Effectiveness of Electroconvulsive Therapy - Essay Example

?Running Head: Safety and Efficacy of Electroconvulsive Therapy. Safety and Efficacy of Electroconvulsive Therapy       Instructor’s Name:       Institution:       Date: Introduction Electroconvulsive therapy (ECT) is a form of treatment that applies electric stimulus briefly to the brain via electrodes attached on the scalp in a bid to produce a seizure meant to deliver a therapeutic effect. ECT is applied on anesthetized patients, and muscle relaxants are also used to avoid muscle spasms. The general induced seizure’s mode of action is not well understood, but according to O’Sullivan and Gilbert (2003), the seizure makes an induction on the brain that leads to the release of neurotransmitters, which help in reducing the severity of symptoms and frequency of illness. Currently, ECT is mostly applied in treating catatonia, mania and severe depression that fails to respond to other forms of therapy. According to the 2001 guidelines by the “American Psychiatric Association” (APA), ECT should be indicated in patients that have depression, which results from intolerance or lack of response to antidepressant therapy. The therapy is also indicated in cases where previous ECT therapies have shown little response and in cases that require definitive and rapid response such as suicidal behaviour and psychosis. The introduction of this therapy occurred in 1938 through Bini Lucio and Ugo Cerletti-psychiatrists from Italy. The therapy acquired widespread application in 1940s and 50s in the treatment of psychiatric conditions (Edward, 1997). However, it is good to be cognizant of the fact that the use of seizure induction to treat psychiatric conditions did not commence with Bini and Ugo. The method had actually begun way back in the 16th century, where chemical agents were used to induce seizure in bids to treat psychiatric conditions. The use of metrazol and camphor was first introduced in 1934 by Meduna, J. Ladislas-a Hungarian psychiatrist. The widespread use of chemical agents such as cardiazol to induce seizure in the treatment of psychiatric conditions began after the 1937 international meeting held in Switzerland. The convulsive therapy meeting was organized by Muller-a Swiss Psychiatrist-and it’s proceedings were documented in the “American Journal of Psychiatry.” In spite of being in use for over 60 years, the therapy is still very controversial, perhaps because very little is understood about its mode of action. The controversy has greatly led to a decline in the application of the therapy in the treatment of psychiatric cases, and perhaps this is why it has been relegated to the last resort class for serious cases such as suicide and psychosis, which have failed to respond to other therapies. The designation of its indication is an implication that it either has a greater associated risk, low effectiveness or is rather least understood in terms of action and thus its effectiveness is not easily determinable. For the same reason, it has been made mandatory for practitioners to acquire informed consent from the patient prior to its administration. The numbers of associated side-effects that characterize the therapy such as memory loss are also part of the contributions to the controversy. Amidst the controversy and negative portrayal, there are long-time practitioners that strongly belief in the effectiveness and safety of the ECT therapy. An example is Max Fink, a long-term practicing psychiatrist and author of numerous scientific papers and books on ECT and general psychiatry. In much of his work, Fink portrays the use of ECT as being effective and safe (Fink, 1984). In fact, in 1990 he wrote a letter currently available on http://www.ect.org, where he recommends that the FDA (Food and Drug Administration) should not exclude the indication of ECT for some psychiatric conditions. He also recommends that the FDA should remove the ECT devices from class III device category, which is a class for medical devices with a high risk and place it in Class II category, which has less associated risk. Apparently, the “Neurological Devices Advisory Panel” under FDA had placed the ECT devices under category III because of what they perceived to be a high risk. However, Fink disputes, this stating that it is not in line with what most research cases have portrayed through time. This paper particularly reviews the safety and effectiveness of ECT in a bid to determine whether Fink’s claims are true according to information from practice and research in the use of ECT in the treatment of psychiatric conditions. Safety of Electroconvulsive therapy There have been concerns about dangerous and even inappropriate applications of ECT therapy especially on elderly patients that have cardiovascular conditions as well as the use of the therapy without patient consent. ECT is contraindicated for various conditions and cases in which it may pose a threat to life. ECT should be avoided in cases where there is high intracranial pressure, and when patients have suffered from Myocardial infarction or brain vascular conditions (Read & Bentall, 2010). A large number of other contraindications result from anaesthesia based reasons-the frequent application of ECT also requires regular administration of anaesthesia and muscle relaxants, which also cause some risk. In some rare cases the therapy may cause status epilepticus or an extended fit, which may require termination by the anaesthetist. Death associated risk in ECT application is low and can be compared to the rate of deaths reported in the general populace. According to Geddes, Mayou and Gelder (2006), ECT-caused death rates were approximately four per 100000 ECT procedures. The use of the therapy has the ability to occasionally induce manic rebounds, especially in bipolar affective disorder. As such, it is prudent to avoid the therapy in such cases or otherwise make close observations on the patient if signs of rebounds appear. A part from brain effects, there are general physical risks of the therapy akin to those experienced in brief anaesthesia. The most common adverse effect that follows the therapy is confusion and amnesia. The confusion states often disappear after some few hours. The therapy should however, be used with caution on patients with neurological disorders or epileptics because it has a natural tendency to cause minor seizures. Muscle soreness after ECT is common however; this is associated with the effects of the muscle relaxants rather than the therapy itself or activity of the muscles. The combination of deep sleep therapy and ECT could cause brain damage if its administration may be done in such a way that it may cause anoxia or hypoxia (Geddes et al. 2006). Concerns of memory loss also influence the concerns on safety because ECT can cause acute memory loss. ECT has the capability to cause both retrograde and anterograde amnesia (Benbow, 2004). Slater and Squire (1983), state that retrograde loss of memory is significant for occurrences in months or weeks prior to therapy. The study also states that some findings on amnesia studies show that even if people lost memory from years prior to therapy they virtually regained their full memory in seven months after treatment with the only permanent loss being in a few days before therapy. There is marked improvement in regaining memory after treatment however; some people’s problems of amnesia persist for longer. Bilateral ECT is cited as the most probable cause of most persistent forms of amnesia that result from ECT. Bilateral ECT has been found to cause persistent loss of memory when compared to other forms of ECT (Sackheim et al. 2000). A research by Duke University found that most patients are not aware of ECT induced cognitive deficits (Logue et al. 2008). The 2008 study assessed the neuropsychological attitudes and effects in people treated with ECT. This study that involved psychological and neuropsychological tests had 46 participants all of whom underwent ECT. The study’s findings showed that there was significant impairment on cognition after the therapy. The researchers found that cognitive impairment occurred on a number of memory tests such as prose passages, word lists’ verbal memory tests and visual memory tests based on geometric shapes (Logue et al. 2008). In their recommendations, the researchers stated that the potential effect of ECT on cognition should be reviewed by the patients and the effects on cognition functions and emotional functioning made clear. This is particularly essential when the therapy is used on adolescents because it is bound to affect their academic performance. The researchers held that there should be a cost-benefit analysis on the emotional functioning improvement as compared to the possible impact on real-world functioning (Logue et al. 2008). Efficacy of Electroconvulsive therapy There have been numerous research studies aimed at testing the efficacy of ECT and these have been designed in varied ways, and their results have been equally varied. The general review on most of these research studies shows that ECT has a positively significant effect than the use of pharmacotherapy. A meta-analytical review by the “United Kingdom ECT Review Group” in 2003 reviewed various research studies in which ECT was compared to antidepressants and placebo treatments using simulated ECT. The results from the meta-analytical review showed that there was a significant effect in size for ECT versus antidepressants as well as the placebo (UK ECT Review Group, 2003). Actual ECT was found to be more effective than the simulation. The use of ECT also had significant results that showed more effectiveness than the use of pharmacologic drugs. Additionally, the research tried to find out whether there was a difference between different types of ECT. In this study unipolar ECT was found to be less effective than bilateral ECT. The interpretation from the research showed that ECT displays better effectiveness in the short-term in depression cases, which was more effective than other therapies (UK ECT Review Group, 2003; Read & Bentall, 2010). Additionally, a high ECT dose was found to be more effective than low ECT dose (UK ECT Review Group, 2003). In a contrasting twist, a study by Ross in 2006, which reviewed several placebo-controlled trials, showed that there was no study among those reviewed which had resulted in a significant difference between simulated and actual ECT after one month of ECT therapy (Ross, 2006). From the results of this research it could be inferred that the ECT therapy is only significantly effective in the short run, but it loses its effectiveness with time. A literature review examining various placebo controlled studies by Read and Bentall in 2010 showed that ECT had less significant benefits for patients with schizophrenia and depression. The same review found that there were no studies that gave supportive evidence to show that ECT could prevent suicide (Read & Bentall, 2010). Read and Bentall’s review concluded that the risk-benefit analysis for the therapy was very poor and its application in practice could not be scientifically proven because of the strongly persistent brain dysfunction witnessed through cases of amnesia (anterograde and retrograde) as well as a slight, but increased risk of mortality (Read & Bentall, 2010). A report by Surgeon General in 1999 reporting on psychiatric conditions gave a brief opinion on the effectiveness of the therapy in which it stated that documented research and clinical experience had demonstrated effectiveness at a remission rate of approximately 70% in cases of mania, acute psychosis, and severe depression (Surgeon General, 1999). The report also stated that there was no demonstrable effectiveness in cases of personality disorder, anxiety, substance abuse and dysthymia. The report finally recommended ECT as a short-term solution that should be accompanied by pharmacologic treatments (Surgeon General, 1999). Another study on effectiveness of ECT in a community set up was carried out by Sackheim et al. in 2004. The study’s findings showed a remission rate of 30—47% out of which 64% of the cases relapsed in a six month period. However, the removal of patients with schizoaffective disorder led to a significant change in which the remission rose to 60-70% (Sackheim et al. 2004). Significant variations in findings as indicated above, legal restrictions, the ability to cause adverse effects, former therapy recipients testimonies’, negative public opinion and disputes of efficacy show that the therapy is still a controversial issue. This is portrayed by the varied findings that are arrived at by different quarters within the medical field of practice. These facts find reflection in FDA’s decision to classify the ECT devices as class III devices, which are counted as risky for most cases except for individuals experiencing catatonia (Prudic et al. 2001). The restrictions on conditions indicated in the therapy are also an indicator of the uncertainty that surrounds the condition. The major uncertainties that characterize the use of the therapy originate from the inconsistencies in findings and the lack of long-term documentation of results and effects on the use of the therapy over a significantly long time. The rate of remission followed by relapses is great and the effectiveness of the therapy on its own is not proven. Furthermore, the high rates of relapse in the short run seem to point to inefficiency in the long run (Prudic et al. 2001). Relapse it often reduced through the combination of the therapy and psychotherapeutic drugs. The high rate of relapse has been attributed to the severity of the conditions that the therapy is exclusively indicated for, but there is no research to explicitly prove this proposition. In conclusion, ECT has some form of comparative effectiveness, especially in the short run as demonstrated by most studies. However, the sustenance of this positive effect is only possible when in combination with pharmacologic approaches. There are no demonstrable findings from long-term research that can prove effectiveness. As such, the lack of long-term evidence becomes the biggest challenge when deciding whether ECT is effective or not. The high rates of short-term relapse (within six months) also cast great doubt on the therapy in the long run. These uncertainties coupled with the short-term demonstrable evidence through various research studies indicate that the therapy could be effective in handling extreme conditions such as psychosis and suicide related cases, so as to pave way for other therapies for long-term purposes. On the other hand, it is agreeable that with the exception of amnesia the therapy has less adverse effects. There is no high mortality rates associated, but the air of uncertainty about its mode of action raises safety concerns because very little is understood in this regard. The whole picture shows a very confusing state characterized by insufficient long-term research findings and poor understanding of mechanism of operation. As such, further long-term research studies to clear the air are necessary because Fink’s arguments do not get sufficient support for aspects such as efficacy and safety. References Benbow, S. M. (2004). The adverse effects of ECT, In AIF Scott (ed.) The ECT Handbook, second edition. London: The Royal College of Psychiatrists, pp. 170–174. Edward, S. (1997). A History of Psychiatry: from the era of the asylum to the age of Prozac. Hoboken, NJ: John Wiley and Sons. Fink, M. (1984). The Origins of Convulsive Therapy; American Journal of Psychiatry, 141 (9): 1034–41 Geddes, J. Mayou, R. Gelder, M. (2006). Psychiatry, 3rd edition, Oxford: Oxford University Press Gilbert, J. & O’Sullivan, J. (2003). ECT (Electroconvulsive Therapy), retrieved on April 24th 2012 http://www.health.qld.gov.au/rbwh/docs/ect.pdf” Logue, P. E. Sollers, J. Hill, K. L. Wellington, C. Edwards, L. Romero, H. Jonassaint, C. Whitfield, K. Byrd, G. Johnson, S. Raynor, R. McDougald, C. Sudhakar, S. Edwards, L. C. & Feliu, M. (2008). Neuropsychological Effects and Attitudes in Patients following Electroconvulsive Therapy; Neuropsychiatric Disease and Treatment 4 (3): 613–17. Prudic, J. Cooper, B. T. Crowe, R. R. Greenberg, M. R. Pettinati, H. M. Mann, J. J. Thase, M. E. Mulsant, B. H. Haskett, F. R. Sackheim, A. H. (2001). Continuation Pharmacotherapy in Prevention of Relapse following Electroconvulsive Therapy: A randomized controlled trial. JAMA, 285(10):1299–307. Read, J. & Bentall, R. (2010). The Effectiveness of Electroconvulsive Therapy: A literature review, Epidemiologia e psichiatria sociale 19 (4): 333–47. Ross, A. C. (2006). The sham ECT literature: Implications for consent to ECT. Ethical Human Psychiatry and Psychology 8 (1): 17–28. Sackheim, A. H. Devanand, D. P. Prudic, J. Maddox, J. H. & Lisanby, H. S. (2000). The Effects of ECT on Memory of Autobiographical and Public Events; Archives of General Psychiatry 57 (6): 581–90. Sackheim, A. H. Fuller, B. R. Marcus, C. S. Olfson, M. & Prudic, J. (2004). The Effectiveness of Electroconvulsive Therapy in Community Settings; Biological Psychiatry 55 (3): 301–12. Slater, P. C. & Squire, L. R. (1983). Electroconvulsive Therapy and Complaints of Memory Dysfunction: A prospective three-year follow-up study. British Journal of Psychiatry 142 (1): 1–8. Surgeon General (1999). Mental Health: A report of the surgeon general, Chapter Four. Retrieved on April 24th 2012 from http://www.surgeongeneral.gov/library/mentalhealth/home.html U.K. ECT Review Group (2003). Efficacy and Safety of Electroconvulsive Therapy in Depressive Disorders: A systematic review and meta-analysis. The Lancet, 361(9360):799-808. Read More