions reviewed past practices and set new standards. In 1978, the American Psychiatric Association released its first task-force report in which new standards for consent were introduced and the use of unilateral electrode placement was recommended. The 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task-force report in 1990, where specific details on the delivery, education, and training of ECT were documented. Finally in 2001, the American Psychiatric Association released its latest task-force report. This report emphasizes the importance of informed consent, and the expanded role that the procedure has in modern medicine.
Efficacy of Electroconvulsive Therapy
ECT is a safe procedure with a mortality rate calculated to approximately 0.2 per 100,000 treatments. It is currently used in the treatment of major depressive disorder, mania, schizophrenia, and catatonia. It has different levels of efficacy depending on the disorder it is called on to treat.
Major Depressive Disorder
For major depressive disorder, ECT is generally used only when other treatments have failed, or in emergencies, such as imminent suicide. A meta-analysis done on the effectiveness of ECT in unipolar and bipolar depression was conducted in 2012. Findings showed that, although patients with unipolar depression and bipolar depression responded to other medical treatments very differently, both groups responded equally well to ECT. Overall remission rate for patients with unipolar depression after a round of ECT treatment was 51.5%, and 50.9% in those with bipolar depression. When ECT was followed by treatment with antidepressants, about 50% of people relapsed by 12 months following successful initial treatment with ECT, with about 37% relapsing within the first 6 months. About twice as many relapsed with no antidepressants.
Catatonia
ECT is generally a second-line treatment for people with catatonia who don't respond to other treatments, but is a first-line treatment for severe or life-threatening catatonia. There is a lack of clinical evidence for its efficacy but it has been used successfully in the treatment of this disorder.
Mania
ECT is used to treat people who have severe or prolonged mania; however, it is recommended only in life-threatening situations or when other treatments have failed.
Schizophrenia
ECT is rarely used in treatment-resistant schizophrenia, but is sometimes recommended for schizophrenia when short-term global improvement is desired, or the subject shows little response to antipsychotics alone.
Criticisms of Electroconvulsive Therapy
In the past, ECT was called "electroshock therapy" and "shock treatments." For many years it was distrusted as a form of therapy because of its early years, in which it was a very traumatic experience. A major contributor to the public's mistrust of ECT was the film (and the novel it was based on) One Flew Over the Cuckoo's Nest, which portrayed ECT as dangerous and cruel.
Today, ECT is generally more well-regarded, and controversies surrounding its use are due to its side effects. The physical side effects of ECT include short-term nausea, headaches, muscle pain, dental injuries and oral lacerations, and myalgia. These effects seem to be short-lived and respond to symptomatic treatment. Of much more concern are the cognitive side effects and transient confusion that have been reported. Memory loss and problems forming new memories, word-finding difficulties, and deficits in memory may continue for longer periods of time, making this approach to treatment highly controversial. Memory loss occurs to some extent in almost all ECT recipients. The American Psychiatric Association report acknowledged in 2001 that ECT can lead to "persistent or permanent memory loss." It is the effects of ECT on long-term memory that give rise to much of the concern surrounding its use today.