Electroconvulsive therapy

Electroconvulsive therapy (ECT) is a controversial medical treatment to relieve the signs and symptoms of mental illnesses by introducing a small, carefully controlled amount of electricity into the brain. This electrical stimulation, used with anesthesia and muscle relaxant medications, produces a mild generalized seizure or convulsion. It is most effective in treating severe depression, and is used after other forms of therapy--such as medications or psychotherapy--have not been effective, can't be tolerated, or won't 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 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.

The most common risks associated with ECT are disturbances in heart rhythm and memory loss. ECT is offered on both an inpatient and outpatient basis. Hospitals have specially equipped rooms with oxygen, suction, and cardiopulmonaryresuscitation (CPR) in order to deal with the rare emergency.

Many people think that ECT began with the ancient Roman tradition of applyingelectric eels to the head as a cure for madness. In fact, its true origins can be traced to the late 1700s, when a machine using weak electric currents was used in Middlesex Hospital in England to treat a range of illnesses. At the time, London brain surgeon John Birch used this machine to shock the brainsof depressed patients just as American inventor Ben Franklin was shocked into unconsciousness (and experienced a brief memory loss) during one of his electricity experiments. It is said that Franklin subsequently recommended electric shock for the treatment of mental illness. The modern practice of electric shock to treat depression and mental illness is only about 65 years old. Itwas a Hungarian psychiatrist who noticed studies commenting on the fact thatschizophrenia and epilepsy don't occur in the same patient; this led to theidea that an artificially-induced seizure might cure schizophrenia. Subsequently, seizures were induced with camphor and other drugs, until eventually Italian psychiatrist Ugo Cerleetti explored the possibility of using electric shock for the same result. Cerletti's version was felt to be better than the drug-induced seizures, which were associated with toxic side effects.

Because ECT was cheap and easy, it quickly became popular and by the 1950s was firmly established as the nation's primary method of treating depression. ECT was used for a wide range of psychiatric problems, and was sometimes usedto control troublesome patients. As its use spread, it began to be used inappropriately not just to treat patients, but to subdue them. The procedure wasfrightening for patients because it was then administered without anesthesiaor muscle relaxants, and the uncontrolled seizures sometimes broke bones.It was not until the discovery of antidepressants that its use began to decline.

Today, the American Psychiatric Association has very strict guidelines for ECT administration, which supports use of ECT only to treat severe, disabling mental disorders; never to control behavior. Before a doctor can administer ECT, the patient must give written consent; in most states, if the patient is too ill to make decisions a court-appointed guardian (usually one of the patient's family members) will sign. The person consenting to the procedure is kept informed of progress as the treatment continues, and may withdraw consent at any time.

The costs for treatment vary widely, depending on tlocation, but ECT ranges between $300 and $800 per treatment; therefore, an eight-course treatment would 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. If theuse of ECT shortens a hospital stay, its net cost may be substantially less.

Before the first treatment, the patient is shown videotapes that explain theprocedure, has a chance to ask the doctor questions, and signs an "Informed Consent Form." The doctor does a complete physical examination, and orders tests such as a chest x ray, an electrocardiogram (ECG), urinalysis, spinal x ray, brain wave (EEG) and complete blood count (CBC) to help identify any potential problem.

The patient must stop taking some medications (such as lithium and most antidepressants) before treatment, since there have been rare cases of people on antidepressants such as Prozac having prolonged seizures after ETC. Because there doesn't seem to be a benefit in having people take antidepressants whilereceiving ECT, it's better to discontinue drug treatment three to 10 days before ECT is scheduled. (The only exception to this is the suicidal patient, when there isn't time to wait). However, after ECT is given, antidepressants are usually prescribed to help maintain normal mood. In addition, patients should not eat or drink for at least eight hours before the procedure.

How It Works

Approximately 30 minutes before treatment begins, the patient may receive a needle containing a medicine (such as atropine) which will keep the pulse ratefrom decreasing too much during the convulsion. Next, the patient is placedon a cot and hooked up to a machine that automatically takes and displays temperature, pulse, respiration and blood pressure. A mild anesthetic is injected into a vein, followed by a medicine (such as Anectine) that relaxes all ofthe muscles so that the seizure is mild, and the risk of broken bones is virtually eliminated. When the patient is relaxed and asleep, an airway is placedin the mouth to aid with breathing. Electrodes are placed on the sides of the head. An electric current is passed through the brain with a machine designed for this purpose. In the first stage of the seizure, the muscles in the body that have not been paralyzed by medication contract for 5-15 seconds. In the second stage, which lasts approximately 10-60 seconds, the patient twitches. The entire procedure lasts about 30 minutes.

After the treatment, the patient is moved to a recovery area where vital signs are monitored and given mild medications such as aspirin for headache, muscle pain, or back pain. On regaining consciousness, patients seem to resemblethose who have experienced post-traumatic amnesia. Tests on memory of patients after this treatment have revealed a temporary memory impairment; after a number of treatments, some patients report a more serious memory loss involving everyday forgetfulness which usually disappears a few eeks after treatment.New research suggests that ECT given on only one side of the head produces equal benefit to the standard method, without any accompanying memory loss.

The number of treatments a patient receives depends upon factors such as age,diagnosis, the history of illness, family support, and response to therapy.Patients with depression, for example, usually require 6-12 treatments. Treatments are usually administered every other day, three times a week. For patients who do not respond to medicine or who have severe allergic reactions, ECTmay be the only treatment that will help.

The controversy surrounding ECT is likely to continue, especially since it remains unclear whether ECT affects permanent memory. While many studies indicate that ECT doesn't have any extensive effects on permanent memory function,all patients show some amount of amnesia for events immediately before treatment. Some scientists believe that some people may falsely conclude their memory is impaired. In one study, scientists found significant differences between pateints who report memory problems and those who didn't. Those who complained tended to believe that ECT hadn't helped their depression, which could mean that their own assessment of memory might be the result of their continuing illness. Three years after treatment, this group insisted their amnesia remained, eventhough there was no objective proof of this. Researchers suspect their innitial experience of true amnesia immediately after ECT might ahve caused them to question whether their memory function had ever returned.The amount and duration of memory problems with ECT vary with the type of ECT; it isless of a problem when ECT is used only on one side of the head.

On the other hand, researchers have found no evidence that ECT damages the brain. 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 benecessary to damage brain tissue. It is true, however, that ECT in older depressed people who are also demented can worsen their condition. It is also true that ECT can be abused as a treatment. Even ECT proponents admit there isa low incidence of adverse reaction to the treatment, although estimates of how great a risk vary.

Today, about 33,000 hospitalized Americans received ECT in 1980, the last year for which the National Institute of Mental health has figures. Many studiessince the 1940s have demonstrated ECT's effectiveness, revealing taht it canlead to substantial improvement in at least 80 percent of patients.

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