Electroconvulsive therapy (ECT), formerly known as electroshock therapy, and often referred to as shock treatment, is a psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders. The ECT procedure was first conducted in 1938 and is the only currently used form of shock therapy in psychiatry. ECT is often used with informed consent as a last line of intervention for major depressive disorder, mania, and catatonia. ECT machines have been placed in the Class III category by the United States Food and Drug Administration (FDA) since 1976.
A round of ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or bipolar. Follow-up treatment is still poorly studied, but about half of people who respond relapse within 12 months. Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia.:259 Immediately following treatment, the most common adverse effects are confusion and memory loss. Among treatments for severely depressed pregnant women ECT is one of the least harmful to the gestating fetus.
A usual course of ECT involves multiple administrations, typically given two or three times per week until the patient is no longer suffering symptoms. ECT is administered under anesthetic with a muscle relaxant. Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and symptom remission. Placement can be bilateral, in which the electric current is passed across the whole brain, or unilateral, in which the current is passed across one hemisphere of the brain. Bilateral placement seems to have greater efficacy than unilateral, but also carries greater risk of memory loss. After treatment, drug therapy is usually continued, and some patients receive maintenance ECT.
MECTA spECTrum 5000Q with electroencephalography (EEG) in a modern ECT suite
|Synonyms||Electroshock therapy, shock treatment|
ECT is used with informed consent in treatment-resistant major depressive disorder, treatment-resistant catatonia, or prolonged or severe mania, and in conditions where "there is a need for rapid, definitive response because of the severity of a psychiatric or medical condition (e.g., when illness is characterized by stupor, marked psycho-motor retardation, depressive delusions or hallucinations, or life-threatening physical exhaustion associated with mania)."
For major depressive disorder, ECT is generally used only when other treatments have failed, or in emergencies, such as imminent suicide. ECT has also been used in selected cases of depression occurring in the setting of multiple sclerosis, Parkinson's disease, Huntington's chorea, developmental delay, brain arteriovenous malformations and hydrocephalus.
A meta-analysis on the effectiveness of ECT in unipolar and bipolar depression was conducted in 2012. Results indicated 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 given a round of ECT treatment was 51.5% for those with unipolar depression and 50.9% for those with bipolar depression. The severity of each patient’s depression was assessed at the same baseline in each group.
There is little agreement on the most appropriate follow-up to ECT for people with major depressive disorder. When ECT is 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. Most of the evidence for continuation therapy is with tricyclics; evidence for relapse prevention with newer antidepressants is lacking.
In 2004, a meta-analytic review paper found in terms of efficacy, "a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus TCAs and ECT versus MAOIs."
In 2003, The UK ECT Review group published a systematic review and meta-analysis comparing ECT to placebo and antidepressant drugs. This meta-analysis demonstrated a large effect size (high efficacy relative to the mean in terms of the standard deviation) for ECT versus placebo, and versus antidepressant drugs.
Compared with transcranial magnetic stimulation for people with treatment-resistant major depressive disorder, ECT relieves depression about twice as well, reducing the score on the Hamilton Rating Scale for Depression by about 15 points, while TMS reduced it by 9 points.
ECT is generally a second-line treatment for people with catatonia who do not 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 "the excellent efficacy of ECT in catatonia is generally acknowledged". For people with autism spectrum disorders who have catatonia, there is little published evidence about the efficacy of ECT; as of 2014 there were twelve case reports, and while ECT had "life saving" efficacy in some, results were mixed and temporary, and maintenance ECT was necessary to sustain any benefit.
ECT is used to treat people who have severe or prolonged mania; NICE recommends it only in life-threatening situations or when other treatments have failed and as a second-line treatment for bipolar mania.
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. It is useful in the case of severe exacerbations of catatonic schizophrenia, whether excited or stuporous.
Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia; the U.S. Surgeon General's report says that there are "no absolute health contraindications" to its use.:259 Immediately following treatment, the most common adverse effects are confusion and memory loss. It must be used very cautiously in people with epilepsy or other neurological disorders because by its nature it provokes small tonic-clonic seizures, and so would likely not be given to a person whose epilepsy is not well controlled. Some patients experience muscle soreness after ECT. This is due to the muscle relaxants given during the procedure and rarely due to muscle activity. ECT, especially if combined with deep sleep therapy, may lead to brain damage if administered in such a way as to lead to hypoxia or anoxia in the patient. The death rate due to ECT is around 4 per 100,000 procedures. There is evidence and rationale to support giving low doses of benzodiazepines or else low doses of general anesthetics which induce sedation but not anesthesia to patients to reduce adverse effects of ECT.
While there are no absolute contraindications for ECT, there is increased risk for patients who have unstable or severe cardiovascular conditions or aneurysms; who have recently had a stroke; who have increased intracranial pressure (for instance, due to a solid brain tumor), or who have severe pulmonary conditions, or who are generally at high risk for receiving anesthesia.:30
In adolescents, ECT is highly efficient for several psychiatric disorders, with few and relatively benign adverse effects.
In a study published in 2017 which involved 30 National Health Service (NHS) patients from Worcestershire, 80% said they would readily have the treatment again although 37% said it was frightening.
Retrograde amnesia occurs to some extent in almost all ECT recipients. The American Psychiatric Association report (2001) acknowledges: “In some patients the recovery from retrograde amnesia will be incomplete, and evidence has shown that ECT can result in persistent or permanent memory loss”. It is the purported effects of ECT on long-term memory that give rise to much of the concern surrounding its use.
However, the methods used to measure memory loss are generally poor, and their application to people with depression, who have cognitive deficits including problems with memory, have been problematic.
The acute effects of ECT can include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment). Memory loss and confusion are more pronounced with bilateral electrode placement rather than unilateral, and with outdated sine-wave rather than brief-pulse currents. The use of either constant or pulsing electrical impulses also varied the memory loss results in patients. Patients who received pulsing electrical impulses as opposed to a steady flow seemed to incur less memory loss. The vast majority of modern treatment uses brief pulse currents.
Retrograde amnesia is most marked for events occurring in the weeks or months before treatment, with one study showing that although some people lose memories from years prior to treatment, recovery of such memories was "virtually complete" by seven months post-treatment, with the only enduring loss being memories in the weeks and months prior to the treatment. Anterograde memory loss is usually limited to the time of treatment itself or shortly afterwards. In the weeks and months following ECT these memory problems gradually improve, but some people have persistent losses, especially with bilateral ECT. One published review summarizing the results of questionnaires about subjective memory loss found that between 29% and 55% of respondents believed they experienced long-lasting or permanent memory changes. In 2000, American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with more persistently impaired memory of public events as compared to RUL ECT.
Considerable controversy exists over the effects of ECT on brain tissue, although a number of mental health associations—including the American Psychiatric Association—have concluded that there is no evidence that ECT causes structural brain damage. A 1999 report by the U.S. Surgeon General states: "The fears that ECT causes gross structural brain pathology have not been supported by decades of methodologically sound research in both humans and animals."
Many expert proponents of ECT maintain that the procedure is safe and does not cause brain damage. Dr. Charles Kellner, a prominent ECT researcher and former chief editor of the Journal of ECT, stated in a 2007 interview that, "There are a number of well-designed studies that show ECT does not cause brain damage and numerous reports of patients who have received a large number of treatments over their lifetime and have suffered no significant problems due to ECT." Dr. Kellner cites a study purporting to show an absence of cognitive impairment in eight subjects after more than 100 lifetime ECT treatments. Dr. Kellner stated "Rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness."
If steps are taken to decrease potential risks, ECT is generally accepted to be relatively safe during all trimesters of pregnancy, particularly when compared to pharmacological treatments. Suggested preparation for ECT during pregnancy includes a pelvic examination, discontinuation of nonessential anticholinergic medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate antacid. During ECT, elevation of the pregnant woman's right hip, external fetal cardiac monitoring, intubation, and avoidance of excessive hyperventilation are recommended. In many instances of active mood disorder during pregnancy, the risks of untreated symptoms may outweigh the risks of ECT. Potential complications of ECT during pregnancy can be minimized by modifications in technique. The use of ECT during pregnancy requires thorough evaluation of the patient’s capacity for informed consent.
Whether psychiatric medications are terminated prior to treatment or maintained, varies.:1885 However, drugs that are known to cause toxicity in combination with ECT, such as lithium, are discontinued, and benzodiazepines, which increase seizure thresholds, are either discontinued, a benzodiazepine antagonist is administered at each ECT session, or the ECT treatment is adjusted accordingly.:1879:1875
The placement of electrodes, as well as the dose and duration of the stimulation is determined on a per-patient basis.:1881
In unilateral ECT, both electrodes are placed on the same side of the patient's head. Unilateral ECT may be used first to minimize side effects such as memory loss.
In bilateral ECT, the two electrodes are placed on opposite sides of the head. Usually bitemporal placement is used, whereby the electrodes are placed on the temples. Uncommonly bifrontal placement in used; this involves positioning the electrodes on the patient's forehead, roughly above each eye.
Unilateral ECT is thought to cause fewer cognitive effects than bilateral treatment, but is less effective unless administered at higher doses.:1881 Most patients in the US and almost all in the UK receive bilateral ECT.
The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT.:1881 Below these levels treatment may not be effective in spite of a seizure, while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe cognitive impairment without additional therapeutic gains. Seizure threshold is determined by trial and error ("dose titration"). Some psychiatrists use dose titration, some still use "fixed dose" (that is, all patients are given the same dose) and others compromise by roughly estimating a patient's threshold according to age and sex. Older men tend to have higher thresholds than younger women, but it is not a hard and fast rule, and other factors, for example drugs, affect seizure threshold.
Immediately prior to treatment, a patient is given a short-acting anesthetic such as methohexital, etomidate, or thiopental, a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation.:1882 In a minority of countries such as Japan, India, and Nigeria, ECT may be used without anesthesia. The Union Health Ministry of India recommended a ban on ECT without anesthesia in India's Mental Health Care Bill of 2010 and the Mental Health Care Bill of 2013. Some psychiatrists in India argued against the ban on unmodified ECT due to a lack of trained anesthesiologists available to administer ECT with anesthesia. The practice was abolished in Turkey's largest psychiatric hospital in 2008.
The patient's EEG, ECG, and blood oxygen levels are monitored during treatment.:1882
ECT is usually administered three times a week, on alternate days, over a course of two to four weeks.:1882–1883
Most modern ECT devices deliver a brief-pulse current, which is thought to cause fewer cognitive effects than the sine-wave currents which were originally used in ECT. A small minority of psychiatrists in the US still use sine-wave stimuli. Sine-wave is no longer used in the UK or Ireland. Typically, the electrical stimulus used in ECT is about 800 milliamps and has up to several hundred watts, and the current flows for between one and 6 seconds.
In the US, ECT devices are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and Mecta. In the UK, the market for ECT devices was long monopolized by Ectron Ltd, which was set up by psychiatrist Robert Russell.
Despite decades of research, the exact mechanism of action of ECT remains elusive. Neuroimaging studies in people who have had ECT, investigating differences between responders and nonresponders, and people who relapse, find that responders have anticonvulsant effects mostly in the frontal lobes, which corresponds to immediate responses, and neurotrophic effects primarily in the medial temporal lobe. The anticonvulsant effects are decreased blood flow and decreased metabolism, while the neurotrophic effects are opposite - increased perfusion and metabolism, as well as increased volume of the hippocampus.
As of 2001, it was estimated that about one million people received ECT annually.
There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists. International practice varies considerably from widespread use of the therapy in many Western countries to a small minority of countries that do not use ECT at all, such as Slovenia.
About 70 percent of ECT patients are women. This may be due to the fact that women are more likely to be diagnosed with depression. Older and more affluent patients are also more likely to receive ECT. The use of ECT is not as common in ethnic minorities.
Sarah Hall reports, "ECT has been dogged by conflict between psychiatrists who swear by it, and some patients and families of patients who say that their lives have been ruined by it. It is controversial in some European countries such as the Netherlands and Italy, where its use is severely restricted".
ECT became popular in the US in the 1940s. At the time, psychiatric hospitals were overrun with patients whom doctors were desperate to treat and cure. Whereas lobotomies would reduce a patient to a more manageable submissive state, ECT helped to improve mood in those with severe depression. A survey of psychiatric practice in the late 1980s found that an estimated 100,000 people received ECT annually, with wide variation between metropolitan statistical areas. Accurate statistics about the frequency, context and circumstances of ECT in the US are difficult to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information. In 13 of the 50 states, the practice of ECT is regulated by law. One state which does report such data is Texas, where, in the mid-1990s, ECT was used in about one third of psychiatric facilities and given to about 1,650 people annually. Usage of ECT has since declined slightly; in 2000–01 ECT was given to about 1500 people aged from 16 to 97 (in Texas it is illegal to give ECT to anyone under sixteen). ECT is more commonly used in private psychiatric hospitals than in public hospitals, and minority patients are underrepresented in the ECT statistics. In the United States, ECT is usually given three times a week; in the United Kingdom, it is usually given twice a week. Occasionally it is given on a daily basis. A course usually consists of 6–12 treatments, but may be more or fewer. Following a course of ECT some patients may be given continuation or maintenance ECT with further treatments at weekly, fortnightly or monthly intervals. A few psychiatrists in the US use multiple-monitored ECT (MMECT), where patients receive more than one treatment per anesthetic. Electroconvulsive therapy is not a required subject in US medical schools and not a required skill in psychiatric residency training. Privileging for ECT practice at institutions is a local option: no national certification standards are established, and no ECT-specific continuing training experiences are required of ECT practitioners.
In the UK in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then to about 12,000 per annum in 2002. It is still used in nearly all psychiatric hospitals, with a survey of ECT use from 2002 finding that 71 percent of patients were women and 46 percent were over 65 years of age. Eighty-one percent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. Sixteen percent were treated without their consent. In 2003, the National Institute for Health and Care Excellence, a government body which was set up to standardize treatment throughout the National Health Service in England and Wales, issued guidance on the use of ECT. Its use was recommended "only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode".
The guidance received a mixed reception. It was welcomed by an editorial in the British Medical Journal but the Royal College of Psychiatrists launched an unsuccessful appeal. The NICE guidance, as the British Medical Journal editorial points out, is only a policy statement and psychiatrists may deviate from it if they see fit. Adherence to standards has not been universal in the past. A survey of ECT use in 1980 found that more than half of ECT clinics failed to meet minimum standards set by the Royal College of Psychiatrists, with a later survey in 1998 finding that minimum standards were largely adhered to, but that two-thirds of clinics still fell short of current guidelines, particularly in the training and supervision of junior doctors involved in the procedure. A voluntary accreditation scheme, ECTAS, was set up in 2004 by the Royal College, but as of 2006 only a minority of ECT clinics in England, Wales, Northern Ireland and the Republic of Ireland have signed up.
The Mental Health Act 2007 allows people to be treated against their will. This law has extra protections regarding ECT. A patient capable of making the decision can decline the treatment, and in that case treatment cannot be given unless it will save that patient's life or is immediately necessary to prevent deterioration of the patient's condition. A patient may not be capable of making the decision (they "lack capacity"), and in that situation ECT can be given if it is appropriate and also if there are no advance directives that prevent the use of ECT.
ECT was introduced in China in the early 1950s and while it was originally practiced without anesthesia, as of 2012 almost all procedures were conducted with it. As of 2012, there are approximately 400 ECT machines in China, and 150,000 ECT treatments are performed each year. Chinese national practice guidelines recommend ECT for the treatment of schizophrenia, depressive disorders, and bipolar disorder and in the Chinese literature, ECT is an effective treatment for schizophrenia and mood disorders. Although the Chinese government stopped classifying homosexuality as an illness in 2001, electroconvulsive therapy is still used by some establishments as a form of "conversion therapy".
As early as the 16th century, agents to induce seizures were used to treat psychiatric conditions. In 1785, the therapeutic use of seizure induction was documented in the London Medical Journal. As to its earliest antecedents one doctor claims 1744 as the dawn of electricity's therapeutic use, as documented in the first issue of Electricity and Medicine. Treatment and cure of hysterical blindness was documented eleven years later. Benjamin Franklin wrote that an electrostatic machine cured "a woman of hysterical fits." In 1801, Giovanni Aldini used galvanism to treat patients suffering from various mental disorders. G.B.C. Duchenne, the mid-19th century "Father of Electrotherapy", said its use was integral to a neurological practice.
In the second half of the 19th century, such efforts were frequent enough in British asylums as to make it notable.
Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then metrazol (cardiazol). Meduna is thought to be the father of convulsive therapy. In 1937, the first international meeting on convulsive therapy was held in Switzerland by the Swiss psychiatrist Muller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide. Italian Professor of neuropsychiatry Ugo Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his colleague Lucio Bini developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1938, experimented for the first time on a person. It was believed early on that inducing convulsions aided in helping those with severe schizophrenia but later found to be most useful with affective disorders such as depression. Cerletti had noted a shock to the head produced convulsions in dogs. The idea to use electroshock on humans came to Cerletti when he saw how pigs were given an electric shock before being butchered to put them in an anesthetized state. Cerletti and Bini practiced until they felt they had the right parameters needed to have a successful human trial. Once they started trials on patients, they found that after 10-20 treatments the results were significant. Patients had much improved. A positive side effect to the treatment was retrograde amnesia. It was because of this side effect that patients could not remember the treatments and had no ill feelings toward it. ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening and more convenient. Cerletti and Bini were nominated for a Nobel Prize but did not receive one. By 1940, the procedure was introduced to both England and the US. In Germany and Austria, it was promoted by Friedrich Meggendorfer. Through the 1940s and 1950s, the use of ECT became widespread.
In the early 1940s, in an attempt to reduce the memory disturbance and confusion associated with treatment, two modifications were introduced: the use of unilateral electrode placement and the replacement of sinusoidal current with brief pulse. It took many years for brief-pulse equipment to be widely adopted. In the 1940s and early 1950s ECT, was usually given in "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones. In the 1940s, psychiatrists began to experiment with curare, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction of suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to the more widespread use of "modified" ECT. A short-acting anesthetic was usually given in addition to the muscle relaxant in order to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants.
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 during the 1950s to the 1970s. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given, and that "these now-antiquated practices contributed to the negative portrayal of ECT in the popular media." The New York Times described the public's negative perception of ECT as being caused mainly by one movie: "For Big Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and, in the public mind, shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".
In 1976, Dr. Blatchley demonstrated the effectiveness of his constant current, brief pulse device ECT. This device eventually largely replaced earlier devices because of the reduction in cognitive side effects, although as of 2012 some ECT clinics still were using sine-wave devices. The 1970s saw the publication of the first American Psychiatric Association (APA) task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001). The report endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT. Specifically, critics pointed to shortcomings such as noted side effects, the procedure being used as a form of abuse, and uneven application of ECT. The use of ECT declined until the 1980s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression". In 1985, the National Institute of Mental Health and National Institutes of Health convened a consensus development conference on ECT and concluded that, while ECT was the most controversial treatment in psychiatry and had significant side-effects, it had been shown to be effective for a narrow range of severe psychiatric disorders.
Because of the backlash noted previously, 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. By 2017, ECT was routinely covered by insurance companies for providing the "biggest bang for the buck" for otherwise intractable cases of severe mental illness, was receiving favorable media coverage, and was being provided in regional medical centers.
Surveys of public opinion, the testimony of former patients, legal restrictions on the use of ECT and disputes as to the efficacy, ethics and adverse effects of ECT within the psychiatric and wider medical community indicate that the use of ECT remains controversial. This is reflected in the January 2011 vote by the FDA's Neurological Devices Advisory Panel to recommend that FDA maintain ECT devices in the Class III device category for high risk devices except for patients suffering from catatonia. This may result in the manufacturers of such devices having to do controlled trials on their safety and efficacy for the first time. In justifying their position, panelists referred to the memory loss associated with ECT and the lack of long-term data.
In the US, this doctrine places a legal obligation on a doctor to make a patient aware of the reason for treatment, the risks and benefits of a proposed treatment, the risks and benefits of alternative treatment, and the risks and benefits of receiving no treatment. The patient is then given the opportunity to accept or reject the treatment. The form states how many treatments are recommended and also makes the patient aware that consent may be revoked and treatment discontinued at any time during a course of ECT. The US Surgeon General's Report on Mental Health states that patients should be warned that the benefits of ECT are short-lived without active continuation treatment in the form of drugs or further ECT, and that there may be some risk of permanent, severe memory loss after ECT. The report advises psychiatrists to involve patients in discussion, possibly with the aid of leaflets or videos, both before and during a course of ECT.
To demonstrate what he believes should be required to fully satisfy the legal obligation for informed consent, one psychiatrist, working for an anti-psychiatry organisation, has formulated his own consent form using the consent form developed and enacted by the Texas Legislature as a model.
According to the US Surgeon General, involuntary treatment is uncommon in the US and is typically used only in cases of great extremity, and only when all other treatment options have been exhausted. The use of ECT is believed to be a potentially life-saving treatment.
In one of the few jurisdictions where recent statistics on ECT usage are available, a national audit of ECT by the Scottish ECT Accreditation Network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent.
In the UK, in order for consent to be valid it requires an explanation in "broad terms" of the nature of the procedure and its likely effects. One review from 2005 found that only about half of patients felt they were given sufficient information about ECT and its adverse effects and another survey found that about fifty percent of psychiatrists and nurses agreed with them.
A 2005 study published in the British Journal of Psychiatry described patients' perspectives on the adequacy of informed consent before ECT. The study found that "About half (45–55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not." The authors also stated:
Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form. The proportion who feel they did not freely choose the treatment has actually increased over time. The same themes arise whether the patient had received treatment a year ago or 30 years ago. Neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ECT, at least in England and Wales.
Procedures for involuntary ECT vary from country to country depending on local mental health laws.
In the US, ECT devices came into existence prior to medical devices being regulated by the Food and Drug Administration; when the law came into effect the FDA was obligated to retrospectively review already existing devices and classify them, and determine whether clinical trials were needed to prove efficacy and safety. While the FDA has classified the devices used to administer ECT as Class III medical devices, as of 2011 the FDA had not yet determined whether the devices should be withdrawn from the market until clinical trials prove their safety and efficacy.:5 The FDA considers ECT machinery to be experimental devices. In most states in the US, a judicial order following a formal hearing is needed before a patient can be forced to undergo involuntary ECT. However, ECT can also be involuntarily administered in situations with less immediate danger. Suicidal intent is a common justification for its involuntary use, especially when other treatments are ineffective.
Until 2007 in England and Wales, the Mental Health Act 1983 allowed the use of ECT on detained patients whether or not they had capacity to consent to it. However, following amendments which took effect in 2007, ECT may not generally be given to a patient who has capacity and refuses it, irrespective of his or her detention under the Act. In fact, even if a patient is deemed to lack capacity, if they made a valid advance decision refusing ECT then they should not be given it; and even if they do not have an advance decision, the psychiatrist must obtain an independent second opinion (which is also the case if the patient is under age of consent). However, there is an exception regardless of consent and capacity; under Section 62 of the Act, if the treating psychiatrist says the need for treatment is urgent they may start a course of ECT without authorization. From 2003 to 2005, about 2,000 people a year in England and Wales were treated without their consent under the Mental Health Act. Concerns have been raised by the official regulator that psychiatrists are too readily assuming that patients have the capacity to consent to their treatments, and that there is a worrying lack of independent advocacy. In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 2003 also gives patients with capacity the right to refuse ECT.
A questionnaire survey of 379 members of the general public in Australia indicated that more than 60% of respondents had some knowledge about the main aspects of ECT. Participants were generally opposed to the use of ECT on depressed individuals with psychosocial issues, on children, and on involuntary patients. Public perceptions of ECT were found to be mainly negative.
Ernest Hemingway, an American author, died by suicide shortly after ECT at the Mayo Clinic in 1961. He is reported to have said to his biographer, "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...." American surgeon and award-winning author Sherwin B. Nuland is another notable person who has undergone ECT. In his 40s, this successful surgeon's depression became so severe that he had to be institutionalized. After exhausting all treatment options, a young resident assigned to his case suggested ECT, which ended up being successful. Author David Foster Wallace also received ECT for many years, beginning as a teenager, before his suicide at age 46.
Award-winning New Zealand author Janet Frame had ECT. She later wrote about this in her novel Faces in the Water.
Electroconvulsive therapy has been depicted in fiction, including fictional works partly based on true experiences. These include Sylvia Plath's autobiographical novel, The Bell Jar, Ken Loach's film Family Life, and Ken Kesey's novel One Flew Over the Cuckoo's Nest; Kesey's novel is a direct product of his time working the graveyard shift as an orderly at a mental health facility in Menlo Park, California.
In the 2000 film Requiem for a Dream, Sarah Goldfarb receives "unmodified" electroconvulsive therapy after experiencing severe amphetamine psychosis following prolonged stimulant abuse. In the 2014 TV series Constantine, the protagonist John Constantine is institutionalized and specifically requests electroconvulsive therapy as an attempt to alleviate or resolve his mental problems.
The musical Next to Normal centers around the family of a woman who undergoes the procedure.
Robert Pirsig suffered a nervous breakdown and spent time in and out of psychiatric hospitals between 1961 and 1963. He was diagnosed with paranoid schizophrenia and clinical depression as a result of an evaluation conducted by psychoanalysts, and was treated with electroconvulsive therapy on numerous occasions, a treatment he discusses in his novel, Zen and the Art of Motorcycle Maintenance.
In the HBO series Six Feet Under season 5, George undergoes an ECT treatment to deal with his increasing paranoia. The depiction is shown realistically, with an actual ECT machine.
In the WB/CW TV series Smallville, Lionel Luthor condemns his son Lex Luthor to electroshock therapy to remove Lex's short-term memory of a murder he discovered Lionel committed.
Throughout the history of ECT, women have received it two to three times as often as men. Currently, about 70 percent of ECT patients are women. This may be due to the fact that women are more likely to be diagnosed with depression. A 1974 study of ECT in Massachusetts reported that women made up 69 percent of those given ECT. The Ministry of Health in Canada reported that from 1999 until 2000 in the province of Ontario, women were 71 percent of those given ECT in provincial psychiatric institutions, and 75 percent of the total ECT given was given to women.
ECT treatment of severely autistic children with violent, sometimes self-harming behaviour first began in parts of the US during the early years of 21st century. Each session reportedly alleviates symptoms for up to 10 days at a time, but it is not claimed as a cure. One practitioner, Charles Kellner, ECT director at Mount Sinai Hospital in New York, is so convinced ECT is effective and safe that he allowed a parent to witness a procedure and the BBC to record the intervention.
Though ECT use declined with the advent of modern antidepressants, there has been a resurgence of ECT with new modern technologies, techniques and lower side effect profile. It may be the most effective short-term treatment of depression. The 1975 film One Flew Over the Cuckoo's Nest has convinced viewers that ECT is a horrific procedure which only results in the patient's complete memory loss. Scientists have since debunked the notion that patients suffer acute memory loss after treatment, but the stigma of ECT has remained. In the last decade, physicians and patients have returned to using ECT to treat various mental illnesses including depression and bipolar disorder. In 2014, the American Psychiatric Association launched a petition to reclassify ECT as a low-risk treatment. Many pro-ECT patients have publicly come forward with their positive response to the treatment. One patient by the name of Shelley Miller claims that "medications have a success rate of 50-60% of patients getting better, while ECT succeeds at a rate of 70-90%."
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Catatonia is a state of psycho-motor immobility and behavioral abnormality manifested by stupor. It was first described in 1874 by Karl Ludwig Kahlbaum, in German: Die Katatonie oder das Spannungsirresein (Catatonia or Tension Insanity).
Though catatonia has historically been related to schizophrenia (catatonic schizophrenia), it is now known that catatonic symptoms are nonspecific and may be observed in other mental disorders and neurological conditions. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), catatonia is not recognized as a separate disorder, but is associated with psychiatric conditions such as schizophrenia (catatonic type), bipolar disorder, post-traumatic stress disorder, depression and other mental disorders, narcolepsy, as well as drug abuse or overdose (or both). It may also be seen in many medical disorders including infections (such as encephalitis), autoimmune disorders, focal neurologic lesions (including strokes), metabolic disturbances, alcohol withdrawal and abrupt or overly rapid benzodiazepine withdrawal. In the fifth edition of the DSM, it is written that a variety of medical conditions may cause catatonia, especially neurological conditions: encephalitis, cerebrovascular disease, neoplasms, head injury. Moreover, metabolic conditions: homocystinuria, diabetic ketoacidosis, hepatic encephalopathy, hypercalcaemia.It can be an adverse reaction to prescribed medication. It bears similarity to conditions such as encephalitis lethargica and neuroleptic malignant syndrome. There are a variety of treatments available; benzodiazepines are a first-line treatment strategy. Electroconvulsive therapy is also sometimes used. There is growing evidence for the effectiveness of NMDA receptor antagonists for benzodiazepine-resistant catatonia. Antipsychotics are sometimes employed but require caution as they can worsen symptoms and have serious adverse effects.Controversies about psychiatry
As long as psychiatry has existed it has been subject to controversy. Psychiatric treatments are sometimes seen to be ultimately more damaging than helpful to patients. Psychiatry is often thought to be a benign medical practice, but at times is seen by some as a coercive instrument of oppression. Psychiatry is seen to involve an unequal power relationship between doctor and patient, and critics of psychiatry claim a subjective diagnostic process, leaving much room for opinions and interpretations. In 2013, psychiatrist Allen Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests". Every society permits compulsory treatment of mental patients.Psychiatry's history involves what some view as dangerous treatments. Electroconvulsive therapy is one of these, which was used widely between the 1930s and 1960s and is still in use today. The brain surgery procedure lobotomy is another practice that was ultimately seen as too invasive and brutal. The term anti-psychiatry was coined by psychiatrist David Cooper in 1967 and is understood in current psychiatry to mean opposition to psychiatry's perceived role in many aspects of treatment.Harold A. Sackeim
Harold A. Sackeim is an American psychologist and proponent of electroconvulsive therapy. He has been Chief of the Department of Biological Psychiatry at New York State Psychiatric Institute and Professor of Clinical Psychology in Psychiatry and Radiology at Columbia University. He received his Bachelor's degree from Columbia in 1972; in 1974, he received his Master's degree from Oxford University; and in 1977 he received his Ph.D. from the University of Pennsylvania.Sackeim is co-author of more than 300 publications relating to electroconvulsive therapy. Until 2007 all of his research expounded on its positive effects. For many years he denied that electroconvulsive therapy had any permanent or negative side effects, including memory loss, despite the many complaints of individuals who had undergone the procedure. Finally, in 2007, his research found that excessive electrical dosage correlated with risk of memory loss. For many years during his research of electroconvulsive therapy, Sackheim consulted for MECTA and Somatics, companies that manufacture devices for its administration, constituting what many consider a conflict of interest. In 2007 Sackeim and his colleagues published the results of a study which followed 250 patients who had received electroconvulsive therapy. The study found that the various techniques used when giving electroconvulsive therapy can have a direct impact on the adverse effects experienced by patients. Sackeim and colleagues later demonstrated that right unilateral electroconvulsive therapy with an ultra brief pulse appears to be the most efficacious, while remaining the least likely to cause adverse effects.History of electroconvulsive therapy in the United Kingdom
Electroconvulsive therapy (ECT, in the past sometimes called electric convulsion therapy, convulsion treatment or electroplexy) is a controversial psychiatric treatment in which seizures are induced with electricity. ECT was first used in the United Kingdom in 1939 and, although its use has been declining for several decades, it was still given to about 11,000 people a year in the early 2000s.In contemporary psychiatric practice, ECT is used mainly in the treatment of depression. It is occasionally used in the treatment of other disorders such as schizophrenia. When undergoing modern ECT, a patient is given an anaesthetic and a muscle relaxant. A brief-pulse electric current of about 800 milliamperes is passed between two electrodes on the head for several seconds, causing a seizure. The resulting convulsion is modified by the muscle relaxant. ECT is usually given on an inpatient basis; about one in five treatments are given on an outpatient basis. Treatment is usually given twice a week (occasionally three times a week) for a total of 6–12 treatments, although courses may be longer or shorter. About 70 per cent of ECT patients are women. About 1,500 ECT patients a year in the UK are treated without their consent under the Mental Health Acts or the provisions of common law.History of electroconvulsive therapy in the United States
Electroconvulsive Therapy (ECT) is a controversial therapy used to treat certain mental illnesses such as major depressive disorder, schizophrenia, depressed bipolar disorder, manic excitement, and catatonia. These disorders are difficult to live with and often very difficult to treat, leaving individuals suffering for long periods of time. In general, ECT is not looked at as a first line approach to treating a mental disorder, but rather a last resort treatment when medications such as antidepressants are not helpful in reducing the clinical manifestations.
"Electroconvulsive therapy entails deliberately inducing a modified generalized seizure under medically-controlled conditions to obtain a therapeutic effect." The therapeutic effect being reduced clinical manifestations of one's mental disorder, therefore leading to less suffering. “ECT has been shown through various research trials to cause significant physiological and chemical changes at a molecular level of the brain; however, it is thought that the sustainability of ECT is threatened due to associated stigma and poor impression of the treatment itself”. In order to decrease the associated stigma and keep the treatment available to those who need it, the evidence on the efficacy needs to be publicized.Leonard Roy Frank
Leonard Roy Frank (July 15, 1932 – January 15, 2015,) was an American human rights activist, psychiatric survivor, editor, writer, aphorist, and lecturer.
Frank lived in San Francisco from 1959 until his death, where he managed an art gallery before he began collecting quotations. It was Leonard Roy Frank who discovered notable artist G. Mark Mulleian in 1969 and displayed his work at the Frank gallery.Frank graduated from the Wharton School of the University of Pennsylvania in 1954. He then served in the US Army and later sold real estate. In 1962, in San Francisco, Frank was committed to a psychiatric hospital for being 'paranoid schizophrenic' and given insulin shock therapy treatments and dozens of electroconvulsive therapy (ECT) treatments.By 1972, Frank worked at Madness Network News. In December 1973, he and Wade Hudson founded Network Against Psychiatric Assault (NAPA), a patients' and survivors' advocacy group.Of ECT, Frank wrote: "Over the last thirty-five years I have researched the various shock procedures, particularly electroshock or ECT, have spoken with hundreds of ECT survivors, and have corresponded with many others. From all these sources and my own experience, I have concluded that ECT is a brutal, dehumanizing, memory-destroying, intelligence lowering, brain-damaging, brainwashing, life-threatening technique."
Due to his years of anti-ECT testimony and activism, Linda Andre wrote in Doctors of Deception, "If Marilyn Rice was the Queen of Shock, Leonard Roy Frank was the King." The author Peter Lehmann called Frank "one of the important people who helped to develop the theory and practice of humanistic antipsychiatry" and mentioned him in Lehmann's "Expression of Gratitude on the Occasion of the Award of an Honorary Doctoral Degree by the School of Psychology of the Aristotle University of Thessaloniki (Greece), September 28, 2010".A published author, Frank compiled numerous books of quotes and passages, as well as writing about his own experiences.Linda Andre
Linda Andre is an American psychiatric survivor activist and writer, living in New York City, who is the director of the Committee for Truth in Psychiatry (CTIP), an organization founded by Marilyn Rice in 1984 to encourage the U.S. Food and Drug Administration (FDA) to regulate ECT (electroconvulsive therapy) machines.List of people who have undergone electroconvulsive therapy
This is a list of notable cases of treatment with electroconvulsive therapy (ECT).Lucio Bini
Lucio Bini (1908–1964) was an Italian psychiatrist and professor at the University of Rome La Sapienza, Italy. Together with Ugo Cerletti, a neurophysiologist and a psychiatrist, he researched and discovered the method of electroconvulsive therapy, a type of shock therapy for mental diseases.MindFreedom International
MindFreedom International is an international coalition of over one hundred grassroots groups and thousands of individual members from fourteen nations. Based in the United States, it was founded in 1990 to advocate against forced medication, medical restraints, and involuntary electroconvulsive therapy. Its stated mission is to protect the rights of people who have been labeled with psychiatric disorders. Membership is open to anyone who supports human rights, including mental health professionals, advocates, activists, and family members. MindFreedom has been recognized by the United Nations Economic and Social Council as a human rights NGO with Consultative Roster Status.Outline of psychiatry
The following outline is provided as an overview of and topical guide to psychiatry:
Psychiatry – medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive, and perceptual abnormalities.Peter Breggin
Peter Roger Breggin (born May 11, 1936) is an American psychiatrist and critic of shock treatment and psychiatric medication. In his books, he advocates replacing psychiatry's use of drugs and electroconvulsive therapy with psychotherapy, education, empathy, love, and broader human services.Breggin is the author of many books critical of psychiatric medication, including Toxic Psychiatry, Talking Back to Prozac and Talking Back to Ritalin. His most recent book, Brain-Disabling Treatments in Psychiatry, discusses his theory of medication spellbinding (in which patients are said to do worse after treatment but fail to see this or recognize why), the adverse effects of drugs and electroconvulsive therapy (ECT), the hazards of diagnosing and medicating children, Breggin's theory of a "psychopharmaceutical complex", and guidelines for psychotherapy and counseling.
Breggin now lives in the Finger Lakes Region of Central New York and practices psychiatry in Ithaca, New York.Pramiracetam
Pramiracetam is a central nervous system stimulant and nootropic agent belonging to the racetam family of drugs. It is marketed by Menarini under the brand name Pramistar as a treatment for memory and attention deficits in aging people with neurodegenerative and vascular dementias in Italy and some Eastern European countries.Pramiracetam was discovered by scientists at Parke-Davis, at that time a division of Warner-Lambert, in the late 1970s; patents expired in 1996. Warner-Lambert conducted clinical trials in Alzheimer's Disease and abandoned that indication after Phase II trials showed mixed results; it then began to develop it as an orphan drug as an adjunct to electroconvulsive therapy for major depressive disorder, in part to take advantage of the administrative exclusivity provided by the orphan status. It licensed European rights to Menarini which continued developing it for dementias, and in 1991 it licensed US and other non-European rights to Cambridge Neuroscience, Inc, (CNI) which pursued the ECT indication, as well as a use in restoring cognitive function after stroke or traumatic brain injury. CNI obtained the orphan designation for the ECT use from the FDA in 1991, which was later withdrawn when CNI abandoned the drug.CNI conducted a clinical trial in four people who had cognitive problems following a head injury. Trials conducted by or on behalf of Menarini and Warner-Lambert included two small trials conducted in Ukraine, one in people with cerebrovascular disease and another in people with concussion. Another small trial was performed in Italy, on healthy people in whom amnesia was induced with scopolamine.Psychiatric somatotherapy
Psychiatric somatotherapy (or somatic therapy) is the treatment of mental illness by physical means (such as medication, electroconvulsive therapy, or psychosurgery) rather than psychotherapy.Shock therapy (psychiatry)
Shock therapy describes a set of techniques used in psychiatry to treat depressive disorder or other illnesses, by inducing seizures or other extreme brain states.
The term "shock therapy" is a misnomer. The pathophysiological state of shock was not routinely induced by any of the therapies and does not occur at all as a result of the only treatment still in use, electroconvulsive therapy. The term was coined long before the advent of the use of electricity as a mode of treatment.
The only form in current clinical practice is electroconvulsive therapy. Other forms, no longer in use, include:
Insulin shock therapy, introduced by Sakel in 1933 for the treatment of schizophrenia.
Convulsive therapy, using pentylenetetrazol or other agents to induce seizures. The first use was with cardiazol by von Meduna of Budapest; the belief at the time was there was "some kind of biological antagonism between schizophrenia and epilepsy".
Deep sleep therapy.Treatment-resistant depression
Treatment-resistant depression (TRD) or treatment-refractory depression is a term used in clinical psychiatry to describe a condition that affects people with major depressive disorder (MDD) who do not respond adequately to a course of appropriate antidepressant medication within a certain time. Typical definitions of TRD vary, and they do not include a resistance to psychological therapies. Inadequate response has traditionally been defined as no clinical response whatsoever (e.g. no improvement in depressive symptoms). However, many clinicians consider a response inadequate if the person does not achieve full remission of symptoms. People with treatment-resistant depression who do not adequately respond to antidepressant treatment are sometimes referred to as pseudoresistant. Some factors that contribute to inadequate treatment are: early discontinuation of treatment, insufficient dosage of medication, patient noncompliance, misdiagnosis, and concurrent psychiatric disorders. Cases of treatment-resistant depression may also be referred to by which medications people with TRD are resistant to (e.g.: SSRI-resistant).Ugo Cerletti
Ugo Cerletti (26 September 1877 – 25 July 1963) was an Italian neurologist who discovered the method of electroconvulsive therapy used in psychiatry. Electroconvulsive therapy is a therapy in which electric current is used to provoke a seizure for a short duration. This therapy is used in an attempt to treat certain mental disorders, and may be useful when other possible treatments have not, or cannot, cure the person of their mental disorder.Waxy flexibility
Waxy flexibility is a psychomotor symptom of catatonia as associated with schizophrenia, bipolar disorder, or other mental disorders which leads to a decreased response to stimuli and a tendency to remain in an immobile posture. Attempts to reposition the patient are met by "slight, even resistance", and after being repositioned, the patient will typically remain in the new position. Waxy flexibility rarely occurs in cases of delirium. The presence of waxy flexibility along with at least two other catatonic symptoms such as stupor or negativism are enough to warrant a diagnosis of catatonia.If one were to move the arm of someone with waxy flexibility, the patient would keep that arm where it had been positioned until moved again, as if positioning malleable wax. Further alteration of an individual's posture is similar to bending a candle. Although waxy flexibility has historically been linked to schizophrenia, there are also other disorders which it may be associated with, such as mood disorders with catatonic behaviour.Electroconvulsive therapy is often used as a treatment for catatonia. A study has found that catatonic patients with waxy flexibility responded faster to electroconvulsive therapy, compared to patients with other symptoms of catatonia.Yang Yongxin
Yang Yongxin (Chinese: 杨永信) is a highly controversial Chinese clinical psychiatrist who advocated and practiced electroconvulsive therapy (ECT) without anesthesia or muscle relaxants as a cure for claimed Internet addiction in teenagers. Yang is currently deputy chief of the Fourth Hospital of Linyi (Linyi Mental Hospital), a hospital in Linyi, Shandong province. Yang runs the Internet Addiction Treatment Center, a boot camp at Linyi Mental Hospital specializing in treating teenage Internet addiction.
According to media reports, the families of teenaged patients sent to the hospital paid CNY 5,500 (US$805) per month for a treatment that employed psychiatric medication in addition to ECT, which Yang dubbed "xingnao" (Chinese: 醒脑, brain-waking) treatments. Yang treated nearly 3000 children with the therapy before the practice was banned by the Chinese Ministry of Health. Yang claimed that 96% of the patients treated by his electric therapy had shown improvement, a figure that was questioned by the Chinese media. After the ban, Yang has begun to use another therapeutic method he invented, known as "low-frequency pulse therapy", which is alleged by former patients to be more painful than ECT. As of year 2016, the center is still in operation, and the number of children they claimed to have treated has increased to more than 6000.