note: I have put this article on the ect.org web site, rather than a link to the APA site, after many complaints that the APA site is difficult to access (i.e. busy and slow). However, it is from the APA's site.
Electroconvulsive Therapy (ECT)
This article provided by the American Psychiatric Association
Electroconvulsive Therapy, more commonly known as "ECT," is a medical
treatment performed only by highly skilled health professionalsincluding
doctors and nursesunder the direct supervision of a psychiatrist, who is a
medical doctor trained in diagnosing and treating mental illnesses. Its
effectiveness in treating severe mental illnesses is recognized by the
American Psychiatric Association, the American Medical Association, the
National Institute of Mental Health and similar organizations in Canada,
Great Britain and many other countries.
A course of treatment with ECT usually consists of six to twelve treatments
given three times a week for a month or less. The patient is given general
anesthesia and a muscle relaxant. When these have taken full effect, the
patient's brain is stimulated, using electrodes placed at precise locations
on the patient's head, with a brief controlled series of electrical pulses.
This stimulus causes a seizure within the brain which lasts for
approximately a minute. Because of the muscle relaxants and anesthesia, the
patient's body does not convulse and the patient feels no pain. The patient
awakens after five to ten minutes, much as he or she would from minor
surgery.
How ECT Works
The brain is an organ that functions through complex electrochemical
processes, which may be impaired by certain types of mental illnesses.
Scientists believe ECT acts by temporarily altering some of these processes.
Indications for Use
Electroconvulsive therapy is generally used with severely depressed patients
when other forms of therapysuch as medications or psychotheraphave not been
effective, cannot be tolerated, or (in lifethreatening cases) will not help
the patient quickly enough. ECT also helps patients who suffer with most
forms of mania (a mood disorder which is associated with grandiose,
hyperactive, irrational and destructive behavior), some forms of
schizophrenia, and a few other mental and neurological disorders. ECT is
also useful in treating these mental illnesses in older patients for whom a
particular medication may be unadvisable.
Extent of Use
Psychiatrists are very selective in their use of electroconvulsive therapy.
According to the National Institute of Mental Health, approximately 33,000
hospitalized Americans received ECT in 1980, the last year for which NIMH
has figures. That comes out to only about two tenths of one percent of the
9.4 million who suffer with depression, the four million who suffer with
schizophrenia and the more than one million who suffer with mania during any
given year. Some patientsa minorityalso undergo ECT as an outpatient
procedure.
Effectiveness
Numerous studies since the 1940s have demonstrated ECT's effectiveness.
Clinical evidence indicates that for uncomplicated cases of severe major
depression, ECT will produce a substantial improvement in at least 80
percent of patients (1). ECT has also been shown to be effective in
depressed patients who do not respond to other forms of treatment (2).
Medication is usually the treatment of choice for mania, but here too
certain patients don't respond. Many of these patients have been
successfully treated with ECT (3).
Risks
Any medical procedure entails a certain amount of risk. However ECT is no
more dangerous than minor surgery under general anesthesia, and may at times
be less dangerous than treatment with antidepressant medications. This is in
spite of its frequent use with the elderly and those with coexisting medical
illnesses (1,4). A small number of other medical disorders increase the risk
associated with ECT, and patients are carefully screened for these
conditions before a psychiatrist will recommend them for the treatment.
Side Effects
Immediate side effects from ECT are rare except for headaches, muscle ache
or soreness, nausea and confusion, usually occuring during the first few
hours following the procedure. Over the course of ECT, it may be more
difficult for patients to remember newly learned information, though this
difficulty disappears over the days and weeks following completion of the
ECT course. Some patients also report a partial loss of memory for events
that occurred during the days, weeks, and months preceding ECT. While most
of these memories typically return over a period of days to months following
ECT, some patients have reported longerlasting problems with recall of these
memories. However, other individuals actually report improved memory ability
following ECT, because of its ability to remove the amnesia that is
sometimes associated with severe depression. The amount and duration of
memory problems with ECT vary with the type of ECT that is used and are less
a concern with unilateral ECT (where one side of the head is stimulated
electrically) than with bilateral ECT.
Myths About Brain Damage
Researchers have found no evidence that ECT damages the brain (5,6). There
are medical conditions such as epilepsy that cause spontaneous seizures which,
unless prolonged or otherwise complicated, do not harm the brain. ECT
artificially stimulates a seizure; but ECTinduced seizures occur under much
more controlled conditions than those that are "naturally occurring" and are
safe. A recent study by Coffey and colleagues (7) found no changes in brain
anatomy with ECT, as measured by very sensitive scans of the brain using
magnetic resonance imaging (MRI) equipment. Other research has established
that the amount of electricity which actually enters the brain, (only a
small fraction of what is applied to the scalp) is much lower in intensity
and shorter in duration than that which would be necessary to damage brain
tissue (5).
Restrictions
The idea of ECT is frightening to many people, thanks in part to its
depiction in the film "One Flew Over the Cuckoo's Nest." Some may not know
that muscle relaxants and anesthesia make it a safe, practically painless
procedure.
Some people who advocate legislative bans against ECT are former psychiatric
patients who have undergone the procedure and believe they have been harmed
by it and that the treatment is used to punish patients' misbehavior and
make them more docile. This is untrue.
It is true that many years ago, when psychiatric knowledge was less
advanced, ECT was used for a wide range of psychiatric problems, sometimes
even to control troublesome patients. The procedure was frightening for
patients because it was then administered without anesthesia or muscle
relaxants, and the uncontrolled seizures sometimes broke bones.
Today, the American Psychiatric Association has very strict guidelines for
ECT administration. This organization supports use of ECT only to treat
severe, disabling mental disorders; never to control behavior.
Patient Rights
No psychiatrist simply "decides" to treat a patient with ECT. Before he or
she can administer ECT, he or she must first obtain written consent from the
patient or (in most states), if the patient is too ill to make decisions for
him or herself, from a courtappointed guardian (usually one of the patient's
family members).
Under the APA's recommended "informed consent" protocol, permission to
administer ECT comes after a careful review of the treatment. This review is
not a simple recitation of dry, confusing facts; the psychiatrist explains
in clear language what ECT involves, what other treatments might be
available, and the benefits and risks these procedures may entail. The
patient or family member is informed of when, where, and by whom the
treatment will be administered and the number of treatments expected.
Questions are encouraged. The person consenting to the procedure is kept
informed of progress as the treatment continues, and may withdraw consent at
any time.
Costs
The costs for any psychiatric treatment vary widely, depending on the state
and the facility administering it. Usually, however, ECT costs between $300
and $800 per treatment, an amount which covers the psychiatrist,
anesthetist, and a variety of hospital charges. With eight as the average
number of treatments, this means a course of ECT treatment will usually cost
between $2,400 and $6,400. The cost of ECT is at least partially reimbursed
by most insurance plans offering coverage for mental disorders. In cases
where the use of ECT shortens the duration of a hospital stay, its net cost
may be substantially less.
Bibliography
1. Weiner RD, Coffey CE: Indications for use of electroconvulsive therapy,
in Review of Psychiatry, Vol 7. Edited by Frances AJ, Hales RE. Washington,
DC: American Psychiatric Press Inc., pp 45881, 1988
2. Sackheim, HA, Prudic J, Devanand DP: Treatment of medicationresistant
depres sion with electroconvulsive therapy, in Review of Psychiatry, Vol. 9.
Edited by Tasman A, Goldfinger SM, Kaufman CA, Washington, DC: American
Psychiatric Press, Inc., pp 91115, 1990
3. Small JG, Klapper MH, Kellams JJ, Miller MJ, Milstein V, Sharpley PH,
Small IF: Electroconvulsive treatment compared with lithium in the
management of manic states. Arch Gen Psychiatry 45:72732, 1988
4. Weiner RD, Coffey CE: Electroconvulsive therapy in the medical and
neurological patient, in Psychiatric Care of the Medical Patient. Edited by
Stoudemire A, Fogel B. New York: Oxford University Press, pp 207224, 1993
5. Weiner RD: Does ECT cause brain damage? Brain Behav Sci 7:153, 1984
6. Meldrum BS: Neuropathological consequences of chemically and
electrically induced seizures. Ann NY Acad Sci 462:18693, 1986
7. Coffey CE, Weiner RD, Djang WT, Figiel GS, Soady SAR, Patterson LJ, Holt
PD, Spritzer CE, Wilkinson WE: Brain ana tomic effects of ECT: A prospective
Magnetic resonance imaging study. Archives of General Psychiatry
115:10131021, 1991
8. American Psychiatric Association: The Practice of ECT: Recommendations
for Treatment, Training, and Privileging. Washington, DC: American
Psychiatrc Press Inc., 1990
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