ELECTROCONVULSIVE THERAPY

Introduction
Electroconvulsive therap (ECT), also known as electroshoc!, is a well-
established, albeit controversial, psychiatric treatment in which seizures are electrically
induced in anesthetized patients for therapeutic effect. Today, ECT is most often used as a
treatment for severe maor depression which has not responded to other treatment, and is
also used in the treatment of mania (often in bipolar disorder), and catatonia.
!"#
$t was first
introduced in the "%&'s and (ained widespread use as a form of treatment in the "%)'s
and "%*'s+ today, an estimated " million people worldwide receive ECT every year,
usually in a course of ,-". treatments administered . or & times a week.
Electroconvulsive therapy can differ in its application in three ways/ electrode
placement, len(th of time that the stimulus is (iven, and the property of the stimulus. The
variance of these three forms of application have si(nificant differences in both adverse
side effects and positive outcomes. 0fter treatment, dru( therapy can be continued, and
some patients receive continuation1maintenance ECT. $nformed consent is a standard of
modern electroconvulsive therapy. $nvoluntary treatment is uncommon in countries that
follow contemporary standards and is typically only used when the use of ECT is
believed to be potentially life savin(.
"eanin# and $e%inition
Electroconvulsive therap or ECT for short is a controversial treatment in
which a convulsion or seizure is produced by passin( an electric current throu(h the
brain. ECT is primarily used for treatment-resistant depression and may also be
prescribed for mania and schizophrenia. 2iven under anesthesia, ECT may be unilateral
(electrodes on one side of the head) or bilateral (electrodes on both sides). The most
common side effect of electroconvulsive therapy is memory loss.
Histor
0s early as the ",th century, a(ents to produce seizures were used to treat
psychiatric conditions. $n "34*, the therapeutic use of seizure induction was documented
in the 5ondon 6edical 7ournal. Convulsive therapy was introduced in "%&) by 8un(arian
neuropsychiatrist 5adislas 7. 6eduna who, believin( mistakenly that schizophrenia and
epilepsy were anta(onistic disorders, induced seizures with first camphor and then
metrazol (cardiazol). 9ithin three years metrazol convulsive therapy was bein( used
worldwide. $n "%&3, the first international meetin( on convulsive therapy was held in
:witzerland by the :wiss psychiatrist 6uller. The proceedin(s were published in the
0merican 7ournal of ;sychiatry and, within three years, cardiazol convulsive therapy was
bein( used worldwide. $talian ;rofessor of neuropsychiatry <(o Cerletti, who had been
usin( electric shocks to produce seizures in animal e=periments, and his collea(ue 5ucio
>ini developed the idea of usin( electricity as a substitute for metrazol in convulsive
therapy and, in "%&3, e=perimented for the first time on a person. :herwin >. ?uland
havin( discussed the matter with a first-hand observer in the "%3's (ave the followin(
description of the results of the first use of ECT on a person/
@They thou(ht, A9ell, weAll try ** volts, two-tenths of a second. ThatAs not (oin(
to do anythin( terrible to him.A :o they did that. !...# This fellow B remember, he
wasnAt even put to sleep B after this maor (rand mal convulsion, sat ri(ht up,
looked at these three fellows and said, A9hat the fuck are you assholes tryin( to
doCA 9ell, they were happy as could be, because he hadnAt said a rational word in
the weeks of observation.@
ECT soon replaced metrazol therapy all over the world because it was cheaper,
less fri(htenin( and more convenient. Cerletti and >ini were nominated for a ?obel ;rize
but did not receive one. >y "%)', the procedure was introduced to both En(land and the
<:. Throu(h the )'As and *'As the use of ECT became widespread. ECT is the only form
of shock treatment still performed by modern medicine.
$n the early "%)'s, in an attempt to reduce the memory disturbance and confusion
associated with treatment, two modifications were introduced/ the use of unilateral
electrode placement and the replacement of sinusoidal current with brief pulse. $t took
many years for brief-pulse eDuipment to be widely adopted
!"'"#
<nilateral ECT has never
been popular with psychiatrists and is still only (iven to a minority of ECT patients. $n
the "%)'s and early "%*'s ECT was usually (iven in @unmodified@ form, without muscle
rela=ants, and the seizure resulted in a full-scale convulsion. 0 rare but serious
complication of unmodified ECT was fracture or dislocation of the lon( bones. $n the
"%)'s psychiatrists be(an to e=periment with curare, the muscle-paralyzin( :outh
0merican poison, in order to modify the convulsions. The introduction of
su=amethonium (succinylcholine), a safer synthetic alternative to curare, in "%*" led to
the more widespread use of @modified@ ECT. 0 short-actin( anesthetic was usually (iven
in addition to the muscle rela=ant in order to spare patients the terrifyin( feelin( of
suffocation that can be e=perienced with muscle rela=ants.
!"'"#
The steady (rowth of antidepressant use alon( with ne(ative depictions of ECT in
the mass media led to a marked decline in the use of ECT durin( the *'As to the 3'As. The
:ur(eon 2eneral stated there were problems with electroshock therapy in the initial years
before anesthesia was routinely (iven and, these now antiquated practices contributed to
the negative portrayal of ECT in the popular media. The ?ew Eork Times described the
publicAs ne(ative perception of ECT as bein( caused mainly by one movie, @For >i(
?urse in One Flew Over the Cuckoo's est! it was a tool of terror, and in the public mind
shock therapy has retained the tarnished ima(e (iven it by Gen GeseyAs novel/ dan(erous,
inhumane and overused@.
$n "%3,, Hr. >latchley demonstrated the effectiveness of his constant current,
brief pulse device ECT. This device eventually lar(ely replaced earlier devices because of
the reduction in co(nitive side effects, althou(h some ECT clinics in the <: still use sine-
wave devices. The "%3's saw the publication of the first 0merican ;sychiatric
0ssociation task force report on electroconvulsive therapy (to be followed by further
reports in "%%' and .''"). The report endorsed the use of ECT in the treatment of
depression. The decade also saw criticism of ECT. :pecifically critics pointed to
shortcomin(s such as noted side effects, the procedure bein( used as a form of abuse, and
uneven application of ECT. The use of ECT declined until the "%4's, @when use be(an to
increase amid (rowin( awareness of its benefits and cost-effectiveness for treatin( severe
depression@. $n "%4* the ?ational $nstitute of 6ental 8ealth and ?ational $nstitutes of
8ealth convened a consensus development conference on ECT and concluded that, whilst
ECT was the most controversial treatment in psychiatry and had si(nificant side-effects,
it had been shown to be effective for a narrow ran(e of severe psychiatric disorders.
Hue to the backlash noted previously, national institutions reviewed past practices
and set new standards. $n "%34, The 0merican ;sychiatric 0ssociation released its first
task force report in which new standards for consent were introduced and the use of
unilateral electrode placement was recommended. The "%4* ?$68 Consensus
Conference confirmed the therapeutic role of ECT in certain circumstances. The
0merican ;sychiatric 0ssociation released its second task force report in "%%' where
specific details on the delivery, education, and trainin( of ECT were documented. Finally
in .''" the 0merican ;sychiatric 0ssociation released its latest task force report. This
report emphasizes the importance of informed consent, and the e=panded role that the
procedure has in modern medicine.
Indications
There is considerable variability in opinion amon( e=perts as to whether ECT is
appropriate as a first-line treatment or if its use should be reserved for patients who have
not responded to other interventions such as medication and psychotherapy.
The 0merican ;sychiatric 0ssociation (0;0) .''" (uidelines (ive the primary
indications for ECT amon( patients with depression as a lack of a response to, or
intolerance of, antidepressant medications+ a (ood response to previous ECT+ and the
need for a rapid and definitive response (e.(. because of psychosis or a risk of suicide).
The decision to use ECT depends on several factors, includin( the severity and chronicity
of the depression, the likelihood that alternative treatments would be effective, the
patientAs preference, and a wei(hin( of the risks and benefits.
:ome (uidelines recommend that co(nitive behavioral therapy or other
psychotherapy should (enerally be tried before ECT is used. 8owever, treatment
resistance is widely defined as lack of therapeutic response to two antidepressants. The
0;0 states that at times patients will prefer to receive ECT over alternative treatments,
but commonly the opposite will be the case.
The 0;0 ECT (uidelines state that severe maor depression with psychotic
features, manic delirium, or catatonia are conditions for which there is a clear consensus
favorin( early reliance on ECT. The ?$CE (uidelines recommend ECT for patients with
severe depression, catatonia, or prolon(ed or severe mania.
The .''" 0;0 (uidelines support the use of ECT for relapse prevention, but the
.''& ?$CE (uidelines do not.
The .''" 0;0 ECT (uidelines say that ECT is rarely used as a first-line treatment
for schizophrenia but is considered after unsuccessful treatment with antipsychotic
medication, and may also be considered in the treatment of patients with schizoaffective
or schizophreniform disorder. The .''& ?$CE ECT (uidelines do not recommend ECT
for schizophrenia.
The ?$CE .''& (uidelines state that doctors should be particularly cautious when
considerin( ECT treatment for women who are pre(nant and for older or youn(er people,
because they may be at hi(her risk of complications with ECT. The .''" 0;0 ECT
(uidelines say that ECT may be safer than alternative treatments in the infirm elderly and
durin( pre(nancy, and the .''' 0;0 depression (uidelines stated that the literature
supports the safety for mother and fetus, as well as the efficacy durin( pre(nancy.
Procedure
ECT is usually (iven & times a week. 0 patient may reDuire as few as & or )
treatments or as many as ". to "*. Ince the family J patient consider that the patient is
more or less back to his normal level of functionin(, it is usual for the patient to have " or
. additional treatments in order to prevent relapse. Today the method is painless, J with
modifications in techniDue it bears little relationship to the unmodified treatments of the
"%)'s.
The patient is put to sleep with a very short-actin( barbiturate, J then the dru(
succinycholine is administered to temporarily paralyze the muscles so they do not
contract durin( the treatment J cause fractures. 0n electrode is placed above the temple
of the nondominant side of the brain, J a second in the middle of the forehead (this is
called unilateral ECT)+ or one electrode is placed above each temple (this is called
bilateral ECT). 0 very small current is passed throu(h the brain, activatin( it J producin(
a seizure. >ecause the patient is anesthetized J his body is totally rela=ed by the
succinycholine, he sleeps peacefully while an electroencephalo(ram (EE2) monitors the
seizure activity J an electrocardio(ram (EG2) monitors the heart rhythm. The current is
applied for one second or less, J the patient breathes pure o=y(en throu(h a mask. The
duration of a clinically effective seizure ran(es from &' seconds to sometimes lon(er than
a minute, J the patient wakes up "' to "* minutes later. <pon awakenin(, a patient may
e=perience a brief period of confusion, headache or muscle stiffness, but these symptoms
typically ease in a matter of .' to ,' minutes. Hurin( the few seconds followin( the ECT
stimulus there may be temporary drop in blood pressure. This may be followed by a
marked increase in heart rate, which may then lead to a rise in blood pressure. 8eart
rhythm disturbances, not unusual durin( the period of time, (enerally subside without
complications. 0 patient with a history of hi(h blood pressure or other cardiovascular
problems should have a cardiolo(y consultation first.
>ecause as many as .' to *' percent of the people who respond well to a course of ECT
relapse within , months, a maintenance treatment of antidepressants, lithium or ECT at
monthly or , week intervals mi(ht be advisable.
:hort-term memory loss has always been a concern to patients who receive ECT,
but several studies conclude that patients who received unilateral ECT performed better
on attention1memory tests than those who received bilateral ECT. 8owever, there is a
Duestion as to whether unilateral is as effective. E=perts a(ree that chan(es in memory
function do occur J persist for a few days followin( treatment, but that patients return to
normal within a month. 0 "%4* ?$68 Consensus Conference concluded that while some
memory loss is freDuent after ECT, it is estimated that one-half of " percent of ECT
patients suffer severe loss. 6emory problems usually clear within 3 months of treatment,
althou(h there may be a persistent memory deficit for the period immediately
surroundin( the treatment.
Non&clinical patient characteristics
0bout 3' percent of ECT patients are women. This is lar(ely, but not entirely, due
to the fact that women are more likely to receive treatment for depression. Ilder and
more affluent patients are also more likely to receive ECT. The use of ECT treatment is
@markedly reduced for ethnic minorities.@
E%%ectiveness
The "%%% <.:. :ur(eon 2eneralAs Keport on 6ental 8ealth summarized
psychiatric opinion at the time about the effectiveness of ECT. $t stated that both clinical
e=perience and published studies had determined ECT to be effective (with an avera(e ,'
to 3' percent remission rate) in the treatment of severe depression, some acute psychotic
states, and mania. $ts effectiveness had not been demonstrated in dysthymia, substance
abuse, an=iety, or personality disorder. The report stated that ECT does not have a lon(-
term protective effect a(ainst suicide and should be re(arded as a short-term treatment for
an acute episode of illness, to be followed by continuation therapy in the form of dru(
treatment or further ECT at weekly to monthly intervals. 0 .'') lar(e multicentre clinical
follow-up study of ECT patients in ?ew EorkBdescribin( itself as the first systematic
documentation of the effectiveness of ECT in community practice in the ,* years of its
useBfound remission rates of only &' to )3 percent, with ,) percent of those relapsin(
within si= months.
ECT on its own does not usually have a sustained benefit. Lirtually all those who
remit end up relapsin( within si= months followin( a course, even when (iven a placebo.
The relapse rate in the first si= months may be reduced by the use of psychiatric
medications or further ECT, but remains hi(h.
6ost, but not all, published reviews of the literature have concluded that ECT is
effective in the treatment of depression. $n .'',, research psychiatrist Colin 0. Koss
reviewed the entire body of placebo-controlled literature on ECT and found that no study
showed a si(nificant difference between real and placebo ECT at one month post-
treatment. The review also found that many of these studies failed to find a difference
between real and placebo ECT even durin( the period of treatment. >ased on these
observations, Hr. Koss concludes that @claims in te=tbooks and review articles that ECT
is effective are not consistent with the published data@, and that consent forms for the
procedure should state that @real ECT is only mar(inally more effective than placebo.@
The review was hi(hly critical of other published reviews concludin( that ECT was
effective, because these reviews often relied primarily on studies that were not placebo-
controlled.
Adverse e%%ects
0side from effects in the brain, the (eneral physical risks of ECT are similar to
those of brief (eneral anesthesia+ the <nited :tatesA :ur(eon 2eneralAs report says that
there are @no absolute health contraindications@ to its use. $mmediately followin(
treatment the most common adverse effects are confusion and memory loss. The state of
confusion usually disappears after a few hours. :ome patients e=perience muscle soreness
after ECT. This is due to either the muscle rela=ants (iven durin( the procedure or due to
the muscle activity caused by the seizure.
E%%ects on 'e'or
$t is the effects of ECT on lon(-term memory that (ive rise to much of the
concern surroundin( its use. The acute effects of ECT can include amnesia, both
retro(rade (for events occurrin( before the treatment) and antero(rade (for events
occurrin( after the treatment). 6emory loss and confusion are more pronounced with
bilateral electrode placement rather than unilateral, and with sine-wave rather than brief-
pulse currents. The vast maority of modern treatment uses brief pulse currents. Kesearch
by 8arold :ackeim has shown that e=cessive current causes more risk for memory loss,
and shockin( only the ri(ht side of the head protects the left side, which contains the
brainAs verbal structure.
Ketro(rade amnesia is most marked for events occurrin( in the weeks or months
before treatment, with one study showin( that althou(h some people lose memories from
years prior to treatment, recovery of such memories was @virtually complete@ by seven
months post-treatment, with the only endurin( loss bein( memories in the weeks and
months prior to the treatment. 0ntero(rade memory loss is usually limited to the time of
treatment itself or shortly afterwards. $n the weeks and months followin( ECT these
memory problems (radually improve, but some people have persistent losses, especially
with bilateral ECT. Ine published review summarized the results of seven studies
reportin( on perceived memory loss and found that between .%M and **M of
respondents believed they e=perienced lon(-lastin( or permanent memory chan(es. $n
.''', 0merican psychiatrist :arah 5isanby and collea(ues found that bilateral ECT left
patients with persistent impairment for memory of public events as compared to K<5
ECT.
:tudies have found that patients are often unaware of substantial co(nitive deficits
induced by ECT. For e=ample, in 7une .''4, a Huke <niversity study
!
was published
assessin( the neuropsycholo(ical effects and attitudes in patients after ECT. Forty-si=
patients participated in the study, which involved neuropsycholo(ical and psycholo(ical
testin( before and after ECT. The study documented substantial co(nitive decline after
ECT on a variety of memory tests, includin( @verbal memory for word lists and prose
passa(es and visual memory of (eometric desi(ns.@ The study further found that a
si(nificant number of patients erroneously believed that their memory had improved after
ECT despite the fact that neuropsycholo(ical testin( clearly showed the opposite. 0s
stated by the researchers, @$ndeed, there was a sli(ht trend towards !patients reportin(#
improved memory functionin(, despite the obective neuropsycholo(ical data indicatin(
si(nificantly lower reco(nition and delayed recall.@ >ased on their findin(s, the authors
issued the followin( recommendation/
@9hen ECT is provided to adolescents, the potential impact of such co(nitive
chan(es should be discussed with the patients and their parents or (uardians in terms of
implications for not only the patientNs emotional functionin( but co(nitive functionin( as
well, particularly upon his or her academic performance. $n summary, we ar(ue that an
individual cost-benefit analysis should be made in li(ht of the implications of the
potential benefits versus costs of ECT upon improvin( emotional functionin( and the
impact that potential memory chan(es may have on real-world functionin( and Duality of
life.@
Controvers over lon#&ter' e%%ects on #eneral co#nition
0ccordin( to prominent ECT researcher 8arold :ackeim, @despite over fifty years
of clinical use and on(oin( controversy@, until .''3 there had @never been a lar(e-scale,
prospective study of the co(nitive effects of ECT.@ $n this first-ever lar(e-scale study
(&)3 subects), :ackeim and collea(ues found that at least some forms (namely bilateral
application and sine wave currents) of ECT @routine!ly#@ lead to @adverse co(nitive
effects,@ includin( (lobal co(nitive deficits and memory loss, that persist for at least si=
months after treatment, su((estin( that the induced deficits may be permanent. The
authors also warned that their findin(s did not su((est that ri(ht-unilateral ECT did not
also lead to chronic co(nitive deficits.
8arold :ackeim can be seen in a videotaped deposition briefly discussin( the
findin(s of this study and why, in his opinion, earlier studies had failed to find evidence
of lon(-term harm from ECT. Hespite over fifty years of clinical use, :ackeim states that
prior to .''", @the field itself never really had an opportunity to have a discussion about
patients who have complaints about lon(-term memory loss.@ $n this video clip, :ackeim
also reveals that at a California ECT conference with .'' practitioners present, when
polled as to whether they think ECT can lead to chronic co(nitive deficits, two-thirds
raised their hands. :ackeim says this was @almost a watershed moment for the field@, and
was the @first time publicly that the field itself said AnoA to the position that it canAt
happen.@
$n 7uly .''3, a second study was published concludin( that ECT routinely leads
to chronic, substantial co(nitive deficits, and the findin(s were not limited to any
particular forms of ECT. The study, led by psychiatrist 2lenda 6acOueen and collea(ues,
found that patients treated with ECT for bipolar disorder show marked deficits across
multiple co(nitive domains. 0ccordin( to the researchers, @:ubects who had received
remote ECT had further impairment on a variety of learnin( and memory tests when
compared with patients with no past ECT. This de(ree of impairment could not be
accounted for by illness state at the time of assessment or by differential past illness
burden between patient (roups.@ Hespite the findin(s of chronic, (lobal co(nitive deficits
in post-ECT patients, 6acOueen and collea(ues su((est that it is @unlikely that such
findin(s, even if confirmed, would si(nificantly chan(e the risk-benefit ratio of this
notably effective treatment.@
:i= months after the publication of the :ackeim study documentin( routine, lon(-
term memory loss after ECT, prominent ECT researcher 6a= Fink published a review in
the ournal "sychosomatics concludin( that patient complaints of memory loss after ECT
are @rare@ and should be @characterized as somatoform disorders, rather than as evidence
of brain dama(e, thus warrantin( psycholo(ical treatment for such disorders.@ >ased on
his findin(s, Fink su((ests that, @$nstead of endorsin( these reports as the direct
conseDuence of ECT, especially in patients who have recovered from their depressive
illness, lost their suicidal drive, and have improved social functionin(, is it not more
useful to accept the complaint as a somatoform disorder, e=plore the basis in the
individualNs history and e=perience, and offer appropriate supportive treatmentC@
6ost recent reviews of the literature and other articles continue to characterize
ECT as safe and effective. For e=ample, in 7une .''%, ;ortu(uese researchers published a
review on the safety and efficacy of ECT in an article entitled, Electroconvulsive
Therapy# $yths and Evidences. $n their review, the researchers conclude that ECT is an
@efficient, safe and even life savin( treatment for several psychiatric disorders.@ $n .''4,
Eale researchers published a review on the safety and efficacy of ECT in elderly patients.
0ccordin( to the authors, @ECT is well established as a safe and effective treatment for
several psychiatric disorders.@ 0nd in a 7une .''% article published in the %ournal of
ECT, $ranian researchers observe that, @Hespite the wide consensus over the safety and
efficacy of electroconvulsive therapy (ECT), it still faces ne(ative publicity and
unfavorable attitudes of patients and families.@
;sychiatrist ;eter >re((in, chief editor of the ournal Ethical &uman "sychology
and "sychiatry, is a leadin( critic of ECT who believes the procedure is neither safe nor
effective. $n a published article reviewin( the findin(s of 8arold :ackeimAs .''3 study on
the co(nitive effects of ECT, >re((in accuses 6a= Fink and other pro-ECT researchers
of havin( a history of @systematically coverin( up dama(e done to millions of !ECT#
patients throu(hout the world.@ 8e disa(rees with the position that findin(s of chronic,
(lobal co(nitive deficits should have no bearin( on the risk-benefit ratio of ECT, and he
believes itAs important to address the @actual impact of these losses on the lives of
individual patients.@ $n a section of his paper entitled 'estroying (ives, Hr. >re((in
writes, @Even when these inured people can continue to function on a superficial social
basis, they nonetheless suffer devastation of their identities due to the obliteration of key
aspects of their personal lives. The loss of the ability to retain and learn new material is
not only humiliatin( and depressin( but also disablin(. Even when relatively subtle, these
activities can disrupt routine activities of livin(.@
0 study published in .'') in the %ournal of $ental &ealth reported that &* to
).M of patients said ECT resulted in loss of intelli(ence. The study also reported, @There
is no overlap between clinical and consumer studies on the Duestion of benefit.@
0 recent article by a neuropsycholo(ist and a psychiatrist in Hublin su((ests that
ECT patients who e=perience co(nitive problems followin( ECT should be offered some
form of co(nitive rehabilitation. The authors say that the failure to attempt to rehabilitate
patients may be partly responsible for the ne(ative public ima(e of ECT.
E%%ects on (rain structure
Considerable controversy e=ists over the effects of ECT on brain tissue despite
the fact that a number of mental health associations, includin( the 0merican ;sychiatric
0ssociation, have concluded that there is no evidence that ECT causes structural brain
dama(e. 0 "%%% report by the <nited :tates :ur(eon 2eneral states, @The fears that ECT
causes (ross structural brain patholo(y have not been supported by decades of
methodolo(ically sound research in both humans and animals@. 8owever, not all e=perts
a(ree that ECT does not cause brain dama(e, and two studies have been published since
.''3 findin( that at least some forms of ECT may result in widespread! persisting!
generali)ed cognitive dysfunction, which would seem to support claims that ECT causes
brain dama(e.
0 leadin( critic of ECT, psychiatrist ;eter >re((in has published books and
reviews of the literature purportin( to show that ECT routinely causes brain dama(e as
evidenced by a considerable list of studies in humans and animals. $n particular, Hr.
>re((in asserts that animal and human autopsy studies have shown that ECT routinely
causes Pwidespread pinpoint hemorrhages and scattered cell death.N 0ccordin( to Hr.
>re((in, the "%%' 0;0 task force report on ECT i(nored much of the scientific literature
pointin( out the ne(ative effects of electroshock therapy. For e=ample, in "%*. 8ans
8artelius conducted and published an animal study on cats entitled Cerebral Changes
Following Electrically *nduced Convulsions in which a double-blind microscopic
patholo(y e=amination showed that it was possible to distin(uish the 4 shocked animals
from the 4 non-shocked animals with remarkable accuracy based on statistically
si(nificant structural chan(es to the brain, includin( vessel wall chan(es, (liosis, and
nerve cell chan(es. >ased on the detection of shadow cells and neuronopha(ia, 8artelius
determined that there was irreversible dama(e to neurons associated with electroshock.
;roponents ar(ue that the addition of hyper o=y(enation and refinement in
techniDue in the last thirty years has made ECT safe, and a maority of published reviews
in recent decades have reflected this position. $n a .'') study desi(ned to evaluate
whether modern ECT techniDues lead to identifiable brain dama(e, twelve monkeys
underwent daily electroshock for si= weeks under conditions meant to simulate human
ECT+ the animals were then sacrificed and their brains were compared to monkeys
under(oin( anesthesia alone. 0ccordin( to the researchers, @?one of the ECT-treated
monkeys showed patholo(ical findin(s.@
There are recent animal studies that have documented si(nificant brain dama(e
after an electroshock series. For e=ample, in .''*, Kussian researchers published a study
entitled, Electroconvulsive +hock *nduces euron 'eath in the $ouse &ippocampus#
Correlation of eurodegeneration with Convulsive ,ctivity. $n this study, the researchers
found that after an electroshock series, there was a si(nificant loss of neurons in parts of
the brain and particularly in defined parts of the hippocampus where up to "'M of
neurons were killed. The researchers conclude that @the main cause of neuron death is
convulsions evoked by electric shocks.@ $n .''4, ;ortu(uese researchers conducted a rat
study aimed at answerin( the Duestion of whether an electroshock series causes structural
chan(es in vulnerable parts of the brain. 0ccordin( to the authors, @This study answers
positively the Duestion of whether repeated administration of EC: seizures can cause
brain lesions. Iur data are consistent with findin(s from other animal models and from
human studies in showin( that neurons located in the entorhinal corte= and in the hilus of
the dentate (yrus are particularly vulnerable to repeated seizures.@
6any e=pert proponents of ECT maintain that the procedure is safe and does not
cause brain dama(e. Hr. Charles Gellner, a prominent ECT researcher and former chief
editor of the %ournal of ECT states in a recent published interview that, @There are a
number of well-desi(ned studies that show ECT does not cause brain dama(e and
numerous reports of patients who have received a lar(e number of treatments over their
lifetime and have suffered no si(nificant problems due to ECT.@ Hr. Gellner cites
specifically to a study purportin( to show an absence of co(nitive impairment in ei(ht
subects after more than "'' lifetime ECT treatments. Ine of the authors of the cited
study, 8arold :ackeim, published a lar(e-scale study less than a month after this
interview concludin( that the type of ECT used in the ei(ht patients receivin( the "''
lifetime treatments, bilateral sine wave, routinely leads to persistent, (lobal co(nitive
deficits (discussed supra). Hr. Gellner states that, @Kather than cause brain dama(e, there
is evidence that ECT may reverse some of the dama(in( effects of serious psychiatric
illness.@
E%%ects in pre#nanc
$f steps are taken to decrease potential risks, ECT is (enerally accepted to be
relatively safe durin( all trimesters of pre(nancy, particularly when compared to
pharmacolo(ical treatments. :u((ested preparation for ECT durin( pre(nancy includes a
pelvic e=amination, discontinuation of nonessential ant choliner(ic medication, uterine
tocodynamometry, intravenous hydration, and administration of a no particulate antacid.
Hurin( ECT, elevation of the pre(nant womanAs ri(ht hip, e=ternal fetal cardiac
monitorin(, intubation, and avoidance of e=cessive hyperventilation are recommended.
6uch of the medical literature in this area is composed of case studies of sin(le or twin
pre(nancies, and althou(h some have reported serious complications, the maority have
found ECT to be safe.
Ad'inistration
$nformed consent is sou(ht before treatment. ;atients are informed about the risks
and benefits of the procedure. ;atients are also made aware of risks and benefits of other
treatments and of not havin( the procedure done at all. Hependin( on the urisdiction the
need for further inputs from other medical professionals or le(al professionals may be
reDuired. ECT is usually (iven on an in-patient basis. ;rior to treatment a patient is (iven
a short-actin( anesthetic such as methohe=ital, propofol, etomidate, or thiopental, a
muscle rela=ant such as su=amethonium (succinylcholine), and occasionally atropine to
inhibit salivation.
>oth electrodes can be placed one on the same side of the patientAs head. This is
known as unilateral ECT. <nilateral ECT is used first to minimize side effects (memory
loss). 9hen electrodes are placed on both sides of the head, this is known as bilateral
ECT. $n bifrontal ECT, an uncommon variation, the electrode position is somewhere
between bilateral and unilateral. <nilateral is thou(ht to cause fewer co(nitive effects
than bilateral but is considered less effective. $n the <:0 most patients receive bilateral
ECT. $n the <G almost all patients receive bilateral ECT.
The electrodes deliver an electrical stimulus. The stimulus levels recommended
for ECT are in e=cess of an individualAs seizure threshold/ about one and a half times
seizure threshold for bilateral ECT and up to ". times for unilateral ECT. >elow these
levels treatment may not be effective in spite of a seizure, while doses massively above
threshold level, especially with bilateral ECT, e=pose patients to the risk of more severe
co(nitive impairment without additional therapeutic (ains. :eizure threshold is
determined by trial and error (@dose titration@). :ome psychiatrists use dose titration,
some still use @fi=ed dose@ (that is, all patients are (iven the same dose) and others
compromise by rou(hly estimatin( a patientAs threshold accordin( to a(e and se=. Ilder
men tend to have hi(her thresholds than youn(er women, but it is not a hard and fast rule,
and other factors, for e=ample dru(s, affect seizure threshold.
ECT 'achines
6ost modern ECT machines deliver a brief-pulse current, which is thou(ht to
cause fewer co(nitive effects than the sine-wave currents which were ori(inally used in
ECT.
!%#
0 small minority of psychiatrists in the <:0 still use sine-wave stimuli.
!,'#
:ine-
wave is no lon(er used in the <G.
!,"#
Typically, the electrical stimulus used in ECT is
about 4'' milliamps and has up to several hundred watts, and the current flows for
between one and , seconds.
!,.#
$n the <:0, ECT machines are manufactured by two
companies, :omatics, which is owned by psychiatrists Kichard 0brams and Conrad
:wartz, and 6ecta. The Food and Hru( 0dministration has classified the devices used to
administer ECT as Class $$$ medical devices.
!,&#
Class $$$ is the hi(hest-risk class of
medical devices. $n the <G, the market for ECT machines was lon( monopolized by
Ectron 5td, althou(h in recent years some hospitals have started usin( 0merican
machines. Ectron 5td was set up by psychiatrist Kobert Kussell, who to(ether with a
collea(ue from the Three Counties 0sylum, >edfordshire, invented the ;a(e-Kussell
techniDue of intensive ECT.
Variations in international practice
There is wide variation in ECT use between different countries, different
hospitals, and different psychiatrists. $nternational practice varies considerably from
widespread use of the therapy in many western countries to a small minority of countries
that do not use ECT at all, such as :lovenia. 2uidelines on the use of ECT are strin(ent in
the <:0 and the <G. 6odern standards are not always followed throu(hout the world
and not all countries that use ECT have written technical standards. The use of both
anesthesia and muscle rela=ants is universally recommended in the administration of
ECT. $f anesthesia and muscle rela=ants are not used the procedure is called unmodified
ECT. $n a minority of countries such as 7apan, $ndia,
!
and ?i(eria, ECT may be used
without anesthesia. 98I has called for a worldwide ban on unmodified ECT and the
topic is currently bein( debated in countries like $ndia. The practice has been recently
abolished in TurkeyAs lar(est psychiatric hospital. 0 maor difficulty for developin(
countries in eliminatin( unmodified ECT is a lack of trained anesthesiolo(ists available
to administer the procedure. 0 small minority of countries never seek consent before
administerin( ECT. This si(nificantly uneven application of ECT around the world
continues to make ECT a controversial procedure.
:arah 8all reports, @ECT has been do((ed by conflict between psychiatrists who
swear by it, and some patients and families of patients who say that their lives have been
ruined by it. $t is controversial in some European countries such as the ?etherlands and
$taly, where its use is severely restricted@.
"echanis' o% action
The aim of ECT is to induce a therapeutic clonic seizure (a seizure where the
person loses consciousness and has convulsions) lastin( for at least "* seconds. 0lthou(h
a lar(e amount of research has been carried out, the e=act mechanism of action of ECT
remains elusive. The main reasons for this are the difficulty of isolatin( the therapeutic
effect from the plethora of effects that accompany the anesthetic, electric shock and
seizure+ the differences between the brains of humans and those of other animals+ and the
lack of satisfactory animal models of mental illness.
Electroconvulsive Therapy (ECT) increases serum brain-derived neurotrophic factor
(>H?F) in dru( resistant depressed patients.
Le#al status
In%or'ed consent
$t is widely acknowled(ed internationally that obtainin( the written, informed consent of
the patient is important before ECT is administered. The 9orld 8ealth Ir(anization, in
its .''* publication @8uman Ki(hts and 5e(islation 98I Kesource >ook on 6ental
8ealth,@ specifically states, @ECT should be administered only after obtainin( informed
consent.@
!4)#
$n the <:, this doctrine places a le(al obli(ation on a doctor to make a patient aware of/
the reason for treatment, the risks and benefits of a proposed treatment, the risks and
benefits of alternative treatment, and the risks and benefits of receivin( no treatment. The
patient is then (iven the opportunity to accept or reect the treatment. The form states
how many treatments are recommended and also makes the patient aware that the
treatment may be revoked at anytime durin( a course of ECT. The :ur(eon 2eneralAs
Keport on 6ental 8ealth states that patients should be warned that the benefits of ECT
are short-lived without active continuation treatment in the form of dru(s or further ECT,
and that there may be some risk of permanent, severe memory loss after ECT. The report
advises psychiatrists to involve patients in discussion, possibly with the aid of leaflets or
videos, both before and durin( a course of ECT.
To demonstrate what he believes should be reDuired to fully satisfy the le(al obli(ation
for informed consent, one psychiatrist, workin( for an anti-psychiatry or(anization, has
formulated his own consent form
!4*#
usin( the consent form developed and enacted by the
Te=as 5e(islature as a model.
!4,#
$n the <G, in order for consent to be valid it reDuires an e=planation in @broad terms@ of
the nature of the procedure and its likely effects.
!43#
Ine review from .''* found that only
about half of patients felt they were (iven sufficient information about ECT and its
adverse effects,
!44#
and another survey found that about fifty percent of psychiatrists and
nurses a(reed with them.
!4%#
0 .''* study published in the -ritish %ournal of "sychiatry described patientsA
perspectives on the adeDuacy of informed consent before ECT. The study found that,
@0bout half ()*-**M) of patients reported they were (iven an adeDuate e=planation of
ECT, implyin( a similar percenta(e felt they were not.@ The authors also stated/
@0ppro=imately a third did not feel they had freely consented to ECT even when they had
si(ned a consent form. The proportion who feels they did not freely choose the treatment
has actually increased over time. The same themes arise whether the patient had received
treatment a year a(o or &' years a(o. ?either current nor proposed safe(uards for patients
are sufficient to ensure informed consent with respect to ECT, at least in En(land and
9ales.@
Involuntar ECT
;rocedures for involuntary ECT vary from country to country dependin( on local mental
health laws. 5e(al proceedin(s are reDuired in some countries, while in others ECT is
seen as another form of treatment that may be (iven involuntarily as lon( as le(al
conditions are observed.
$n most states in the <:0, a udicial order followin( a formal hearin( is needed
before a patient can be forced to under(o involuntary ECT. ;atients may be represented
by le(al counsel at the hearin(. Ire(on Kevised :tatutes allow for involuntary ECT with
the si(nature of a physician independent of the patientAs facility, and no udicial order or
le(al counsel are reDuired. 0ccordin( to the :ur(eon 2eneralAs Keport on 6ental 8ealth,
@0s a rule, the law reDuires that such petitions are (ranted only where the prompt
institution of ECT is re(arded as potentially lifesavin(, as in the case of a person in (rave
dan(er because of lack of food or fluid intake caused by catatonia.@ 8owever, there are
le(al loopholes that thwart strict adherence to this principle. For e=ample, an 0merican
citizen was bein( forced to under(o ECT a(ainst his will in .''%, even thou(h his life
was not in dan(er. $n this 6arch "3, .''% video, the man, his mother, and advocates,
speak out a(ainst his forced ECT. The description of the video states that @Thou(h
:andford, *), is not char(ed with any crime, he has received over )' such rounds of
shocks on an outpatient basis so far - even after his ori(inal mental problems have lon(
since subsided and he has repeatedly asked for the shocks to stop. Iver the obections of
:andford, his mother and friends, his le(al conservator at 5utheran :ocial :ervice of 6?
(5::6?) has (one to court and succeeded in mandatin( a continuation of the
procedure.@ Twin Cities $ndymedia asserts @5ike all other <:0 states, 6innesota has
!le(al# loopholes allowin( !its# citizens to receive electroshock over their e=pressed
wishes.@
<ntil .''% in En(land and 9ales, the 6ental 8ealth 0ct "%4& allowed the use of
ECT on detained patients whether or not they had capacity to consent to it, so lon( as the
treatment was likely to alleviate or prevent deterioration in a condition and was
authorized by a psychiatrist from the 6ental 8ealth 0ct CommissionAs panel. 8owever,
followin( amendments which took effect in .''%, ECT may not be (iven to a patient who
has capacity to refuse to consent to it, irrespective of his or her detention under the 0ct,
althou(h treatment may still be (iven to capacitous patients in an emer(ency under
:ection ,. of the 0ct. $f the treatin( psychiatrist thinks the need for treatment is ur(ent
they may start a course of ECT before authorization. 0bout .,''' people a year in
En(land and 9ales are treated without their consent under the 6ental 8ealth 0ct, with a
small number of informal patients treated in this way under common law. $n :cotland the
6ental 8ealth (Care and Treatment) (:cotland) 0ct .''& (ives patients with capacity the
ri(ht to refuse ECT.
Huress in involuntary ECT makes reports about its effects, by patients while
under duress, uncertain in their validity.
$nvoluntary electroshock contravenes the principle of autonomy in medical ethics.
The ma=im of autonomy is @Loluntas ae(roti suprema le=.@ This rule states that the will
of the patient is supreme. $t implies that a patient has the ri(ht to refuse a medical
treatment, such as ECT.
Patient e)perience
The 0;0 ECT taskforce (uidelines report findin(s that most patients find ECT no
worse than (oin( to the dentist, and many found it less stressful than the dentist. They
report that other research finds that most patients would voluntarily receive ECT a(ain if
needed.
?$CE ECT (uidelines report that some individuals consider ECT to have been a
beneficial and lifesavin( treatment, while others reported feelin(s of terror, shame and
distress, and found it positively harmful and an abusive invasion of personal autonomy,
especially when administered without their consent.
Individual positive depictions
Gitty Hukakis, wife of politician 6ichael Hukakis, reports in a ewsweek article
mostly positive effects from electroconvulsive therapy, and re(ards memory loss as an
acceptable price to pay for relief from depression.
For me, the memory issues are real but mana(eable. Thin(s $ lose (enerally come
back. Ither memories $ prefer to lose, includin( those about the depression $ was
sufferin(. >ut there are some memoriesBof meetin(s $ have attended, peopleAs homes $
have visitedBthat $ donAt want to lose but $ canAt help it. They (enerally involve thin(s $
did two weeks before and two weeks after ECT. Iften they are ust wiped out....$ have
learned ways to partly compensate for whatever loss $ still e=perience. $ call my sister
7inny, 6ichael and my kids, askin( what my niece >etsyAs phone number is, what we did
yesterday and what we are plannin( to do tomorrow. $ apolo(ize prior to askin(. $ wonder
when they are (oin( to run out of patience with @Gitty bein( Gitty.@ $ hate losin(
memories, which means losin( control over my past and my mind, but the control ECT
(ives me over my disablin( depression is worth this relatively minor cost. $t ust is.
0merican psychotherapist 6artha 6annin(As autobio(raphical
.ndercurrentsacknowled(es the downside of treatment/ @$ felt like $Ad been hit by a truck
for a while, but that was, comparatively speakin(, not so bad,@ as well as the upside/
@0fterwards, $ thou(ht, do re(ular people feel this way all the timeC $tAs like youAve not
been in on a (reat oke for the whole of your life.@
$n his autobio(raphical book Electroboy, 0merican writer 0ndy >ehrman
describes under(oin( ECT as a treatment for bipolar disorder while under house-arrest/ @$
wake up thirty minutes later and think $ am in a hotel in 0capulco. 6y head feels as if $
have ust downed a frozen mar(arita too Duickly. 6y aws and limbs ache. >ut $ am
elated.@
Curtis 8artmann, a lawyer in western 6assachusetts, stated/ @ECT, a treatment of
last resort for severe, debilitatin( depression, is all that has ever worked for me. $ awaken
about .' minutes later, and althou(h $ am still (ro((y with anesthesia, much of the
hellish depression is (one. $t is a disease that for me, literally steals me from myselfBa
disease that e=ecutes me and then forces me to stand and look down at my corpse.
Thankfully, ECT has kept my monster at bay, my hope intact@.
Individual ne#ative depictions
?e(ative effects of ECT have been reported by noteworthy individuals.
Ernest 8emin(way, 0merican author, committed suicide shortly after ECT at the
6ennin(er Clinic in "%,". 8e is reported to have said to his bio(rapher, @9ell, what is
the sense of ruinin( my head and erasin( my memory, which is my capital, and puttin(
me out of businessC $t was a brilliant cure but we lost the patient....@
$n .''*, @;e((y :. :alters, ,', sued ;almetto >aptist 6edical Center in
Columbia, as well as the three doctors responsible for her care. 0s the result of an
intensive course of outpatient ECT in .''', she lost all memories of the past &' years of
her life, includin( all memories of her husband of three decades, now deceased, and the
births of her three children. 6s. :alters held a 6asters of :cience in nursin( and had a
lon( career as a psychiatric nurse, but lost her knowled(e of nursin( skills and was
unable to return to work after ECT.@ The ury awarded :alters Q,&*,"33 in compensation
for her inability to work. The ud(ment was upheld upon appeal.
Ke(istered nurse >arbara C. Cody reports in a letter to the /ashington "ost that
her life was forever chan(ed by "& outpatient ECTs she received in "%4&. @:hock
AtherapyA totally and permanently disabled me. EE2s !electroencephalo(rams# verify the
e=tensive dama(e shock did to my brain. Fifteen to .' years of my life were simply
erased+ only small bits and pieces have returned. $ was also left with short-term memory
impairment and serious co(nitive deficits. !deletion# :hock AtherapyA took my past, my
colle(e education, my musical abilities, even the knowled(e that my children were, in
fact, my children. $ call ECT a rape of the soul.@
$n .''3, a ud(e canceled a two year old court order that allowed the involuntary
electroshock of :imone H., a psychiatric patient at Creedmoor ;sychiatric Center in the
state of ?ew Eork. 0lthou(h :imone spoke only :panish, she rarely received access to
staff fluent in her lan(ua(e. :imone previously had .'' electroshocks. 8owever, she
communicated that she did not want more electroshock. :imone stated, @Electroshock
causes more pain. $ suffer more from shock treatmentR @
$n .''4, Havid Tarloff, a psychiatric patient who had received electroshock,
assaulted two therapists in the city of ?ew Eork. Tarloff inured one therapist and killed
the other. Ine of the therapists was Gent :hinbach, a psychiatrist who had an interest in
electroconvulsive therapy. @$t is not clear whether Hr. :hinbach played any role in 6r.
TarloffAs shock therapy@. 8owever, Tarloff told investi(ators that :hinbach had (iven
Tarloff psychiatric treatment at a psychiatric facility initially in "%%".
$n an interview with &ouston Chronicle in "%%,, 6elissa 8olliday, a former e=tra
on -aywatch and model for "layboy stated the ECT she received in "%%*, @ruined her
life.@ :he went on to state, @$Ave been throu(h a rape, and electroshock therapy is worse.
$f you havenAt (one throu(h it, $ canAt e=plain it.@
5iz :pikol, the senior contributin( editor of "hiladelphia /eekly, wrote of her
ECT in "%%,, @?ot only was the ECT ineffective, it was incredibly dama(in( to my
co(nitive functionin( and memory. >ut sometimes itAs hard to be sure of yourself when
everyone @credible@Bscientists, ECT docs, researchersBare tellin( you that your reality
isnAt real. 8ow many times have $ been told my memory loss wasnAt due to ECT but to
depressionC 8ow many times have $ been told that, like a lot of other consumers, $ must
be perceivin( this incorrectlyC 8ow many times have people told me that my feelin(s of
trauma related to the ECT are misplaced and unusualC $tAs as if $ was raped and people
kept tellin( me not to be upsetBthat it wasnAt that bad.@
Pu(lic perception and 'ass 'edia
0 Duestionnaire survey of &3% members of the (eneral public in Australia
indicated that more than ,'M of respondents had some knowled(e about the main
aspects of ECT. ;articipants were (enerally opposed to the use of ECT on
depressed individuals with psychosocial issues, on children, and on involuntary
patients. ;ublic perceptions of ECT were found to be mainly ne(ative.

Nursin# Care
There are four components of nursin( care in ECT/ (") providin( emotional and
educational support to the patient and family1career+ (.) assessin( the pre-treatment plan
and the patientNs behavior, memory, and functional ability prior to ECT+ (&) preparin( and
monitorin( the patient durin( the actual procedure+ and ()) recoverin( patient, observin(
and interpretin( patient responses to ECT with recommendations for chan(es in the
treatment plan as appropriate. These elements of nursin( care should be reflected in the
nursin( care plan for patients receivin( ECT.
;rovidin( Educational 0nd Emotional :upport
?ursin( care starts as soon as the patient and family 1 career are offered ECT as a
possible treatment option. 0t first, a vital role of the nurse will be to (ive the patient and
family 1 carer an opportunity to e=press their feelin(s, includin( any myths or
misconceptions about ECT. ;atients may describe fear of pain, dyin( from electrocution,
sufferin( permanent memory loss, or e=periencin( impaired intellectual functionin(. 0s
the patient e=presses these fears and concerns, the nurse can clarify misconceptions and
emphasise the therapeutic value of the procedure. These first interactions allow for the
buildin( of trust and rapport necessary to maintain a therapeutic nurse-patient
relationship. :upportin( the patient and family 1 career in their need to discuss, Duestion,
and e=plore their feelin(s and concerns about ECT should be an essential part of nursin(
care before, durin( and after treatment.
Continuin( on from this initial meetin( the nurse can be(in SECT teachin(T.
Hependin( on the patientNs presentin( mental state, this should allow for the patientNs
an=iety, readiness to learn, and ability to comprehend.
9here ever possible, family 1 career teachin( should take place at the same time
as patient teachin(, and the amount of information (iven should be individualized for
each patient and family 1 career. The nurse should review the information the patient and
family 1 career have received from the doctor re(ardin( the procedure, and try to answer
any Duestions the patient and family 1 career mi(ht have about this information. Hurin(
this assessment process, the nurse should also try to find out what specific patient
behaviors the family 1 career associates with the patientNs illness, and ascertain whether
the patient or a family member has had ECT in the past. 0ny information about the
familyNs previous e=perience with ECT will help the nurse identify familial beliefs about
the patientNs illness, the ECT treatment, and the e=pected pro(nosis. ;atient and family 1
career should also be asked what other e=posure they may have had to ECT, such as
throu(h friends who have received it, or by readin( about it, or by seein( it portrayed in a
film such as Ine flew over the cuckoos nest. Ipen - ended Duestions can (ive the nurse
the opportunity to identify and correct misinformation and deal with specific concerns the
patient or family 1 career may have about the procedure. E.(. 9hat concerns do you have
about receivin( the anestheticC 8ow do you think you will feel after the first treatmentC
9hat do you know about ECTC These nursin( actions may then promote the familyNs
ability to provide support to the patient durin( the treatment and so further allay the
patientNs an=iety.
0n information booklet and video presentation may be used to supplement
teachin( the patient and family 1 career about ECT. 0 tour of the treatment suite itself
may help familiarize the patient with the area, procedure, and eDuipment. Encoura(in(
the patient to talk with another patient who has benefited from ECT may be an additional
source of information.
The nurse should facilitate fle=ibility in family 1 career visitin( arran(ements,
particularly durin( the patientNs first few treatments, allowin( for family visitation before
and after ECT if the patient and family 1 career desire. This allays the familyNs an=ieties
and concerns about the patientNs treatment, while encoura(in( the family 1 career to
provide support for the patient. The nurse should also encoura(e the family 1 career to
visit the patient freDuently throu(hout the course of treatment. The nurse should ascertain
the chan(es family members observe in the patient and answer Duestions that arise. $n
some instances the patient may reDuest that a member of their family or career be present
in the treatment room whilst they receive ECT. They should discuss this with their doctor.
The appointed family member 1 career should be assessed and prepared, usin( such
resources as a trainin( video which shows someone havin( ECT. The multi disciplinary
team must be informed of the pendin( presence of the family member 1 career in the
treatment room.
$nformed Consent For ECT
$n ?ovember .''" the HI8 published the 2ood practice in consent
implementation (uide / consent to e=amination or treatment.
>efore be(innin( ECT, an informed consent should be si(ned by the patient. $n
En(land and 9ales, if the patient does not have the capacity to consent, a form for section
*4 of the 6ental 8ealth 0ct must be completed by a second opinion approved doctor, or
in an emer(ency and with a view to a section *4 bein( arran(ed a form for a section ,. of
the 6ental 8ealth 0ct can be completed by the Kesponsible 6edical Ifficer. The patient
should be provided with 6ental 8ealth 0ct leaflet & in these cases. The consent
acknowled(es the patientNs ri(hts to obtain or refuse treatment. The consent form must
comply with the recent Hepartment of 8ealth (uidelines on consent documentation. Even
thou(h it is the doctorNs ultimate responsibility to provide an e=planation of the procedure
when obtainin( consent, the nurse plays an inte(ral role in the consent process.
$nformed consent is a dynamic process that is not completed with the si(nin( of a
formal document, but it implies a process that continues throu(hout the course of
treatment. $t su((ests a number of nursin( activities. $t is helpful if a nurse is present at
the time when the information for consent is presented to the patient. The most
appropriate nurse is one who has established a trustin( and therapeutic relationship with
the patient and who is best able to assess whether the patient comprehends the
e=planation. The presence of a nurse at this time may facilitate the patientNs confidence in
askin( Duestions, and the nurse may be able to simplify the lan(ua(e if necessary. The
nurse can also ensure that the patient has been provided with a full e=planation+
understands the nature, purpose, and implications of the treatment, includin( the option to
withdraw consent at any time+ and has had all his or her Duestions answered before
si(nin( the consent form. 0fter si(nin( the informed consent, but prior to be(innin(
treatment, the nurse should a(ain thorou(hly review this information. The nurse should
discuss the treatment in an open and direct manner, so communicatin( that ECT is an
accepted and beneficial form of treatment.
$t is the responsibility of the psychiatrist to obtain the patientNs consent. Hepressed
patients freDuently e=perience impaired concentration and so are less likely to
comprehend and retain new information. For these patients, it is essential that the nurse
repeat the information (iven by the psychiatrist at re(ular intervals, because new
knowled(e is seldom fully absorbed after only one e=planation. Throu(hout the patientNs
treatment course, the nurse should reinforce what the patient already understands, (note,
the level of understandin( varies from patient to patient, and some patients may never
understand the information (iven to them). 9here applicable, the nurse should remind
the patient of anythin( he or she has for(otten, and provide the patient with the
opportunity to ask new Duestions. 9ritten information also available in other lan(ua(es
should be provided to the patient and their family 1 career. 0n interpreter should be
arran(ed if reDuired. The patient should be informed about how to obtain additional
information and access to an independent advocate.
;retreatment ?ursin( Care
The ECT treatment nurse should ensure that the treatment suite is properly
prepared for the ECT procedure. The eDuipment needed to provide optimal ECT patient
care, as recommended by the Koyal Colle(e of ;sychiatrists is stipulated in their ECT0:
standards. 0n adustable hei(ht stretcher trolley should be available for the less ambulant
patients. Ither movin( and handlin( aids should also be accessible.
$n order to provide best practice nursin( care for the ECT patient, a pre-treatment
checklist should be completed as desi(nated by local hospital policy. 0rran(ements
should be made for the safekeepin( of the patientNs valuables. The ECT nurse should
check that all relevant documentation has been completed. The nurse should e=plain the
procedure to the patient a(ain and ask whether they have any more Duestions or Dueries,
providin( reassurance.
>ecause (eneral anesthesia is reDuired for ECT, the patient should fast from food
and fluids, ( as per local policy) before treatment to prevent possible aspiration. The
e=ceptions could be the patients who are takin( cardiac medications, anti hypertensive, or
8. blockers routinely. These medications should be administered before treatment as
directed by the doctor, with a sip of water. Hay patients should avoid a heavy meal the
evenin( before the treatment. In the mornin( of treatment the patient should be asked to
remove make up, nail varnish, body piercin( etc. The nurse should ask the patient when
he or she last ate and last drank. The patientNs hair should be clean and dry to allow for
electrode contact. 8airpins, hairnets and other hair ornaments should also be removed for
the same reason. The patient should be encoura(ed to pass urine before the treatment to
avoid incontinence durin( the procedure and to minimize the likelihood of bladder
distension and dama(e durin( treatment. ;rostheses, dentures, (lasses, hearin( aids,
contact lenses, should be removed at the latest possible moment, prior to the
administration of the anesthetic, to prevent problems of communication with the patient.
The patientNs identity is checked and the patient wears an identity bracelet. 0 protocol for
day 1 out patients should be in place which covers their needs, inclusive of / preparin(
them for leavin( hospital after treatment, and a written 1 verbal contract that they will not
drive and have a responsible adult to care for them for .) hours after treatment,
arran(ements for further appointments.
The patient must be escorted to the ECT clinic waitin( area, throu(h ECT and
recovery and back to the ward by a Dualified nurse or eDuivalent. (%) $n the case of in-
patients, the ideal escort is the patientNs ?amed ?urse, while in the case of out-patients,
the patientNs community nurse, key-worker, a member of the ECT team or out-patient
department team should perform a similar function. The escort should be known to the
patient and be aware of the patientNs le(al and consent status and have an understandin(
of ECT. To further minimise an=iety the escort nurse should consider the use of an=iety
mana(ement techniDues, ensurin( as short a wait as possible in the treatment waitin(
room, offerin( reassurance and support. The doctor may prescribe a pre-med as per local
protocol.
:pecial arran(ements should be made when patients are (iven ECT in a clinic
remote from a hospital base, i.e. the patient should have an individual trained nurse
escort, and commutin( patients should be treated at the be(innin( of the session to allow
ma=imum time for recovery. Ke(ardin( anesthesia outside hospital, the view of the
0ssociation of 0nesthetists is that the standards of monitorin( used durin( (eneral
anaesthesia should be e=actly the same in all locations.
?ursin( Care Hurin( The ;rocedure
>ecause there will be several people in the treatment room, includin(
psychiatrists, the treatment nurse and the anesthesia staff, the patient should be
introduced to each member of the team and (iven a brief e=planation of the memberNs
role in the ECT procedure. The patient should then be assisted on to a trolley and asked to
remove his 1 her prostheses, dentures, (lasses etc. Kemovin( the patients shoes will
allow for the clear observation of the patientNs e=tremities durin( the treatment.
Ince comfortably on the trolley, a member of the anesthetic staff will insert a
cannulae, while the treatment nurse and other members of the team place leads for
various monitors. Ine member of the team should provide e=planation of the procedure
as it occurs. Hual channel EE2 monitorin( is recommended by the Koyal Colle(e of
;sychiatrists (KC;). Ine electrode is placed to the side of the forehead and the other is
behind the ear, on either side. EC2, pulse o=imeter and blood pressure monitorin( are
also recommended by the KC;. Capno(raph is also recommended by the KC;, in the
event of a patient needin( to be intubated. 0 peripheral nerve stimulator and a means of
measurin( the patientNs temperature should also be available for use. :ome ECT
machines incorporate monitorin( eDuipment for movement when the seizure is induced.
0n initial recordin( of the patientNs blood pressure, pulse and o=y(en saturation should be
made at this sta(e.
The psychiatrist or nurse cleans areas of the patientNs head with alcohol swabs and
1 or (el at the sites of electrode contact as per local protocol. This is to reduce impedance
and improve the contact of the electrodes with the patientNs head. The areas bein( cleaned
should be either both the temples for bilateral ECT, or the temple on the non-dominant
side of the brain for unilateral ECT. E=act placement of electrodes for unilateral ECT is
dependent on KC; (uidelines and local policy. The anesthetic, muscle rela=ant and
o=y(en are administered. 0 disposable or autoclavable bite block is inserted into the
patientNs mouth prior to the delivery of the stimulus to prevent tooth, ton(ue or (um
dama(e or oint dislocation. Ine member of the treatment team records the time elapsed
durin( the seizure. 0 local stimulus dosin( policy should be in use. 5ocal protocols for
missed seizures and termination of prolon(ed seizures should be adhered to.
$f reDuired and in the absence of the psychiatric trainee, the nurse can assist the
treatin( psychiatrist by pressin( the test 1 treat button on the ECT machine, whilst the
psychiatrist holds the electrodes on the patientNs head. The nurse must have been trained
and deemed competent by the consultant psychiatrist responsible for ECT. 0 local
protocol, to ensure the psychiatrist is aware of the nurseNs actions at each sta(e of the
procedure and to check the dose (iven, should be adhered to. This protocol must have
been approved by the consultant psychiatrist responsible for ECT.

Ince the anesthetist is satisfied that the patient is breathin( a(ain and
maintainin( their own airway or able to do so with assistance, he 1 she will be transferred
to the recovery area.
;ost treatment ?ursin( Care
The recovery area should be ne=t to the treatment room to allow access for the
anesthetic staff in the event of an emer(ency. I=y(en should be administered routinely to
the patient. The area must contain, suction, monitorin( and emer(ency eDuipment as
recommended by the KC;. The nurse should maintain the patientNs airway and monitor 1
record vital si(ns at re(ular intervals or more freDuently if complications arise. The
patient should be observed by a staff member in close pro=imity until he or she awakens.
The number of staff in the recovery area should e=ceed the number of unconscious
patients by one. 0 post-operative checklist prompts nurses to check for the presence or
absence of common or worryin( side-effects at re(ular intervals after treatment. The
patient may not remember havin( the treatment, and their thinkin( may be somewhat
concrete. The nurse should provide freDuent reassurance and reorientation until the
patient retains the information. 9hen interactin( with the patient, brief distinct direction
is best. ?ote, in some instances the patient may never retain some information. :imple
co(nitive testin( pre and post treatment should (ive some indication of any abnormality
as a result of ECT.
The patient may become restless, a(itated, a((ressive (post-ictal confusion) and 1
or disorientated for a short period of time. The nurse should maintain the patientNs safety.
Lerbal interaction is usually ineffective. 9hen the episode has resolved the patient should
be reoriented. 0 small dose of a benzodiazepine may be effective. 9hen the patient is
ready he or she should be escorted to a final sta(e area for refreshments and rest until the
recovery staff deem him or her fit to return to the ward.
The recovery nurse should pass on information to the ward nurse 1 escort about
the patientNs condition, medication administered, patientNs behavior, untoward procedures
or treatment response. This information should be recorded in the ECT notes. 0 len(thy
seizure may cause an increase in time of patient bein( disorientated or confused. 0 lon(er
time for rest and reorientation may be reDuired. Closer observation may be reDuired. The
patient should be assessed on return to the ward re(ardin( level of observation reDuired
and de(ree of orientation. $f the patient complains of a headache, muscle soreness,
anal(esia such as paracetemol may be administered. The patient should be encoura(ed to
rest. ?ausea may be treated with an anti-emetic. 9ard staff should continue to provide
support, reminders to the patient of the treatment and reorientation to eliminate patient
distress from post treatment amnesia. The co(nitive impairments associated with ECT
treatment mostly reflect chan(es in memory - i.e. temporary antero(rade amnesia and
retro(rade amnesia. 6emory deficits do not seem to be restricted to personal
autobio(raphical memory. 6emory loss may be distressin( to the patient. The nurse
should reinforce that the maority of the memory difficulties will pass within several
weeks, with a minimal amount of memory problems lastin( up to , months.
:taffin(
0 trained nurse with relevant e=perience must be present at each sta(e of the
treatment. ECT should be administered only in a suitably eDuipped unit by
professionals who have been trained in its delivery and in the anesthetic techniDues
reDuired for the administration of ECT. $n busy ECT clinics it is advisable to use
nursin( assistants to assist the Score teamT with low skill tasks. E.(. 0ssistin( with
movin( a patient, ensurin( the patient receives refreshments post ECT, telephone
communication. 0ll nursin( staff workin( in the ECT team should receive >asic
5ife :upport trainin( (monthly), 6ovin( and handlin( trainin( (annual), 6ental
8ealth 0ct competency (annual). Kecovery nursin( staff should receive local
recovery skills trainin( inclusive of airway mana(ement, aspiration and suction
techniDues (, monthly). Their competency in recovery must have been assessed.
0ll staff should be familiar with ECT policies and procedures. The same team
should work in the clinic every week for the purposes of continuity. 0 bud(et for
staff trainin( specific to ECT, should be available. :taff should be encoura(ed to
keep up to date with best practice and their trainin( needs should be formally
assessed by appraisal. ECT nursin( staff should attend appropriate trainin( and
conference events, e.(. re(ional ECT nurse (roup meetin(s, ECT nurse trainin(
conferences and the KC; ECT trainin( course.
The ECT Clinic ?urse 6ana(er (ECT ?urse)
This nurse (minimum (rade F K6? or eDuivalent) is responsible for the
development and implementation of a cohesive ECT service actin( as a clinical and
functional lead. Therefore, he 1 she should have appropriate ECT related knowled(e 1
e=perience and have under(one an induction pro(ramme coverin( ECT policies and
procedures, medical eDuipment safety and clinical mana(ement. 8e 1 she should have an
up to date ob description with clearly defined roles and responsibilities.
8e 1 she should ensure that the patients, eDuipment and personnel are prepared and
or(anised for the session. Emer(ency resus eDuipment and dru(s should be checked
weekly, or as per local policy. The ECT machine output and electrodes should be
checked. The ECT nurse should ensure that the ECT machine functionin( and
maintenance is checked and recorded at least every year or accordin( to machine
(uidance. 0 record of ECT administration should be maintained for Duality assurance. 0n
e=ample of (ood practice in this area is the :cottish ECT 0udit ?etwork. 0ppropriate
induction and on-(oin( trainin( of staff should be maintained, e.(. ECT policies and
procedures, C;K, 6ovin( and 8andlin(, 6ental 8ealth 0ct, Control and Kestraint. The
nurse should offer clinical advice to services across the Trust and assist with liaison
between the ECT clinic team and the patientNs own team..
The nurse should have desi(nated sessional time for the clinics, auditin(, teachin(
student nurses, risk assessments, administration, supervisin( and research into best
practise in ECT. 8e 1 she should support the ECT consultant with the trainin( of unior
doctors. The ECT nurse should be able to spend time with patients and relatives in order
to provide support and information. <ser 1 carer support (roups related to ECT should be
supported by the ECT nurse. 8e 1 she should receive re(ular supervision and maintain a
personal development plan related to ECT. 8e 1 she should attend specific ECT trainin(
sessions, e.(. Koyal Colle(e ;sychiatrists Trainin( Hays, and 1 or become actively
involved in their re(ional ECT ?urse 2roup. The nurse should have protected time to
carry out all of the above duties and should not be e=pected to be coverin( a ward or
other responsibilities on the days of treatment. There should be a nominated trained
deputy to cover the absence of the ECT nurse.
Conclusion
Electroconvulsive Therapy has received some bad press as a result of what the
treatment used to be. Eet @ECT has a hi(her success rate for severe depression than any
other form of treatment.@ $t has also been shown to be an effective form of treatment for
schizophrenia accompanied by catatonia, e=treme depression, mania, or other affective
components. The followin( e=cerpt on its use in depression from Ivercomin( Hepression
by Hr. Hemitris ;opolos should help shed some li(ht on the issue.
ThereAs been a resur(ence of interest in ECT because it has evolved into a safe
option, one that works. >ut for a public influenced by Gen GeseyAs Ine Flew Iver the
CuckooAs ?est, whose associations with ECT start with the electric chair J move on to
li(htnin( bolts, electric eels J third rails, it makes for Dueasy conversation. For all of us.
5etAs replace a few of the myths with facts.
ECT has a hi(her success rate or severe depression than any other form of
treatment. $t can be life-savin( J produce dramatic results. $t 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 J pre(nant women
who suffer from depression or mania. 0 patient who is very intent on suicide, J who
would not wait & weeks for an antidepressant to work, would be a (ood candidate for
ECT because it works more rapidly. $n fact, suicide attempts are relatively rare after ECT.
*i(lio#raph
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&. @Electroconvulsive therapy discussion hosted at the 628@.
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). Carla Curran (.''3-'%-"3). @:hock Therapy 6akes a Comeback/ :tates
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9ashin(ton, HC/ 0merican ;sychiatric ;ublishin(, .''".
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"%, pp. "%&%-"%)*
4. @2uidance on the use of electroconvulsive therapy@ (;HF). ?ational $nstitute for
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http/11www.nice.or(.uk1nicemedia1pdf1*%ectfull(uidance.pdf. Ketrieved .''4-'3-
.,.
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0 Tasman, 7 Gay, 70 5ieberman (eds) "sychiatry! +econd Edition. Chichester/
7ohn 9iley J :ons 5td, "4,*-"%'".
"'. Keid 98, Geller :, 5eatherman 6, 6ason 6 (7anuary "%%4). @ECT in Te=as/ "%
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inpatient population and in the electroconvulsive therapy clinic@. % ECT ++ ())/
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".. :ur(eon 2eneral ("%%%). $ental &ealth# , 0eport of the +urgeon 1eneral,
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"). :ackeim 80, 8askett KF, 6ulsant >8, Thase 6E, 6ann 77, ;ettinati 86,
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",. Gellner C8, Gnapp K2, ;etrides 2, Kummans T0, 8usain 66, Kasmussen G,
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0? 0::$2?6E?T I?
ELECTRO
CONVULSIVE THERAPY