Electro-Convulsive Therapy (ECT )

A New Look at Old and More Modern Uses and Results

L F Lowenstein PhD
Southern England Psychological Services
2005

Abstract

Electroconvulsive therapy (ECT) is probably less controversial now than has been the case in the past. Initially ECT was viewed as a panacea for various mental illnesses. This was followed by doubt that it was really of value, especially as it was uncertain how it worked.

ECT has been viewed more recently as an ultimate way of helping those suffering from severe depression when medications have failed to bring about improvement. There is little doubt that ECT, despite the uncertainty as to how it functions, has saved lives. Severely depressed individuals are often prone to suicide and ECT has helped to reduce the numbers who are likely to become casualties.

What follows is a review of the positive and negative aspects of ECT for children, the elderly and the normal adult population.

Electro-convulsive therapy (ECT) was first developed in the 1930's by two Italian physicians, Hugo Cerletti and Lucio Bini. Its uses have altered somewhat throughout the years but its method of use has remained the same. Two electrodes are attached to a patients forehead and an electrical current of 65 to 140 volts are briefly passed through the brain, causing seizures or convulsions. More often than not there is the considerable improvement of many patients but certainly not all patients. 60 % appear to be improved (Weschler et al, 1965). In the United States it is used on tens of thousands of depressed individuals annually (Foderaero, 1993). ECT tends to be used with individuals who have severe depressive episodes and when such episodes are unresponsive to other forms of treatment (Buchan et al, 1992). Despite this its use is still controversial (Fink, 1992; Breggin, 1979).

The main opposition to its use comes from the possible side effects which include memory loss and neurological damage. There are two types of administration: bilateral ECT, where one electrode is applied to each side of the forehead, and the more commonly used unilateral ECT in which the electrodes are placed so that the current passes through only one side of the brain.

The electrical current causes a convulsion or brain seizure that last from 25 seconds to a few minutes. Patients can be put to sleep with barbiturates before the ECT is administered with no reduction of therapeutic impact. The use of muscle relaxants are also routinely used to minimise the danger of physical injury from flailing about during the convulsions. The patients tend to wake about ten minutes after the current is applied. The usual dosage consists of 6 to 9 treatments administered over 2 to 4 weeks (Lerer, 1995). The use of ECT can be traced as far back historically as Dr W. Oliver, a physician to the English Royal family in 1785 (Taylor & Carrow, 1987).

In addition to using ECT for depression, it has been used to deal with other psychoses but its effects have largely been considered to be ineffective (Taylor & Carroll, 1987). Only a small number of individuals suffering from depression have suffered significant permanent memory loss with a very large majority returning to normal functioning in a matter of months (Calev et al, 1991; 1995). At this point in time it has not been established just how or why ECT reduces depression. In addition to memory loss there have been reported symptoms such as headaches, muscle aches or muscle soreness, nausea and confusion. There are varying opinions as to how the memory is affected by ECT. Many patients report loss of memory for events that occurred in the days, weeks, or months before the ECT was administered. Many have found that their memories return although not always. For months, short term memory may be affected also but this could be due to the initial depression.

Initially in the past, ECT led to 1 death in a thousand patients. More recent research indicates a lower mortality rate of 2.9 deaths per ten thousand patients. This effect leads to controversies as to whether ECT should be used.

Nations and patients vary in their view of ECT with some considering it as a therapy that poses minimal risks and others believing it to cause side effects such as striking memory loss. There is even the view that neurological damage may be caused just because it has been shown to be effective and fast acting with severe unipolar depression (Weiner & Coffey, 1988). Currently unilateral ECT has been increasingly used. It is often combined with muscle relaxant to prevent physical injury. A typical program appears to be 6 to 9 treatments administered over 2 to 4 weeks (Lerer et al, 1995). The result tends to be less depression for many individuals following treatment (Fink, 1992). Those who criticise the use of ECT, particularly bilateral ECT in that affects memory have found that the memory appears to clear up in a matter of months (Calev et al, 1991; 1995). Long-term memory has also been found to be affected in some cases as noted by Squire (1984; 1987). A number of studies have noted an overall improvement by as much as 60 or 70 % in the use of ECT patients who suffer from unipolar depression (Ray & Walters, 1997).

More Recent Views and Research into ECT

As pointed out by Dowman et al (2005) there is still a stigma surrounding the use of ECT even in the present day and this probably remains the greatest barrier to the full acceptance of this treatment. Most research indicates a favourable response to the use of ECT. At the present time there are only a few pieces of research that indicate the negative impact of ECT. It has been found to be effective in a large number of cases but has also been criticised (Winslade, 1988; Rothman, 1985). In 1947 a psychiatric taskforce investigated ECT and issued a critical report noting that this method should not be used indiscriminately or excessively. The American Psychiatric Association, however, in 1978 endorsed the use of ECT in severe depression when drug therapy had failed to have a positive result stressing that it needed to be administered with the consent of the patient (Winslade 1988; Winslade et al, 1984).

In the United States there have been legal and judicial restrictions on the use of ECT (Cauchon, 1995). Protecting individuals from its misuse have also been recommended by Tenenbaum, 1993; Friedberg, 1975; Tien, 1975). Mollenberg (1997) emphasises that ECT often assists in the reduction of depression better than drug therapies. Similar results were obtained by Augoustides et al (2005) using anaesthesia for ECT. No post ECT nausea or vomiting were reported.

A combination of ECT and drug therapy also led to rapid improvement in a late stage idiopathic Parkinsonian disease. The co morbid conditions were depression. Because the patient did not respond to other treatment modalities, ECT was applied and a rapid improvement was observed both in the patient's neuroleptic malignant syndrome (NMS) and also in Parkinson's and in psychiatric symptoms (Ozer et al, 2005). The application of ECT allowed the patient to remain stable for a five year period with quite low doses of Levodopa (30mg/d). Later the patient had two episodes of depressive and psychotic symptoms, which were again successfully treated with the ECT. The author suggested that ECT might be an effective and life saving therapy with patients who have severe, drug resistant NMS.

Another successfully treated individual was a 48 year old male treated for hypothyroidism and a long standing history of depression. A computer tomography scan of the brain revealed atrophy in the frontal regions. This finding was significant because the patient had no history of traumatic brain injury, inhalant or alcohol abuse or prolonged exposure to gasoline (Amison & Foster, 2005). Fronto-temporal dementia was considered in the diagnosis and was thought to explain the individuals chronic symptoms of apathy, anhedonia, and suicidal ideation. ECT was implemented and resulted in a resolution of the patients depressed mood and neurovegetative symptoms of depression.

Another study (Kisa et al, 2005) which combined ECT and psychotropic drugs to combat post-partum depression demonstrated promising results. The seizure in the first ECT treatment lasted 30 seconds. While under the care of ECT the patient was diagnosed as having a urinary tract infection. For this reason ciprofloxacin therapy of 1000 mg a day was initiated. The second ECT seizure, which was on the third day of ciprofloxacin therapy was terminated with 3 mg of intravenous midazolam at the 150 th second. Then the ciprofloxacin therapy was discontinued. The ECT therapy was started 3 days later, and a total of 8 treatment sessions were completed lasting 35 to 70 seconds. Because the first ECT lasted for 30 seconds and subsequent therapy, which was reinitiated after discontinuation of ciprofloxacin, lasted no longer than 70 seconds, the extended seizure in the patient was thought to be related to ciprofloxacin.

Mamah et al (2005) found ECT a safe procedure, infrequently associated with life threatening complications. However the authors did identify pulmonary embolism as one rarely reported complication of ECT. The authors concluded that ECT was safe but identified risk factors relevant to the pathophysiology of pulmonary embolism and made suggestions about the management of patients with suspicious symptoms. In recent times only one study has been identified which describes a case of migrainosus precipitated by ECT (Stead & Josephs, 2005). In this case however the condition was resolved with dihydroergotamine (DHE).

Use of ECT with the Elderly

There have in recent times been studies cited which deal specifically with the geriatric population suffering from severe depression. Delano-Wood & Abeles (2005) indicate that geriatric depression is very prevalent and disturbs the quality of life of the elderly population. Empirically supported somatic treatments and their side effect were discussed with the emphasis on the efficacy and effectiveness of pharmacotherapy, ECT, exercise, and photo therapy (bright light therapy). On the whole however, it has been found that the use of various treatments of the elderly suffering depression including ECT has been found to be not as effective as when it is used on younger samples (Mohlman, 2005). Some older adults with deficits in executive skills may respond poorly to most popular treatments for depression and anxiety compared with those with intact executive functions.

Williams & Ostroff (2005) presented a case study of a 60 year old man with a history of chronic renal failure and severe bipolar depression. He was referred due to the worsening of his psychotic depression associated with the refusal of oral intake of medication. He also suffered from severe hypokinesia and was unresponsive to several antidepressant regimens. He was successfully treated instead by a course of bilateral ECT. The patient experienced a robust experience to treatment with a 34 to 6 reduction in the Hamilton Depression Rating Scale score.

Use of ECT with Children and Young Persons

As already stated ECT is a controversial treatment procedure and is only rarely performed on children and adolescents. There is still a paucity of published data relating to the clinical outcome and complications of ECT and this age group. There are ethical and moral issues surrounding the use of ECT in these patients which makes control data very difficult to come by. The authors, Segal et al (2004), are therefore modest in not declaring any outcomes from their own considered cases. One study however by Slooter et al (2005) using ECT for malignant catatonia demonstrated an improvement which led to the recommendation that ECT be used for children with this syndrome.

Finally, in a large scale juvenile study by Quintana (2005) A total of 1034 children aged 2 weeks to 18 years used transcranial magnetic stimulation (single pulse TMS, paired TMS, and repetitive TMS). No significant adverse effects or seizures were reported following such treatment.

Conclusions

It appears that in the recent studies there has been considerable praise for the use of ECT in a variety of conditions especially with those individuals suffering from severe depression who do not respond to medication. Success has also been achieved with children, and the elderly as well as adults. It is unfortunate that it is still unknown why ECT has any beneficial result in many cases in those suffering especially from severe depression.

It is concluded that ECT is still of secondary consideration when seeking to reduce or treat severe depression effectively. Pharmacological approaches still appear to be preferred in the first instance and this will undoubtedly continue to be the case due to the unknown long-term effects of ECT. When ECT has been used due to medication proving unsuccessful, there has been considerable improvement in many patients. There is also the view that if ECT is again unsuccessful in promoting improvement, as is the case in some instances, then its use may also need to be curtailed.

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