Electroconvulsive therapy

Electroconvulsive therapy (ECT), formerly known as electroshock, is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown. Today, ECT is most often recommended for use as a treatment for severe depression that has not responded to other treatment, and is also used in the treatment of mania and catatonia. It was first introduced in 1938 by Italian neuropsychiatrists Ugo Cerletti and Lucio Bini, and gained widespread use as a form of treatment in the 1940s and 1950s.

Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and positive outcomes. After treatment, drug therapy is usually continued, and some patients receive continuation/maintenance ECT. In the United Kingdom and Ireland, drug therapy is continued during ECT.

Informed consent is a standard of modern electroconvulsive therapy. According to the Surgeon General, involuntary treatment is uncommon in the United States and is typically only used in cases of great extremity, and only when all other treatment options have been exhausted and the use of ECT is believed to be a potentially life saving treatment. However, caution must be exercised in interpreting this assertion as, in an American context, there does not appear to have been any attempt to survey at national level the usage of ECT as either an elective or involuntary procedure in almost twenty years. In one of the few jurisdictions where recent statistics on ECT usage are available, a national audit of ECT by the Scottish ECT Accreditation Network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent.

Despite the fact that the majority of psychiatric clinicians regard ECT as a safe and effective procedure, surveys of public opinion, the testimony of former patients, legal restrictions on its use and disputes as to the efficacy, ethics and adverse effects of ECT within the psychiatric and wider medical community indicate that the use of ECT remains controversial. This is reflected in the recent decision by the FDA's Neurological Devices Advisory Panel to maintain ECT devices in the Class III device category for high risk devices except for patients suffering from catatonia. This will result in the manufacturers of such devices having to do controlled trials on their safety and efficacy for the first time. In justifying their position panelists referred to the memory loss associated with ECT and the lack of long-term data.

History
As early as the 16th century, agents to produce seizures were used to treat psychiatric conditions. In 1785, the therapeutic use of seizure induction was documented in the London Medical Journal. Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures with first camphor and then metrazol (cardiazol). In 1937, the first international meeting on convulsive therapy was held in Switzerland by the Swiss psychiatrist Muller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide. Italian Professor of neuropsychiatry Ugo Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his colleague Lucio Bini developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1937, experimented for the first time on a person. Sherwin B. Nuland, having discussed the matter with a first-hand observer in the 1970s, gave the following description of the results of the first use of ECT on a person:


 * "They thought, 'Well, we'll try 55 volts, two-tenths of a second. That's not going to do anything terrible to him.' So they did that. [...] This fellow — remember, he wasn't even put to sleep — after this major grand mal convulsion, sat right up, looked at these three fellows and said, 'What the f** are you a****s trying to do?' Well, they were happy as could be, because he hadn't said a rational word in the weeks of observation."

ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening and more convenient. Cerletti and Bini were nominated for a Nobel Prize but did not receive one. By 1940, the procedure was introduced to both England and the US. In Germany and Austria it was promoted by Friedrich Meggendorfer. Through the 1940s and 1950s the use of ECT became widespread. ECT is the only form of shock treatment still performed by modern medicine.

In the early 1940s, 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. It took many years for brief-pulse equipment to be widely adopted Unilateral ECT has never been popular with psychiatrists and is still only given to a minority of ECT patients. In the 1940s and early 1950s ECT was usually given in "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones. In the 1940s psychiatrists began to experiment with curare, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction of suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to the more widespread use of "modified" ECT. A short-acting anesthetic was usually given in addition to the muscle relaxant in order to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants.

The steady growth of antidepressant use along with negative depictions of ECT in the mass media led to a marked decline in the use of ECT during the 1950s to the 1970s. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given, and that "these now-antiquated practices contributed to the negative portrayal of ECT in the popular media." The New York Times described the public's negative perception of ECT as being caused mainly by one movie. "For Big Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and, in the public mind, shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".

In 1976, Dr. Blatchley demonstrated the effectiveness of his constant current, brief pulse device ECT. This device eventually largely replaced earlier devices because of the reduction in cognitive side effects, although some ECT clinics in the US still use sine-wave devices. The 1970s saw the publication of the first American Psychiatric Association task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001). The report endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT. Specifically critics pointed to shortcomings such as noted side effects, the procedure being used as a form of abuse, and uneven application of ECT. The use of ECT declined until the 1980s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression". In 1985 the National Institute of Mental Health and National Institutes of Health convened a consensus development conference on ECT and concluded that, whilst ECT was the most controversial treatment in psychiatry and had significant side-effects, it had been shown to be effective for a narrow range of severe psychiatric disorders.

Due to the backlash noted previously, national institutions reviewed past practices and set new standards. In 1978, The American Psychiatric Association released its first task force report in which new standards for consent were introduced and the use of unilateral electrode placement was recommended. The 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task force report in 1990 where specific details on the delivery, education, and training of ECT were documented. Finally in 2001 the American Psychiatric Association released its latest task force report. This report emphasizes the importance of informed consent, and the expanded role that the procedure has in modern medicine.

Mechanism of action
The aim of ECT is to induce a therapeutic clonic seizure (a seizure where the person loses consciousness and has convulsions) lasting for at least 15 seconds. Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive. The main reasons for this are that the human brain can not be studied directly before and after ECT and therefore scientists rely on animal models of depression and ECT, with major limitations. While animal models are acknowledged to model merely aspects of depressive illness, human and animal brains are very similar at a molecular level, enabling detailed study of the molecular mechanisms involved in ECT.

There is a vast literature on the effects of Electroconvulsive Shock (ECS) in animals. In animal models of depression, particularly "Learned helplessness" and "Social defeat", there is evidence of pruning of normally dense synaptic connections in the hippocampus, a richly connected area deep in the temporal lobe which is vital in controlling both mood and memory. ECS has been shown to increase levels of Brain-derived neurotrophic factor (BDNF) and Vascular Endothelial Growth Factor (VEGF) in the rodent hippocampus. This reverses the toxic effects of depression on this area of the brain, increasing both new synapse formation and the formation of new brain cells (hippocampal neurogenesis). Both these effects have been noted to be present in antidepressant-treated animals, however they are neither necessary nor sufficient for antidepressant response. ECT is a more robust inducer of these neuroplastic effects than antidepressants. Electroconvulsive Therapy (ECT) has also been shown to increase serum brain-derived neurotrophic factor (BDNF) in drug resistant depressed patients. This suggests a common molecular mechanism of action, albeit in need of much further study.

Guidelines for treatment
Experts disagree on whether ECT is an appropriate first-line treatment or if it should be reserved for patients who have not responded to other interventions such as medication and psychotherapy.

The American Psychiatric Association (APA) 2001 guidelines give the primary indications for ECT among patients with depression as a lack of response to, or intolerance of, antidepressant medications; a good response to previous ECT; and the need for a rapid and definitive response (e.g. because of psychosis or a risk of suicide). The decision to use ECT depends on several factors, including the severity and chronicity of the depression, the likelihood that alternative treatments would be effective, the patient's preference and capacity to consent, and a weighing of the risks and benefits.

Some guidelines recommend cognitive behavioral therapy or other psychotherapy before ECT is used. However, treatment resistance is widely defined as lack of therapeutic response to two antidepressants at adequate doses for an adequate duration and with good compliance. The APA states that at times patients will prefer to receive ECT over alternative treatments, but commonly the opposite will be the case.

The APA ECT guidelines state that severe major depression with psychotic features, manic delirium, or catatonia are conditions where there is a clear consensus favoring early ECT. The UK's National Institute for Health and Clinical Excellence (NICE) guidelines recommend ECT for patients with severe depression, catatonia, or prolonged or severe mania. It did not recommend the use of ECT as a maintenace therapy in depressive illness as "the long-term benefits and risks ... had not been clearly established". Due to a lack of data, The NICE Guidelines for the Treatment and Management of Adult Depression (2009) issued no updated treatment recommendation for the use of maintenance or relapse prevention ECT. The 2001 APA guidelines support the use of ECT for relapse prevention.

The 2001 APA ECT guidelines 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 2003 NICE ECT guidelines do not recommend ECT for schizophrenia, and this has been supported by meta-analytic evidence showing no or little benefit versus placebo, or in combination with antipsychotic drugs, including Clozapine.

The NICE 2003 guidelines state that doctors should be particularly cautious when considering ECT treatment for women who are pregnant and for older or younger people, because they may be at higher risk of complications with ECT. The 2001 APA ECT guidelines say that ECT may be safer than alternative treatments in the infirm elderly and during pregnancy, and the 2000 APA depression guidelines stated that the literature supports the safety for mother and fetus, as well as the efficacy during pregnancy.

Non-clinical patient characteristics
About 70 percent of ECT patients are women. This is almost entirely due to women being at twice the risk of depression. Older and more affluent patients are also more likely to receive ECT. The use of ECT treatment is "markedly reduced for ethnic minorities."

Duration of effect
ECT on its own does not usually have a sustained benefit. Half those who remit then relapse within six months. This is similar to the rate of relapse after discontinuing antidepressant medication, and is a function of the usual severity and chronicity of pre-existing illness rather than ECT itself. The relapse rate in the first six months is reduced by the use of psychatric medications or further ECT, but remains high.

Probability of remission
The 1999 U.S. Surgeon General's Report on Mental Health summarized psychiatric opinion at the time about the effectiveness of ECT. It stated that both clinical experience and published studies had determined ECT to be effective (with an average 60 to 70 percent remission rate) in the treatment of severe depression, some acute psychotic states, and mania. Its effectiveness had not been demonstrated in dysthymia, substance abuse, anxiety, or personality disorder. The report stated that ECT does not have a long-term protective effect against suicide and should be regarded as a short-term treatment for an acute episode of illness, to be followed by continuation therapy in the form of drug treatment or further ECT at weekly to monthly intervals.

A 2004 large multicentre clinical follow-up study of ECT patients in New York&mdash;describing itself as the first systematic documentation of the effectiveness of ECT in community practice in the 65 years of its use&mdash;found remission rates of only 30 to 47 percent, with 64 percent of those relapsing within six months. However, when patients with co-morbid personality disorders or who were suffering from schizoaffective disorder were removed from the analysis, the remission rates climbed to 60-70%.

Degree of effectiveness
All systematic published reviews of the literature have concluded that ECT is effective in the treatment of depression. In 2003, The UK ECT Review group published a systematic review and meta-analysis comparing ECT to placebo and antidepressant drugs. This meta-analysis demonstrated a large effect size for ECT versus placebo, and versus antidepressant drugs. In 2006, research psychiatrist Colin A. Ross reviewed the placebo-controlled trials one-by-one and found that no single study showed a significant difference between real and placebo ECT at one month post-treatment. Dr. Ross was highly critical of other published reviews, which concluded that ECT is effective, and Ross stated that these reviews often relied primarily on studies that were not placebo-controlled.

In a 2010 review of placebo controlled studies Bentall and Read found ECT to give slightly higher recovery/remission rates to sham-ECT during treatment but equal rates on follow up after treatment. Their conclusions are as follows: "Given the strong evidence of persistent and, for some, permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and the evidence of a slight but significant increased risk of death, the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified."

Related experimental therapeutics
Recent research has investigated whether implantable devices such as DBS (deep brain stimulation) could result in clinical improvements for patients with treatment-resistant depression. However, in North America, DBS has not been authorized as an approved, effective therapy for treatment-resistant depression.

Adverse effects
Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia; the United States' Surgeon General's report says that there are "no absolute health contraindications" to its use. Immediately following treatment the most common adverse effects are confusion and memory loss. The state of confusion usually disappears after a few hours. It can be tolerated by pregnant women who are not suffering major complications. It can be used with diabetic or obese patients, and with caution in those whose cancers are in remission or under control. It can be used in some immunocompromised patients. It must be used very cautiously in people with epilepsy or other neurological disorders because by its nature it provokes small tonic-clonic seizures, and so would likely not be given to a person whose epilepsy is not well-controlled. Some patients experience muscle soreness after ECT. This is due to the muscle relaxants given during the procedure and rarely due to muscle activity. The death rate due to ECT is around 4 per 100,000 procedures.

Effects on memory
It is the purported effects of ECT on long-term memory that give rise to much of the concern surrounding its use. The acute effects of ECT can include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment). However, the vast majority of these effects are short lived. Memory loss and confusion are more pronounced with bilateral electrode placement rather than unilateral, and with outdated sine-wave rather than brief-pulse currents. The vast majority of modern treatment uses brief pulse currents. Research by Harold Sackeim has shown that excessive current causes more risk for memory loss, and using right-sided electrode placement may reduce verbal memory disturbance.

Retrograde amnesia is most marked for events occurring in the weeks or months before treatment, with one study showing that although some people lose memories from years prior to treatment, recovery of such memories was "virtually complete" by seven months post-treatment, with the only enduring loss being memories in the weeks and months prior to the treatment. Anterograde memory loss is usually limited to the time of treatment itself or shortly afterwards. In the weeks and months following ECT these memory problems gradually improve, but some people have persistent losses, especially with bilateral ECT. One published review summarizing the results of questionnaires about subjective memory loss found that between 29% and 55% of respondents believed they experienced long-lasting or permanent memory changes. In 2000, American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with more persistently impaired memory of public events as compared to RUL ECT.

Some studies have found that patients are often unaware of cognitive deficits induced by ECT. For example, in June 2008, a Duke University study was published assessing the neuropsychological effects and attitudes in patients after ECT. Forty-six patients participated in the study, which involved neuropsychological and psychological testing before and after ECT. The study documented substantial cognitive impairment after ECT on a variety of memory tests, including "verbal memory for word lists and prose passages and visual memory of geometric designs." The study further found that a significant number of patients believed that their memory had improved after ECT despite the fact that neuropsychological testing clearly showed the opposite. As stated by the researchers, "Indeed, there was a slight trend towards [patients reporting] improved memory functioning, despite the objective neuropsychological data indicating significantly lower recognition and delayed recall." Based on their findings, the authors issued the following recommendation:

""When ECT is provided to adolescents, the potential impact of such cognitive changes should be discussed with the patients and their parents or guardians in terms of implications for not only the patient’s emotional functioning but cognitive functioning as well, particularly upon his or her academic performance. In summary, we argue that an individual cost-benefit analysis should be made in light of the implications of the potential benefits versus costs of ECT upon improving emotional functioning and the impact that potential memory changes may have on real-world functioning and quality of life.""

Severe memory loss from ECT is described in an autobiographical book, Doctors of Deception: What They Don't Want You to Know about Shock Treatment.

Controversy over long-term effects on general cognition
According to prominent ECT researcher Harold Sackeim, "despite over fifty years of clinical use and ongoing controversy", until 2007 there had "never been a large-scale, prospective study of the cognitive effects of ECT." In this first-ever large-scale study (347 subjects), Sackeim and colleagues found that at least some forms (namely bilateral application and outdated sine-wave currents) of ECT "routine[ly]" lead to "adverse cognitive effects," including global cognitive deficits and memory loss, that persist for up to six months after treatment, suggesting that the induced deficits may be permanent. The authors also warned that their findings did not suggest that right-unilateral ECT did not also lead to chronic cognitive deficits. However, the several limitations of this study include the lack of a depressed control group with which to compare memory decay over 6 months. The measure of autobiographical memory used, the Columbia Autobiographical Short-Form (AMI-SF) is not capable of showing memory improvement, with scores at followup expressed as percentages of baseline.

Harold Sackeim can be seen in a videotaped deposition briefly discussing the findings of this study and why, in his opinion, earlier studies had failed to find evidence of long-term harm from ECT. Despite over fifty years of clinical use, Sackeim states that prior to 2001, "the field itself never really had an opportunity to have a discussion about patients who have complaints about long-term memory loss." In this video clip, Sackeim also reveals that at a California ECT conference with 200 practitioners present, when polled as to whether they think ECT can lead to chronic cognitive deficits, two-thirds raised their hands. Sackeim says this was "almost a watershed moment for the field", and was the "first time publicly that the field itself said 'no' to the position that it can't happen."

In July 2007, a second study was published concluding that ECT routinely leads to chronic, substantial cognitive deficits, and the findings were not limited to any particular forms of ECT. The study, led by psychiatrist Glenda MacQueen and colleagues, found that patients treated with ECT for bipolar disorder show marked deficits across multiple cognitive domains. According to the researchers, "Subjects who had received remote ECT had further impairment on a variety of learning and memory tests when compared with patients with no past ECT. This degree of impairment could not be accounted for by illness state at the time of assessment or by differential past illness burden between patient groups." Despite the findings of chronic, global cognitive deficits in post-ECT patients, MacQueen and colleagues suggest that it is "unlikely that such findings, even if confirmed, would significantly change the risk–benefit ratio of this notably effective treatment."

Six months after the publication of the Sackeim study documenting routine, long-term memory loss after ECT, prominent ECT researcher Max Fink published a review in the journal Psychosomatics concluding that patient complaints of memory loss after ECT are "rare" and should be "characterized as somatoform disorders, rather than as evidence of brain damage, thus warranting psychological treatment for such disorders." Based on his findings, Fink suggests that, "Instead of endorsing these reports as the direct consequence of ECT, especially in patients who have recovered from their depressive illness, lost their suicidal drive, and have improved social functioning, is it not more useful to accept the complaint as a somatoform disorder, explore the basis in the individual’s history and experience, and offer appropriate supportive treatment?"

Most recent reviews of the literature and other articles continue to characterize ECT as safe and effective. For example, in June 2009, Portuguese researchers published a review on the safety and efficacy of ECT in an article entitled, Electroconvulsive Therapy: Myths and Evidences. In their review, the researchers conclude that ECT is an "efficient, safe and even life saving treatment for several psychiatric disorders." In 2008, Yale researchers published a review on the safety and efficacy of ECT in elderly patients. According to the authors, "ECT is well established as a safe and effective treatment for several psychiatric disorders." And in a June 2009 article published in the Journal of ECT, Iranian researchers observe that, "Despite the wide consensus over the safety and efficacy of electroconvulsive therapy (ECT), it still faces negative publicity and unfavorable attitudes of patients and families."

Psychiatrist Peter Breggin, chief editor of the journal Ethical Human Psychology and Psychiatry, is a leading critic of ECT who believes the procedure is neither safe nor effective. In a published article reviewing the findings of Harold Sackeim's 2007 study on the cognitive effects of ECT, Breggin accuses Max Fink and other pro-ECT researchers of having a history of "systematically covering up damage done to millions of [ECT] patients throughout the world." He disagrees with the position that findings of chronic, global cognitive deficits should have no bearing on the risk-benefit ratio of ECT, and he believes it's important to address the "actual impact of these losses on the lives of individual patients." In a section of his paper entitled Destroying Lives, Dr. Breggin writes, "Even when these injured 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 humiliating and depressing but also disabling. Even when relatively subtle, these activities can disrupt routine activities of living."

A study published in 2004 in the Journal of Mental Health reported that 35 to 42% of patients responding to a questionnaire reported ECT resulted in loss of intelligence. The study also reported, "There is no overlap between clinical and consumer studies on the question of benefit."

Doctors of Deception: What They Don't Want You to Know About Shock Treatment reports before-and-after IQ testing of persons receiving ECT, including the author, that show 30 to 40 point losses.

A recent opinion article by a neuropsychologist and a psychiatrist in Dublin suggests that ECT patients who experience cognitive problems following ECT should be offered some form of cognitive rehabilitation. The authors say that the failure to attempt to rehabilitate patients may be partly responsible for the negative public image of ECT. The article speculates on what aspects of such rehabilitation might be useful, without reviewing the literature on its presence or absence.

Effects on brain structure
Considerable controversy exists over the effects of ECT on brain tissue although a number of mental health associations, including the American Psychiatric Association, have concluded that there is no evidence that ECT causes structural brain damage. A 1999 report by the United States Surgeon General states, "The fears that ECT causes gross structural brain pathology have not been supported by decades of methodologically sound research in both humans and animals". However, the word "gross" is a synonym for major, leaving the possibility open for real brain damage which the US Surgeon General considers minor. However, not all experts agree that ECT does not cause brain damage, and two studies have been published since 2007 finding that at least some forms of ECT may result in widespread, persisting, generalized cognitive dysfunction, which might support claims that ECT causes brain damage.

A leading critic of ECT, psychiatrist Peter Breggin has published books and journalistic reviews of the literature purporting to show that ECT routinely causes brain damage as evidenced by a considerable list of studies in humans and animals. In particular, Dr. Breggin asserts that animal and human autopsy studies have shown that ECT routinely causes ‘widespread pinpoint hemorrhages and scattered cell death.’ According to Dr. Breggin, the 1990 APA task force report on ECT ignored much of the scientific literature pointing out the negative effects of electroshock therapy. For example, in 1952 Hans Hartelius conducted and published an animal study on cats entitled Cerebral Changes Following Electrically Induced Convulsions in which a double-blind microscopic pathology examination showed that it was possible to distinguish the 8 shocked animals from the 8 non-shocked animals with remarkable accuracy based on statistically significant structural changes to the brain, including vessel wall changes, gliosis, and nerve cell changes. Based on the detection of shadow cells and neuronophagia, Hartelius determined that there was irreversible damage to neurons associated with electroshock.

Proponents argue that the addition of hyperoxygenation and refinement in technique in the last thirty years has made ECT safe, and a majority of published reviews in recent decades have reflected this position. In a 2004 study designed to evaluate whether modern ECT techniques lead to identifiable brain damage, twelve monkeys underwent daily electroshock for six weeks under conditions meant to simulate human ECT; the animals were then sacrificed and their brains were compared to monkeys undergoing anesthesia alone. According to the researchers, "None of the ECT-treated monkeys showed pathological findings."

There are recent animal studies that have documented significant brain damage after an electroshock series. For example, in 2005, Russian researchers published a study entitled, Electroconvulsive Shock Induces Neuron Death in the Mouse Hippocampus: Correlation of Neurodegeneration with Convulsive Activity. In this study, the researchers found that after an electroshock series, there was a significant loss of neurons in parts of the brain and particularly in defined parts of the hippocampus where up to 10% of neurons were killed. The researchers conclude that "the main cause of neuron death is convulsions evoked by electric shocks." In 2008, Portuguese researchers conducted a rat study aimed at answering the question of whether an electroshock series causes structural changes in vulnerable parts of the brain. According to the authors, "This study answers positively the question of whether repeated administration of ECS seizures can cause brain lesions. Our data are consistent with findings from other animal models and from human studies in showing that neurons located in the entorhinal cortex and in the hilus of the dentate gyrus are particularly vulnerable to repeated seizures." However, they question the applicability of their own research with respect to Electroconvulsive therapy in humans: "An important caveat of our results is that it is unclear to what extent they are relevant to the use of electroconvulsive therapy in psychiatry, because the protocol employed in this study is different from that used clinically. Evidence from previous studies (Gombos et al., [1999]; Vaidya et al., [1999]) and from our pilot experiments indicates that treating rats either with five to ten widely spaced ECS (at 24- or 48-hr schedules) or with two stimulations only 2 hr apart does not lead to loss of hippocampal neurons".

Many expert proponents of ECT maintain that the procedure is safe and does not cause brain damage. Dr. Charles Kellner, a prominent ECT researcher and former chief editor of the Journal of ECT states in a recent published interview that, "There are a number of well-designed studies that show ECT does not cause brain damage and numerous reports of patients who have received a large number of treatments over their lifetime and have suffered no significant problems due to ECT." Dr. Kellner cites specifically to a study purporting to show an absence of cognitive impairment in eight subjects after more than 100 lifetime ECT treatments. One of the authors of the cited study, Harold Sackeim, published a large-scale study less than a month after this interview concluding that the type of ECT used in the eight patients receiving the 100 lifetime treatments, bilateral sine wave, routinely leads to persistent, global cognitive deficits (discussed supra). Dr. Kellner states that, "Rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness."

Effects in pregnancy
If steps are taken to decrease potential risks, ECT is generally accepted to be relatively safe during all trimesters of pregnancy, particularly when compared to pharmacological treatments. Suggested preparation for ECT during pregnancy includes a pelvic examination, discontinuation of nonessential anticholinergic medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate antacid. During ECT, elevation of the pregnant woman's right hip, external fetal cardiac monitoring, intubation, and avoidance of excessive hyperventilation are recommended. Much of the medical literature in this area is composed of case studies of single or twin pregnancies, and although some have reported serious complications, the majority have found ECT to be safe. ECT is not performed on the fetus.

Administration
Informed consent is sought before treatment. Patients are informed about the risks and benefits of the procedure. Patients are also made aware of risks and benefits of other treatments and of not having the procedure done at all. Depending on the jurisdiction the need for further inputs from other medical professionals or legal professionals may be required. ECT is usually given on an in-patient basis. Prior to treatment a patient is given a short-acting anesthetic such as methohexital, etomidate, or thiopental, a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation.

Both electrodes can be placed one on the same side of the patient's head. This is known as unilateral ECT. Unilateral ECT is used first to minimize side effects (memory loss). When electrodes are placed on both sides of the head, this is known as bilateral ECT. In bifrontal ECT, an uncommon variation, the electrode position is somewhere between bilateral and unilateral. Unilateral is thought to cause fewer cognitive effects than bilateral but is considered less effective. In the USA most patients receive bilateral ECT. In the UK almost all patients receive bilateral ECT.

The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT. Below these levels treatment may not be effective in spite of a seizure, while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe cognitive impairment without additional therapeutic gains. Seizure threshold is determined by trial and error ("dose titration"). Some psychiatrists use dose titration, some still use "fixed dose" (that is, all patients are given the same dose) and others compromise by roughly estimating a patient's threshold according to age and sex. Older men tend to have higher thresholds than younger women, but it is not a hard and fast rule, and other factors, for example drugs, affect seizure threshold.

ECT machines
Most modern ECT machines deliver a brief-pulse current, which is thought to cause fewer cognitive effects than the sine-wave currents which were originally used in ECT. A small minority of psychiatrists in the USA still use sine-wave stimuli. Sine-wave is no longer used in the UK or Ireland. Typically, the electrical stimulus used in ECT is about 800 milliamps and has up to several hundred watts, and the current flows for between one and 6 seconds. In the USA, ECT machines are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and Mecta. The Food and Drug Administration has classified the devices used to administer ECT as Class III medical devices. Class III is the highest-risk class of medical devices. In the UK, the market for ECT machines was long monopolized by Ectron Ltd, although in recent years some hospitals have started using American machines. Ectron Ltd was set up by psychiatrist Robert Russell, who together with a colleague from the Three Counties Asylum, Bedfordshire, invented the Page–Russell technique of intensive ECT.

Variations in international practice
There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists. International 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 Slovenia. Guidelines on the use of ECT are stringent in the USA and the UK. Modern standards are not always followed throughout the world and not all countries that use ECT have written technical standards. The use of both anesthesia and muscle relaxants is universally recommended in the administration of ECT. If anesthesia and muscle relaxants are not used the procedure is called unmodified ECT. In a minority of countries such as Japan, India, and Nigeria, ECT may be used without anesthesia. WHO has called for a worldwide ban on unmodified ECT and the topic is currently being debated in countries like India. The practice has been recently abolished in Turkey's largest psychiatric hospital. A major difficulty for developing countries in eliminating unmodified ECT is a lack of trained anesthesiologists available to administer the procedure. A small minority of countries never seek consent before administering ECT. This significantly uneven application of ECT around the world continues to make ECT a controversial procedure.

Sarah Hall reports, "ECT has been dogged 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. It is controversial in some European countries such as the Netherlands and Italy, where its use is severely restricted".

United States
In the United States, a survey of psychiatric practice in the late 1980s found that an estimated 100,000 people received ECT annually, with wide variation between metropolitan statistical areas. Accurate statistics about the frequency, context and circumstances of ECT in the United States are difficult to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information. One state which does report such data is Texas, where in the mid-1990s ECT was used in about one third of psychiatric facilities and given to about 1,650 people annually. Usage of ECT has since declined slightly; in 2000–01 ECT was given to about 1,500 people aged from 16 to 97 (in Texas it is illegal to give ECT to anyone under sixteen). ECT is more commonly used in private psychiatric hospitals than in public hospitals, and minority patients are underrepresented in the ECT statistics. In the United States, ECT is usually given three times a week; in the UK, it is usually given twice a week. Occasionally it is given on a daily basis. A course usually consists of 6–12 treatments, but may be more or fewer. Following a course of ECT some patients may be given continuation or maintenance ECT with further treatments at weekly, fortnightly or monthly intervals. A few psychiatrists in the USA use multiple-monitored ECT (MMECT) where patients receive more than one treatment per anesthetic. Electroconvulsive therapy is not a required subject in US medical schools and not a required skill in psychiatric residency training. Privileging for ECT practice at institutions is a local option, no national certification standards are established, and no ECT-specific continuing training experiences are required of ECT practitioners.

United Kingdom
In the United Kingdom in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then to about 12,000 per annum. It is still used in nearly all psychiatric hospitals, with a survey of ECT use from 2002 finding that 71 percent of patients were women and 46 percent were over 65 years of age. Eighty-one percent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. Sixteen percent were treated without their consent. In 2003, the National Institute for Clinical Excellence, a government body which was set up to standardize treatment throughout the National Health Service in England and Wales, issued guidance on the use of ECT. Its use was recommended "only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode". The guidance received a mixed reception. It was welcomed by an editorial in the British Medical Journal but the Royal College of Psychiatrists launched an unsuccessful appeal. The NICE guidance, as the British Medical Journal editorial points out, is only a policy statement and psychiatrists may deviate from it if they see fit. Adherence to standards has not been universal in the past. A survey of ECT use in 1980 found that more than half of ECT clinics failed to meet minimum standards set by the Royal College of Psychiatrists, with a later survey in 1998 finding that minimum standards were largely adhered to, but that two-thirds of clinics still fell short of current guidelines, particularly in the training and supervision of junior doctors involved in the procedure. A voluntary accreditation scheme, ECTAS, was set up in 2004 by the Royal College, but as of 2006 only a minority of ECT clinics in England, Wales, Northern Ireland and the Republic of Ireland have signed up.

India
The Union Health Ministry of India has decided in the Mental Health Care Bill of 2010 that they will no longer use direct ECT. The Health Ministry recommended a ban on the whole procedure.

Informed consent
It is widely acknowledged internationally that obtaining the written, informed consent of the patient is important before ECT is administered. The World Health Organization, in its 2005 publication "Human Rights and Legislation WHO Resource Book on Mental Health," specifically states, "ECT should be administered only after obtaining informed consent."

In the US, this doctrine places a legal obligation 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 receiving no treatment. The patient is then given the opportunity to accept or reject the treatment. The form states how many treatments are recommended and also makes the patient aware that the treatment may be revoked at anytime during a course of ECT. The Surgeon General's Report on Mental Health states that patients should be warned that the benefits of ECT are short-lived without active continuation treatment in the form of drugs 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 during a course of ECT.

To demonstrate what he believes should be required to fully satisfy the legal obligation for informed consent, one psychiatrist, working for an anti-psychiatry organisation, has formulated his own consent form using the consent form developed and enacted by the Texas Legislature as a model.

In the UK, in order for consent to be valid it requires an explanation in "broad terms" of the nature of the procedure and its likely effects. One review from 2005 found that only about half of patients felt they were given sufficient information about ECT and its adverse effects and another survey found that about fifty percent of psychiatrists and nurses agreed with them.

A 2005 study published in the British Journal of Psychiatry described patients' perspectives on the adequacy of informed consent before ECT. The study found that, "About half (45–55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not." The authors also stated:

""Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form. The proportion who feel they did not freely choose the treatment has actually increased over time. The same themes arise whether the patient had received treatment a year ago or 30 years ago. Neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ECT, at least in England and Wales.""

Involuntary ECT
Procedures for involuntary ECT vary from country to country depending on local mental health laws. Legal proceedings are required in some countries, while in others ECT is seen as another form of treatment that may be given involuntarily as long as legal conditions are observed. Involuntary electroshock contravenes the principle of autonomy in medical ethics. The maxim of autonomy is "Voluntas aegroti suprema lex." This rule states that the will of the patient is supreme. It implies that a patient has the right to consent to, or to refuse a medical treatment, such as ECT. Persons considered not to be of sound mind are in many jurisdictions considered incapable of giving true consent. In such a case, the patient's "assent" may be sought; opinions are divided as to whether this should be routinely done, or whether a patient who is not competent to consent to therapy should retain the right to refuse it.

Citizens in western societies often undergo emergency medical procedures when they have lost the capacity to consent (such as neurosurgery after head injury). Under these circumstances, the principles of benificence and non-maleficence must be adhered to.

United States
In most states in the USA, a judicial order following a formal hearing is needed before a patient can be forced to undergo involuntary ECT. Patients may be represented by legal counsel at the hearing. According to the Surgeon General's Report on Mental Health, "As a rule, the law requires that such petitions are granted only where the prompt institution of ECT is regarded as potentially lifesaving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia." However, there are legal loopholes that thwart strict adherence to this principle. For example, an American citizen was being forced to undergo ECT against his will in 2009, even though his life was not in danger. In this March 17, 2009 video, the man, his mother, and advocates, speak out against his forced ECT. The description of the video states that "Though Sandford, 54, is not charged with any crime, he has received over 40 such rounds of shocks on an outpatient basis so far – even after his original mental problems have long since subsided and he has repeatedly asked for the shocks to stop. Over the objections of Sandford, his mother and friends, his legal conservator at Lutheran Social Service of MN (LSSMN) has gone to court and succeeded in mandating a continuation of the procedure." Twin Cities Indymedia asserts "Like all other USA states, Minnesota has [legal] loopholes allowing [its] citizens to receive electroshock over their expressed wishes."

Great Britain
Until 2009 in England and Wales, the Mental Health Act 1983 allowed the use of ECT on detained patients whether or not they had capacity to consent to it, so long as the treatment was likely to alleviate or prevent deterioration in a condition and was authorized by a psychiatrist from the Mental Health Act Commission's panel. However, following amendments which took effect in 2009, ECT may not be given to a patient who has capacity to refuse to consent to it, irrespective of his or her detention under the Act, although treatment may still be given to capacious patients in an emergency under Section 62 of the Act. If the treating psychiatrist thinks the need for treatment is urgent they may start a course of ECT before authorization. About 2,000 people a year in England and Wales are treated without their consent under the Mental Health Act. In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 also gives patients with capacity the right to refuse ECT.

Patient experience
The APA ECT taskforce guidelines report findings that most patients find ECT no worse than going 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 again if needed.

NICE ECT guidelines report that some individuals consider ECT to have been a beneficial and lifesaving treatment, while others reported feelings 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
Kitty Dukakis, wife of politician Michael Dukakis, reports in a Newsweek article mostly positive effects from electroconvulsive therapy, and regards memory loss as an acceptable price to pay for relief from depression.

"For me, the memory issues are real but manageable. Things I lose generally come back. Other memories I prefer to lose, including those about the depression I was suffering. But there are some memories—of meetings I have attended, people's homes I have visited—that I don't want to lose but I can't help it. They generally involve things I did two weeks before and two weeks after ECT. Often they are just wiped out....I have learned ways to partly compensate for whatever loss I still experience. I call my sister Jinny, Michael and my kids, asking what my niece Betsy's phone number is, what we did yesterday and what we are planning to do tomorrow. I apologize prior to asking. I wonder when they are going to run out of patience with "Kitty being Kitty." I hate losing memories, which means losing control over my past and my mind, but the control ECT gives me over my disabling depression is worth this relatively minor cost. It just is."

American psychotherapist Martha Manning's autobiographical Undercurrents acknowledges the downside of treatment: "I felt like I'd been hit by a truck for a while, but that was, comparatively speaking, not so bad," as well as the upside: "Afterwards, I thought, do regular people feel this way all the time? It's like you've not been in on a great joke for the whole of your life."

In his autobiographical book Electroboy, American writer Andy Behrman describes undergoing ECT as a treatment for bipolar disorder while under house-arrest: "I wake up thirty minutes later and think I am in a hotel in Acapulco. My head feels as if I have just downed a frozen margarita too quickly. My jaws and limbs ache. But I am elated."

Curtis Hartmann, a lawyer in western Massachusetts, stated: "ECT, a treatment of last resort for severe, debilitating depression, is all that has ever worked for me. I awaken about 20 minutes later, and although I am still groggy with anesthesia, much of the hellish depression is gone. It is a disease that for me, literally steals me from myself—a disease that executes me and then forces me to stand and look down at my corpse. Thankfully, ECT has kept my monster at bay, my hope intact".

Beverley Callard is a British actress, best known for her role as Liz McDonald in Coronation Street. In her recently published autobiography titled "Unbroken", she describes her experience with ECT for severe depression, stating that the treatment was responsible, in part for her recovery.

Depictions of severe long-term, permanent memory loss
Ernest Hemingway, American author, committed suicide shortly after ECT at the Mayo Clinic in 1961. He is reported to have said to his biographer, "Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient...."

In a poem, The Hanging Man, by Sylvia Plath ECT is described:

By the roots of my hair some god got hold of me.

I sizzled in his blue volts like a desert prophet.

The nights snapped out of sight like a lizard's eyelid:

A world of bald white days in a shadeless socket.

A vulturous boredom pinned me in this tree.

If he were I, he would do what I did.

In a letter to the editor published in the Washington Post in December, 2000, registered nurse Barbara C. Cody wrote that her life was forever changed by 13 outpatient ECTs she received in 1983. She wrote, "'Shock 'therapy' totally and permanently disabled me. EEGs [electroencephalograms] verify the extensive damage shock did to my brain. Fifteen to 20 years of my life were simply erased; only small bits and pieces have returned. I was also left with short-term memory impairment and serious cognitive deficits. ... Shock 'therapy' took my past, my college education, my musical abilities, even the knowledge that my children were, in fact, my children. I call ECT a rape of the soul.'" Similarly, writer Johnanton Cott claims to have completely lost 15 years of memory in On the Sea of Memory: A Journey from Forgetting to Remembering.

Despite former patients having reported devastating, permanent amnesia and cognitive impairment since ECT was first invented, the first lawsuit for ECT amnesia, Marilyn Rice v. John Nardini, was not brought until 1975; dozens of suits followed. While there have been a few settlements, including one for half a million dollars, no former patient had won a case until 2005. In a 2005 South Carolina court proceeding, Peggy S. Salters became the first ECT survivor to win a jury verdict and compensation. Ms. Salters sued Palmetto Baptist Medical Center in Columbia, as well as the three doctors responsible for her care, for an intensive course of outpatient ECT that she received in 2000, at age 55 years old, that caused her to lose all memories of the past 30 years of her life, including all memories of her husband of three decades, then deceased, and the births of her three children. She held a Masters of Science in nursing and, prior to the ECT, had a long career as a psychiatric nurse; but, as a result of the ECT, lost her knowledge of nursing skills and was unable to return to work. The jury awarded Salters $635,177 in compensation for her inability to work. The judgement was upheld upon appeal in an unpublished opinion.

Accounts of severe cognitive diminishment
Liz Spikol, the senior contributing editor of Philadelphia Weekly, wrote of her ECT in 1996, "'Not only was the ECT ineffective, it was incredibly damaging to my cognitive functioning and memory. But sometimes it's hard to be sure of yourself when everyone 'credible' — scientists, ECT docs, researchers — are telling you that your reality isn't real. How many times have I been told my memory loss wasn't due to ECT but to depression? How many times have I been told that, like a lot of other consumers, I must be perceiving this incorrectly? How many times have people told me that my feelings of trauma related to the ECT are misplaced and unusual? It's as if I was raped and people kept telling me not to be upset—that it wasn't that bad.'"

Involuntary or other problems in administrating ECT
In 2007, a judge canceled a two-year-old court order that allowed the involuntary electroshock of Simone D., a psychiatric patient at Creedmoor Psychiatric Center in the state of New York. Although Simone spoke only Spanish, she rarely received access to staff fluent in her language. Simone previously had 200 electroshocks. However, she communicated that she did not want more electroshock. Simone stated, "Electroshock causes more pain. I suffer more from shock treatment! "

In 2008, David Tarloff, a psychiatric patient who had received electroshock, assaulted two therapists in the city of New York. Tarloff injured one therapist and killed the other. One of the therapists was Kent Shinbach, a psychiatrist who had an interest in electroconvulsive therapy. "It is not clear whether Dr. Shinbach played any role in Mr. Tarloff's shock therapy". However, Tarloff told investigators that Shinbach had given Tarloff psychiatric treatment at a psychiatric facility initially in 1991.

Other descriptions
In an interview with Houston Chronicle in 1996, Melissa Holliday, a former extra on Baywatch and model for Playboy stated the ECT she received in 1995, "ruined her life." She went on to state, "I've been through a rape, and electroshock therapy is worse. If you haven't gone through it, I can't explain it."

Public perception and mass media
A questionnaire survey of 379 members of the general public in Australia indicated that more than 60% of respondents had some knowledge about the main aspects of ECT. Participants were generally opposed to the use of ECT on depressed individuals with psychosocial issues, on children, and on involuntary patients. Public perceptions of ECT were found to be mainly negative.

Fictional examples
Electroconvulsive therapy has been depicted in fiction and works based on true experiences. These include The Snake Pit, Quantum Leap (TV series), Frances, Requiem for a Dream, the novel One Flew Over the Cuckoo's Nest by Ken Kesey as well as the movie adaptation, Melrose Place, A Beautiful Mind, The Caretaker, The Best of Youth, House; The Bell Jar by Sylvia Plath, Shine, the film version of Girl, Interrupted, Insanitarium, Changeling, Ciao! Manhattan, Next to Normal, Return to Oz, Private Practice, Ghost Whisperer, From Beyond, the novel Zen and the Art of Motorcycle Maintenance, Helen, Oz, Royal Pains, and "The Wolfman (2010 film)."