Joanna Fogg-Waberski, M.D. and Witold Waberski, M.D.

(June 2000) -- Electroconvulsive therapy (ECT) remains one of the most controversial treatments currently used in psychiatric practice despite its long-standing record of safety and efficacy. This controversy has been fueled by attention generated from the media, by the compelling testimony of former patients, and by the nature and history of the treatment itself.^1,2 A brief discussion of the origins of ECT is helpful to understanding how this dramatic form of therapy came to be incorporated in psychiatric practice and why it continues to be enigmatic to both medical practitioners and the general public.

Historically, the therapeutic value of induced convulsions was not initially linked to electricity but to other methods of inducing seizures. In the early 1930s, researchers in Europe induced convulsions by injections of insulin and later with other drugs such as camphor in oil and Metrazol (a convulsive agent). The first successful electroconvulsive treatment was described to the medical world in 1938 when two Italian psychiatrists, Ugo Cerletti and Lucio Bini, administered an electrical stimulus to induce convulsions in a human.

Since then, introducing ECT as a treatment in the United States has not been an easy matter. The United States, after all, was the country that invented the electric chair. Electrocution was used in this country for executing imprisoned murderers. Cerletti and Bini's experiment with ECT was the only other circumstance in which loss of consciousness had been induced purposefully via electric current.³ Decades ago, patients underwent ECT without anesthesia. Unmodified treatments did harm memory, so much so that memory loss came to be seen as an essential part of the treatment. Some patients experienced bone fractures from uncontrolled motor seizures induced by ECT. In addition to the physical trauma, graphic examples of abuse in books and movies (eg, Ken Kesey's "One Flew Over the Cuckoo's Nest") have portrayed ECT as punitive, cruel and violative of patients' legal rights. One can understand the concerns that have been linked to this form of therapy since its inception.⁴

With the introduction of anesthetic induction agents, muscle relaxants, and monitoring, the adverse physical effects of ECT have been significantly attenuated. This has made the procedure more acceptable to the medical community and to the general public in North America. The description "electroconvulsive therapy" came to be used in place of Cerletti's more disturbing term, "electroshock treatment." In today's psychiatric practice, ECT typically involves a series of six to 12 treatments of electrically induced grand mal seizures administered under general anesthesia to a patient with a severe emotional disorder. Examples of mental illnesses which respond best to ECT are major depression with psychosis, acute mania, and catatonia. Recent studies have expanded treatment indications to other conditions such as Neuroleptic Malignant Syndrome, Parkinsonism, and schizophrenia. While beneficial effects of electrically induced seizures are evident and predictable in most patients, a unified mechanism of action has not yet been established and remains the subject of numerous investigations. ECT treatments can be administered on an inpatient or outpatient basis depending on the severity of symptoms.

The most common side effect of ECT, feared by patients and their families, is memory loss. Cognitive deficits are known to affect patients undergoing ECT. These can be categorized as: acute, subacute, and long-term effects. Acute disturbance of orientation and memory can take place immediately following ECT with lasting effects from one to several hours. Subacute effects may persist for days or weeks following completion of the course of ECT. Although there are occasional anecdotal reports of permanent (long-term) memory loss, substantiation of these reports remains a legitimate topic for longitudinal study. Adverse cognitive effects of ECT have been reduced by the use of standardized ECT equipment delivering brief pulse stimulation (as opposed to sine wave stimulation). Unilateral electrode placement over the nondominant hemisphere also significantly reduces the patient's exposure to post-ECT memory loss. It is recommended that all patients undergoing ECT should have their cognitive functions (particularly memory) closely monitored with mental status assessments performed throughout the course of treatment. Occasionally, in patients suffering from pre-existing cognitive impairment, detailed neuropsychological testing pre- and post- ECT is necessary in order to disentangle the effects of illness from those of the treatment.⁵

continue

top . pages 1 2 . send to friend . depression site map

Reviewed: 01/2006