Electroconvulsive therapy

As early as the 16th century, agents to induce seizures were used to treat psychiatric conditions. In 1785, the therapeutic use of seizure induction (by administering camphor orally) was documented in the London Medical and Surgical Journal. As to its earliest antecedents one doctor claims 1744 as the dawn of electricity's therapeutic use, as documented in the first issue of Electricity and Medicine. Treatment and cure of hysterical blindness was documented eleven years later. Benjamin Franklin wrote that an electrostatic machine cured "a woman of hysterical fits." By 1801, James Lind as well as Giovanni Aldini had used galvanism to treat patients with various mental disorders. G.B.C. Duchenne, the mid-19th century "Father of Electrotherapy", said its use was integral to a neurological practice. In the second half of the 19th century, such efforts were frequent enough in British asylums as to make it notable. Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then metrazol (cardiazol). Meduna is thought to be the father of convulsive therapy. In 1937, the first international meeting on schizophrenia and convulsive therapy was held in Switzerland by the Swiss psychiatrist Max Müller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide. and rapidly replaced less safe and effective forms of biological treatments in use at the time. Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his assistant Lucio Bini at Sapienza University of Rome developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1938, experimented for the first time on a person affected by delusions. It was believed early on that inducing convulsions aided in helping those with severe schizophrenia but later found to be most useful with affective disorders such as depression. Cerletti had noted a shock to the head produced convulsions in dogs. The idea of a procedure on humans came to Cerletti when he saw how pigs were given an electric shock before being butchered to put them in an anesthetized state. Cerletti and Bini practiced until they felt they had the right parameters needed to have a successful human trial. Once they started trials on patients, they found that after 10–20 treatments the results were significant. Patients had much improved. A positive side effect to the treatment was retrograde amnesia and it was because of this side effect that patients could not remember the treatments and had no ill feelings toward it. Cerletti and Bini were nominated for a Nobel Prize but did not receive one. By 1940, the procedure was introduced to both England and the US. In Germany and Austria, it was promoted by Friedrich Meggendorfer. Through the 1940s and 1950s, the use of ECT became widespread. At the time the ECT device was patented and commercialized abroad, the two Italian inventors had competitive tensions that damaged their relationship. In the 1960s, despite a climate of condemnation, the original Cerletti-Bini ECT apparatus prototype was contended by scientific museums between Italy and the US. The ECT apparatus prototype is now owned and displayed by the Sapienza Museum of the History of Medicine in Rome. In the 1940s and early 1950s, ECT was usually given in an "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones. In the 1940s, psychiatrists began to experiment with curare, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction of suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to the more widespread use of "modified" ECT. A short-acting anesthetic was usually given in addition to the muscle relaxant in order to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants. The New York Times described the public's negative perception of ECT as being caused mainly by one fictional work: "For Big Nurse in ''One Flew Over the Cuckoo's Nest, it was a tool of terror, and, in the public mind, shock therapy'' has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused". In 1976, Dr. Blatchley demonstrated the effectiveness of his constant current, brief pulse device ECT. This device eventually largely replaced earlier devices because of the reduction in cognitive side effects, although as of 2012 some ECT clinics still were using sine-wave devices. The 1970s saw the publication of the first American Psychiatric Association (APA) task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001). The report endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT. Specifically, critics pointed to shortcomings such as noted side effects, the procedure being used as a form of abuse, and uneven application of ECT. The use of ECT declined until the 1980s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression". Because of the backlash noted previously, national institutions reviewed past practices and set new standards. In 1978, the American Psychiatric Association released its first task force report in which new standards for consent were introduced and the use of unilateral electrode placement was recommended. The 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task force report in 1990 where specific details on the delivery, education, and training of ECT were documented. Finally, in 2001 the American Psychiatric Association released its latest task force report. Though ECT use declined with the advent of modern antidepressants, there has been a resurgence of ECT with new modern technologies and techniques. Modern shock voltage is given for a shorter duration of 0.5 milliseconds where conventional brief pulse is 1.5 milliseconds. In a review from 2022 of neuroimaging studies based on a global data collaboration, ECT was suggested to work via a temporary disruption of neural circuits followed by augmented neuroplasticity and rewiring. == Modern use ==

ECT is used, where possible, with informed consent in treatment-resistant major depressive disorder, bipolar depression, treatment-resistant catatonia, prolonged or severe mania, and in conditions where "there is a need for rapid, definitive response because of the severity of a psychiatric or medical condition (e.g., when illness is characterized by suicidality, psychosis, stupor, marked psychomotor retardation, depressive delusions or hallucinations, or life-threatening physical exhaustion associated with mania)." Major depressive disorder For major depressive disorder, despite a Canadian guideline and some experts arguing for using ECT as a first line treatment, ECT is generally used only when one or other treatments have failed, or in emergencies, such as imminent suicide. ECT has also been used in selected cases of depression occurring in the setting of multiple sclerosis, Parkinson's disease, Huntington's chorea, developmental delay, brain arteriovenous malformations, and hydrocephalus. Efficacy A meta-analysis on the effectiveness of ECT in unipolar and bipolar depression indicated that although patients with unipolar depression and bipolar depression responded to other medical treatments very differently, both groups responded equally well to ECT. Overall remission rate for patients given a round of ECT treatment was 50.9% for those with unipolar depression and 53.2% for those with bipolar depression. Most severely depressed patients respond to ECT. In 2004, a meta-analysis found in terms of efficacy, "a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus tricyclics and ECT versus monoamine oxidase inhibitors." In 2003, the UK ECT Review Group published a systematic review and meta-analysis comparing ECT to placebo and antidepressant drugs. This meta-analysis demonstrated a large effect size (high efficacy relative to the mean in terms of the standard deviation) for ECT versus placebo, and versus antidepressant drugs. Compared with repetitive transcranial magnetic stimulation (rTMS) for people with treatment-resistant major depressive disorder, ECT relieves depression as shown by reducing the score on the Hamilton Rating Scale for Depression by about 15 points, while rTMS reduced it by 9 points. Other estimates regarding the response rate in treatment resistant depression vary between 60–80%, with a remission rate of 50–60%. In addition to reducing symptoms of depression and inducing relapse, ECT has also been shown to reduce the risk of suicide, improve functional outcomes and quality of life as well as reduce the risk of re-hospitalization. The initial course of ECT is then transitioned to maintenance ECT, pharmacotherapy or both. When ECT is stopped abruptly, without a bridge to maintenance ECT or medications (usually antidepressants and Lithium), it is associated with a relapse rate of 84%. Catatonia ECT is generally a second-line treatment for people with catatonia who do not respond to other treatments, but is a first-line treatment for severe or life-threatening catatonia. There is a plethora of evidence for its efficacy, notwithstanding a lack of randomised controlled trials, such that "the excellent efficacy of ECT in catatonia is generally acknowledged". Mania ECT is used to treat people who have severe or prolonged mania; and as a second-line treatment for bipolar mania. Schizophrenia ECT is widely used worldwide in the treatment of schizophrenia. However, in North America and Western Europe it is invariably used only in treatment resistant schizophrenia when symptoms show little response to antipsychotics. ECT may improve medium-term clinical response relative to standard care, but may not affect other outcomes. Evidence is lacking to support the practice's superiority to placebo treatment (sham ECT) or antipsychotic supplementation. It is useful in the case of severe exacerbations of catatonic schizophrenia, whether excited or stuporous. ==Effects and adverse effects==

Aside from effects on the brain, the general risk for adverse effects stemming from ECT are similar to those of brief general anesthesia; a Surgeon General of the United States's report stated that there are "no absolute health contraindications" to its use. Severe adverse cardiac events occur in between one in forty and, maximally, one in fifteen patients administered ECT. While there are no absolute contraindications for ECT, there is an increased risk for patients who have unstable or severe cardiovascular conditions or aneurysms; who have recently had a stroke; who have increased intracranial pressure (for instance, due to a solid brain tumor); who have severe pulmonary conditions; or who are generally at high risk for adverse effects from anesthesia. Risk of death A meta-analysis from 2017 found that the death rate of ECT was around 2.1 per 100,000 procedures. A review from 2011 reported an estimated ECT mortality rate of fewer than one death per 73,440 treatments. Cognitive impairment Cognitive impairment sometimes occurs after ECT. The American Psychiatric Association (APA) report in 2001 acknowledged: "In some patients the recovery from retrograde amnesia will be incomplete, and evidence has shown that ECT can result in persistent or permanent memory loss". The acute effects of ECT can include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment). Memory loss and confusion are more pronounced with bilateral electrode placement rather than unilateral and with outdated sine-wave rather than brief-pulse currents. Using either constant or pulsing electrical impulses also varied the memory loss results in patients. Patients who received pulsing electrical impulses, as opposed to a steady flow, seemed to incur less memory loss. The vast majority of modern treatments use brief pulse currents. In 2000, American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with more persistently impaired memory of public events as compared to right unilateral ECT. However, bilateral ECT may be more efficacious than unilateral in the treatment of mood disorders. Kellner cites a study purporting to show an absence of cognitive impairment in eight subjects after more than 100 lifetime ECT treatments. Kellner stated, "Rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness." Two meta-analyses find that ECT is associated with brain matter growth. Effects in pregnancy If steps are taken to decrease potential risks, ECT is generally considered relatively safe during all trimesters of pregnancy, particularly when compared to pharmacological treatments. Suggested preparation for ECT during pregnancy includes a pelvic examination, discontinuation of nonessential anticholinergic medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate antacid. During ECT, elevation of the pregnant woman's right hip, external fetal cardiac monitoring, intubation, and avoidance of excessive hyperventilation are recommended. Effects on the heart ECT can cause a lack of blood flow and oxygen to the heart, heart arrhythmia, and "persistent asystole". A 2019 systematic review and meta-analysis of 82 studies found that the rate of major adverse cardiac events with ECT was 1 in 39 patients or about 1 in 200 to 500 procedures. The risk of death with ECT however is low. If death does occur, cardiovascular complications are considered as causal in about 30% of individuals. == Procedure ==

in Bristol, England and used for example at the Asyl psychiatric hospital in Kristiansand, Norway, from the 1960s to the 1980s The placement of electrodes, as well as the dose and duration of the stimulation is determined on a per-patient basis. and almost all in the UK receive bilateral ECT. The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT. In a minority of countries such as Japan, India, and Nigeria, ECT may be used without anesthesia. The Union Health Ministry of India recommended a ban on ECT without anesthesia in India's Mental Health Care Bill of 2010 and the Mental Health Care Bill of 2013. The practice was abolished in Turkey's largest psychiatric hospital in 2008. The patient's EEG, ECG, and blood oxygen levels are monitored during treatment. Concurrent pharmacotherapy Whether psychiatric medications are terminated prior to treatment or maintained, varies. However, drugs that are known to cause toxicity in combination with ECT, such as lithium, are discontinued, and benzodiazepines, which increase the seizure threshold, are either discontinued, a benzodiazepine antagonist is administered at each ECT session, or the ECT treatment is adjusted accordingly. Treatment team In the US, the medical team performing the procedure typically consists of a psychiatrist, an anesthetist, an ECT treatment nurse or qualified assistant, and one or more recovery nurses. Typically, 70 to 120 volts are applied externally to the patient's head, resulting in approximately 800 milliamperes of direct current passing between the electrodes, for a duration of 100 milliseconds to 6 seconds, either from temple to temple (bilateral ECT) or from front to back of one side of the head (unilateral ECT). However, only about 1% of the electrical current crosses the bony skull into the brain because skull impedance is about 100 times higher than skin impedance. In the US, ECT devices are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and Mecta. In the UK, the market for ECT devices was long monopolized by Ectron Ltd, which was set up by psychiatrist Robert Russell. == Mechanism of action ==

Despite decades of research, the exact mechanism of action of ECT remains elusive. A review from 2022 of neuroimaging studies based on a global data collaboration, resulted in a model of temporary disruption of neural circuits followed by augmented neuroplasticity and rewiring. ==Use==

As of 2001, it was estimated that about one million people received ECT annually. and Luxembourg. About 70 percent of ECT patients are women. In Sweden, which has a complete register of all ECT treatments in the country, in 2013 the rate of persons treated in that year per 100,000 inhabitants was 41. Almost the same rate had already been present in 1975 with 42 patients per 100,000 inhabitants. United States ECT became popular in the US in the 1940s. At the time, psychiatric hospitals were overrun with patients whom doctors were desperate to treat and cure. Whereas lobotomies would reduce a patient to a more manageable submissive state, ECT helped to improve mood in those with severe depression. A survey of psychiatric practice in the late 1980s found that an estimated 100,000 people received ECT annually, with wide variation between metropolitan statistical areas. Accurate statistics about the frequency, context and circumstances of ECT in the US are difficult to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information. In 13 of the 50 states, the practice of ECT is regulated by law. In the mid-1990s in Texas, ECT was used in about one third of psychiatric facilities and given to about 1,650 people annually. Usage of ECT has since declined slightly; in 2000–01 ECT was given to about 1,500 people aged from 16 to 97 (in Texas it is illegal to give ECT to anyone under sixteen). ECT is more commonly used in private psychiatric hospitals than in public hospitals, and minority patients are underrepresented in the ECT statistics. United Kingdom In the UK in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then to about 12,000 per annum in 2002. In 2003, the National Institute for Health and Care Excellence, a government body which was set up to standardize treatment throughout the National Health Service in England and Wales, issued guidance on the use of ECT. Its use was recommended "only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode". The guidance received a mixed reception. It was welcomed by an editorial in the British Medical Journal but the Royal College of Psychiatrists launched an unsuccessful appeal. The NICE guidance, as the British Medical Journal editorial points out, is only a policy statement and psychiatrists may deviate from it if they see fit. Adherence to standards has not been universal in the past. A survey of ECT use in 1980 found that more than half of ECT clinics failed to meet minimum standards set by the Royal College of Psychiatrists, with a later survey in 1998 finding that minimum standards were largely adhered to, but that two-thirds of clinics still fell short of current guidelines, particularly in the training and supervision of junior doctors involved in the procedure. A voluntary accreditation scheme, ECTAS, was set up in 2004 by the Royal College, and the vast majority of ECT clinics in England, Wales, Northern Ireland and the Republic of Ireland have signed up. The Mental Health Act 2007 allows people to be treated against their will. This law has extra protections regarding ECT. A patient capable of making the decision can decline the treatment, and in that case treatment cannot be given unless it will save that patient's life or is immediately necessary to prevent deterioration of the patient's condition. A patient may not be capable of making the decision (they "lack capacity"), and in that situation ECT can be given if it is appropriate and also if there are no advance directives that prevent the use of ECT. China ECT was introduced in China in the early 1950s and while it was originally practiced without anesthesia, as of 2012 almost all procedures were conducted with it. As of 2012, there are approximately 400 ECT machines in China, and 150,000 ECT treatments are performed each year. Chinese national practice guidelines recommend ECT for the treatment of schizophrenia, depressive disorders, and bipolar disorder and in the Chinese literature, ECT is an effective treatment for schizophrenia and mood disorders. Alleged Internet addiction (or general unruliness) in adolescents is also known to have been treated with ECT, sometimes without anesthesia, most notably by Yang Yongxin. The practice was banned in 2009 after a news story featuring Yang was published. ==Society and culture==

Controversy Surveys of public opinion, the testimony of former patients, disputes as to the efficacy, ethics and adverse effects of ECT within the psychiatric and wider medical community indicate that the use of ECT remains controversial. In one of the few jurisdictions where recent statistics on ECT usage are available, a national audit of ECT by the Scottish ECT Accreditation Network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent. In the UK, in order for consent to be valid it requires an explanation in "broad terms" of the nature of the procedure and its likely effects. One review from 2005 found that only about half of patients felt they were given sufficient information about ECT and its adverse effects and another survey found that about fifty percent of psychiatrists and nurses agreed with them. A 2005 study published in the British Journal of Psychiatry described patients' perspectives on the adequacy of informed consent before ECT. United Kingdom Until 2007 in England and Wales, the Mental Health Act 1983 allowed the use of ECT on detained patients whether or not they had capacity to consent to it. However, following amendments which took effect in 2007, ECT may not generally be given to a patient who has capacity and refuses it, irrespective of his or her detention under the Act. In fact, even if a patient is deemed to lack capacity, if they made a valid advance decision refusing ECT then they should not be given it; and even if they do not have an advance decision, the psychiatrist must obtain an independent second opinion (which is also the case if the patient is under age of consent). However, there is an exception regardless of consent and capacity; under Section 62 of the Act, if the treating psychiatrist says the need for treatment is urgent they may start a course of ECT without authorization. From 2003 to 2005, about 2,000 people a year in England and Wales were treated without their consent under the Mental Health Act. Concerns have been raised by the official regulator that psychiatrists are too readily assuming that patients have the capacity to consent to their treatments, and that there is a worrying lack of independent advocacy. In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 2003 also gives patients with capacity the right to refuse ECT. Regulation In the US, ECT devices came into existence prior to medical devices being regulated by the Food and Drug Administration. In 1976, the Medical Device Regulation Act required the FDA to retrospectively review already existing devices, classify them, and determine whether clinical trials were needed to prove efficacy and safety. The FDA initially classified the devices used to administer ECT as Class III medical devices. In 2014, the American Psychiatric Association petitioned the FDA to reclassify ECT devices from Class III (high-risk) to Class II (medium-risk). A similar reclassification proposal in 2010 did not pass. In 2018, the FDA re-classified ECT devices as Class II devices when used to treat catatonia or a severe major depressive episode associated with major depressive disorder or bipolar disorder. By country Australia In Western Australia, ECT has been heavily restricted since 2014, after a bill passed with bipartisan support introducing restrictions on ECT, which were welcomed by mental health experts. Children under 14 are prohibited from receiving ECT, while those aged 14 to 18 must have informed consent approval from the Mental Health Tribunal. The law imposes a $15,000 fine on anyone who performs ECT on a child under the age of 14. Similarly, ECT is also banned on children under the age of 12 in the Australian Capital Territory (ACT). United States Many mental health facilities offer ECT for specific diagnoses, such as chronic depression, mania, catatonia and schizophrenia. However, ECT is often only used as a treatment of last resort. To be considered for ECT, often testing such as an EKG and lab tests are required, in addition to a physical and neurological exam. Certain medications and conditions, such as cardiac conditions or hypertension, may disqualify a patient from ECT. Patients should give proper informed consent before ECT is performed. In the United States, ECT is performed under general anesthesia. Both trained health professionals with experience in ECT administration as well as a specifically trained and certified anesthesiologist should administer the procedure and anesthesia respectively. Public perception A questionnaire survey of 379 members of the general public in Australia indicated that more than 60% of respondents had some knowledge about the main aspects of ECT. Participants were generally opposed to the use of ECT on depressed individuals with psychosocial issues, on children, and on involuntary patients. Public perceptions of ECT were found to be mainly negative. A sample of the general public, medical students, and psychiatry trainees in the United Kingdom found that the psychiatry trainees were more knowledgeable and had more favorable opinions of ECT than did the other groups. More members of the general public believed that ECT was used for control or punishment purposes than medical students or psychiatry trainees. He is reported to have said to his biographer, "Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient." However, the same biographer (Hotchner, 1966) and also a second biographer (Lynn, 1987) emphasized, according to a review from 2008, "that Hemingway's serious mental illness and plans for suicide significantly predated his ECT treatments." • Robert Pirsig had a nervous breakdown and spent time in and out of psychiatric hospitals between 1961 and 1963. He was diagnosed with paranoid schizophrenia and clinical depression as a result of an evaluation conducted by psychoanalysts, and was treated with electroconvulsive therapy on numerous occasions, a treatment he discusses in his novel, Zen and the Art of Motorcycle Maintenance. • Thomas Eagleton, United States Senator from Missouri, was dropped from the Democratic ticket in the 1972 United States Presidential Election as the party's vice presidential candidate after it was revealed that he had undergone electroconvulsive therapy in the past for depression. Presidential nominee George McGovern replaced him with Sargent Shriver, and later went on to lose by a landslide to Richard Nixon. • American surgeon and award-winning author Sherwin B. Nuland is another notable person who has undergone ECT. In his 40s, his depression became so severe that he had to be institutionalized. After exhausting all treatment options, a young resident assigned to his case suggested ECT, which was successful. • Author David Foster Wallace also received ECT for many years, beginning as a teenager, before his suicide at age 46. • New Zealand author Janet Frame experienced both insulin coma therapy and ECT (but without the use of anesthesia or muscle relaxants). She wrote about this in her autobiography, An Angel at My Table (1984), • American actor Carrie Fisher wrote about her experience with memory loss after ECT treatments in her memoir Wishful Drinking. • Lou Reed had ECT as a teenager. He later claimed it had induced multiple personality disorder, and resulted in his hatred of psychiatrists. Some authors have levelled accusations that the treatment was performed in order to abate homosexual urges that Reed had confessed to. After Reed's death, his sister denied this, citing that their parents were not homophobic, and asserting that they had only been suggested the treatment by doctors as a way to treat Reed's mental and behavioral issues. Fictional examples Electroconvulsive therapy has been depicted in fiction, including fictional works partly based on true experiences. These include Sylvia Plath's semi-autobiographical novel The Bell Jar, Ken Loach's film Family Life, and Ken Kesey's novel ''One Flew Over the Cuckoo's Nest''; Kesey's novel was a direct product of his time working the graveyard shift as an orderly at a mental health facility in Menlo Park, California. Two analyses of large numbers of films using ECT scenes found that almost all presented fictional settings that were unrelated to real treatment routines and were apparently aimed at stigmatizing ECT as a tool of repression and of mind and behavior control - having effects of memory-erosion, pain and damage. The song "The Mind Electric" by Miracle Musical is typically interpreted as depicting someone undergoing ECT. In the television series "Mr Bates vs The Post Office", which is based on true events, the character of Saman Kaur receives ECT following a deep depression and attempted suicide. == See also ==