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- What Is It?
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Uncommonly bifrontal placement in used; this involves positioning the electrodes on the patient's forehead, roughly above each eye. Unilateral ECT is thought to cause fewer cognitive effects than bilateral treatment, but is less effective unless administered at higher doses. The electrodes deliver an electrical stimulus.
The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: 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. Immediately prior to treatment, a patient is given a short-acting anesthetic such as methohexital , etomidate , or thiopental , [1] a muscle relaxant such as suxamethonium succinylcholine , and occasionally atropine to inhibit salivation.
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ECT is usually administered three times a week, on alternate days, over a course of two to four weeks. Most modern ECT devices deliver a brief-pulse current, which is thought to cause fewer cognitive effects than the sine-wave currents which were originally used in ECT. Despite decades of research, the exact mechanism of action of ECT remains elusive. Neuroimaging studies in people who have had ECT, investigating differences between responders and nonresponders, and people who relapse, find that responders have anticonvulsant effects mostly in the frontal lobes , which corresponds to immediate responses, and neurotrophic effects primarily in the medial temporal lobe.
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The anticonvulsant effects are decreased blood flow and decreased metabolism, while the neurotrophic effects are opposite - increased perfusion and metabolism, as well as increased volume of the hippocampus. As of , it was estimated that about one million people received ECT annually. There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists.
About 70 percent of ECT patients are women. The use of ECT is not as common in ethnic minorities. 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".
ECT became popular in the US in the s. At the time, psychiatric hospitals were overrun with patients whom doctors were desperate to treat and cure. Whereas lobotomies would reduce a patient to a more manageable submissive state, ECT helped to improve mood in those with severe depression. A survey of psychiatric practice in the late s found that an estimated , people received ECT annually, with wide variation between metropolitan statistical areas.
Following a course of ECT some patients may be given continuation or maintenance ECT with further treatments at weekly, fortnightly or monthly intervals. Privileging for ECT practice at institutions is a local option: In the UK in , an estimated 50, people received ECT annually, with use declining steadily since then [78] to about 12, per annum in Eighty-one percent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis.
Sixteen percent were treated without their consent. The guidance received a mixed reception.
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It was welcomed by an editorial in the British Medical Journal [81] but the Royal College of Psychiatrists launched an unsuccessful appeal. Adherence to standards has not been universal in the past. A survey of ECT use in 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 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.
The Mental Health Act allows people to be treated against their will. This law has extra protections regarding ECT. A patient capable of making the decision can decline the treatment, and in that case treatment cannot be given unless it will save that patient's life or is immediately necessary to prevent deterioration of the patient's condition. A patient may not be capable of making the decision they "lack capacity" , and in that situation ECT can be given if it is appropriate and also if there are no advance directives that prevent the use of ECT.
ECT was introduced in China in the early s and while it was originally practiced without anesthesia, as of almost all procedures were conducted with it.
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As early as the 16th century, agents to induce seizures were used to treat psychiatric conditions. In , the therapeutic use of seizure induction was documented in the London Medical Journal. Treatment and cure of hysterical blindness was documented eleven years later. Benjamin Franklin wrote that an electrostatic machine cured "a woman of hysterical fits.
Duchenne, the midth century "Father of Electrotherapy", said its use was integral to a neurological practice.
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In the second half of the 19th century, such efforts were frequent enough in British asylums as to make it notable. Convulsive therapy was introduced in by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then metrazol cardiazol. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide.
It was believed early on that inducing convulsions aided in helping those with severe schizophrenia but later found to be most useful with affective disorders such as depression. Cerletti had noted a shock to the head produced convulsions in dogs. The idea to use electroshock on humans came to Cerletti when he saw how pigs were given an electric shock before being butchered to put them in an anesthetized state.
Once they started trials on patients, they found that after treatments the results were significant. Patients had much improved. A positive side effect to the treatment was retrograde amnesia. It was because of this side effect that patients could not remember the treatments and had no ill feelings toward it. By , the procedure was introduced to both England and the US. In Germany and Austria, it was promoted by Friedrich Meggendorfer. Through the s and s, the use of ECT became widespread. In the early s, in an attempt to reduce the memory disturbance and confusion associated with treatment, two modifications were introduced: It took many years for brief-pulse equipment to be widely adopted.
A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones. In the s, 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 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 s to the s. 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. 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 as of some ECT clinics still were using sine-wave devices.
The report endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT. The use of ECT declined until the s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression". Because of the backlash noted previously, national institutions reviewed past practices and set new standards. In , 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 American Psychiatric Association released its second task force report in where specific details on the delivery, education, and training of ECT were documented.
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Finally, in the American Psychiatric Association released its latest task force report. By , ECT was routinely covered by insurance companies for providing the "biggest bang for the buck" for otherwise intractable cases of severe mental illness, was receiving favorable media coverage, and was being provided in regional medical centers.
Surveys of public opinion, the testimony of former patients, legal restrictions on the use of ECT 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 may result in the manufacturers of such devices having to do controlled trials on their safety and efficacy for the first time. The World Health Organization advises that ECT should be used only with the informed consent of the patient or their guardian if their incapacity to consent has been established.
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.