|
Electro Convulsive Therapy
(ECT)
Electro Convulsive
Therapy, more commonly known as
"ECT," is a medical treatment performed only by highly skilled
health professionals--including doctors and nurses--under 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 therapy--such as
medications or psychotherapy--have not been effective, cannot be
tolerated, or (in life-threatening 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
patients--a minority--also 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
occurring 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 longer-lasting 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 ECT-induced 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
court-appointed 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 medication resistant depres ion with electroconvulsive
therapy, in Review of Psychiatry, Vol. 9. Edited by Tasman A,
Goldfinger SM, Kaufman CA, Washington, DC: American Psychiat ric 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 L J, Holt PD, Spritzer CE, Wilkinson WE: Brain anatomic 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 Psychiatric Press Inc., 1990 |
