What is ECT?

ECT is a form of electrical stimulation of the brain that has been in use since the 1930s. It is also known as electroshock therapy. A psychiatrist, an anesthesiologist, and other supportive medical personnel supervise the treatment. The person being treated is anesthetized. In bilateral ECT, electrodes are placed on the scalp above each temple. In unilateral ECT, the electrodes are placed above the temple on one side of the brain and in the middle of the forehead. An electrical current is then passed through the brain, inducing a grand mal seizure similar to that experienced in epilepsy. Clinically effective seizures generally last from about 30 seconds to just over a minute. The body does not convulse, and the person being treated feels no pain. Some persons may experience headache, nausea, confusion and muscle stiffness upon awakening. A typical course of ECT treatment requires six to 12 treatments over a period of less than a month. To sustain the response to ECT, continuation treatment, often including medication, should be provided when the ECT course has been completed.

Different types of ECT

There are currently three different ways to administer ECT: bilateral pulse stimulation, unilateral pulse stimulation, and sine wave stimulation. Sine wave stimulation is no longer considered justifiable under American Psychiatric Association guidelines because there is a considerably greater risk of memory loss without any increased benefit.[ii] Bilateral and unilateral brief pulse stimulation are each accepted treatments. A recent study showed that bilateral pulse stimulation, the former “gold standard” for ECT, produces greater risks of memory loss than unilateral pulse stimulation and suggests that, while it may still be necessary to use bilateral pulse stimulation during the course of treatment as the recipient’s threshold increases, unilateral pulse stimulation should always be used first.[iii] If unilateral pulse stimulation is not effective, the recipient should have the opportunity to reconsider consent before bilateral pulse stimulation is administered.

Tailoring ECT to individual recipients. Within each method of ECT administration, the charge dose, pulse length, and duration may be varied. Each of these variables in ECT administration may be adjusted to tailor the treatment to the needs of the person receiving ECT. The best practice is to tailor the treatment to the recipient throughout the course of treatment. Tailoring the treatment permits physicians to induce the desired seizure with the minimal amount of energy.

Benefits of ECT. ECT can be the best course of treatment for some individuals with severe , some psychotic states, and mania.[iv] ECT may be particularly suitable for people who have not responded to medication, or for whom medication is not a suitable treatment. While ECT has been shown to be effective, it is not a cure and many recipients will at some point after the treatment is terminated.

The primary difficulty in measuring the efficacy of ECT is determining the rate of relapse. About 50% of people who receive ECT (without continuing ECT) relapse between 6 and 12 months after treatment, and the relapse rate 4 to 5 years after treatment is around 72%.[v] Several studies have indicated that the relapse rate after 6 months, with medication, is between 30% and 50%.[vi] Another study indicated that after 2 years of treatment, the relapse rate was 48%, and rose to 82% at 5 years out.[vii] When continuing ECT is administered, studies have indicated that the relapse rate is significantly lower than without continuing ECT.[viii] One study showed that with continuing ECT, at 2 years after treatment, the treatment was 93% effective, and at 5 years after treatment, 72% still had not relapsed.[ix]

Risks of ECT

Memory loss and other cognitive damage are the primary reasons for the ongoing controversy over the use of ECT. There are varying degrees of memory loss and other damage, depending on the recipient. There are also varying opinions as to how memory is affected by ECT. Many people report loss of memory concerning events that occurred in the period surrounding the ECT. The 1999 report of the Surgeon General asserted that “confusion and disorientation seen upon awakening from ECT typically clear within an hour.” [x] Some memory loss is common and generally affects the period from up to six months before treatment to up to two months afterward but may affect a longer period. Some of this memory loss may be caused by the depression that the ECT is being used to treat.[xi] In some cases, the memory loss and other cognitive damage can be significant. Recent studies show that the risks of memory loss are correlated with the type of ECT administered and how it is administered. For instance, sine wave stimulation carries the highest risk of memory loss and should not be used. Bilateral stimulation is associated with greater memory loss than unilateral stimulation.

In addition to controversy surrounding the practice of ECT, there is also a considerable . Popular culture often calls ECT by another name – shock therapy. This conjures up strong images of draconian administrative practices like those shown in One Flew Over the Cuckoo’s Nest. Administration of ECT has changed considerably since this depiction, yet the image remains as a primary reference in American culture. Today, advances have been made that make ECT safer and have reduced the cognitive side effects. A minority of people who have received ECT have had devastating memory loss and other cognitive damage. Mental Health America is concerned because we now know that the risk of memory loss can be substantially reduced by adherence to current clinical practice standards, yet those standards are often ignored.

In an article published in 2007, Dr. Harold Sackeim, an expert in the use of ECT, reported that “adverse cognitive effects can persist for an extended period, and that they characterize routine treatment with ECT. . . .”[xii] The administration of ECT has been refined over the years, and practice guidelines have been devised that reduce the risk of memory loss, but the danger of memory loss and other cognitive damage remains significant.

Monitoring treatment practices

It is important for the states to know how ECT is being administered so that they can devise suitable regulations and ensure that practitioners are using current methods. States should implement a monitoring system that collects data concerning how much ECT is being administered, who is receiving ECT, the age of the person receiving ECT, what type of ECT is being administered, how it is being administered (dosage, duration, number of treatments, etc.), the legal basis for the administration (informed consent, judicial process, advance directive, etc.), and the number of injuries and adverse outcomes resulting from ECT.

Regulation of treatment practices. The states should regulate how ECT is administered to ensure that treating physicians conform with current clinical guidelines. The states should focus efforts to ensure conformity with current standards through licensing and mandatory continuing education. In some states a significant number of practitioners are still administering sine wave stimulation.[xiii] Some practitioners may be over-administering bilateral stimulation when unilateral stimulation may be sufficient.[xiv] Finally, many facilities administer a fixed dose of electricity to the recipients instead of tailoring the administration to create the desired effect with the minimal amount of electricity.[xv] Continuing education and licensing requirements will help insure appropriate use of ECT to avoid the evils of past practice.

Regulation of informed consent for ECT

Informed consent suggests that the recipient of treatment has both the intellectual capacity and the judgment to give consent. Most individuals who are candidates for ECT have severe depression. A mood disorder, such as depression, may cause an individual to agree to ECT while giving insufficient to, or not caring about, the harms that ECT poses.

When an individual lacks ability to give informed consent, the states must provide an adequate alternative that ensures substantial procedural safeguards. Use of advance directives will improve and enhance autonomy, and is encouraged. However, in the absence of an advance directive, states should have a judicial process that provides individuals with a hearing and an attorney. During the hearing, the fact finder should hear evidence on the risks and benefits of treatment, and if an order for treatment is granted, it should specify the treatment type to be administered, and the maximum number of treatments.

SOURCE: Mental Health America

Other Sources
[ii] American Psychiatric Association (2001). The Practice of ECT: Recommendations for , Training and Privileging, 2nd ed. (American Psychiatric Press Washington, DC.).
[iii] Sackeim et al: “The Cognitive Effects of Electro-convulsive Therapy in a Community Setting,” Journal of Neuropsychopharmacology (2007), http://www.nature.com/npp/journal/v32/n1/full/1301180a.html#bib3.

[iv] See, generally, Rudorfer, M. V., Henry, M. E., and Sackeim, H. A., “Electroconvulsive Therapy,” in A. Tasman, J. Kay, and J. A. Lieberman (Eds.), Psychiatry, W. B. Saunders (Philadelphia 1997).

[v] Aronson TA, Shulka S, Hoff A: Continuation therapy after ECT for Delusional Depression: a Naturalistic Study of Prophylactic Treatments and Relapse. Convuls Ther 3:251-259 (1987).

[vi] Malcom K, Dean J, Rowlands P, Peet M. Amtidepressant drug treatment in relation to the use of ECT. J Psychopharmacol 5:255-258 (1991); Sackeim HA, Prudic J, Devanand DP, “Effects of Stimulus Intensity and Electrode Placement on the Efficacy and Cognitive Effects of Electroconvulsive Therapy, N Engl J Med 328:8390846 (1993); Aronson TA, Shulka S, Hoff A, “Continuation therapy after ECT for Delusional Depression: a Naturalistic Study of Prophylactic Treatments and Relapse, Convuls Ther 3:251-259 (1987).

[vii] Gagne GG, Furman MJ, “Efficacy of Continuation ECT and Antidepressant Drugs Compared to Long-term Antidepressants Alone in Depressed Patients, Am J Phychiatry 157:1960-1965 (2000).

[viii] This is generally accepted, but there are methodological problems with these retrospective studies, and often times the size of the study is very small.

[ix] Gagne GG, Furman MJ, op. cit.

[x] Id. at p. 259.
[xi] Id.

[xii] Sackeim et al: “The Cognitive Effects of Electro-convulsive Therapy in a Community Setting,” Journal of Neuropsychopharmacology (2007), at p.253,

[xiii] Olfson & Sackeim: “Electroconvulsive Therapy Practice in Community,” Journal of Psychological Medicine 31(5) pp 929-934 (2001).
[xiv] Id.

[xv] Pippard, J: “Audit of Electroconvulsive Treatment in Two National Health Service Regions,” British Journal of Psychiatry 160:621-637 (1992).

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