Reprinted from "Seniors' Mental Health" issue of Visions Journal, 2002, No. 15, p. 11
Electroconvulsive therapy (ECT) was first introduced in 1938 by Cerlitti and Bini in Italy. Since then, there have been numerous changes with regards to ECT devices, techniques, reasons to consider ECT, and anaesthetic procedures. ECT practice guidelines have been developed in Canada (1992), Great Britain (1995), Australia (2000), and the United States (2000), which update standards for delivering ECT. The recentlypublished BC Guidelines for ECT (2002), soon available online at www.healthservices. gov.bc.ca/mhd, attempt to set the standards for ECT in BC. Despite the stigma and media controversy surrounding ECT, “modern” ECT is safe and likely the most effective single treatment for certain psychiatric conditions. It can be life saving in some of those with suicidal behaviour, and in those with malnourishment and dehydration. The following attempts to dispel some of the myths surrounding “shock” therapy.
What is “Modern” ECT?
ECT involves the passage of electricity through the skull and into the brain in order to produce a brief convulsion. A typical successful course constitutes 6-12 treatments. Despite many hypotheses, the mechanism of action is unknown, but ECT effectively treats a number of psychiatric conditions, (most commonly for depression, sometimes for mania, and occasionally for schizophrenia), and medical conditions (e.g. Parkinson’s Disease). Some will benefit from outpatient, less frequent continuation of ECT in order to maintain improvement. “Modern” ECT over the past 25 years incorporates the mandatory use of modern ECT devices, general anaesthesia, and muscle relaxation. Heart monitoring and oxygenation are essential during and after ECT. “Modern” ECT looks at the best available techniques in order to minimize side effects, and is stringently applied only for certain conditions deemed treatable by ECT, but not for individuals considered strictly “antisocial” or “criminal.”
Is ECT Painful?
ECT is performed under general anesthesia and no discomfort is experienced during treatment. Properly applied ECT does not lead to burns to the skin or hair. On occasion, headaches and muscle aches are side effects, which are not incapacitating and last less than a day.
Does ECT Cause Brain Damage?
There is no evidence that, in the era of “modern” ECT, it causes “brain damage,” (i.e. structural changes to the brain). ECT does not change a person’s personality, nor is it designed to treat those with just primary “personality disorders.” ECT can cause transient short-term memory — or new learning — impairment during a course of ECT, which fully reverses usually within one to four weeks after an acute course is stopped. Whether ECT can rarely cause memory loss for certain (but not all) types of remote events is controversial and is an area of active research. Adjusting the dose of energy delivered and the ECT technique employed can minimize the risk of memory impairments.
Is ECT Risky for the Elderly?
In general, being elderly does not mean there is an increased risk for complications related to ECT. In fact, studies indicate the elderly respond to a higher degree to ECT than younger adults. Being elderly means the increased likelihood of having medical conditions and dementia. Having certain medical conditions can increase the risk when undergoing ECT, and need to be considered in light of potential benefits. It is generally safe to administer ECT in those with dementia, and could be considered in these individuals who may also have depression (though the evidence is less clear regarding its use for people with dementia without depression).
How Were the Guidelines Developed?
The guidelines were developed by several UBC-affiliated psychiatrists, a nurse clinician, and an anaesthetist. Dr. Martha Donnelly, Head of the Division of Geriatric Psychiatry, chaired the group. An advisory committee was also formed that was comprised of representatives from the UBC Department of Psychiatry based in Vancouver and Prince George, from the BC Ministry of Health, from the Mood Disorders Association, and from the Department of Psychiatry at the University of Toronto. The guidelines establish contemporary standards for delivering ECT throughout the province, and deem each local health authority as the organization responsible for implementation and monitoring. The guidelines incorporate how consent for ECT should be obtained in the light of the recent Health Care Consent Legislation and Facilities Care Act (HCCFCA) of BC encompassing competency issues, and in light of the Provincial Mental Health Act governing voluntary/involuntary patient status and treatment. Those with dementia may not be competent to provide consent, and the guidelines have special sections dealing with these individuals who require ECT. In the HCCFCA, there is also a provision to automatically involve the Community Legal Assistance Society to advocate for such individuals deemed “incompetent to consent for ECT” under this piece of legislation.
ECT is a safe and effective procedure for a variety of conditions in younger and older adults. Negative depictions of ECT in the press and cinema have contributed to misperceptions surrounding current ECT practice. This is unfortunate, as ECT remains an important tool in combating the devastating consequences of certain mental illnesses.