Electroconvulsive Therapy and Mental Health - Case Study Example

Electroconvulsive Therapy and Mental Health: A History of Treatment March 31, Electroconvulsive Therapy and Mental Health: A History of Treatment Electroconvulsive therapy has been used consistently by the psychiatric community for over sixty years. It is used mostly in the treatment of major depression, bipolar disorder, and relapsing psychotic disorders, especially catatonic schizophrenia. It is also used in cases where pharmaceutical treatment would be dangerous, such as during pregnancy or in elderly adults (Mayo Clinic Staff 2010). ECT is a highly technical procedure requiring a team that consists of an anaesthetist, a psychiatrist, psychiatric nurses and recovery nurses. Doing a study on how ECT has changed over the years has given me an insight of how the use of ECT in the treatment of mental health illness has changed over the years. Undergoing this study has also enabled me to implement an important role in caring for patient who receive ECT, especially in the areas of pre- and post-treatment care. Mental health nursing care for the ECT patient has evolved from a traditional supportive and adjunctive practice to the current practice of independent and collaborative nursing actions. The nurse’s multifaceted role in ECT is enacted by providing education and support, performing pre-treatment assessments, monitoring the procedure, observing and interpreting post-treatment patient responses, and this study has helped me understand how I fit into that role. Electroconvulsive therapy is considered one of the more effective methods for the treatment of persistent depression that has proven resistant to treatment with medication or psychotherapy. The method even has an extremely high rate of success, reportedly between fifty up to ninety percent, when ECT is used as an initial treatment for severe cases of index depression, a major depressive episode that presents with a specific start date and normal mood before that date. If used for schizophrenia, ECT is usually combined with pharmaceutical treatments as well. When used together in this manner, the treatment is shown to reduce the risks of future relapse, more so than treatment with the medication alone (Taylor 2007). Mechanism of Treatment and Treatment Activities Electroconvulsive therapy treats psychiatric disorders through the induction of generalized seizure activity in the brain, and some have suggested that the seizure activity alone is the mechanism of treatment (Bolwig 2011). However, despite the years of experience with the treatment in the medical community and just as many years of research, the exact reasons for its success are still unclear (Madsen et al 1999). Many possible reasons for it have been suggested. One possible suggestion for the mechanism of the treatment has been that it may induce neurogenesis (Madsen et al 1999). Neurogenesis is the growth of new neural cells, but only recently has it been discovered that such new neurons can grow in the adult human brain throughout life. Adult neurogenesis has been suggested as a method to treat neurological and psychological disorders, as part of or separate from ECT (Eisch & Nestler 2002). ECT has also been found to increase synaptic activity in the brain as well as forming these new neurons and neural connections, another possibility for its mechanism (Bolwig 2011). Another suggestion for mechanism is based on its efficacy in the treatment of major depressive disorder. Patients who are treated for major depressive disorder with ECT are found to have elevated levels of pancreatic polypeptide after successful treatment, which is known to be secreted after activation of the vagal nerve complex. Researchers have used these findings to conclude that vagal nerve stimulation may be the responsible mechanism for electroconvulsive therapy, at least for those patients being treated for depressive disorders (Bär et al. 2010). During electroconvulsive therapy, the patient is put under general anaesthesia and pharmacologically restrained in order to protect them from the convulsions induced by the therapy. The use of general anaesthetic, while increasing some risks to the patient, is absolutely necessary for the safety of the procedure due to the extreme convulsions that can be produced and the possible resultant pain if anaesthesia is not administered. The use of a blood pressure cuff preventing one extremity, such as a hand or foot, from becoming paralysed by the muscle relaxant allows the staff to determine if a seizure has been induced. Patients will also be given an electrocardiogram in order to ensure that their heart is healthy enough for the treatment. Cardiovascular conditions can greatly increase the risks associated with ECT. Different medications can be used to reduce these and other risks of co-morbid conditions, and generally muscle relaxants are used to help protect the patient from physical harm (Mayo Clinic Staff 2010). Patients must be closely monitored following a course of treatment. Patients are often confused and suffering amnesia after a treatment and cannot be left to their own devices in case they become a danger to themselves or others. They should also be evaluated as to the success and side effects of the treatment as soon as is feasible afterwards, to determine their need for future treatments or medications. Some patients suffer lingering physical effects, such as jaw pain or muscle spasms, that can be treated with analgesics (Mayo Clinic Staff 2010). History Electroconvulsive therapy was first researched in Denmark. “In August 1939, at the 3rd International Neurological Congress in Copenhagen, Professor Lucio Bini reported on the first use of electricity to induce a seizure for therapeutic purposes in psychotic patients” (Faedda et al., 2010). Bini was also one of the first to realize that it was the seizure itself that was providing the therapeutic effects, and not simply the results of the exposure of the patient to the electric current alone, in opposition to most medical thought of the time (Faedda et al., 2010). The use of electricity in medical treatment, however, was already widely practised when Binis research study was published (Berrios 1997). Binis paper was and still is considered a breakthrough in treatment for schizophrenia. His research was based on the drug-induced convulsive therapy work of Ladislaus von Meduna in catatonic schizophrenics (Taylor 2007). von Medunas work, in turn, was based on the long-time use of pharmacologically-induced convulsions to treat other mental health conditions (Abrams 2002). While Binis work was therefore still revolutionary, it was clearly an idea whose time had come. The first clinical use of electroconvulsive therapy was performed in early 1940 at Columbus Hospital in New York City, by Dr. Renato Almansi and Dr. David Impastato (Abrams 2002). From there, due to its success for many previously treatment-resistant conditions, the treatment rapidly gained more legitimacy in the scientific and medical communities. This was greatly assisted through the work of Max Fink in applying scientific testing methods to the treatment during the 1950s (Taylor, 2007). Finks work was systematic and deliberate, and covered nearly every field that had or could ever touch on electroconvulsive therapies. He was also the author of one of the earliest textbooks devoted entirely to the treatment, which was the first to deal critically rather than anecdotally with the conclusions drawn from the available research literature (Abrams 2002). Changes Since Inception and Future Roles of Treatment Much has changed in the efficacy and safety of electroconvulsive therapy since Binis original paper in 1939. The use of modern anaesthesia and other medications have reduced the risks of ECT to the point where it is even safe in people with co-morbid physical conditions. Despite these gains in patient safety, the use of ECT has dropped dramatically in recent years due to the widespread medicalisation of psychotherapy. This has lead to many to believe that the use of psychoactive medications, combined with psychotherapy, could treat most or all mental health conditions. The viewpoint for many has become that such physical treatments as ECT are outdated, obsolete, and no longer necessary (Taylor 2007). Public perception and legal obstacles have also reduced usage of the treatment (Shorter et al. 2007). Many of the recent innovations in the areas of brain imaging techniques have also had major implications and effects on the use and research of ECT. Physicians and psychiatrists can make use of this technology to view what portions of the brain are affected by the use of different methods of ECT. Imaging can therefore help determine by what mechanism the treatment functions and in what ways to improve upon the the treatments efficacy and safety. For example, bi-frontal, bi-temporal, and right unilateral methods of ECT all have different effects on the brain, affect blood flow differently, and therefore have different treatment results with differing side effects. The use of imaging technology is what originally made it possible for researchers and clinicians to understand these blood flow differences and help to decide the course of future research to improve the treatment (Crowley et al. 2008). Changes have also occurred in the type of electrical stimulus used during ECT. Until recently, electroconvulsive seizures were induced through the use of sine wave electricity, but this has been almost completely replaced by treatment through the use of pulse wave electricity (Abrams 2002). Since sine wave ECT requires nearly three times the exposure as pulse wave, the pulse wave treatment type is much safer (Azuma et al. 2007). Other research performed on the treatment has shown that sine wave ECT leads to much higher levels of cognitive impairment after treatment than does the pulse wave method (Fujita et al. 2006). As these gains have come without a corresponding loss in treatment success rates, most practitioners now use the pulse wave method. Electroconvulsive therapy has many treatment options for the future in expanding uses for diseases with similar presentation and mechanism. For example, childhood autism often results in psychotic catatonia, as well as similar complications such as compulsions, tics, and self-injury (Dhossche et al. 2009). As a result of these similar characteristics, ECT has been suggested as a maintenance therapy for autism with catatonia along with medications (Kakooza-Mwesige et al. 2008). ECT also has a role in many neuropsychiatric and neurophysiological disorders, in addition to its widespread and well-studied uses in mental health disorders (Hazin et al. 2009). Treatment Limitations and Side Effects Despite the often impressive results of ECT in mental health treatment, its use as a treatment does have several major limitations. Primarily among these is the transient nature of the results of the treatment. Patients who undergo electrocovulsive therapy for persistent or relapsing conditions, such as psychotic disorders, will usually require maintenance treatments. Patients are also generally not “cured” by the treatment, but merely sent into remission, and will often relapse (Taylor 2007). Higher dosages of electric current generally show better results even in severe cases with regard to mood disorders, but also result in an increase in reported side effects, and do not have any effect on the propensity for relapse (Sackheim, Prudic, et al. 1993). Most people in the general public have negative feelings about the treatment, especially fear of side effects. However, people who have undergone ECT generally have favourable opinions of the treatment. While a significant minority of those treated expressed criticism, this balance of favour indicates that the treatment is generally effective, safe, and not an overly distressing experience from the viewpoint of the patient (Chakrabarti et al., 2010). For example, subjectively, many patients report that they do not experience memory-related side effects or that their memory actually improves after treatment; the results of attempts to measure this effect objective seem to be highly reliant on the methodology of testing (Berman, Prudic, et al. 2008). Regardless of the actual results of measuring cognitive impairments, if the subjects do not feel impaired, it cannot truly be said that they are harmed in this way by the treatment. As well, most of the reported memory effects are short-term, surround only the weeks immediately prior to and after the treatments, and usually spontaneously resolves (Taylor 2007). Besides the temporary amnesia and other memory difficulties experienced after a treatment, there are many other cognitive side effects experienced by patients. One of the most common is a state of confusion. This confusion can be extremely severe, to the point of not knowing who or where they are, and continue for up to several hours after a treatment. Older adults are more prone to this confusion, and may require even days of rest before the confusion subsides to a point where they can resume their normal daily activities. During this time period, patients need to be closely monitored to ensure they do not become a danger to themselves or others (Mayo Clinic Staff 2010). Legal, Ethical, and Treatment Implications Australia has recently limited the use of electroconvulsive therapy to treatment of solely psychiatric disorders, failing to take into account the possible benefits of the treatment in neurological disorders. The wording of the law also prohibits the use of deep brain stimulation, an emerging study that has great possibility in the treatment of many psychiatric and neurological disorders (Loo et al. 2010). While the attempt of the legislation to protect patient safety is admirable, the legislators must realize the possible consequences of this law. Restricting the use of ECT only feeds into the negative public perception of this treatment, possibly reducing its use in cases where it could be greatly beneficial. The legislation could also be expanded into countries outside of Australia, further limiting treatment benefits. Public perception of the treatment is so poor that it has at times led to legal battles. For example, one program aired on the American television network ABC in 1977 called “Madness and Medicine” presented such a negative and unbalanced view of the treatment that the American Psychiatric Association threatened a lawsuit against the television network. However, in many other cases, patients who felt they had been wronged by the treatment took legal action against the medical staff that had treated them, the hospitals housing the treatment centers, and even the APA itself. Thankfully for the many patients who continue to benefit from the treatment, over time cooler heads have prevailed and the treatment has not been banned or exiled to the realm of drastic emergency treatments (Shorter et al. 2007). There are also legal and ethical implications in the medical arena. For example, failing to take all factors affecting dosage into consideration can lead to over-dosing a patient with regard to electrical current. For example, using the least powerful current and the smallest pulse can help to reduce adverse effects. Using a dosage plan that simply summarizes rather than mathematically allowing for these factors can result in an overdose as well, which would have serious ethical and legal implications for the practitioner that allowed such a dosage to be given (Peterchev et al. 2010). Conclusion Electroconvulsive therapy receives quite a bit of bad press, and those outside the psychiatric community discredit and even fear the treatment. Despite the early discovery of the treatment, the safety and efficiency of the treatment has been greatly improved over time, with the help of modern pharmacology and medical technology. Electroconvulsive therapy is an excellent addition to the treatment arsenal of a mental health professional and should not be discounted as a possibility for treatment. References Abrams, R., 2002. Electroconvulsive therapy, Oxford University Press US. Azuma, H. et al., 2007. 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Electroconvulsive Therapy: A Review of History, Patient Selection, Technique, and Medication Management. Southern Medical Journal, 100(5), p.494-498 10.1097/SMJ.0b013e318038fce0. Available at: http://journals.lww.com/smajournalonline/Fulltext/2007/05000/Electroconvulsive_Therapy__A_Review_of_History,.13.aspx. Read More