Electroconvulsive Therapy

From Enpsychopedia

Electroconvulsive therapy (ECT), also known as electroshock, is a controversial psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Today, ECT is most often used as a treatment for severe major depression which has not responded to other treatment, and is also used in the treatment of mania (often in bipolar disorder), catatonia, schizophrenia and other disorders. It was first introduced in the 1930s and gained widespread use as a form of treatment in the 1940s and 50s; today, an estimated 1 million people worldwide receive ECT every year, usually in a course of 6-12 treatments administered 2 or 3 times a week.

1 What Is ECT
2 ECT machines
3 References
4 Websites

What Is ECT

Electroconvulsive therapy consists of a series of grand mal epileptic seizures induced by electric shocks through the brain.

The essence of a grand mal epileptic seizure is the intensely rapid "firing" of every brain cell. In a natural seizure this activity of the brain causes the body to thrash about wildly, but when a seizure is induced in ECT the movements of the body are largely suppressed by a drug. In either case, if a complete grand mal seizure is occurring in the brain, the person is unconscious.

How is ECT Given?

An ECT treatment is usually given in the morning before breakfast. First the patient receives an injection to reduce secretions in the mouth. Then she is taken to the treatment room, where she is given a general anesthetic through a vein in the arm. This takes effect quickly and is followed by another drug through the same needle, this being the one that suppresses muscle movement. The anesthetic is not necessary for the shock treatment as such, for the shock itself would produce unconsciousness, but it is given to spare the patient the trauma of the ECT. Next, two electrodes are applied to the head and a current passed briefly between them. (Most commonly, the electrodes are on the temples and the shock is about 140 volts for half a second, but these particulars may vary.) The brain seizure that is triggered by the shock lasts about a minute.

Throughout the treatment procedure the patient does not experience pain or discomfort, but she awakens soon afterward in a state of confusion. When the confusion subsides, she can resume her daily routine. Headache, mild muscle soreness, or nausea sometimes occur, but these usually respond to simple medication.

Treatments are usually given three times a week, and a typical course of ECT consists of from six to ten treatments.

Are There Adverse Effects Or Risks?

The American Psychiatric Association and the National Institute for Health and Clinical Excellence have concluded that the procedure does not cause brain damage, however ECT has one adverse effect that occurs in all cases. That is memory loss.

During a course of treatment the patient experiences a cumulative eradication of memory, which begins with recent events and learning and thoughts (including worries), and gradually extends to the distant past. Once the course is ended, memory gradually returns in the opposite time order until, in about a month, the patient has regained the main outlines of her personal history and also knowledge and skills acquired early in life. After this length of time there is little further automatic return of memory, although a good deal more has become strong enough that it can later be revived by reminders or efforts at relearning.

The extent of the permanent memory loss varies with the number of treatments, age of patient, placement of electrodes, and other factors, but the pattern of loss is the same for all patients. The loss is total or near total for the period of the ECT course and tapers back over previous years with smoothly diminishing severity and no precise cut-off point. The patient's remaining memory appears "spotty" in that the smooth amnesic blanket has merely dimmed some memories but submerged others, depending upon their original relative clarity.

In addition to this erasure of pre-shock memory, which is certain to occur, there may also be a permanent adverse effect upon memory function after the shocking. That is, the patient's memory for new experiences and new learning may fade rapidly.

Some patients do not mind their memory changes and seldom have occasion to notice them. At the opposite extreme are persons whose work or way of life is made impossible by them. In between are persons who gradually adjust to various degrees of handicap.

Aside from adverse effects on memory, ECT contains also, like other major medical and surgical procedures, some element of ordinary risk. Fatalities are very rare, but there is a slight possibility that a stroke or heart attack could occur during a treatment. There is also the possibility that a particular individual may experience one or more untoward after-effects in addition to the expected deleterious effect on memory.

How Does ECT Work?

ECT is one of a number of drastic psychiatric treaments, including insulin coma and psychosurgery, that relieve suffering temporarily. All of them "work" by destroying brain tissue. That is their common denominator. In ECT both the electrical shocks and the grand mal seizures are destructive. For some still unknown reason, reducing the size of the brain not only reduces the amount of stored memory but also counteracts states of physical pain and any kind of emotion.

ECT machines

Most modern ECT machines deliver a brief-pulse current, which is thought to cause fewer cognitive effects than the sine-wave currents which were originally used in ECT. A small minority of psychiatrists in the USA still use sine-wave stimuli. Typically, the electrical stimulus used in ECT is about 800 milliamps, and the current flows for between one and 6 seconds.

In the USA, ECT machines are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and MECTA.

"The majority of patients who receive ECT . . . are well satisfied with the results and are hardly motivated to influence public opinion on the subject - they are too busy getting on with their lives. . ." -- from Richard Abrams' "Electroconvulsive Therapy.

When medical students learn about shock therapy, they turn to the only textbook on the subject: Electroconvulsive Therapy, published by Oxford University Press. Richard Abrams, a professor of psychiatry at the Chicago Medical School, writes that shock therapy is proven safe and effective for depression and other problems, even in children and the elderly. He advises that shock should be considered as the first treatment given, not as the last resort. He concludes with an attack on doctors who criticize shock treatment and attaches a form to have patients sign when they consent to shock therapy.

But Abrams doesn't tell the medical students one thing: He owns Somatics Inc., one of the nation's two shock machine manufacturers. He didn't tell his publisher, either.

"Wow," says Joan Bossert, executive editor of Oxford University Press. "I did not know that." She would have had him disclose that in the book's preface, she says. "I really wish he'd told us, but it doesn't take away from his expertise," she says.

Neither did Abrams disclose his financial interest in the academic journal Psychiatric Clinics in September 1994, when he wrote an upbeat article on shock titled, "The Treatment That Will Not Die."

In some recent articles, Abrams disclosed that he's a "director" of Somatics. But readers weren't told that he is also president and owns the company with shock researcher Conrad Swartz, a University of South Carolina psychiatry professor. [...]

"It's a nonissue. Every doctor who does ECT makes money, just as every doctor who prescribes drugs does," he says. "Patients know . . . and don't particularly care." Swartz says Somatics was founded because MECTA wasn't listening to psychiatrists who do shock therapy. "I'm now able to improve machines. Who else can best advance ECT? Someone like me, who knows what they're doing," says Swartz, who has a Ph.D. in engineering as well as a medical degree.

For his part, Abrams is the most quoted shock therapy researcher. The American Psychiatric Association's 1990 task force report on how to practice shock therapy cites him more than any other expert. His 340-page textbook is often the sole source of information about shock therapy in general medical books and articles read by doctors and patients. Abrams' textbook never mentions Somatics by name. But he describes new shock machine innovations found only on Somatics machines. (Dennis Cauchon, Doctor's Financial Stake in Shock Therapy, USA Today -- December 6, 1995)

Regarding MECTA, the competition:

Since the mid-1980s, Harold A. Sackeim worked as a consultant to the ECT device manufacturer Mecta Corp. He never revealed his financial interest in ECT to the National Institute of Mental Health, as required by federal law, and, until 2002, did not reveal it to New York officials as required by state law. Neuropsychopharmacology has endured negative publicity over its failure to disclose financial conflicts of journal authors, resulting in the editor's resignation and a promise to disclose such conflicts in the future; yet there is no disclosure of Sackeim's long-term relationship with Mecta, nor did Sackeim disclose his financial conflict when his NIMH grant was renewed to 2009 at approximately $500,000 per year".

In a video of legal proceedings in 2004, Harold Sackeim says that, in exchange for consulting for Somatics Inc., he received honorariums from Somatics worth $1500. In the same video, Sackeim says he disagrees with president of Somatics Richard Abrams, because 'he tends to...umm...be overly...uh...dismissive of the types of side effects ECT can have'. In another video of the proceedings, Sackeim admits that he charged Mecta $10,875, at a rate of $500 per hour, and made a deal to be a witness in defense of Mecta at trial. (Harold Sackeim, Designer of ECT machines)

Harold Sackeim has recently reversed his position on ECT as reported in an NIMH-funded research study published in the January 2007 issue ofNeuropsychopharmacology which is summarized as follows:

After 25 years and millions of dollars of federal funding to research the adverse cognitive effects of ECT—25 years in which not one single longterm followup study was ever published—self-proclaimed “world expert” on ECT Harold Sackeim has now reversed his position, admitting that ECT routinely causes permanent memory loss and deficits in cognitive abilities. His new study—the first to be published in which he followed patients as long as six months, and one of his only studies to use controls—validates a generation of patient reports of permanent iatrogenic disability, and disproves Sackeim’s previously published claims that these reports were simply symptoms of mental illness. Other findings: there is no evidence that ECT increases intelligence, as Sackeim has previously claimed; and women are much more likely than men to experience severe permanent amnesia. (Harold Sackeim reverses position in upcoming study)

The Food and Drug Administration classifies the devices used to administer ECT as Class III medical devices. Class III is the highest-risk class of medical devices. This classification designates a device as needing safety investigation and more study. In 1984, the American Psychiatric Association (APA) petitioned FDA to reclassify the device to Class II, which action would constitute recognizing ECT as a safe treatment without an investigation. This was opposed by the Committee for Truth in Psychiatry. In 1990, the FDA, under pressure from psychiatrists, published in the Federal Register of September 5, a "proposal to reclassify" the ECT device to Class II. Since then, the classification (and investigation) have been "on hold", with no reclassification or investigation having yet taken place. (CTIP)