SEIZING UPON ECT`S OPPORTUNITIES

In Europe and America during the first half of the 20th century, before the dawn of the psychopharmacologic revolution, thousands of patients languished in hundreds of psychiatric hospitals. Physicians and scientists desperately sought effective treatments.

Their search resulted in four physiologic shock therapies:

• malaria-induced fever (in 1917)

• insulin coma and convulsions (1927) (See Behavioral Healthcare, February 2006, p. 9)

• metrazol convulsions (1934)

• electric shock therapy (EST) (1938), currently known as electroconvulsive therapy (ECT)

Physicians also tried one surgical approach, prefrontal lobotomy (1936) (See Behavioral Health Management, May/June 2004, p. 14). Of these five therapies, only ECT remains in use today.

This article explores ECT's discovery, mechanism of action, and controversies. We also examine current indications and administration protocols. Finally, we identify ECT's place among modern psychiatric treatments.

ECT's Discovery

The road to ECT began with the work of Ladislaus Joseph von Meduna, the superintendent of Budapest's Royal State Mental Hospital in 1933. He observed, based on tissue samples, that patients with epilepsy had thickened glial tissue in the cortex in comparison with patients with schizophrenia.1 He concluded that there was a “biological antagonism” between epilepsy and schizophrenia and that seizures might be used to cure schizophrenia.2 With this in mind, Meduna set out to find a chemical method of inducing seizures, first using camphor and later metrazol. Meduna reported improvement in 50% of patients who received metrazol at seizure-producing doses.

Ugo Cerletti, a neurologist at the Neuropsychiatric Clinic in Genoa, believed that metrazol's side effects (including severe vomiting and confusion) were unacceptable despite its efficacy. Cerletti thought that electricity might be a more consistent stimulus than metrazol for seizure induction, and he began its use on a trial basis. Although he had some success using electrical current for seizure induction in dogs, he sought another animal model before using it on humans.

Cerletti serendipitously discovered that slaughterhouses in Rome employed electricity to convulse pigs into submission before killing them. Cerletti started electrically inducing seizures in pigs and noted that the swine recovered from the convulsions without obvious sequelae.3

Having perfected the technique, Cerletti and his colleague Lucino Bini were the first to actually administer ECT to a human. The first subject was a man in his 40s presumed to have schizophrenia. This individual had been found speaking gibberish upon his arrival in Rome from Milan by train, and Rome's police commissioner referred him to Cerletti and Bini. 4 As a result of this single treatment, the patient became more coherent, to the satisfaction of the two researchers.

Cerletti (Image courtesy of the American Psychiatric Association Library and Archives)

How ECT Works

Although ECT's efficacy for treating severe depression, catatonia, mania, and some forms of schizophrenia has been documented in many clinical studies, its mechanism of action remains elusive.5 Frequent psychological and physiologic explanations advanced over the years have failed to produce a definitive consensus as to how ECT works.

Among the early psychological theories is the hypothesis that ECT is perceived as punishment for personal guilt. ECT, therefore, addressed guilt in two ways: (1) It induced amnesia surrounding the event that triggered the depression, and (2) the actual fear of ECT as a form of punishment was a way of addressing the guilt. Unsurprisingly, this theory has not been substantiated.6

Physiologic mechanisms of action suggested over the years have included neurotransmitter, neurologic, endocrine, vascular, genetic, and electrical explanations.7,8 Some have reported alterations in serotonergic transmission as a result of ECT.9 Others have reported generations of new neurons and endocrine changes following treatment.9 Fink argues that the lack of the moodaltering peptide antidepressin is the cause of depression, and that ECT stimulates its production.10

Three other hormones shown to be increased by ECT and implicated as possible factors in ECT-related improvement are prolactin, cortisol, and oxytocin.9 Others note that ECT increases vascular growth (angiogenesis) in the dentate gyrus of animals.11 Altar et al suggest changes in gene transcription in the hippocampus are ECT's mechanism of action in rats.12 Finally, Alexander and Selesnick have cited “clearing” of neural feedback and “reverberating” circuits as causing post-ECT improvement.1 Regardless of which mechanism actually accounts for ECT's efficacy, the one agreed-upon requirement for effectiveness is that ECT must cause an electrically induced grand mal seizure.6

Many Controversies

ECT has been controversial since its inception,13 horrifying and frightening many people who would probably agree with the coach in the 1980 film Ordinary People: “I would never let them put electricity in my head.” ECT opponents have noted that the same America that used ECT extensively in the 1940s and 1950s also invented the electric chair for capital punishment.5 Contributing to the opposition to ECT was the fact that in the early days patients were not anesthetized for treatment.

It's worth noting that ECT employs approximately 100 volts for 0.3 seconds while the electric chair uses 2,000 volts for approximately 20 seconds. ECT uses considerably less energy than a cardiac defibrillator. Sadly, ECT was imposed on patients in certain institutions as punishment, as depicted in Ken Kesey's 1962 book, One Flew Over the Cuckoo's Nest, and the subsequent film featuring Jack Nicholson.2

ECT's side effects have fueled the controversy. In ECT's early days, patients experienced a high mortality rate (1 death per 1,000 patients receiving ECT), vertebral fractures because no muscle relaxant was used during the induced convulsions, and memory loss. The current mortality rate is 2.0 to 4.5 per 100,000 treatments, which is similar to the mortality rate of general anesthesia for minor surgery. The simultaneous use of anesthesia with a muscle relaxant introduced by the 1960s has eliminated fracture occurrence during ECT.6

Even today the most well-known and annoying ECT side effect is the influence on memory. Each patient may experience up to four different types of memory effects.6 The first is the immediate post-ictal effect, an acute sense of disorientation and recollection which lasts up to 12 hours following a seizure. In addition, the patient may experience retrograde and anterograde amnesia relative to the seizure. Both types of amnesia may persist for one to six months after treatment. Finally, some patients live through a lingering sense of long-term memory loss that is difficult to quantitate and consists of random deficits in the fabric of total memory.

Despite an improved safety profile, ECT remains controversial. Certain religious groups (e.g., the Church of Scientology) and some state legislatures have voiced concerns about ECT. In 1972, the California legislature banned ECT, which was reversed by state courts on the grounds that such a ban interfered with the practice of medicine.5

Despite these controversies, more than 80% of patients in one study indicated a high degree of satisfaction with their treatment.14 Many patients have written poems about their experiences with ECT.15 These poems echo a number of themes: psychic pain before treatment, the immense positive benefits, the bizarre character of the treatment, fears of electrocution, and concerns about memory loss.15

The American Psychiatric Association, the National Institute of Mental Health, the American Medical Association, the Food and Drug Administration, and the U.S. Surgeon General (along with similar organizations in Canada, Great Britain, and many other countries) all support the effectiveness of ECT when used by highly skilled doctors trained to diagnose and treat mental illness. ECT is routinely paid for by both government and private insurers because of its demonstrated efficacy for several major psychiatric disorders.

Indications and Contraindications

Although ECT initially was considered a possible treatment for schizophrenia, it proved more effective for major depression. ECT is rarely used as a primary treatment modality, but rather after failure of pharmacotherapy. ECT is most efficacious when given in combination with antipsychotic medications. A task force of the American Psychiatric Association found significant advantages of ECT in comparing real with sham ECT.16

Current indications, besides major depression, include bipolar disorder (both for depression and mania), schizoaffective disorder, and catatonic schizophrenia. ECT may be especially effective in acutely suicidal individuals because of its rapid action. It is highly useful in depressed pregnant women who must avoid drugs that risk fetal effects. ECT has much less of an effect on a fetus than drugs. There have been some instances of fetal cardiac arrhythmias that last for a few moments after ECT, but they did not cause any adverse effects noted at birth. More recent uses have been for neuroleptic malignant syndrome, Parkinson's disease, and refractory epilepsy.6

The one absolute contraindication is an intracranial neoplasm.6 Relative contraindications include ischemic heart disease, tachycardia, hypertension, ventricular ectopy, gastroesophageal reflux, and recurrent vertebral compression.17

Current Administration

Modern ECT typically is performed in an operating room or recovery room. The patient receives succinylcholine, a brief-acting induction anesthetic, oxygen, and a muscle relaxant, as well as having an oral airway placed. The patient fasts overnight for the morning procedure.

There are two types of electrode placements. In unilateral placement, one electrode is placed midline at the vertex, and the other on the dominant hemisphere (the hemisphere controlling the dominant hand) on a line between the outer canthus of the eye and the external auditory meatus. Bilateral placement is in the temporal region of each side. Bilateral placement is more effective but has a greater effect on memory.17

One of the advantages of using electricity is precise control of its administration. Once the seizure threshold has been determined, the ECT machine is set using the mCi (millicuries) calibration at low (50% over threshold), moderate (150% over threshold), or high (400-500% over threshold).18 ECT is normally administered three times a week, on an every-other-day basis, for a total of 6 to 12 treatments. An EEG monitor is sometimes used to demonstrate the presence of the seizure. After the electrical convulsion, the patient slowly recovers within 10 to 20 minutes.19

The patient should continue to be treated until full recovery or until no further gains are seen. Patients may be treated as outpatients if they have good supports. The ECT suite should be equipped with emergency equipment and medications, as well as suction, oxygen, and the ECT device. It should be located in an area that facilitates easy consultation between the psychiatrist and the anesthesiologist.19

A Developing Area

An estimated 100,000 Americans annually receive ECT.5 Electrical therapies are an important developing area in psychiatric treatment. There have been significant refinements in methods to induce the generalized seizure. For example, magnetic seizure therapy involves a powerful electromagnet placed on the scalp to trigger a seizure; this method is now being used to decrease memory loss.20 Trans-cranial magnetic stimulation, in which an electromagnetic coil is placed over the patient's forehead and a fluctuating magnetic force is briefly applied to a conscious patient, currently is being studied for antidepressant and antipsychotic efficacy.21

Two other newer therapies are deep brain stimulation and vagus nerve stimulation. The benefits of these therapies may include clinical improvement in those who do not respond to medication and potentially less memory loss than in traditional ECT.22

Acknowledgment

The authors wish to acknowledge with thanks the contributions of Ronald Green, DO, of the UMASS Medical School Department of Psychiatry, who reviewed the manuscript and made helpful comments.

Stephen M. Soreff, MD, is President of Education Initiatives in Nottingham, New Hampshire, and is associated with the Metropolitan College at Boston University, Fisher College, Worcester State College, and Southern New Hampshire University. He also works in the School Health Section of the New Hampshire Department of Education.
Patricia H. Bazemore, MD, is an Associate Professor in the departments of Family Medicine, Community Medicine, and Psychiatry at the University of Massachusetts Medical School in Worcester. She is also Chief of Medicine at Worcester State Hospital.

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