BEHAVIOR
May 9, 2007

ECT — Fact and Fiction

It is hard to think of a medical treatment that has received worse press in recent decades than electroconvulsive therapy (ECT), once known as electro-shock. Popular fear of electricity and its association with execution have not helped. Neither have books and films such as Ken Kesey's "One Flew Over the Cuckoo's Nest," which portray ECT as a quasi-medieval device used to intentionally inflict pain.

At the same time, many mental health experts have argued that the popular perception of ECT is miles away from the reality — that ECT is among the safest and most effective treatments for certain types of severe depression.

One of these experts is Dr. Stephen Taylor of the University of Louisville. Dr. Taylor reviews the history and current use of ECT for depression and other psychiatric disorders in the May 2007 issue of the Southern Medical Journal.

Dr. Taylor argues that ECT, which works, essentially, by provoking a brain seizure, is actually underused in cases of severe depression which do not respond to other treatments, and that it should be considered more often in the earlier stages of the illness, rather than exclusively as a last resort.

"Electroconvulsive therapy has been shown to be a highly effective, safe, and even life-saving treatment for persistent and severe depression, bipolar disorder, and schizophrenia," writes Taylor. The idea of inducing seizures to treat psychiatric disorders has a long history, but it was not until the 1950s-a time when there were few other effective treatments for serious mental illness-that scientific studies confirmed the effectiveness of ECT. "The 'antipsychiatry movement' and the promise that drugs would cure mental illness contributed to a decline in ECT use in the ensuing decades," Dr. Taylor writes.

However, "ECT has shown a strong comeback in the last decade, which is a testament to its continued efficacy and safety," according to Dr. Taylor. For patients with depression that does not improve with other drugs or treatments, ECT produces a response rate of up to 55 percent. Recent studies have reported even higher response rates-80 to 90 percent-when ECT is used as initial treatment for severe depression. Compared to most drug treatments, these results are impressive.

The procedure is very safe, with health risks comparable to those of childbirth or minor surgery. Although concerns have been raised that ECT causes memory loss, this is usually limited and clears up within a few weeks.

Another possible source of popular fear of ECT is the fact that we do not really know how it works. Effects on brain neurotransmitters, such as serotonin, dopamine, and norepinephrine may be involved.

Several treatments are often needed to achieve a response to ECT; although improvement may occur after the first session, six to twelve treatments are the norm. Dr. Taylor emphasizes, "it should be stressed that ECT represents a treatment that will bring remission, not a cure." Many patients will need "maintenance" treatments over time, because the effects of ECT are temporary.

An accompanying editorial by Dr. James N. Kimball of Wake Forest University Baptist Medical Center, Winston-Salem, N.C., echoes the call for doctors and their patients to be open to the possibility of pursuing ECT for persistent depression and other disorders. "It is not right for everyone, but it is a treatment health professionals should consider in their therapeutic arsenal," Dr. Kimball writes. "[ECT] is one of the oldest treatments currently in modern psychiatry, but also one whose time has come."
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