What is shock therapy?

Indications and Procedures

Shock therapy, also known as shock treatment, is an intervention that has been used for many years to treat severe psychiatric conditions, such as life-threatening depression and psychotic disorders. Many methods of shock treatment exist, ranging from chemically induced shock (via substances such as insulin) to electrically induced shock (from an electrical current). What all the methods share is the purpose of inducing a temporary loss of consciousness, convulsions, and/or seizure in an effort to disrupt brain activity and reset it to a healthier state.

Insulin shock therapy was developed in 1933 by Manfred Sakel. He found that intramuscular administrations of insulin were able to induce a coma that appeared effective for treating severe cases of schizophrenia. By and large, this approach was replaced with other methods of shock therapy, predominantly electroconvulsive therapy (ECT); however, it is still used today when other methods of shock therapy or intervention are judged to be less appropriate. Modern-day procedures are superior to what was originally done. The impact of the shock on the body is better controlled, and the shock treatment itself is more refined in its application.

Historically shock therapy is equated with ECT. Formerly called electroshock therapy, it is a very powerful treatment for psychiatric conditions such as mood disorders and psychotic disorders. It is based on the idea that electrically induced convulsions change the chemistry of the brain in a way that relieves the symptoms of severe mental illness, in which depression, mania, or both become debilitating.

In most situations, electroconvulsive therapy involves the participation of the psychiatrist providing the treatment and an anesthesiologist, who anesthetizes the patient for the procedure. The patient is instructed to take nothing by mouth for eight hours prior to the treatment, so that the stomach is empty for the induction of general anesthesia. The danger of having food or liquid in the stomach is that it might be aspirated into the lungs, where it could cause pneumonia, respiratory obstruction, or death. An intravenous needle is placed in an arm vein. The patient is then connected to a number of monitors, including a blood pressure cuff, electrocardiogram, and pulse oximeter (to measure the level of tissue oxygenation). The patient is then anesthetized with a short-acting intravenous drug (usually methohexital, also known as Brevital). This is followed by the administration of a short-acting muscle relaxant (usually succinylcholine). Ventilation is controlled by mask, using 100 percent oxygen. As soon as it is
determined that the muscles are paralyzed, a mild electrical current is administered to the patient’s brain. The duration of the stimulus is two seconds or less. There is a brief contraction of the muscles of the face, followed by a generalized seizure, which is monitored on the electroencephalogram. Small amounts of physical movement may be seen in the face, feet, or hands. These movements are not nearly as severe as those that occurred before the advent of muscle relaxants. The anesthesiologist continues to ventilate the patient until the effects of the muscle relaxant have worn off and spontaneous respiration is reestablished (three to five minutes). There is a period of confusion and disorientation that rapidly follows the treatment; it clears quickly. With each successive treatment, the patient is left with an ongoing loss of memory which will gradually clear after the course of therapy is finished. The average patient requires between six and twelve treatments. They are administered two or three times per week.

The decision to conduct electroconvulsive therapy usually comes after there has been failure in other forms of treatment, including medication and psychotherapy. Since there are so many medications and combinations of medication that can be used, however, ECT arguably cannot be thought of as a treatment of last resort, as it was in earlier decades. The idea of administering ECT generally arises when it is critical that the patient improve as rapidly as possible. This consideration is often punctuated by frustration on the part of the patient, the family, and/or the psychiatrist with the slowness of response to current therapeutic modalities. In the 1980’s, ECT began to be considered earlier rather than later in the course of treatment. It is realistic to say that if one or two medications are not successful, it is unlikely that others will be successful. Yet there are always those cases in which a sudden and complete remission in mood and psychotic disorders occurs without the use of ECT.

Mood and psychotic disorders tend to recur. When treating a patient for the first time, the doctor cannot know whether the effect of ECT will last for a week, months, or years. Some people need only one course of ECT in a lifetime; others will respond well and remain symptom-free for many years, requiring further ECT when symptoms recur. For many patients who develop devastating symptoms with their illnesses, the early initiation of a course of ECT is warranted. Those who have responded well to ECT in the past will forgo medication trials in favor of starting ECT as soon as the symptoms reappear. For those patients who respond well to ECT but who have recurrences within weeks or months, maintenance ECT may be a reasonable option. With this regimen, a single treatment is given every four to twelve weeks in order to prevent a recurrence of psychiatric distress. The actual frequency of treatment is based on each patient’s particular clinical course and history. For many patients, maintenance ECT has been a way of preventing multiple and frequent hospitalizations. Very little cognitive impairment is associated with low-frequency maintenance ECT, and patients go on to live very productive lives while being maintained in this way.

The following case is an example of the uses of electroconvulsive therapy in clinical practice: A seventy-five-year-old white, widowed female was referred by her psychiatrist for evaluation for electroconvulsive therapy. She had been well until two years prior to this evaluation. At that time, a month following the death of her husband, she began to experience a variety of symptoms, including loss of appetite with a ten-pound weight loss, decreased interest in her friends and the ordinary activities of life which she had found enjoyable, and sleep disturbance characterized by difficulty falling asleep and early morning awakening. The sleep difficulty was responsive to the use of triazolam, a sleep-inducing drug. Additionally, she began to experience episodes of dizziness that were made worse by antidepressant medications. She was not actively suicidal, but she did experience a wish to die and join her husband, whom she believed was waiting for her. She had been treated with tricyclic antidepressants (nortriptyline and desipramine) with lithium augmentation, but the side effects of constipation and dizziness made these medications intolerable. Her depression did not improve, and she began to exhibit medical signs of dehydration and malnutrition. The treating psychiatrist believed that electroconvulsive therapy was indicated and that it should be instituted as rapidly as possible as a lifesaving measure.

The patient was given a course of seven unilateral ECT treatments over the period of a month. She responded to the treatments with an elevation in her mood, an improvement in sleep and appetite, and increasing engagement with hospital staff and family. When she was discharged from the hospital, she showed evidence of mild memory impairment. In the weeks following her treatment, her memory improved, and she became brighter and resumed her normal activities with vigor. She was started on a small dose of fluoxetine (Prozac), an antidepressant known to have a milder side effect profile than the medications she had taken previously. After one year of follow-up, she was still doing well.

Electroconvulsive therapy continues to be widely practiced in the United States and abroad. There is consensus within the field of psychiatry that it is a valuable tool in the psychiatric armamentarium. Patients, patient advocates, and clinicians alike, however, continue to be concerned about its ethical and appropriate use. Practitioners support efforts of the lay community to ensure the proper and ethical use of ECT as long as it does not obstruct access to the treatment for those who require it.

Uses and Complications

Electroconvulsive therapy is used for a variety of psychiatric conditions, including major depressive disorder, depressed bipolar disorder, manic bipolar disorder, mixed bipolar disorder, schizophrenia, manic excitement, and catatonia. Before starting electroconvulsive therapy, all patients are screened for medical illnesses, for two reasons. First, a variety of medical illnesses are associated with depression or mania; the list is long and includes occult cancer, hypothyroidism, vitamin deficiencies, endocrine abnormalities, and brain tumors or infections, among many others. If there is a treatable cause for depression, it must be found and treated before the decision to perform electroconvulsive therapy is made. Once it is clear that the psychiatric illness is not being caused by something else, ECT may be used. It is important to note that there are certain untreatable medical causes for depression or mania in which the disorder may respond to ECT. For example, depressed patients with Alzheimer’s disease may respond to ECT, showing significant improvements in mood. Brain-injured patients with depression may, in some circumstances, respond to electroconvulsive therapy.

The second reason for screening the patient is to establish that it is safe to proceed with ECT. A routine evaluation should include a medical history and physical examination, psychiatric history, mental status examination, blood count, blood chemistries, urinalysis, and electrocardiogram. Other tests may be done if they seem important to rule out other possible illnesses. Such tests might include a computed tomography (CT) scan, a magnetic resonance imaging (MRI) scan, an electroencephalogram (EEG, or brain wave study), or tests for antidepressant drug levels.

There are no absolute reasons not to perform electroconvulsive therapy. There are certain conditions, however, that produce a significant increase in risk with ECT. Cerebral aneurysm may increase the danger of electroconvulsive therapy. An aneurysm is a balloonlike swelling of an artery, which may cause severe brain damage if it bursts. The high blood pressure associated with ECT may cause a cerebral aneurysm to burst. Patients who have recently experienced a heart attack are at increased risk of dying with ECT. Electroconvulsive therapy should be delayed for six months, if possible, following a heart attack. Other illnesses that increase risk include emphysema, multiple sclerosis, and muscular dystrophy.

Despite these risks, electroconvulsive therapy is considered by many to be the safest of the somatic treatments available in psychiatry. The death rate from ECT itself is one patient in ten thousand—much lower, for example, than the death rate for patients taking antidepressant medications; the death rate from suicide in depressed people is much higher. Electroconvulsive therapy may be done safely with patients representing a broad range of age and physical condition. For the elderly, malnourished patient, it is clearly safer and more effective than medication. Prior to the use of muscle relaxants, broken bones and vertebrae were a considerable problem with ECT. This is no longer the case. Complications such as uncontrolled hypertension, stroke, and heart attack rarely occur; they are extremely unlikely, because the patients are medically screened prior to beginning the treatment.

In each situation, the risk of doing ECT must be weighed against the risk of not doing the treatment. If the patient is imminently suicidal—so that he or she cannot be left alone—ECT may be indicated even though the risk is high. Similarly, patients who are starving to death as a result of their illness may require immediate treatment. Patients with manic excitement or delirium, who are completely out of control and require seclusion, may require ECT despite increased risk. For individuals who cannot tolerate or effectively process antidepressant medications, as a result of a compromised liver or other health conditions, ECT may the most effective choice to save their lives.

The most disturbing and severe side effect of ECT is memory loss
. It is believed that this side effect is attributable to the electricity that is passed through the brain. The postseizure state may also have some effect. What seems to be clear is that this memory deficit is not the result of physical damage to the brain. Some memories, especially those of events that occur around the time of the treatment, may be permanently lost. Many patients will lose their memory of the periods of most severe depression or mania. The ability to learn new information may be temporarily lost. Most people return to reasonable function within the first month and to complete function after six months.

There are a number of ways to gauge the response of a patient to ECT. It is a complicated process that has to take into account and weigh three factors: the improvement of the mood of the patient, the number of treatments or total seizure seconds, and the amount of confusion and/or memory loss that is produced. Additionally, it is important to gauge the emotional response of the patient and the family to the changes being brought about by the treatment.

With each successive treatment, the patient’s mood should get better. If the patient has been depressed, there should be a decrease of the depressive symptoms. Appetite and sleep patterns should improve. There should be an increased level of activity, and social engagement should get better. These changes may first be noticeable to the family and hospital staff. Very often, the improvement becomes apparent to the patient later. Occasionally, the improvement will not be obvious until there has been a chance for the confusion and memory loss to resolve. If the patient is manic, there should be an improvement in symptoms of hyperactivity, grandiosity, irritability, and inability to organize activity and behavior. The response of mania to ECT is often very rapid, and the results may be quite gratifying.

If confusion occurs too early in the course of ECT and it is clear that more treatment needs to be done, decreasing the frequency of treatment from three times a week to once or twice a week may be indicated. Ultimately the decision to stop ECT is based on balancing the above-mentioned factors in an optimal way. This determination is made by the clinician with the input of the patient and all the others (psychiatrist, family, and staff) who know the patient best. If the patient does not seem to be improving and is not having memory difficulty, ECT should be continued. Some patients may need as many as twenty treatments to achieve resolution of psychiatric distress.

Electroconvulsive therapy is the most effective treatment for major mood disorders and for psychotic disorders with a mood component. The likelihood of success depends on the specific diagnosis as well as the accuracy of the diagnostic assessment. Patients who have not responded to adequate trials of medication are less likely to respond to ECT than are those who have not been treated with medication. This would seem to reflect the idea that treatment-resistant psychiatric distress is less likely to respond to any form of treatment.

Perspective and Prospects

Electroconvulsive therapy was discovered as a therapy of mental illness in 1938. It was first used by Ugo Cerletti and Lucio Bini in Italy. The basis of its use was the observation that patients with epilepsy did not suffer from schizophrenia. It was believed that there was something about brain seizures that either prevented or was protective against schizophrenia. While that clinical observation was not accurate, it became the impetus for research into the curative effects of electrically induced seizures.

The first electrical convulsions were induced without the benefit of general anesthesia. Patients had violent seizures and often suffered broken bones and teeth. They were held down in order to keep the seizures from causing excessive physical harm. The responses to ECT in certain patients were quite dramatic. Symptoms such as depression and mania could often be eliminated. Agitated behavior associated with schizophrenia could be mitigated, and patients suffering from catatonia would often become animated as a result of a course of electroconvulsive therapy. The therapy was soon brought to the United States, where it enjoyed frequent use until the early 1950’s.

At that time, antipsychotic and antidepressant medications for the treatment of psychiatric illnesses became available. The drugs chlorpromazine and imipramine were shown to be effective in managing the symptoms of schizophrenia and mood disorders. As a result, electroconvulsive therapy was used less frequently and then only in severe, treatment-refractory cases. The political climate of the 1960’s and 1970’s and films such as One Flew over the Cuckoo’s Nest (1975) portrayed ECT as a tool of the repressive and oppressing psychiatric establishment to exert behavioral and mind control over an unwitting public. Laws were passed in many jurisdictions making it more difficult for patients to obtain ECT. There were efforts to outlaw ECT. Now, however, even the most powerful patient advocacy groups accept the appropriate use of this treatment.

Electroconvulsive therapy has been utilized with increasing frequency for a number of reasons: recognition of its efficacy, the safety of electroconvulsive therapy in medically ill patients, the increased safety of anesthetic techniques, improved diagnostic criteria, an improved process of informed consent, and disappointing efficacy and side effects of medication in certain patients.

During the 1990’s, an alternative stimulatory procedure to the use of ECT as a standard treatment for severe depression was developed. Transcranial magnetic stimulation (TMS) is able to provide a similar adjustment to brain activity without the use of electric current or chemically induced shock. The procedure uses a magnetic coil to deliver a pulse to specified areas of the brain, generally in the region of the prefrontal cortex above the temple. The stimulating coil is held close to the scalp so that the field is focused and can pass through the skull. Rapid-rate TMS can deliver up to fifty stimuli per second. When stimulation is delivered at regular intervals, it is termed repetitive TMS (rTMS). TMS therapy can be used on an outpatient basis, reducing the necessity to hospitalize the patient. Unlike ECT, no side effects such as vomiting, fatigue, or memory loss are typically seen with TMS. The use of TMS is also being studied in connection with movement disorders, epilepsy, bipolar disorders, anxiety disorders, developmental stuttering, Tourette’s syndrome, and schizophrenia.

One of the reasons for the renewed interest in ECT is the improvement in informed consent procedures. Physicians no longer adopt as authoritative an attitude toward patients as they did in the past. In the early years of ECT, patients were not informed of all the potential side effects of the treatment. They were often not told that they had alternatives and what the risks and side effects of the alternatives were. The result was that they experienced complications and side effects for which they were not prepared. They became disappointed and angry. Modern informed consent procedures allow the patient to participate as fully as possible in the decision to take any particular form of therapy. The patient is cognizant of the fact that there are choices and alternatives. The patient is also aware that he or she may decide to discontinue treatment at any time if there is no benefit and the side effects are intolerable. Accurate descriptions of side effects and complications are given to the patient. The patient is apprised of the fact that the treatment may fail and that the treatment is being done this time because it is the one that is most likely to help at this juncture. The patient learns that the choice is simply the best choice, not the only one. Both patients and doctors have
benefited from such an enlightened approach to informed consent.

Bibliography

Abrams, Richard. Electroconvulsive Therapy. 4th ed. New York: Oxford University Press, 2002. A textbook on electroconvulsive therapy that presents a complete picture of all aspects of treatment, from the scientific to the clinical.

American Psychiatric Association. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. 2d ed. Washington, D.C.: American Psychiatric Press, 2001. This book is the result of the work of a task force on electroconvulsive therapy in the American Psychiatric Association. It shows how psychiatrists have worked to make the practice of ECT as ethical and safe as possible. Argues for the importance of this form of treatment to psychiatric patients.

Endler, Norman S. Holiday of Darkness. Rev. ed. New York: John Wiley & Sons, 1990. This book documents the clinical depression of the author, a psychologist, who responded well to electroconvulsive therapy. A very important work that many patients who are contemplating the possibility of ECT may find comforting and useful.

Endler, Norman S., and Emmanuel Persad. Electroconvulsive Therapy: The Myths and the Realities. Toronto, Ont.: Hans Huber, 1988. Another good text on electroconvulsive therapy, written by a psychologist who experienced the treatment for his own depression. He has gone on to become a much-honored and internationally recognized teacher and researcher in the field of psychology.

Fink, Max. Convulsive Therapy: Theory and Practice. New York: Raven Press, 1979. This book continues to be an excellent introduction to electroconvulsive therapy by the leading practitioner and researcher in the United States. A classic text.

George, Mark S., and Robert H. Belmaker, eds. Transcranial Magnetic Stimulation in Neuropsychiatry. Blackwood, N.J.: American Psychiatric Press, 2000. Compares the effects of transcranial magnetic stimulation (TMS) and ECT in animal models of depression, showing that their similarities may further support the potential role of TMS as an antidepressant treatment.

Kellner, Charles H., et al. Handbook of ECT. Washington, D.C.: American Psychiatric Press, 1997. This source describes the procedure, its pros and cons, and how it works and is used in contemporary medicine.

Manning, Martha. Undercurrents: A Therapist’s Reckoning with Depression. New York: HarperCollins, 1995. A memoir written by a therapist about her experience with depression and shock therapy.