Electroconvulsive therapy - Research Proposal Example

Keeping in view the risks associated with ECT, is it really useful to treat patients with severe depression with ECT? Background Information Electroconvulsive therapy or ECT is one of the psychotherapeutic methods in which electric current is passed through the brain of the patient to cause convulsions. It is one of the treatments for severe depression. Indications for ECT in severely depressed patients are failure of antidepressants to control symptoms despite using many medications (Medda et al, 2010), severe side effects to antidepressants (Medda et al, 2009) and threat to the patients life due to decreased intake of food and water or due to attempt to suicide (Kellner et al, 2006). Past history of success from ECT is also an indication for ECT (NICE, 2003). The therapy is associated with significant side effects and risks (Prudic, 2008). Administration of ECT affects the central nervous system and also causes changes in the dynamics of the cardiovascular system. This therapy can cause many side effects as discussed below. Some immediate potential complications which are worth mentioning are laryngospasm, status epilepticus and peripheral nerve palsy (NICE, 2003). These events occur in 1 per 1300 to 1400 treatment sessions. However, research has shown that the mortality associated with ECT is in no way more than the mortality associated with administration of general anesthesia for a minor surgery (NICE, 2003). The procedure of giving ECT involves several weeks. The patient develops several epileptic seizures and receives many anesthetics. There are many side effects for this treatment. Short-term side effects include head ache, muscle ache, feeling of muzzy headedness, feeling sick, distress and feeling fearful. In older patients, confusion can occur. There is small risk of death of 1 in 50,000 cases (RCP, 2008). The main impact of ECT is long term. The most important long term side effects are cognitive deficits, mainly memory problems (Porter et al, 2008). Memories return in most of the cases when the course has finished and a few weeks have passed by (Porter, Heenan and Reeves, 2008). The risks associated with this therapy are likely to be increased in older people, in pregnant women and in young people and children. Hence caution must be exerted while recommending ECT to these groups. Special caution must also be exerted in those with risk of cardiovascular event (NICE, 2003). Problem Statement Many researchers often wonder as to whether the procedure is really worth in the wake of many associated risks and side effects. Also there is no clear understanding as to how ECT works. Research has shown that release of certain brain chemicals and stimulation of growth of new blood vessel in certain areas of brain probably helps improvement of the condition of the patient (RCP, 2008). Some researchers propose that ECT works by alteration in the post-synaptic response to the neurotransmitters in the central nervous system (NICE, 2003). Greenhalgh et al (2005) conducted a systematic review to evaluate and establish the cost versus clinical effectiveness of ECT in patients with schizophrenia, mania, catatonia and depressive illness. The researchers concluded that in the short term, ECT is much superior to pharmacotherapy and when tricyclic antidepressants are given along with ECT, the antidepressive effect is enhanced. The benefits of the treatment should be weighed against the risk of cognitive side effects. Research has shown that these side effects do not last more than 6 months, but there is not much evidence which has studied the duration of these effects for more than 6 months. Also, there is not much evidence about the long-term benefits with this treatment. There is no evidence which has been published as far as cost-effectiveness of ECT is concerned. According to the Assessment group from NICE (NICE, 2003) for those with treatment-resistant schizophrenia and severe depression, pharmacological therapy and ECT may be effective equally with no difference seen in outcomes and costs. According to Thompson (2008), administration of ECT is not an easy task, both emotionally and technically and must be delivered only by trained personnel. The psychiatrist argues that though there is evidence that ECT is an effective and valuable treatment, it is difficult to feel responsible for induction of seizures in a patient who is not in a position to give consent. According to her, patients with ECT deserve the dignity of treatment since it is done without their consent. This dignity can be established only by following the guidelines set by The Royal College of Psychiatrists. Regular audit of protocols must be conducted to ensure the guidelines are followed. The Royal College of Psychiatrists put forth a statement which mentioned that "over 80% of patients are satisfied with electroconvulsive therapy and that memory loss is not clinically important." Rose et al (2003) conducted a systematic review to ascertain the views of patients on ECT. According to this study, the statement presented by the Royal College is unfounded. Their study revealed that many patients with ECT are not satisfied and they are definitely worried about the cognitive losses. Thus it can be said that ECT is a complex intervention for resistant depression. The scientific basis of this therapy is not yet understood completely. Though this treatment produces relief of symptoms in the short-term, the long term consequences like memory loss and the potential risk of serious complication like cardiac disturbances, laryngospasm and death question the risk-benefit and cost-effectiveness of this therapy. Limited evidence shows that the risk of serious complications is minimal and is as much as the risk associated with general anesthesia for minor surgery. The therapy is as cost effective as pharmacotherapy for resistant depression cases, catatonia and severe mania. Patients may not be satisfied with this therapy due to short-lasting benefits and long term cognitive deficits. More research is warranted to ascertain the usefulness of this therapy in severe depression as against the side effects and risks associted with it. Purpose The purpose of the study is to evaluate and ascertain the usefulness of ECT in patients with severe and resistant depression with reference to the safety of the therapy. The study will be conducted through systematic review of literature pertaining to the role of ECT in the management of various types of depression. Research questions The research is intended to answer the following questions: 1. Is ECT a useful therapy in severe depression? 2. Is ECT better than pharmacotherapy in severe depression? 3. Is ECT useful in depression that is resistant to pharmacotherapy? 4. Is ECT useful in both unipolar and bipolar depression? 5. Is ECT useful in depression that is manageable with pharmacotherapy but the patient is not able to tolerate the side effects of the medications? 6. What are the side effects of ECT? 7. What is the duration of each side effect? 8. What strategies help to minimise sife effects? 9. What strategies help manage side effects? 10. Despite the risk of side effects, is ECT worthy in patients with severe depression. References Kellner CH, Knapp RG, Petrides G, et al. (2006). Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry, 63(12), 1337-44. Medda, P., Perugi, G., Zanello, S., Ciuffa, M., Cassano, G.B. (2009). Response to ECT in bipolar I, bipolar II and unipolar depression. J Affect Disord., 118(1-3), 42- 53. Medda, P., Perugi, G., Zanello, S., Ciuffa, M., Rizzato, S., Cassano, G.B. (2010). Comparative response to electroconvulsive therapy in medication-resistant bipolar I patients with depression and mixed state. J ECT, 26(2), 82-6. NICE Guidelines. (2003). Guidance on the use of electroconvulsive therapy. Retrieved on June 5th, 2010 from http://www.nice.org.uk/nicemedia/pdf/59ectfullguidance.pdf Prudic J. (2008). Strategies to minimize cognitive side effects with ECT: aspects of ECT technique. J ECT., 24(1), 46-51. Porter RJ, Douglas K, Knight RG. (2008). Monitoring of cognitive effects during a course of electroconvulsive therapy: recommendations for clinical practice. J ECT. 2008 Mar;24(1):25-34 Porter R, Heenan H, Reeves J. (2008). Early effects of electroconvulsive therapy on cognitive function. J ECT. 2008 Mar;24(1):35-9 Rose, D., Flieschmann, P., Wykes, T., Leese, M., and Bindman, J. (2003). Patients perspectives on electroconvulsive therapy: systematic review. BMJ, 326 (7403). Retrieved on June 5th, 2010 from 1363, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=162130 Smith GE, Rasmussen KG Jr, Cullum CM, et al. (2010). A randomized controlled trial comparing the memory effects of continuation electroconvulsive therapy versus continuation pharmacotherapy: results from the Consortium for Research in ECT (CORE) study. J Clin Psychiatry, 71(2), 185-93. The Royal College of Psychiatrists (RCP). (2008). Electroconvulsive Therapy. Retrieved on June 5th, 2010 from http://www.rcpsych.ac.uk/mentalhealthinfoforall/treatments/ect.aspx Thompson, C. (2008). Electroconvulsive Therapy: Sidebar: A Doctors Perspective on Electroconvulsive Therapy. Medscape Pediatrics. Retrieved June 5th, 2010 from http://www.medscape.com/viewarticle/5 86294_2 Read More