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Definition

Electroconvulsive therapy (ECT) is a medical treatment for severe mental illness in which a small, carefully controlled amount of electricity is introduced into the brain. This electrical stimulation, used in conjunction with anesthesia and muscle relaxant medications, produces a mild generalized seizure or convulsion. While used to treat a variety of psychiatric disorders, it is most effective in the treatment of severe depression, and provides the most rapid relief currently available for this illness.

Purpose

The purpose of electroconvulsive therapy is to provide relief from the signs and symptoms of mental illnesses such as severe depression, mania, and schizophrenia. ECT is indicated when patients need rapid improvement because they are suicidal, self-injurious, refuse to eat or drink, cannot or will not take medication as prescribed, or present some other danger to themselves. Antidepressant medications, while effective in many cases, may take two-six weeks to produce a therapeutic effect. Antipsychotic medications used to treat mania and schizophrenia have many uncomfortable and sometimes dangerous side effects, limiting their use. In addition, some patients develop allergies and therefore are unable to take their medicine.

Precautions

The most common risks associated with ECT are disturbances in heart rhythm. Broken or dislocated bones occur very rarely.

Description

The treatment of severe mental illness, such as schizophrenia, using electroconvulsive therapy was introduced in 1938 by two Italian doctors named Cerletti and Bini. In those days many doctors believed that convulsions were incompatible with schizophrenia since, according to their obervations, this disease rarely occurred in individuals suffering from epilepsy. They concluded, therefore, that if convulsions could be artifically produced in patients with schizophrenia, the illness could be cured. Some doctors were already using a variety of chemicals to produce seizures, but many of their patients died or suffered severe injuries because the strength of the convulsions could not be well controlled.

Electroconvulsive therapy is among the most controversial of all procedures used to treat mental illness. When it was first introduced, many people were frightened simply because it was called "shock treatment." Many assumed the procedure would be painful, others thought it was a form of electrocution, and still others believed it would cause brain damage. Unfortunately, unfavorable publicity in newspapers, magazines, and movies added to these fears.

Indeed, in those early years, patients and families were rarely educated by doctors and nurses regarding this or other forms of psychiatric treatment. In addition, no anesthesia or muscle relaxants were used. As a result, patients had violent seizures, and even though they did not remember them, the procedure itself was frightening.

The way these treatments are given today is very different from the procedures used in the past. Currently, ECT is offered on both an inpatient and outpatient basis. Hospitals have specially equipped rooms with oxygen, suction, and cardiopulmonary resuscitation (CPR) in order to deal with the rare emergency.

The treatment is carried out as follows: approximately 30 minutes before the scheduled treatment time, the patient may receive an injection of a medication (such as atropine) that keeps the pulse rate from decreasing too much during the convulsion. Next, the patient is placed on a cot and hooked up to a machine that automatically takes and displays vital signs (temperature, pulse, respiration, and blood pressure) on a television-like monitor. A mild anesthetic is then injected into a vein, followed by a medication (such a Anectine) that relaxes all of the muscles in the body so that the seizure is mild, and the risk of broken bones is virtually eliminated.

When the patient is both relaxed and asleep, an airway is placed in the mouth to aid with breathing. Electrodes are placed on the sides of the head in the temple areas. An electric current is passed through the brain by means of a machine specifically designed for this purpose. The usual dose of electricity is 70-150 volts for 0.1-0.5 seconds. In the first stage of the seizure (tonic phase), the muscles in the body that have not been paralyzed by medication contract for a period of five to 15 seconds. This is followed by the second stage (clonic phase) that is characterized by twitching movements, usually visible only in the toes or in a non-paralyzed arm or leg. These are caused by alternating contraction and relaxation of these same muscles. This stage lasts approximately 10-60 seconds. The entire procedure, from beginning to end, lasts about 30 minutes.

The total number of treatments a patient will receive depends upon many factors such as age, diagnosis, the history of illness, family support, and response to therapy. Patients with depression, for example, usually require six to 12 treatments. Treatments are usually administered every other day, three times a week.

The electrodes may be placed on both sides of the head (bilateral) or one side (unilateral). While bilateral ECT appears to be somewhat more effective, unilateral ECT is preferred for individuals who experience prolonged confusion or forgetfulness following treatment. Many doctors begin treatment with unilateral ECT, then change to bilateral if the patient is not improving.

Post-treatment confusion and forgetfulness are common, though disturbing symptoms associated with ECT. Doctors and nurses must be patient and supportive by providing patients with factual information about recovery. Elderly patients, for example, may become increasingly confused and forgetful as the treatments continue. These symptoms usually subside with time, but a small minority of patients state that they have never fully recovered from these effects.

With the introduction of antipsychotics in the 1950s, the use of ECT became less frequent. These new medications provided relief for untold thousands of patients who suffered greatly from their illness. However, there are a number of side effects associated with these drugs, some of which are irreversible. Another drawback is that some medications do not produce a therapeutic effect for two-six weeks. During this time the patient may present a danger to himself or others. In addition, there are patients who do not respond to medicine or who have severe allergic reactions. For these individuals, ECT may be the only treatment that will help.

Preparation

Patients and relatives are prepared for ECT by being shown video tapes that explain both the procedure and the risks involved. The physician then answers any questions these individuals may have, and the patient is asked to sign an "Informed Consent Form." This gives the doctor and the hospital permission to administer the treatment.

Once the form is signed, the doctor performs a complete physical examination, and orders a number of tests that can help identify any potential problem. These tests may include a chest x ray, an electrocardiogram (ECG), urinalysis, spinal x ray, brain wave (EEG), and complete blood count (CBC).

Some medications, such as lithium and a type of antidepressant known as monoamine oxidase inhibitors, should be discontinued for some time before treatment. Patients are instructed not to eat or drink for at least eight hours prior to the procedure in order to reduce the possibility of vomiting and choking.

Aftercare

After the treatment, patients are moved to a recovery area. Vital signs are recorded every five minutes until the patient is fully awake, which may take 15-30 minutes. Some initial confusion may be present but usually disappears in a matter of minutes. There may be complaints of headache, muscle pain, or back pain. Such discomfort is quickly relieved by mild medications such as aspirin.

Risks

Advanced medical technology has substantially reduced the complications associated with ECT. These include slow heart beat (bradycardia), rapid heart beat (tachycardia), memory loss, and confusion. Persons at high risk for ECT include those with recent heart attack, uncontrolled blood pressure, brain tumors, and previous spinal injuries.

Normal results

ECT often produces dramatic improvement in the signs and symptoms of major depression, especially in elderly individuals, sometimes during the first week of treatment. While it is estimated that 50% of these patients will experience a future return of symptoms, the prognosis for each episode of illness is good. Mania also often responds well to treatment. The picture is not as bright for schizophrenia, which is more difficult to treat and is characterized by frequent relapses.

A few patients are placed on maintenance ECT. This means they return to the hospital every one-two months, as needed, for an additional treatment. These individuals are thus able to keep their illness under control and lead a normal and productive life.

Key Terms

Mania

A mood disorder in which a person experiences prolonged elation or irritability characterized by over activity that can lead to exhaustion and medical emergencies.

 

Relapse

A return of the signs and symptoms of an illness.

 

Schizophrenia

A severe mental illness in which a person has difficulty distinguishing what is real from what is not real. It is often characterized by hallucinations, delusions, and withdrawal from people and social activities.

For more Information:  Please contact your attending physician on your next visit.