Electro-convulsive therapy: What is it?
Electro-convulsive therapy, or ECT, is a medical treatment that has been used for many decades for a number of psychiatric conditions.
The treatment involves placing electrodes on the temples, on one or both sides of the patient's head, and delivering a small electrical current across the brain, with the patient sedated or under anaesthetic. The aim is to produce a seizure lasting up to a minute, after which the brain activity should return to normal. Patients may have one or more treatment a week, and perhaps more than a dozen treatments in total.
Although ECT has been used since the 1930s, there is still no generally accepted theory to explain how it works. One of the most popular ideas is that it causes an alteration in how the brain responds to chemical signals or neurotransmitters.
Why is ECT used?
Modern ECT is used primarily in the treatment of severedepression, and psychiatrists say it has proved the most effective treatment in many cases, particularly when depression doesn’t respond to drug treatments. It has also been used in some cases of schizophrenia and mania but is no longer recommended for the former in the UK. However, mental health campaigners are concerned that, although it may work in the short term, it's unclear what its long-term effects are.
ECT is usually reserved for really difficult-to-treat cases. Data from 1999 for example showed that about 11,000 people in England and Wales are given the treatment each year – this compares to over 30 million prescriptions for anti-depressants drugs issued each year in the UK. Most people receiving ECT were women, many aged over 65, and a quarter were detained under the Mental Health Act. Of the latter, 59 per cent received ECT against their will.
The charity Mind also says ECT is often used against people's will and it wants to see a ban on this. But psychiatrists argue that some people are so very severely depressed that they become incapable of giving or denying consent, and aren't competent to make a decision about a treatment that could benefit them. Psychiatrists say that if patient consent was always necessary, about 20 per cent of patients who now receive the treatment would not get it despite being most in need.
What are the risks of ECT?
Patients are given short-acting anaesthetics, muscle relaxants and breathe pure oxygen during the short procedure in order to minimise the risks. However, although ECT is much safer than it was, there are still side effects to the treatment. The most common are headache, stiffness, confusion and temporary memory loss on awaking from the treatment - some of these can be reduced by placing electrodes only on one side of the head. Memory loss can be permanent in a few cases, and the spasms associated with the seizure can cause fractured vertebrae and tooth damage. However, the recommended use of muscle relaxant nowadays makes the latter a very rare occurrence. Patients can also experience numbness in the fingers and toes.
The death rate from ECT used to be quoted as one for every 1,000 patients, but with smaller amounts of electric current used in modern treatments, accompanied by more safety techniques, this has been reduced to as little as four or five in 100,000 patients.
What are the recommendations?
A common argument against ECT is that it destroys brain cells, with experiments conducted on animals in the 1940s often cited as evidence. However, modern studies have yet to reproduce these findings in the human brain.
Some activists, however, still campaign against the widespread use of ECT in psychiatry, quoting those cases which have resulted in long-term damage or even death, whether because of the built-in chance of problems, or through errors by doctors.
Experts say that given the correct staff training, and when used for the right clinical conditions, ECT can 'dramatically' benefit the patient. An audit of ECT in Scotland between February 1996 and August 1999 said concerns about unacceptable side effects, effectiveness of the treatment and disproportionate use on elderly people were 'largely without foundation'.
It said that in nearly three quarters of cases people with depressive illness showed 'a definite improvement' after ECT. Women were more likely to receive the treatment than men, but the auditors said this was because they were twice as likely to suffer from depression. Only 12 per cent of patients who got ECT were aged over 75. However, the Royal College of Psychiatrists has admitted that in the past the treatment has been administered by untrained, unsupervised junior doctors. However, modern guidelines have changed this and ECTAS (ECT Accreditation Services) exist to check that such treatment is being given safely and efficiently.
Guidelines on ECT from NICE (2003) recommend that it's used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment. options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with:
- Severe depressive illness
- Catatonia
- Prolonged or severe manic episode
NICE also says that 'valid consent should be obtained in all cases where the individual has the ability to grant or refuse consent. The decision to use ECT should be made jointly by the individual and the clinician(s) responsible for treatment, on the basis of an informed discussion. This discussion should be enabled by the provision of full and appropriate information about the general risks associated with ECT and about the risks and potential benefits specific to that individual. Consent should be obtained without pressure or coercion, which may occur as a result of the circumstances and clinical setting, and the individual should be reminded of their right to withdraw consent at any point. There should be strict adherence to recognised guidelines about consent and the involvement of patient advocates and/or carers to facilitate informed discussion is strongly encouraged.
