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Electroconvulsive Therapy and Depression

Barbara Baugh

October 4, 2009

INTRODUCTION

Depression

depression2.jpg        Depression is a mood disorder that grabs hold of a person’s physical, emotional, and mental beings. Each year, over twenty million Americans are affected by clinical depression, including major depression, dysthymia, and manic depression (http://www.nimh.nih.gov/health/publications/depression-a-treatable-illness-fact-sheet/index.shtml). The National Institute of Mental Health lists the following as symptoms of depression:

“Persistent sad, anxious, or ‘empty’ mood; feelings of hopelessness; feelings of guilt, worthlessness, helplessness; loss of interest or pleasure in hobbies and activities that were once enjoyed; decreased energy; difficulty concentrating, remembering, making decisions; trouble sleeping, early-morning awakening or oversleeping; appetite and/or weight changes; thoughts of death or suicide, or suicide attempts; restlessness, irritability; persistent physical symptoms, such as headaches, digestive disorders, and chronic pain, that do not respond to routine treatment.” (http://www.nimh.nih.gov/health/publications/depression-a-treatable-illness-fact-sheet/index.shtml)

hippocampus.jpgMood regulation in the brain is located in the prefrontal cortex and the hippocampus, with the decrease in volumes of these locations being linked to depression (Niculescu, 2005). Common treatments for depression are antidepressant medication, such as Lexapro, Prozac, Paxil, and Zoloft; and psychotherapy, which includes dynamic, interpersonal, and behavior therapies, with a combination of the two being ideal (http://www.healthyplace.com/depression/main/treatment-of-major-depression/menu-id-68/).

Electroconvulsive Therapy (ECT)

        It is possible, however, for patients to not respond to antidepressant medications or psychotherapy. In these cases, electroconvulsive therapy (ECT) has proven to be a successful technique in treating highly severe depression. ECT produces a short seizure in patient’s brains by sending an electric current through the patient’s scalp to directed spots of the brain. A patient will usually do about two to three ECT treatments per week for about two to three weeks (http://www.webmd.com/depression/electroconvulsive-therapy-ect). This process is extremely controversial due to negative reports and depictions on its historical unsafe techniques, and due the fact that little is known about how the procedure actually treats the depression (Arshad et al., 2007). Because of the history of the technique, it is not as trusted. Changes have been made to better the patient’s safety and lessen harmful side effects of the therapy, but people still distrust that the procedure is worth the risks that are still present. Therefore, the final question is – Are the results of using ECT to treat depression worth the risks? To answer this question, the common misconceptions concerning the treatment must be identified cleared up.

EARLY YEARS OF ECT

electro.gif        Electroconvulsive therapy was first used in 1938 by Cerletti and Bini in order to treat severe depression and schizophrenia. Cerletti’s figured that a brain that has been induced with electric shock would release natural substances in order to restore itself for survival, thus fixing the mental disorder (Koukopoulos, 2009). At this time, no extra precautions were used for the patient’s convenience, allowing the patient to stay awake and convulse during the seizure. These intense convulsions commonly led to fractured spines, severely bitten lips, and broken bones (Cloud & Westfield, 2001). Many changes have been made to protect patients (i.e., invention of unilateral ECT, usage of anesthesia and muscle relaxants during the procedure) and scientists continue to experiment with “treatment electrode placement, stimulus waveform, and the number of frequency of induced seizures” (Abrams, 1993) in order to reduce risks even further.

THE RISE OF MISCONCEPTIONS OF ECT

electroshock_NoTwe_183.jpg        Because of the frightening way ECT was initially carried out, people saw it as being inhumane. People do not, however, seem to have full knowledge of the new additions and changes to ECT that make the procedure less painful, such as anesthesia so that the patient is not awake and does not remember the procedure, as well as muscle relaxants so that the patient’s body does not go through convulsions. Another common misconception is that death is a large risk to ECT. The National Institute of Mental Health, however, “says that the figure is 1 in 10,000, about the same as ay procedure involving anesthesia” (Cloud & Westfield, 2001).

nicholson.jpgHollywood’s depiction of electroconvulsive therapy is a large contributor to the misconceptions of the treatment. For example, Jack Nicholson plays a psychiatric patient in the movie One Flew Over the Cuckoo’s Nest (1975). In the scene in which he receives ECT treatment, he experiences violent convulsions and returns to his group therapy session looking like a zombie (http://www.psychiatrictimes.com/display/article/10168/48111?verify=0). Dramatic scenes like this portray a very negative view of the procedure for those watching; and because people know very little about the changes made in the treatment, they remain disturbed by it. Psychiatrists say that as long as it is performed properly, ECT looks very boring compared to its “cinematic counterpart” (Cloud & Westfield, 2001).

        Curtis Hartmann, a lawyer in Massachusetts, has been using electroconvulsive therapy to treat his bipolar disorder since 1976, having received about one hundred treatments total. During each treatment, “an anesthesiologist puts him to sleep, a chemical relaxes his muscles, and a respirator helps him breathe” (Cloud & Westfield, 2001). In the effectiveness of the procedure, Harmann says, “[t]he seizure just kind of dynamites the depression out of my brain somehow.” He often goes to work afterwards, experiencing minor memory problems (such as getting confused about what he ordered for lunch) if anything. He also says, “The people in the office are just agog that you can add two and two, that you’re not drooling.” This goes to show the unrealistic perceptions that the population has of ECT (Cloud & Westfield, 2001).

A questionnaire study was done in Pakistan to assess the perceptions that patients of a local hospital had of ECT. Arshad et al. (2007) found that the more highly educated patients were “more likely to believe that there was a possibility of total insanity after receiving ECT and that it was often used unnecessarily” while the lower educated people believed that ECT is a “permanent treatment.” Arshad et al. (2007) explained that these false beliefs of the more highly educated people was influenced by their “greater access to the electronic and print media, and consequently the negative image portrayed by them,” and the false beliefs of the lower educated people was influenced by “inadequate patient counseling,” which corresponds to the researchers previous explanation of the lack of ECT-training of physicians in developing countries (Arshad et al., 2007).

WHAT TYPES OF PATIENTS WITH DEPRESSION SHOULD GET ECT TREATMENT?

depression.jpg        ECT is usually used for people who do not respond to antidepressant medication or psychotherapy. It is also helpful for people who take medications for other illness that are not safe to take with antidepressants. It is best for patients experiencing a high severity of major depression. It is also a very good source for treatment when a quick response is needed. Antidepressants can take several weeks to begin to show effectiveness and even months to get to their full potential (http://www.webmd.com/depression/guide/electroconvulsive-therapy). ECT is a very successful quick treatment when needed in situations such as patients who are a high suicidal threat. The process is not permanent, so medications would still need to continue (Fink, 2008).

        The directives of the American Psychiatric Association (APA) highly recommend ECT for geriatric depression. They, along with other authors, believe that it is the “sole true therapy for delusional late-life depression” (Fountoulakis et al., 2003), especially considering the large amounts of medications elderly that people tend to take, thus making it difficult to safely give them antidepressants.

TWO MAIN TYPES OF ECT TECHNIQUES

Bilateral ECT

Bilateral ECT.jpgBilateral ECT was the first type of ECT used that delivered a sine-wave current. The electrodes are placed over both temporal areas so that the electric current is focused on the frontal and temporal lobes. This method has been replaced by unilateral ECT’s to reduce negative cognitive side effects. (Abrams, 1993)

Right Unilateral ECT (RUL)

RUL ECT.jpgThis type of ECT was invented in efforts to avoid placing the electrodes on areas of the brain related to speech. This led to a reduction in memory loss and confusion as well as “accentuation of post-ECT slow-wave electroencephalogram (EEG) activity over the treated hemisphere” (Abrams, 1993, p. 18). Electrodes for RUL are configured in a temporal-vertex placement.

Not all patients respond to every form of ECT. A study by Pettinati et al. (1990) reported that “9 of 11 right unilateral ECT non-responders responded when switched to bilateral ECT, experiencing a remarkable 80% total reduction in depression scale scores after achieving only 16% improvement in response to the initial 5 or 6 right unilateral ECTs”(Abrams, 1993, 18-19). Due to the more risky side effects, however, bilateral ECT is only preferred for patients with the highest severities of major depressive disorder.

HOW DOES IT WORK?

        One large reason many people do not trust ECT is that scientists are not exactly sure how the technique treats. They believe that ECT produces changes in the chemicals that regulate your emotions (http://www.theuniversityhospital.com/ect/works.htm), but what these exact chemicals are and what ECT does to change them is still unknown. As Time Magazine writers Cloud and Westfield put it – as far as we know, “it just works, except for when it doesn’t.” (Cloud & Westfield, 2001)

        Some studies have been conducted that make ECT treatment for depression seem paradoxical. Kimiskidis et al. (2007) conducted a study to investigate the association of epilepsy with mood disorders such as depression and anxiety. They found that “depression and anxiety are common psychological disorders in epileptics.” Studies like this that show that seizures and depression come hand-in-hand for some people make ECT more of a mystery as it induces seizures to treat severe depression.

RESULTS OF ECT TREATMENT

Effectiveness of Treating Depression

        ECT is highly known as a successful treatment for severe depression. According to the Surgeon General, the response rate for ECT is 60-70%, which is about the same as antidepressant pills (Cloud & Westfield, 2001). Heikman et al. (2002) conducted a double-blind study in order to compare the effectiveness of right unilateral ECT for people with low versus high severity of major depression.  Their results found that patients with a lower severity of major depression had a significantly lower response rate (8%) than patients with moderate to severe major depression (63%). Due to these results, they concluded that patients with low severity of major depression have “a high risk/benefit ratio” (Heikman et al., 2002). In other words, ECT is not “worth” the risks of harmful side effects for low severity depression patients as much as it is for high severity depression patients.

        A study done by Nakajima et al. (2009) observed the impacts of stitching antidepressants after successful ECT treatment for patients who were previously resistant to the antidepressants. They found that “patients whose antidepressants were switched after ECT were readmitted less frequently in one year than those who received the same antidepressant, and showed better social contacts in six months and one year” (Nakajima et al., 2009, p. 180), making the effectiveness of ECT treatment last much longer.

        Juli Lawrence underwent ECT treatment in 1994. She claims that she and her family were told by her doctor that ECT is an absolute and permanent cure for her depression. She says that she has no memory of any events two years before and a couple months following her treatment. She now has a website, ect.org, that she hopes will increase for patients interested in ECT the risks involved, which she believes will cause many to choose against using the treatment. In 1996, she conducted her own survey of former electroshock patients, in “70% said the treatment had no effect on their depression” (Cloud & Westfield, 2001).

Side Effects

        Although there can be physical side effects from the usage of ECT treatment (such as headaches, nausea, and jaw pain), cognitive side effects are the primary focuses of concern (http://www.webmd.com/depression/electroconvulsive-therapy-ect). Common cognitive side effects of ECT are short-term memory loss and confusion. Many studies state that side effects primarily resolve themselves within a month from the ECT treatment, while others state that there are more long-term effects.

        Falconer et al. (2008) conducted a study that focused on short and long-term cognitive impairment of memory due to ECT. After carrying out neuropsychological tests and questionnaires, they found that “(1) Patients generally self-rated their memory functions as significantly improved after a course of ECT; (2) Delayed recall of paired words and short story were sensitive to the adverse cognitive effects of ECT; (3) Spatial Recognition memory was impaired after ECT; (4) Personal Semantic and Autobiographical Memory for recent events was significantly impaired by ECT; (5) Memory deficits had generally resolved one month after ECT.” Autobiographical memory for events surrounding the ECT remained (Falconer et al., 2008), which was likely to be caused the anesthesia.

        Falconer et al. (2009) conducted another study that used the Cambridge Neuropsychological Test Automated Battery (CANTAB) to assess cognitive impacts of visual and visuospatial memory of bilateral ECT patients. They found “significant impairments in visual and visuospatial memory” and that “most impairments resolved one month following ECT.” They also found, however, that in some cases significant impairments of spatial recognition memory remained. They included that  “this is one of only a few studies that have detected anterograde memory deficits more than two weeks after treatment” (Falconer et al., 2009). This goes to show that while permanent cognitive side effects are not probable, they are still a possibility, especially with bilateral ECT.

        Rucker & Cook (2008) provided a case study that is an example of a possible severe side effect due to ECT – prolonged seizure. They gave the case study of a woman in London. She had highly severe major depressive disorder, having overdosed three times in the past of which two required her going to the ICU. She had had three sets of ECT treatment “without significant side effects but with noticeable benefit to her symptoms (Rucker & Cook, 2008). During the second treatment of her fourth set, she began to seize two minutes after the treatment while she was still unconscious due to the anesthesia. A couple days after the incident, her mood was reported to be improved. Rucker & Cook (2008) used this case report to show that ECT can have unpredictable effects on the brain in the presence of psychotropic medications and that people with such medications should carefully survey the risks and benefits ECT treatment.

        Other serious possible side effects along with prolonged seizures include increased blood pressure and changes in heart rhythm, although they are rare and “resolve quickly without treatment” (http://www.webmd.com/depression/electroconvulsive-therapy-ect).

DISCUSSION OF ONLINE FINDINGS

          The majority of the resources I found were journals and informative medical websites. Of the journal articles I found, researchers were primarily working to measure the severity of the side effects of ECT. In the informative websites, a general description of ECT was given along with possible side effects. These almost always, however, mentioned that the risks of an untreated patient with major depressive disorder are seen as greater than those of ECT. These journals and informative medical websites all had a general conclusion that ECT is necessary in specific cases of depression.

        Other websites I found were ones that seemed to only exist for the purpose of shutting down ECT treatment. Juli Lawrence’s ect.org website is filled with bias against the treatment, although she claims that she simply wants to help people be aware of the risks involved. I believe it is good to provide an informative website for prospective ECT users. This requires straight-forward information and statistics, however, rather than informal rants.

CONCLUSION

There are primarily two types of groups against ECT treatment. The first group aims to completely ban the procedure, saying that it produces brain damage and is inhuman. The second (and more popular) anti-ECT group wants more successful research to be completed before treatment is allowed to continue (Cloud & Westfield, 2001). Pro-ECT groups feel that the positive outcomes of people with severe depression is very much worth the risks involved, especially for those patients who are suicidal and unresponsive to all other forms of treatment. In other words, they believe the risks of untreated severe major depressive disorder are greater than the risks of ECT (http://www.webmd.com/depression/electroconvulsive-therapy-ect). As the risks of ECT have been proven to be primarily short-term, the risks of a person’s untreated major depression last much longer as their mental health and life are on the line.

Before people can accept electroconvulsive therapy as an effective treatment for depression, they need to learn the truth about the procedure and the successful results. Unfortunately, misconceptions about ECT are portrayed in the media and reports. Until then a better understanding is reached, there will continue to be a major controversy between people who see the treatment as inhumane and those who see the treatment as life saving.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Abrams, R. (2009). ECT technique: Electrode placement, stimulus type, and treatment frequency. The Clinical Science of Electroconvulsive Therapy, 17-28.

Arshad, M., Arham, A. Z., Arif, M., Bano, M., Bashir, A., Bokutz, M., et al. (2008). Awareness and perceptions of electroconvulsive therapy among psychiatric patients: A cross-sectional survey from teaching hospitals in Karachi, Pakistan. BMC Psychiatry, 7(27).

Cloud, J., & Westfield. (2001, February 26). New sparks over electroshock. Time Magazine.

Falconer, D., Cleland, J., & Reid, I. (2008). The cognitive impact of electroconvulsive therapy (ECT). Annals of General Psychiatry, 7(168).

Falconer, D. W., Cleland, J., Fielding, S., & Reid, I. C. (2009). Using the Cambridge Neuropsychological Test Automated Battery (CANTAB) to assess the cognitive impact of electroconvulsive therapy on visual and visuospatial memory. Psychological Medicine.

Fink, M. (2008). Who should get ECT? The Clinical Science of Electroconvulsive Therapy. 3-16.

Heikman, P., Ktila, H., Sarna, S., Wahlbeck, K., & Kuoppasalmi, K. (2002). Differential response to right unilateral ECT in depressed patients: impact of comorbidity and severity of illness. BMC Psychiatry, 2(2).

Kimiskidis, V. S., Triantafyllou, N. I., Kararizou, E., Gatzonis, S.-S., Fountoulakis, K. N., Siatouni, A., et al. (2007). Depression and anxiety in epilepsy: The association with demographic and seizure-related variables. Annals of General Psychiatry, 6(28).

Koukopoulos, A. (2009). Ugo Cerletti: Il Romanzo dell’Elettroshock. Journal of ECT, 15(1), 25.

Nakajima, S., Ishida, T., Akaishi, R., Takahata, K., Kitahata, R., Uchida, H., et al. (2009). Impacts of switching antidepressants after successful electroconvulsive therapy on the maintenance of clinical remission in patients with treatment-resistant depression. Journal of ECT, 25(3),  178-181.

Niculescu, A. B. (2005). Genomic studies of mood disorders – the brain as a muscle? Genome Biology, 6(215).

Rucker, J., & Cook, M. (2008). A case of prolonged seizure after ECT in a patient treated with clomipramine, lithium, L-tryptophan, quetiapine, and thyroxine for major depression. Journal of ECT, 24(4), 272-274.

 

 

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