The history of electroconvulsive therapy in the United States and its place in American psychiatry: a personal memoir.

The history of electroconvulsive therapy (ECT) in the United States is traced from its crude beginnings in 1940 to its emergence as a highly sophisticated and effective treatment for many severe psychiatric disorders. The general distrust of all somatic therapies in the 1930s and 1940s expressed by many prominent psychiatrists (both analysts and nonanalysts) contributed to an ambivalent relationship between ECT and the rest of American psychiatry. The media coverage of ECT is reviewed, and suggestions for dealing with the antipsychiatry movement and anti-ECT prejudice are discussed.     

Electroconvulsive therapy: past, present, and future]

Although electroconvulsive therapy (ECT) was first introduced to treat schizophrenia in 1938, it is widely used for the treatment of various major psychiatric disorders, including depression. In western countries, its safety has been improved with the introduction of techniques such as succinylcholine muscle relaxation, barbiturate anesthesia, oxygenation and brief-pulse stimulation. Although the first use of ECT in Japan was reported in 1939, few modifications of the ECT technique have been made since then. From the 1980s, in collaboration with anesthesiologists, ECT with anesthesia and muscle relaxation (modified ECT) has been administered in numerous general hospitals. Moreover, brief-pulse ECT devices were approved in 2002. Rapid progress in ECT practices is expected in Japan. Before administering ECT, informed consent should be obtained from the patient, except when the patient lacks capacity to consent. The major problems in ECT are cognitive side effects and high relapse rates. Furthermore, its mechanisms of action are still unknown. These problems must be solved in the near future.     

Rapid improvement of depression and psychotic symptoms in Huntington's disease: a retrospective chart review of seven patients treated with electroconvulsive therapy

Many patients with Huntington's disease (HD) develop psychiatric symptoms such as depression and psychosis. For severe symptoms, electroconvulsive therapy (ECT) can be a valuable treatment. In this case series, we identified seven patients with HD who received ECT at Massachusetts General Hospital in the past 20 years. In all cases, ECT was well tolerated and produced improvement in psychiatric and behavioral symptoms. Our case series supports the hypothesis of a positive risk–benefit ratio for ECT in patients with HD and severe depression or psychosis.     

Electroconvulsive therapy in Belgium: a questionnaire study on the practice of electroconvulsive therapy in Flanders and the Brussels Capital region

OBJECTIVES: We sought to review and describe the practice of electroconvulsive therapy (ECT) in Flanders and the Brussels Capital region, Belgium, in 2003. METHODS: A 30-item questionnaire was sent to all institutions that provided psychiatric care. Besides questions on training and general attitude toward ECT, most questions concerned technical aspects, quality, and organization of this treatment modality. RESULTS: All psychiatric departments offering ECT and 58% of the hospitals that do not conduct ECT replied to the questionnaire. Forty-three percent of the departments offering ECT indicated less than 10 treatment sessions per month. Forty-three percent of hospitals set a fixed number of treatments per course. Maintenance ECT and ECT on an outpatient basis were rather rare, except for a few departments. The major indication for ECT was depression (88%) rather than schizophrenia (8%), mania (3%), or other psychiatric disorders (1%). Propofol was the anesthetic most commonly used (74%). Seven departments (30%) used a sine wave device. Bilateral electrode placement was the preferred option in 91% of all departments and both fixed high dose and dose titration strategy were used equally (both 47.8%). CONCLUSION: The present findings demonstrate that the practice of ECT in Flanders and the Brussels Capital region in 2003 generally was not performed according to the available guidelines. ECT is underused in Flanders and the Brussels Capital region compared with other countries, although it is available in both specialized psychiatric facilities and in the psychiatric departments of general hospitals.     

Nonpharmacological, somatic treatments of depression: electroconvulsive therapy and novel brain stimulation modalities

Until recently, a review of nonpharmacological, somatic treatments of psychiatric disorders would have included only electroconvulsive therapy (ECT). This situation is now changing very substantially. Although ECT remains the only modality in widespread clinical use, several new techniques are under investigation. Their principal indication in the psychiatric context is the treatment of major depression, but other applications are also being studied. All the novel treatments involve brain stimulation, which is achieved by different technological methods. The treatment closest to the threshold of clinical acceptability is transcranial magnetic stimulation (TMS). Although TMS is safe and relatively easy to administer, its efficacy has still to be definitively established. Other modalities, at various stages of research development, include magnetic seizure therapy (MST), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). We briefly review the development and technical aspects of these treatments, their potential role in the treatment of major depression, adverse effects, and putative mechanism of action. As the only one of these treatment modalities that is in widespread clinical use, more extended consideration is given to ECT Although more than half a century has elapsed since ECT was first introduced, it remains the most effective treatment for major depression, with efficacy in patients refractory to antidepressant drugs and an acceptable safety profile. Although they hold considerable promise, the novel brain stimulation techniques reviewed here will be need to be further developed before they achieve clinical acceptability.     

Electroconvulsive therapy practice in Thailand

OBJECTIVES: To obtain an overview of electroconvulsive therapy (ECT) practice in Thailand. METHODS: Questionnaires were sent to all institutions providing psychiatric care; data were collected from September 1, 2001, to August 31, 2002. RESULTS: Fifty-three responses were received from 67 institutions (79.1%). ECT is available in 26 hospitals. Approximately 6,914 patients received 51,565 ECT treatments, of which, 6,469 patients (93.56%) received 48,240 treatments (93.55%) in the psychiatric hospitals. The ECT utilization rate was 11.15 patients treated per 100,000. Twelve institutions used MECTA (Spectrum or SR1) or Thymatron DGx. Bilateral ECT was used exclusively in all institutions. In 2 medical schools, all patients received double ECT throughout their treatment courses. Unmodified ECT was always used in nine psychiatric hospitals and five general hospitals, and occasionally used in 2 university hospitals comprising 94.2% of all ECT usage. Patients with schizophrenia most frequently received ECT (74%), followed by mania (8%) and major depression (7%). The nurse alone administered ECT in four psychiatric hospitals. Although the death rate was estimated at 0.08%, there was no ECT-related death during the survey period. Continuation ECT was performed in 11 and maintenance ECT in 6 institutions. Five institutions had acceptable training programs for psychiatry residents but none had training syllabus, 2 institutions had teaching schedule for medical students. CONCLUSIONS: ECT use in Thailand is high. Nearly all ECTs (93.6%) were performed in the psychiatric hospital and 94.2% of all treatments were unmodified ECT. Lacking of proper training in ECT is evident.     

Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: a review of the literature

Electroconvulsive therapy (ECT) is well established as a safe and effective treatment for several psychiatric disorders. Responsiveness to ECT does not abate with age, and data indicate that the use of ECT in the treatment of psychiatric disorders in the elderly persons has increased in recent decades. Special consideration must be given to the baseline cognitive abilities of an elderly patient prior to treatment with ECT. Much of the literature on the use of ECT in the elderly persons has focused on the treatment of mood disorders, whereas less research has been devoted to its use in the treatment of other psychiatric conditions. Although depressive syndromes remain the most common indication for ECT in the elderly persons, clinicians treating elderly patients should remain aware of the safety and efficacy of this treatment modality with other psychiatric disorders. This review examines the literature on the use of ECT in elderly patients with some common neuropsychiatric disorders including catatonia, bipolar mania, schizophrenia, dementia with behavioral disturbance, and Parkinson's disease.     

Electroconvulsive treatment of neuroleptic malignant syndrome: a review and report of cases.

OBJECTIVE: Neuroleptic malignant syndrome (NMS) is a potentially lethal adverse effect of neuroleptic medication, with no satisfactory treatment currently available. Electroconvulsive therapy (ECT) has been anecdotally reported to be effective in its treatment. We review 45 published case reports of ECT for NMS and describe nine new cases, to examine its effectiveness, the likelihood of adverse reactions, and the theoretical implications of such treatment. METHOD: The authors used Medline to identify reports in the English literature where ECT was used in cases of suspected NMS. In addition, the charts of patients referred to the second author for treatment of NMS were reviewed and cases in which ECT used were identified. RESULTS: The case reports suggest that ECT is effective in many individuals with NMS, even when drug therapy has failed. The response is usually apparent after a few treatments, generally up to six. The response is not predictable on the basis of age, gender, psychiatric diagnosis or any particular feature of NMS including catatonia. Electroconvulsive therapy is a relatively safe treatment in NMS, although the risk of cardiovascular complications should be considered. Malignant hyperthermia due to the anaesthesia associated with ECT has not been reported in patients with NMS, and succinylcholine has been used safely with the exception of one report of fever and raised creatine kinase levels and another report of hyperkalemia. CONCLUSIONS: Electroconvulsive therapy is the preferred treatment in severe NMS, cases where the underlying psychiatric diagnosis is psychotic depression or catatonia, and in cases where lethal catatonia cannot be ruled out. The effectiveness of ECT for the treatment of NMS has theoretical implications for the relationship between NMS and catatonia, and the possible pathophysiological mechanisms that underlie these disorders.     

Electroconvulsive therapy: predictors and trends in utilization from 1976 to 2000

BACKGROUND: Use of electroconvulsive therapy (ECT) may have changed during the last decades due to advances in psychopharmacology and organizational changes of psychiatric care. OBJECTIVES: To identify predictors for receiving ECT for the first time and to describe temporal trends in ECT utilization. METHODS: A register-based case-control study. The sample included 2010 cases treated with ECT between 1976 and 2000 and 148,284 controls. RESULTS: Predictors for receiving first ECT were unipolar affective disorders, long admissions, and no previous admissions. Significantly fewer patients with bipolar and schizoaffective disorders received the treatment in 2000 compared with 1976. CONCLUSIONS: Unipolar affective disorders, long duration of admissions, and no history of previous admissions are strong predictors of receiving first ECT. Despite a decrease in available inpatient beds, the treatment is used in 5.5% of admissions, and during the last 15 years of the study period, ECT utilization has been remarkably stable.     

Electroconvulsive therapy. Indications, procedure and treatment results

Electroconvulsive therapy (ECT) is one of the most effective forms of treatment for severe and persistent psychiatric disorders. ECT is used for a broad spectrum of diseases; however, it has proven particularly helpful in the treatment of therapy-resistant depressive episodes. In addition it has also been successfully used in the treatment of other disorders, such as acute mania and acute psychotic states. Basically ECT should be considered in all cases of severe psychiatric disorder in which an adequate psychopharmacological and/or psychotherapeutic treatment strategy has failed or when the side-effects of medications have proven unbearable. As with other forms of psychiatric treatment ECT is not always used in the same manner and in different institutions in the same way and there are also differences in opinions between clinicians and researchers on various aspects of ECT. In this article the up-to-date standards for effective ECT treatment are outlined and discussed in the light of the current knowledge.     

Electroconvulsive therapy in treatment of acute life threatening catatonia in toxic epidermal necrolysis (Lyell syndrome)]

Toxic epidermal necrolysis (Lyell syndrome) developed in a 43-year woman treated with carbamazepine, perazine, and sulpiride for recurrent manic bipolar disorder. Five days after withdrawal of all psychotropic medication her psychiatric illness was exacerbated and a syndrome of lethal catatonia developed which was promptly treated with unilateral electroconvulsive therapy (ECT). Rapid remission of lethal catatonia after the first ECT treatment and of her affective disorder within days was achieved. According to clinical observations of the preneuroleptic era, early improvement of lethal catatonia following ECT may have been supported by concurrent high dose corticosteroid therapy for toxic epidermal necrolysis.     

Clinical applications of recent research on electroconvulsive therapy

Electroconvulsive therapy (ECT) has been in use since the late 1930s to treat a variety of severe mental illnesses, most notably major depression. Current research efforts focus on patient selection, memory impairment, and high posttreatment relapse rates. Psychopathological factors such as psychosis and severe psychomotor retardation predict favorable response to ECT in depression. Technical variables that affect memory include electrode placement, stimulus intensity, and treatment frequency. Strategies to reduce posttreatment relapse rates include maintenance ECT and aggressive medication combinations. In this article, I review recent research that bears on these aspects of ECT practice. Additionally, I review some findings on the neurobiological effects of ECT.     

Use of ECT in Drug-Refractory Schizophrenia - A Survey of the Current Literature

Since its introduction in the 1930 s, electroconvulsive therapy (ECT) has maintained an important role as an efficacious and evidence-based somatic treatment option in affective or schizophrenic diseases. As opposed to major depressive disorder, ECT is commonly used to a substantially lesser extent for patients with schizophrenia in the USA, UK and most parts of Europe. Accordingly there is comparably little evidence regarding the clinical effectiveness and tolerability of ECT in schizophrenia. Recent clinical studies, meta-analyses and surveys point to the combination of ECT and antipsychotic medication as being advantageous in the treatment of schizophrenia, particularly in those patients who have shown inadequate responses to psychotropic medication alone. Clinical features considered to be predictive for ECT outcome are delusions, hallucinations, presence of affective and catatonic symptoms and absence of negative symptoms as well as a short duration of the current episode. National and international guidelines suggest ECT as an augmentation strategy in treatment-refractory schizophrenia in acute exacerbation and continuation therapy. Considering the fact that a substantial part of schizophrenic patients does not respond sufficiently to pharmacotherapy there still is a lack of well designed, controlled and randomised clinical trials to improve evidence for the promising role of ECT in schizophrenia.     

Using a hypothetical scenario to inform psychiatric advance directives

OBJECTIVES: The study addressed whether a hypothetical psychiatric scenario is a feasible approach for eliciting psychiatric treatment preferences and identified consumer preferences regarding involuntary care. METHODS: Community-residing adults with serious mental illness (N=150) voluntarily completed the Health Care Preferences Questionnaire to determine treatment preferences in response to the use of psychiatric medications, seclusion and restraint, and electroconvulsive therapy (ECT). A vignette was used to determine preferences first with respect to an imaginary patient and then with respect to the respondent. RESULTS: Few participants were distressed by the psychiatric scenario (7%). In regard to their own care, in an emergency most participants supported the use of involuntary treatments (medications, 70%; medication injection, 76%; and seclusion and restraint, 73%), with the exception of ECT (quick treatment, 32%; if life is in danger, 60%). Participants were less likely to support treatments for themselves than for an imaginary patient. The majority (65%) identified specific medication preferences. CONCLUSIONS: Scenarios about the state of medical and psychiatric health are a feasible method of identifying treatment preferences. They are well tolerated and may serve as a model for assisting persons with serious mental illness in considering difficult treatment decisions.     

ECT in Austria: Is It Still a Valid Treatment? Appraisal of Present Day Standards in a Psychiatric Hospital

We report on the current experience of electroconvulsive therapy (ECT) in a modern regional psychiatric hospital in Austria. The article describes ECT in 120 psychiatric inpatients during 1980-1987. All patients were hospitalized, the main indications for ECT being "neuroleptic treatment resistance" and "catatonia/stupor." Between 1980-1987, an average of 0.7% of admissions (0.6-2.75%) were treated with a course of 10 (62%) or 15 ECTs (25%), with 4% of patients requiring 15 ECTs or more. In more than one-half of the patients, bilateral electrode placement was used. All ECT was done under anesthesia and muscular relaxation. We find ECT to be a valuable treatment-technique for a subgroup of psychotic inpatients.     

Electroconvulsive therapy for the elderly: a review

Treatment of psychiatric disorders among the elderly is complicated by such factors as high incidence of medical illness and changes in drug metabolism; electroconvulsive therapy (ECT) is considered a reasonable treatment alternative for the elderly for several psychiatric syndromes. The authors review indications, complications, and precautions related to ECT for older patients. The primary indication is major depression; about 80 percent of elderly patients respond favorably. ECT appears less effective for depression secondary to dementia or somatization disorder. Although ECT is relatively safe for the elderly, up to one-third may experience a complication that interferes with treatment. Careful pre-ECT medical evaluation is essential, with special attention to cardiovascular factors and to concurrent medications.     

Hollywood and ECT

Electroconvulsive therapy (ECT) has featured in Hollywood films for sixty years. Film depictions continue to exert a powerful and predominantly negative effect on public attitudes towards the treatment. From review of the 22 currently available films that directly refer to ECT the main themes identified are described. While initially portrayed as a dramatic but effective psychiatric intervention, ECT on film has come to stand for something quite different, representing the brutal and generally futile attempts of society to control and suppress the individual, gathering along the way a hackneyed cinematic grammar that emphasizes its inhumane and punitive nature. The film representation now has little in common with ECT as currently practised, such that filmmakers portraying ECT appear influenced more by films such as One Flew Over the Cuckoo's Nest than by evidence of the safety and effectiveness of ECT as a psychiatric treatment. Filmgoers with no personal or professional exposure to the treatment may fail to make the distinction between the demands of film narrative and clinical reality.     

Practice parameter for use of electroconvulsive therapy with adolescents

Electroconvulsive therapy (ECT) may be an effective treatment for adolescents with severe mood disorders and other Axis I psychiatric disorders when more conservative treatments have been unsuccessful. ECT may be considered when there is a lack of response to two or more trials of pharmacotherapy or when the severity of symptoms precludes waiting for a response to pharmacological treatment. The literature on ECT in adolescents, including studies and case reports, was reviewed and then integrated into clinically relevant guidelines for practitioners. Mood disorders have a high rate of response to ECT (75%-100%), whereas psychotic disorders have a lower response rate (50%-60%). Consent of the adolescent's legal guardian is mandatory, and the patient's consent or assent should be obtained. State legal guidelines and institutional guidelines must be followed. ECT techniques associated with the fewest adverse effects and greatest efficacy should be used. The presence of comorbid psychiatric disorder is not a contraindication. Systematic pretreatment and posttreatment evaluation, including symptom and cognitive assessment, is recommended.     

Summary of the practice parameter for the use of electroconvulsive therapy with adolescents

Electroconvulsive therapy (ECT) may be an effective treatment for adolescents with severe mood disorders and other Axis I psychiatric disorders when more conservative treatments have been unsuccessful. ECT may be considered when there is a lack of response to two or more trials of pharmacotherapy or when the severity of symptoms precludes waiting for a response to pharmacological treatment. The literature on ECT in adolescents, including studies and case reports, was reviewed and then integrated into clinically relevant guidelines for practitioners. Mood disorders have a high rate of response to ECT (75-100%), whereas psychotic disorders have a lower response rate (50-60%). Consent of the adolescent's legal guardian is mandatory, and the patient's consent or assent should be obtained. State legal guidelines and institutional guidelines must be followed. ECT techniques associated with the fewest adverse effects and greatest efficacy should be used. The presence of comorbid psychiatric disorder is not a contraindication. Systematic pretreatment and posttreatment evaluation, including symptom and cognitive assessment, is recommended.     

Delusional depression as differential dementia of the Alzheimer type diagnosis

For several years, a 68-year-old patient had been treated for a dementia of Alzheimer's type and finally admitted to a closed gerontopsychiatric nursing home. According to information from his relatives, he first developed psychotic symptoms 3 years prior to admission in our psychiatric department. Several months later, he developed a lack of drive, lack of interests, and reduced emotional reaction. After a standard diagnostic work-up (psychiatric, neurological, and general medical examination, CSF examination, laboratory analyses, cranial computerized tomography), we began electroconvulsive therapy (ECT) with a working hypothesis of major depression with psychotic symptoms. The ECT was able to ameliorate rapidly the psychiatric status of the patient. After 10 weeks of inpatient treatment, he could be discharged from the hospital and was able to take up his usual professional activities on a voluntary basis. This article describes the need for an early differential diagnosis of dementias. Standardized and differential diagnoses of dementias are necessary for an antidementive therapy as well as for the detection of potentially curable diseases.