Convulsive therapy, using chemical inductions, was introduced by Ladislas Meduna in 1934.In 1938, the Italians Ugo Cerletti and Luigi Bini described an easier induction by using electrical impulses.

 

For you must know why the public, doctors and even some psychiatrists are sceptic and afraid of the treatment method.

Convulsive therapy, using chemical inductions, was introduced by Ladislas Meduna in 1934.In 1938, the Italians Ugo Cerletti and Luigi Bini described an easier induction by using electrical impulses. Within a decade, electroconvulsive therapy (ECT) was hailed as the main treatment of hospitalised mentally ill patients. It was used extensively world-wide at the same time as insulin coma and leucotomy. However, the introduction of the psychoactive medicines in the 1950’s led to the rapid abandonment of the treatment. The treatment method re-emerged in the 1970’s when psychiatrists sought ways to help the mentally ill who were unresponsive to medication and psychotherapies. These “therapy resistant” cases pleaded for any useful intervention, and practitioners who had used ECT earlier but discarded their devices in the enthusiasm for psychotropics, recalled their experience and offered ECT again. Their success led to a renewed interest in the procedure.

Background
Despite sixty-eight years of acknow-ledged high efficacy and safety in the treatment of depressive and psychotic illnesses, ECT continues to generate controversy in the media, with limited use mainly in academic and private hospitals. The dismay results from attack by the “anti-psychiatry movements”, people’s misbeliefs and the guarded support by some health professionals.

Belief that the treatment affects the brain, arouses primitive fears that the soul of the individual, one’s inherent individuality and uniqueness, is affected. And the media often portrayed the treatment, as it was first perceived in the movies The Snake Pit (1948), Fear Strikes Out (1957), Shock Corridor (1963) and Shock Therapy (1964) - patients being forced to receive treatment against their will, and used by Svengali-like psychiatrists to control the exited and aggressive behaviour of maniacs.

Furthermore, the very terms electro-shock and electroconvulsive treatment raise the specter of electrocution, and electric chair that ends the lives of murderers.

These misperceptions, preconceived ideas and personal prejudices however are not enough to sustain the controversy. It is also fueled by the persistent activities of the Antipsychiatry Movements. The movement is led by the Citizen’s Commission on Human Rights an establishment of the “Church of Scientology” organised in 1969 in California (USA). These polemicists targeted ECT as sensitive and vulnerable with mixed support from the media and some health professionals. The target was suitable because the lay media portrayed it as used by oppressive physicians, who would without patients’ consent, force treatment on them as a form of punishment.

Horror money-making movies like A Woman Under the Influence (1974), One Flew Over The Cuckoo’s Nest (1975), The Fifth Floor (1980), Frances & Death Wish II (1982), Return to Oz (1985), An Angel at My Table (1990), Heavenly Creatures (1994), Angel Baby (1995), Lilac’s Story (1995), Cosi (‘96) and Shine (1996) reflected this view.

The movement was and is encouraged by pseudophilosophical psychiatrists like Thomas Szasz & Ronald Laing who argued that there were no mental ill-nesses, merely maladaptive relationships to society.

The “Scientologists” seemingly perceive psychiatrists and psychiatric treatment methods as unfair competition in their quest to convince men rather to buy into the salvation they promise. Their vocal members are frequent speakers in afternoon talkshows on radio and TV where the hosts encourage a circus atmosphere rather than reasoned discourse.

The “Citizen’s Commission on Human Rights” assisted by some department officials, are still actively trying to persuade the Minister of Health to outlaw ECT in the RSA.

Negative perceptions held by some mental health professionals usually reflect there

1. Allegiance to a faith in the psychological basis of mental illness; or
2. Preconceived and subjective belief that the public perception of brain damage is indeed true; or
3. Discomfort with a psychiatric practice that calls on medical experience and the laying on of hands; or
4. Ill aquaintedness with the treatment i.e. lack of experience and scientific knowledge.

This turmoil however has had profound effects on the use of the treatment method and because of it, may lead to years of needless suffering as patients are given a lengthy series of ineffective medication trials before ECT is considered.

“Politicalisation” of the treatment method has also resulted in the fact that in South Africa, as in the USA, Canada and the U.K., more than 90% of the recipients are from the high income groups or Caucasion. Access to ECT is most limited for patients who have to make use of public facilities.

On the positive side the controversy has led to extensive renewed research, ultra modern apparatus, and safety monitoring devices, specific guidelines and detailed methods to reduce medical risks - all to the benefit of the patient.

WHAT ARE THE REAL FACTS ABOUT ECT?
In order to assist and inform possible recipients and their families, answers are given to the most frequent questions asked about the treatment method.

What are the indications for the use of ECT, or, in other words, which illnesses respond favourably to ECT?
The General Indications are:

1.    Major Depressive Disorders
The primary indication for ECT is major depression, especially endogenous depression or melancholia with the classical symptoms of sadness or pronounced apathy, loss of appetite and weightloss, constipation, loss of sexual interest, early morning wakening, agita-tion or retardation, emotional emptiness, and ruminations of guilt, worthlessness, hopelessness, death, or suicide. ECT is especially the treatment of preference when depression has rendered the person psychotic (mentally disturbed or stuporous), physically ill, unable to care for him/herself, or dangerous to him/herself or others. The response of melancholia is excellent in both bipolar and unipolar depression. Patients with melancholia are often contrasted with reactive, neurotic, or dysthymic depres-sives whose illness is generally poorly or transiently responsive to ECT and who exhibit self-pity, anxiety rather than sadness or apathy, tendencies to blame others, a scarcity of physiological features, and no distinct onset.

How effective is ECT in the treatment of Major Depression?
Very effective! All present day pro-spective controlled, double-blind, randomised comparisons of ECT versus antidepressants in the treatment of depression favour ECT1.

Most pertinent to modern practice however, is the effectiveness of ECT for patients who do not respond to medications: Almost 1/3 of endogenous depressives fails to respond to adequate 8-10 week medication and combinations trials. In contrast recent outcome data from 4 leading ECT centres, using strict research criteria, demonstrated an 86% efficacy rate for ECT.

2.    Schizophrenia
ECT is also indicated for schizophrenia with acute exacerbation, expressed as excitement, overactivity, hallucinations, delusions, and intense emotional expression (eg. fear, suspicion), emotional lability, altered sensorium (clouding of conscienceness), or mood swings. In contrast it is generally believed that chronic schizophrenia without recent aggravation of positive symptoms (as aforementioned) does not exhibit sustained benefit from ECT but that in such patients a trial of ECT can nevertheless be justified if chemotherapy does not restore the patient to his/her best recent functional level, and that ongoing neuroleptic dosages can often be reduced by doing so.

This scenario however has changed drastically over the past ten years in favour of the use of ECT in chronic or so-called neuroleptic resistant schizophrenia.

How effective then is ECT in Acute and Chronic Schizophrenia?
Antipsychotics are believed to be the mainstay of somatic treatment for patients with schizophrenia, but well-controlled comparisons of ECT versus neuroleptics found the treatment outcome in acute schizophrenia to be equivocal and equipotent. Nonetheless, recent acute treatment trials with neuroleptics found a substantial clinical benefit in only ~50% of patients. Furthermore, the relapse/recurrence rate in neuroleptic responders is as high as 78% during a 2 year follow-up period. The issue of treatment-resistant schizo-phrenia (TRS) further complicates care of these patients. This refers to a subgroup of patients, estimated to be ~10-40%, who do not or only partially respond to neuroleptic (i.e. typical or atypical) treatment. Research on the use of ECT in TRS has concluded that:

1. Combined ECT and neuroleptic therapy effectively reduced psycho-tic symptoms in 57% of treatment-resistant patients with schizophrenia.
2. ECT and neuroleptic treatment are more effective than either ECT or Neuroleptic treatment alone, pro-bably by synergistic effects.
3. ECT alleviates both positive and negative symptoms in schizophrenia.
4. Improvement can be maintained with Continuation-ECT and neuroleptic therapy.²

3.    Mania
Manic episodes usually form part of a Bipolar Affective Disorder. Specific criteria must be met before the diagnosis is made namely:

A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week. During the period of mood disturbance, 3 (or more) of the following symptoms have persisted (4 if mood is only irritable) and have been present at a significant degree.

1. Enflated self-esteem or grandiosity.
2. Decreased need for sleep.
3. More talkative than normal or pressure to keep talking.
4. Flight of ideas or subjective expe-rience that thoughts are racing.
5. Distractibility.
6. Increase goal-directed activity or psychomotor agitation.
7. Extensive involvement in pleasurable activities that have a high potential for painful consequences (e.g. unrestrained buying sprees, sexual indiscretions, or foolish business investments).

The mood disturbance must be sufficiently severe to cause marked impairment in functioning and not due to a substance or a general medical condition.

Is ECT effective in normalising this condition?
Yes, clinical and research investigations over five decades indicate that ECT has robust anti-manic effects.

ECT is more effective than lithium-neuroleptic combinations in the rapid resolvement of the mood disorder. What is even more impressive is that ECT brings about marked clinical improve-ment or full recovery in 80% of manic patients non-responsive to pharmaco-therapy. Maintenance - ECT as an outpatient in refractory Bipolar Disorder also result in significant reduction of health care costs. In the manic-psychotic person it is of utmost importance to restore normal mood and functioning before blatant social indiscretions or major financial losses are incurred. ECT should therefore be regarded as a first-line treatment for acute mania.³

4. Acute Delirious States
What is meant by “delirium” and how does it present itself?
Acute delirium is defined as a clinical condition characterised by disorien-tation, clouding of consciousness, anxiety, sleeplessness, hyperactivity, and exaltation, possibly with hallucinations and delusional ideas. Secondary to these symptoms, the patients often refuse to eat and drink, and as the agitation increases, become dehydrated, develop high temperatures, an increased pulse rate and blood pressure, followed by circulatory collapse. The problem may arise from a physical illness or condition e.g. systemic infection, endocrine disorder, after childbirth or severe physical trauma or toxicity from exogenous substances. It can also develop as a feature in severe affective disorder, acute transient psychotic disorder, or schizophrenia.

Since we picture confusion and impaired memory as part of the ECT process and anticipate worsening of the clinical situation, is ECT really safe and effective to use in such conditions?
Most certainly! Treatment of acute delirium with sedatives and neuroleptics is rarely effective, and without specific treatment patients experience stuporous exhaustion, systemic shock and cardio-vascular collapse. Death can occur in the course of a few days or even hours. In many instances young people with a long life expectancy experience acute delirium. Before the use of ECT, more than 80% of patients with “delirium acutum” died of their disease. After the introduction of ECT practically all survived and recovered completely in the course of a few days.⁴

5.    Medical Conditions

1. Secondary catatonia
2. Neurolept malignant syndrome
3. Intractable seizures and status epileptics
4. Parkinson’s disease
5. Hypopituitarism

The 1990 APA Task Force on ECT (supported more or less by The Second Report of the Royal College of Psychiatrists’ Special Committee on ECT) further made the following recommendations regarding the indications for ECT:

A.    Primary use of ECT

1. Need for a rapid definitive response.
2. Risks of other treatments outweigh ECT risks.
3. History of poor medication response.
4. History of good ECT response.
5. Patient preference.

B.    Secondary use of ECT

1. Antidepressant treatment failure.
2. Adverse or intolerable side-effects of medication.
3. Deterioration in condition increases need for Rapid Response (i.e. refusing food / fluids).

C.    Continuation and Maintenance ECT

1. Recurrent illness with acute & good ECT response.
2. Medication non-responsiveness or intolerance.
3. Ability to comply, voluntary.

How safe or risky is the treatment method in general?
ECT is amongst the safest and least risky medical procedures carried out under induction anaesthesia. To put the mortal risk with ECT in proper perspective, it is only necessary to note that ECT is about 10 times safer than childbirth. One large scale Scandinavian survey found one death in 22,210 treatments for a per treatment mortality rate of 0.004%. Recent figures from the state of California reflected 2 deaths per 99,425 treatments, for a per treatment mortality rate of 0.002%5 and are at the bottom of the reported range for anaesthesia induction alone (0.003% to 0.04%).

The American Psychiatric Association and the Royal College of Psychiatrists recognise no contra-indications to ECT. The same view is held by the South African Society of Psychiatrists.

As in all anaesthesias the greatest risks are in people with severe or un-stable concomitant medical conditions.

How safe is it for people suffering from heart disease?
Good question! Complications like for instance acute myocardial infarction and conduction disturbances are responsible for most of the mortality associated with anaesthesia and said to be for the treatment method, although none of these were reported in the Scandinavian survey cited above. Caution is required in patients with heart problems and the underlying condition should be treated effectively beforehand, however the decision to administer ECT will then be, as always, a matter of informed consent by the patient with due consideration of the risks of giving or not giving ECT, bearing in mind that 10-15% of untreated or medicine-non-responsive severe depressed people commit suicide.

What if I suffer from high blood pressure?
However severe, high blood pressure does not disqualify a person from getting ECT. The treatment even improves high blood pressure in men⁶. Probably because the transient ECT-induced blood pressure rise lasts for only miennutes, stroke is very rare during ECT. Among patients who received ECT for post-stroke depression, 86% improved markedly and none showed new neurological symptoms or worsening of old ones, although several strokes were less than one month old⁷.

If I have an aneurysm, what then?
There are numerous published reports of the uneventful use of ECT in patients with aortic aneurysm, either before or after repair. Untreated brain aneurysms that have bled have a tendency to rebleed, and therefore present a distinct risk with ECT. After surgical correction blocking agents should prevent the short-lived ECT-induced rise in blood pressure.

Can it be given to someone with a brain tumour?
ECT should be avoided where intra-cranial pressure is increased. However, tumours without increased pressure have not been reported to increase the risk with ECT⁸.

Does a scull defect exclude me from having ECT?
As result of previous injury or brain surgery defects in the bony structure may occur, but this does not exclude a person from getting the treatment if needed. Special care only has to be taken in the placement of the electrodes during treatment.

I’m pregnant and severely depressed, can I have ECT during my pregnancy?
Most definitely! Numerous studies amply support the use of ECT during pregnancy. Sophisticated foetal monitoring has found no significant alterations in foetal heart rate, oxygen saturation in the cord blood, foetal movement or uterine tone during the treatment⁹. It is safe in all three trimesters of pregnancy. Where indicated it is the treatment of choice as the brief exposure to anaesthetics involved renders the risk of congenital defects negligible, whereas the use of antidepressants, antipsychotics and mood-stabilisers are usually contraindicated because of the risk of teratogenicity. ECT does not cause miscarriage - even when given at term, and after rupture of the membranes,
ECT is not reported to precipitate labour.

My child/adolescent suffers from a specific mental disorder, is it a safe procedure to use to improve the condition?
Certainly, pending on the specific disorder. However, the attitude of layman shaped by uninformed and inexperienced mental health workers has led to disfavouring the use of ECT in these age groups and therefore the treatment method is totally underutilised. It is a safe and effective treatment in children and adolescents with intractable mental disorder, in particular those with severe mood disorders, and leads to complete recovery and good social integration in most instances¹⁰.

Our mother is in her late seventies and frail. We would like to improve the quality of her life, but only want the best for her. Will ECT be harmful to her or can it bring about an improvement in her mental disorder?
Some of the most rewarding outcome with ECT occurs in elderly, debilitated people whose primary mood or psychotic disorder is expressed as dementia. There is little risk reported in inadvertently treating a person who has Alzheimer’s disease; indeed, ECT mitigates depressive symptoms of patients with primary dementia without worsening of cognitive functioning¹¹.

I’m afraid to have ECT for it is said to cause brain damage, is that true?
The important question of whether ECT causes structural brain damage has been extensively researched. Neuropathologic studies in animals, including cell counts in regions thought to be at highest risk, fail to find evidence of damage when treatments are given under conditions that approximate standard clinical practice¹². Similar findings, i.e. no neuropathological changes, were seen in humans. Lipman & co-workers (1985) recorded no neuropathological changes in a patient who had received 1,250 treatments over a 25-year period.

Studies of compared structural brain imaging findings before and after ECT, found no ECT-induced changes on CAT scans¹³ or MRIs¹⁴.

The most frequent complaint after ECT is that of memory loss. People tend to forget that memory problems form part of psychiatric illnesses per se, e.g. depression is associated an acquisition deficit as revealed by tests of immediate recall or recognition of item lists, and successful treatment of depression with a course of ECT is associated with improved test performance¹⁵. Not surprisingly, one consistent finding is that the greater the severity of depressive symptoms after ECT, the greater the subjective complaints of impaired memory and concentration¹⁶.

Objective memory testing has also shown normal memory and cognitive functioning at long-term post-ECT follow-up examination¹⁷. A few patients are reported to have persistent patchy memory impairment after ECT. Such memory loss might result from con-current antidepressant medications¹⁸, residual depression¹⁹, or progression of pre-existing organic brain disease²⁰.

The APA Task Force on ECT therefore recommends that:

1. All medicines, which may interfere with the formation or recall of memory, be stopped during a treatment series and,
2. Memory functions be evaluated before and after a treatment series.

Is the treatment as such a terrifying experience?
Far from it, surveys done by Hughes et al in 1981, Janicak et al in 1985, Freeman & Kendal in 1986, Bernstein et al in 1998 and Kellner et al in 1999 on patient attitudes about ECT after they’ve had a treatment-series, found that:

1. The majority felt that a visit to the dentist was more distressing.
2. The majority agreed with the statement ‘I wish I had this years ago’.
3. 85% stated that it would be their treatment of choice in future if needed.

Anticipatory anxiety and feelings of uncertainty are to some extent always present when one is confronted by unfamiliar medical procedures, but with the necessary explanations and assu-rances however most these fears can be allayed. The use of tranquillisers and sleeping tablets should be avoided, as they reduce the efficacy of the treatment method.

What work-up is needed before ECT?
ECT is always given whilst the recipient is under induction anaesthesia and a muscle relaxant. Patients who are to undergo this procedure require a complete history and physical exami-nation. In addition, it is advised that the following laboratory examinations are routinely obtained for screening purposes:

• Full blood count including a diffe-rential white cell count.
• Liver functions.
• Blood urea, urate and creatinine.
• Serum electrolytes, calcium and red blood cell magnesium.
• Urinalysis.
• Pseudocholinesterase, where a personal or family history of prolonged apnoea is obtained.

A written and witnessed consent must be given by the patient (or in exceptional conditions by the legal guardian) for every treatment.

The recipient is seen and examined by an anaesthetist beforehand and an appropriate premedication prescribed.

Routine instructions regarding the treatment consist of the following:

1. Treatments will be given on Mon-days, Wednesdays and Fridays or on Tuesdays, Thursdays and Saturdays, starting at 06h30.
2. Nothing by mouth after midnight prior to treatment.
3. Wherever possible and in consulta-tion with your psychiatrist, discon-tinue all psychotropic medicines.
4. Remove all jewellery, hairspray, mousse, make-up, facial cream and nail polish before proceeding to the theatre. A greasy scalp or facial skin hampers proper electrode contact, whereas nail polish interferes with oximetry.
5. Empty bladder immediately before entering of treatment theatre.

What precisely happens during such a treatment? What can you tell your patients?
In the theatre your shoes are removed and you are helped onto a special mobile-bed. A pulse-oximeter is clipped onto the index finger. Electrodes are attached to the chest to ensure constant ECG monitoring of the heart throughout the treatment procedure. At the same time special self-adhesive electrodes are placed on either side of the forehead to measure and observe brain wave activity through all phases of the treatment. The oximeter measures the oxygen saturation of the tissues continuously i.e. before, during and after application of the stimulus. 100% oxygen is administered through a mask.

The anaesthetist then injects intravenously a short-acting anaesthetic, which induces sleep for plus or minus 3 minutes.

At a set interval plus or minus 30 seconds thereafter a muscle-relaxant is given and 100% oxygen is administered by positive pressure at a rate of 20-30 respirations per minute, and continued until return of spontaneous breathing. Half a minute after the administration of the muscle-relaxant, the stimulus is applied through two electrodes to the scalp for a very brief one to two second period. Stimulation of the brainstem and the spreading of the activation process in the brain is carefully monitored, timed and recorded throughout the procedure.

When the person is able to respond to a request to open his/her eyes, transfer to the recovery room takes place. Here the administration of oxygen is conti-nued for another few minutes. When wide-awake from the anaesthetic, tea or coffee is enjoyed before the person goes back to a general ward or as an outpatient to the day clinic.

If you require more information on ECT, please contact the author at (012) 993-2015.

References:

1. Avery & Lubrano, 1979;Abrams, 1982; Siris & co-workers, 1982; Rifkin, 1988; Sackeim & co-workers, 1990; Bernstein & co-workers, 1998; Olfson & co-workers, 1998; Kellner & co-workers, 1999.
2. Benatov & co-workers, 1996; Chanpat-tana, 1997, 1998 & 1999; Christinson & co-workers, 1991; Ezion & co-workers, 1990; Fink & Sackeim, 1996; Frankenburg & co-workers, 1993; Friedel, 1986; Guvajarty, 1987; Hoflich & co-workers, 1995; Klapheke,1991; Krueger & Sackeim, 1995; Landy, 1991; Lohr, 1994; Meltzer, 1991 & 1992; Monroe, 1991; Sajatovic & co-worker, 1993 and Stephens & co-workers, 1993.
3. Alexander & co-workers, 1988; Bertag-noli & Borchardt, 1990; Black & co-workers, 1985 & 1987; Car & co-workers, 1983; Chou, 1991; Fink, 1993; Goodwin & Jamison, 1990; Hill & co-workers, 1997; Kovacs & Pollack, 1995; Lerer, 1985; McCabe, 1976; Milstein & co-workers, 1987; Mukherjee & Sackeim, 1988; Mukherjee, 1989; Mukherjee & co-workers, 1994; Prudic & co-workers, 1990; Schnur & co-workers, 1992; Small & co-workers, 1985, 1987 & 1988.
4. Bolwig & Kramp, 1981; Bush & co-workers, 1996; Dudley & Williams, 1972; Fink, 1979 & 1999; Hafner & Kasper, 1982; Heshe & Roder, 1976; Kalinowsky, 1987; Lipowski, 1990; Mann & co-workers, 1986; Philbrick & Rummans, 1994; Roberts, 1963; Stromgren, 1979 & 1997; Zwil & Pelchat, 1994.
5. Kramer, 1985; Hermann & co-workers, 1995.
6. Swartz & Inglis, 1990.
7. Murray & co-workers, 1986.
8. Alexopoulos & co-workers, 1984; Greenberg, Mofson & Fink,1988.
9. Wise & co-workers, 1984; Repke & Berger, 1984.
10. Baker, 1995; Bertalogni & co-workers, 1990; Mansheim, 1983; Ghaziuddin & co-workers, 1995; Moise & Petrides, 1996; Fink, 1995; Paillere-Martinot & co-workers, 1990; Sackeim & et al, 1987; Schneekloth & co-workers,1993; Strober & Carlson ,1982; Thompson & Blaine, 1987; Weiner & co-workers,1994.
11. Demuth & Rand, 1980 ; Snow &Wells, 1981; McAllister & co-workers, 1982; Dubovsky & co-workers,1985; Price & co-workers, 1989.
12. Dam & Dam, 1986; Meldrum, 1986; Weiner, 1984.
13. Bergsholm & co-workers, 1989; Kendell & Pratt, 1983.
14. Braffman & co-workers, 1988; Coffey & co-workers, 1991 ; Mander & co-workers, 1987; Pande & co-workers, 1990; Scott & co-workers,1990.
15. Cronholm & Ottoson, 1963; Mattes & co-workers, 1990; Pettinati & co-workers, 1984; Sackeim & co workers, 1993; Steif & co-workers, 1986.
16. Frith & co-workers, 1983; Squire & Slater, 1983; Squire, 1986.
17. Squire & Chase, 1975; Weeks & co-workers, 1980; Squire & co-workers, 1983; Abrams & Taylor, 1985; Price & co-workers, 1982; Devenand & co-workers,1991; Coffey & co-workers, 1994.
18. Calev et al, 1989.
19. Squire et al, 1979; Weeks et al, 1980.
20. Coffey et al, 1991.