Also known as shock therapy or shock treatment. The procedure is performed in a small room with a doctor and an anesthesiologist present. Electrodes are attached to the head and chest. The patient is strapped securely to a table and a mouth guard is put in, then they attach the electrodes to a small electric generator. No jewelry may be worn. These days they give general anesthesia and muscle relaxants directly prior to the treatment. The doctors monitor the patient's heart rate, brain waves, and other vital statistics. They put a clamp-type device on either the patient's finger or toe, I believe to measure the pulse. Multiple treatments are administered either on an inpatient or an outpatient basis, every other day. One course of treatment usually involves six to ten ECT procedures.

In the past anesthesia and muscle relaxants were not administered, vital signs were not monitored, the patient was physically held down by orderlies so as not to break any bones while convulsing, as portrayed in One Flew Over a Cuckoo's Nest. Portrayed more recently and accurately to modern methods in Requiem for a Dream.

The objective of ECT is to induce a seizure, generally, a longer seizure is considered better, over two minutes is considered a good lenth seizure. ECT is administered, usually as a last resort, to patients with severely debillitating depression, (and sometimes schizophrenia) when other treatments have proven insufficient. ECT is used as a temporary mood elevator to bring the patient to a point where other treatments, usually antidepressants, can help. ECT is not a cure. One of the scarier aspects of ECT is that although it has been used on mental patients for probably longer than fifty years, it is still not understood why it works. Supposedly the treatment was an evolution of the observation of epilepsey patients with depression. Other disconcerting aspects of ECT are side effects, most notably memory loss. Although the extent of the memory loss is usually portrayed as only affecting events immediately surrounding the time of treatment, it can permanatly erase or obscure memories from months around the treatment, and alter the subsequent quality of the patient's memory, although not in all patients. Other side effects are acute muscle and head pain following treatment due to the severity of the seizures.

People are affected very differently by ECT, with reactions ranging from mild discomfort, to severe emotional trauma. My experiences range on the severe side, and having ECT, especially the first course, was the worst experience of my life. It left me feeling fragile and mentally violated in a way that I can't imagine how to describe except that it was a bit like my entire self, my personality and psyche, had been wrested away from me and destroyed, except just enough so that I was fully aware of what was being done to me. I've tried to make several key people in my life promise never to let me go through it again. But not everyone reacts this badly, I know several people who feel that, except for the discomfort, it was a positive experience.

This may have its origins in Rome in the 4th century AD. Depressed residents were known to slap torpedo fish, which generate about 25V, on their heads in an effort to deal with the depression. It is known that the human brain can withstand somwhere around 140V before it completely knuckles under and fries.

As noted by user anomaly above (see last paragraph), ECT has varying degrees of success, ranging from some improvement to "the worst experience of my life." Ernest Hemingway underwent ECT some decades ago. Shortly before committing suicide, he lamented the loss of quite a bit of long-term memory.

Call me opinionated, but it seems pretty obvious to me that creating a circuit path between a person's scalp down through his brain, neck, and chest, and then juicing him up with current, is a really, really, really stupid idea. See also transorbital leukotomy and prefrontal lobotomy. Regardless of anyone's opinions, it is a matter of fact that its results are rather "wildcard" in nature.

Psychology: The Leap of Faith

Anything that was fun just wasn’t fun anymore. You just can’t do anything. You’re paralyzed.” These are the words of a woman, currently in her sixties, describing the depression she has endured off and on for most of her life; her words are a fairly accurate description of depression, a condition that affects 9.4 million Americans . As one can imagine, many drug companies, notably Pfizer – the maker of Prozac - , make a large amount of money trying to cure this condition. The cure for depression that many seem to forget about is shock therapy, a cure that has been around since 1934.

Shock therapy, also known as Electroshock and Electroconvulsive Therapy (ECT), is a now painless procedure in which a machine sends electrical currents through a person’s brain in an attempt to cure them of a mental illness. Because of the controversy inherent in running electrical currents through mental health patients, and because of its past misuses, ECT remains a treatment that many consider barbaric and somewhat frightening; however, the procedure has changed drastically since it was first introduced in the mid 30s. The real problem with ECT is that though shock therapy has been shown to work and seems to be fairly safe, doctors and scientists alike still do not know what exactly ECT does to the brain or why ECT works.

The procedure of ECT has, in fact, been a guess and check procedure since the invention of shock therapy, when physicians discovered that patients afflicted with dementia praecox, a debilitating mental disease, were sometimes cured of their disorder upon developing epileptic seizures. This discovery was followed by the work of a man named Ladislas Meduna, who noticed while working at the Hungarian Psychiatric Institute in the early 1930s that humans who had dementia praecox had lower amounts of neuroglia in their brains than a normal human would, and that humans who suffered from epilepsy had higher amounts of neuroglia in their brains than a normal human would; neuroglia support and assist neurons, the main cells of the brain. From this observation he concluded that patients who had dementia were often cured with the increase of neuroglia in their brains as a result of epilepsy. Later, in 1934 while working in a mental hospital, Meduna injected patients who had “incurable” mental diseases with camphor-in-oil, a substance known to cause seizures; after several mental health patients were cured, Meduna published his findings in 1937. His method of inducing seizures was improved upon with the advent of ECT, and within fifteen years electroshock became a common treatment for patients of many differing psychological disorders.

It has been awhile since that time when ECT was first invented, and different people have come up with a few theories as to why epileptic seizures can cure so many mental illnesses. One of theories is based upon the secretion of hormones, which are chemicals the body uses to regulate functions such as sleep cycles and mental states; patients with psychological disorders often have hormone levels that are either too high or too low for their body to function normally. For example, a person suffering from depression will have adrenal glands, organs in the body that produce hormones, that create too much of the hormone cortisol; the common symptoms of depression such as sleeplessness, fatigue, and impaired cognitive ability are all related to processes controlled by cortisol. The electrical currents that are run through the patient’s brain during ECT stimulate the hypothalamus, a hormone producing part of the brain, to release hormones which cause the pituary gland, another hormone producing organ, to release its hormones which repress the production of cortisol. After a few treatments the hormones begin to interact normally, and the patient’s eating, sleeping, mood, and muscle activity become normal again. It is not known yet which substances, hormones or otherwise, control functions such as mood, emotion, thought, and muscle activity; so this theory remains a theory. There is as yet no proven explanation as to what ECT does or why it works.

Because ECT is poorly understood, it is usually only used as a last resort when all other treatments have failed or the symptoms of whatever condition the patient has become so severe the patient can no longer tolerate the condition. If such a last resort scenario occurs, the doctor will describe the benefits, procedures, and risks of ECT to the patient; the law also requires that the patient sign a legal consent form before the patient can receive shock therapy. No other psychiatric treatment requires such consent, not even psychotropic drugs with known risks. The patient can also choose to drop out of the treatment process at any time, and many states mandate that the patient sign a consent form before each treatment. Involuntary treatment is usually only legal when the procedure is necessary to save the patient’s life; when a patient’s condition is so severe that he requires supervision to prevent him from harming himself, or the patient requires a nurse to feed him and prevent him from dying from lack of food and water, a judge can enforce involuntary treatment. Sometimes family consent can authorize emergency treatment.

After the legal issues have been dealt with, a blood count, an electrocardiogram (a test of the patients heart), and blood chemistry tests are performed on the patient. The physician in charge of the shock therapy examines all medications taken by the patient; the physician may alter the amounts and types of medications the patient consumes in order to avoid complications. Than an anesthesiologist must find out about all the previous times the patient has been anesthetized so that he can decide how the patient should be anesthetized. Women able to bear children undergo pregnancy tests, since certain drugs administered during ECT could damage the fetus. An examination of the patient’s teeth is also required to insure that his or her teeth are suitable for the mouth guard used in the procedure.

When it is finally time to perform the actual procedure, the patient puts on a surgical gown, and empties his bladder. He goes to a treatment room where he lies down on a stretcher, and a needle is inserted into one of the patient’s veins. The needle is used to medicate the patient during the procedure. Adhesive electrodes are then attached to the patient; some measure heart rate, some measure blood pressure, some measure motor movement, some measure brain activity, some measure the oxygen and carbon dioxide level in the patient’s blood, lungs, and exhaled air, and some apply the electric current. An oxygen mask is then placed over the patient’s mouth and nose; through this mask the patient breathes one hundred percent oxygen during the entire treatment. The anesthesiologist administers a sedative to the patient, and as soon as the patient’s muscles stop twitching a muscle relaxant is administered. A machine then passes a painless electric current through the patient’s body while the anesthesiologist holds a mouth guard in the patient’s mouth, which prevents tongue biting and damage to the teeth and jaws of the patient.

Usually within three minutes the patient can breathe on his own, and after he wakes up he is asked his name, the date, and his current location. In less than fifteen minutes the patient is usually able to answer these questions with some degree of accuracy, and within thirty minutes he is fully aware of himself and his surroundings. Some patients become perturbed after regaining consciousness; such a patient is usually given a dose of Valium or Ativan. After the treatment, patients can perform most activities; however they should not drive until the effect of the anesthetics completely wears off. Also, important decisions such as marriage or divorce should not be made immediately after treatment; if decisions such as these need to be made immediately, a trustworthy adult should supervise the patient.

Most patients derive only limited benefit from one treatment of ECT, so physicians almost always prescribe multiple treatments; however, patients rarely have ECT performed on them daily or twice daily except in emergency situations such as someone who is suicidal. Most patients receive two to three treatments a week, and a complete course of treatment takes a minimum of six months usually. Such a schedule is not sufficient for some patients; they begin what is called “continuation ECT”, and this is usually done on a biweekly basis with a minimum of six treatments.

I question this procedure. How do physicians know how many treatments are sufficient? The only way to tell would have to be a reviewing of past successes and failures; what this means is that the only way a physician can know the safe amount of treatments for an individual patient is to try what has worked in the past and hope for the best.

I interviewed someone who had experienced shock therapy to get a first hand account of the treatment; for the purposes of privacy I will call her Susan. She is now an old woman in her sixties, but a physician had performed shock therapy on her in the early seventies, so she would have been in her forties when she had experienced ECT. At the time, Susan had been experiencing depression that she says was brought on by the overwhelming pressure of taking care of her eight children; she says she never did anything for herself, and it finally caught up with her. In her words, “Anything that was fun just wasn’t fun any more. You just can’t do anything. You’re paralyzed”. She had very little energy at the time, and often could not even get out of bed. She saw a psychiatrist on her sister’s recommendation, and he recommended she go to a hospital where she would be closely monitored. During Susan’s stay, she received no group therapy or any sort of treatment, and talked to a physician only 15 minutes a week. After a month there, she left, and it was after she left the hospital that she received shock therapy. She received a total of twelve treatments, which she said did not help to alleviate her depression. She also lost eight months of her memory, and to this day can not remember her son’s graduation; to this she simply stated “It doesn’t bother me…it was worth a try.” She had not received any medication up to this point, and it was not until three years after the treatments that she began taking antidepressants and sleeping pills, which she says helped. Though her depression returns sometimes, Susan said that these days she feels “really good.”

Like all treatments, ECT does not have a one hundred percent success rate; according to the American Psychiatric Association, “Clinical evidence indicates that for uncomplicated cases of severe major depression, ECT will produce a substantial improvement in at least eighty percent of patients”, so it is not a complete surprise that the treatment did not work for Susan. The memory loss she described, however, still occurs even today. According to Dr. Harold Sackeim, a leader in the field of performing shock therapy, patients may experience memory loss, from a “few months before to a few weeks afterwards”; rarely does the memory loss extend further back. However, many patients have reported long gaps in their memory even with recent treatments of ECT.

On the other hand, the benefits of ECT are just as difficult to ignore as the risks. Memory loss is minimal for modern day shock therapy due to the now-constant monitoring of oxygen inhaled and exhaled by the patient , and the changeover from sinusoidal currents to square wave currents; the percent of people who die from the procedure is about one tenth of the percent of women who die from giving birth. In a study of hospital patients in a large urban area, 0.8 percent of those patients who underwent ECT attempted suicide, while 4.2 percent of the patients being treated solely with antidepressant drugs attempted suicide. In another study, 190 patients underwent bilateral ECT and 156 (72 percent) were deemed recovered. Dr. Harold Sackeim, while on the program Sixty Minutes, claimed that “The medical community recognizes universally that ECT is the most effective antidepressant we have.” ECT can also cure a wide range of mental diseases, including depression, mania, schizophrenia, catatonia, parkinsonian rigidity, and neuroleptic malignant disorder.

In light of both sides of the argument on whether or not to use ECT, I think the National Mental Health Association summed it up best when they said that shock therapy involves “serious risks”, and they urge “increased, rigorous, and objective research on ECT”. They recommend ECT only “after all other treatment approaches, such as medication and psychotherapy, have either failed or have been seriously and thoroughly rejected”. Not only is ECT potentially unsafe, physicians will not know the truly correct way to perform shock therapy until its effects are understood. As it stands, an effective treatment is “seizures in duration of at least 25 seconds in the motor convulsion, 30 to 50 seconds in the heart rate increase, and 30 to 150 seconds in the EEG are now presumed to be effective.” Such a guess and check method of psychiatry is not safe for the patient, especially when ECT involves the passing of electric currents through a patient’s brain. Until shock therapy is truly understood, physicians are putting their patients at risk when they subject them to ECT.

Works Cited

American Psychiatric Association. Professional page. 6 Jun. 2002. American Psychiatric Association. 6 June 2002. http://www.psych.org

Fink, Max. Electroshock: Restoring the Mind. New York: Oxford University Press, 1999

Sixty Minutes. Host Bob Simon. CBS. Cablevision, Massachusetts. 4 Mar. 2001.

Electroconvulsive Therapy (ECT)

ECT not only has a higher success rate for severe depression, but it is also an effective form of treatment for schizophrenia accompanied by catatonia, mania, and manic depression

Recently, there has been an increase in the interest of ECT as it has become a safe option in the treatment of the illnesses mentioned above.  The public has been influenced by what they have seen on television and in movies such as, "One Flew Over the Cuckoo's Nest", whose associations with ECT start with the electric chair and move on to such treatments as harnessing the power from lightning bolts, and electric eels to perform primitive forms of ECT.  This makes for an uneasy conversation about the subject. Let's turn that misconception into the truth about ECT.

This is an ECT

This is first hand knowledge of how an ECT is performed.  The patient is sedated using a very short-acting barbiturate and a drug called succinycholine.  The succinycholine is used to temporarily paralyze the patient's muscles to keep them from contracting during the treatment which could damage the muscles or cause bone fractures.

The physician places an electrode just above the temple on the non-dominate side of the brain, and then places a second one in the middle of the forehead.  This form of ECT is called unilateral.  Another form of ECT called bilateral has one electrode placed just above both temples.  Once the patient is sedated, the process begins.  A very small amount of current is sent through the brain, which produces a seizure.  Since the patient is totally relaxed from the anesthesia, they sleep peacefully through the process while the seizure is being monitored by an electroencephalogram, and their heart rhythm is being monitored by an electrocardiogram

The actual electric current is only applied for about a second, during this time the patient is breathing pure oxygen through an oxygen mask.  The seizure caused by the ECT usually lasts from thirty seconds to a little longer than a minute. During the few seconds that follow the actual ECT current, the patient may experience a temporary drop in blood pressure.  This is often followed by a notable increase in heart rate, which may cause the blood pressure to rise.  Disturbances in heart rhythm are not unusual, and generally will subside without any complications. The patient usually takes roughly ten minutes to wake up after the treatment.  When the patient wakes up, they usually have a brief period of confusion, muscle stiffness, or headache.  These effects usually diminish after about thirty or forty minutes. 

If a patient has a history of high blood pressure or any other cardiovascular problems, they should tell the physician so they can have a consultation with a cardiologist before any treatment could be considered.

I am an ECT patient. I have had numerous ECT treatments; too many to count. When I was in a severely manic state and could not recover from medications, ECT treatments would rapidly bring me back to a stabilized mood. Also, if I was in a severely depressed state they would bring my mood back to stable.

This is a personal opinion. I am not a medical professional. For any patient who has undergone many medication changes and therapy to no avail, I would strongly encourage you to consider ECT.

It is particularly useful for people who suffer from psychotic depressions or intractable mania, people who cannot take antidepressants due to problems of health or lack of response and pregnant women who suffer from depression or mania. A patient who is very intent on suicide, and who would not wait 3 weeks for an antidepressant to work, would be a good candidate for ECT because it works more rapidly.

                                                   What ECT Did For Me

 

Death invited me to a debate

                                               On the benefits of suicide

                I accepted

                                    He won

Integrity demanded action

                                                          But I failed

                                                                                As you have guessed by now

Post eight courses of electroconvulsive therapy

                                                                                                   I have forgotten what he said

 

                                                                       And also much more

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