Electroconvulsive Therapy

If you had asked me six months ago, "When was electroconvulsive therapy last used in a civilized country?" I would have stared at you blankly and said, "1965?" My guess is that most of my readers think ECT (or "shock therapy" as it is commonly known) is dead and gone. One of my readers is going through nursing training at the moment, and described to me watching ECT used to treat a patient in the San Francisco Bay Area. It turns out that ECT, for all the problems that it had into the 1960s, is still commonly used, and is apparently a highly effective treatment for severe depression.

From Tarique D. Perera, Bruce Luber, Mitchell S. Nobler, Joan Prudic, Christopher Anderson and Harold A Sackeim, "Seizure Expression During Electroconvulsive Therapy: Relationships with Clinical Outcome and Cognitive Side Effects," Neuropsychopharmacology [2004] 29:813-825:

Electroconvulsive therapy (ECT) is the most effective acute treatment for major depression (American Psychiatric Association, 2001). It was thought for decades that the generalized seizure provided the necessary and sufficient conditions for ECT's antidepressant effects (Ottosson, 1960; Fink, 1979). However, it is now established that generalized seizures lacking efficacy can be reliably produced (Robin and De Tissera, 1982; Sackeim et al, 1987a, 1993, 2000b; McCall et al, 2000), as clinical outcome is strongly influenced by the anatomic positioning of electrodes and electrical dosage relative to seizure threshold (ST). Therefore, efficacy is dependent on intracerebral current paths and the current density within those paths, implicating anatomic specificity in the circuitry subserving ECT's antidepressant effects. Supporting this perspective, imaging studies have shown that distinct topographic changes in brain activity are associated with ECT's therapeutic and adverse cognitive effects (Nobler et al, 1994, 2000, 2001; Sackeim et al, 1996, 2000a).

Given that the patients who receive ECT are often the most severely ill or those with established treatment resistance, ensuring adequate delivery is especially critical. Yet, previous guidelines, requiring essentially a generalized seizure of sufficient duration, proved to have limited relevance for efficacy. Consequently, there is great interest in identifying physiological markers that predict clinical outcomes with sufficient accuracy to guide alterations in treatment parameters (eg stimulus dosing, switching electrode placements, etc) (Krystal and Weiner, 1994).

From J. Greenhalgh, C. Knight, D. Hind, C. Beverley and S. Walters, "Clinical And Cost-Effectiveness Of Electroconvulsive Therapy For Depressive Illness, Schizophrenia, Catatonia And Mania: Systematic Reviews And Economic Modelling Studies," Health Technology Assessment [2005] 9:9:

ECT has been available for use since the 1930s. It involves passing an electric current through a person’s brain after they have been given a general anaesthetic and muscle relaxants, to produce a convulsion. There is a complex interplay between the stimulus parameters of ECT, including position of electrodes, dosage and waveform of electricity, and its efficacy.

ECT is rarely used as a first line therapy, except in an emergency where the person’s life is at risk as a result of refusal to eat or drink or in cases of attempted suicide. Current guidelines indicate that ECT has a role in the treatment of people with depression and in certain subgroups of people with schizophrenia, catatonia and mania. In England between January and March 1999 there were 16,482 administrations of ECT to 2835 patients, 85% of which were in an inpatient setting. There were important variations in the rates of administration of ECT by gender, age and health region. Women received ECT more frequently than men and the rates of administration for both genders increased with age. In England, rates of administration of ECT are highest in the North West and lowest in London.