The APA 2001 guidelines give the primary indications for ECT among patients with depression as a lack of a response to, or intolerance of, antidepressant medications; a good response to previous ECT; and the need for a rapid and definitive response (e.g. because of psychosis or a risk of suicide). The decision to use ECT depends on several factors, including the severity and chronicity of the depression, the likelihood that alternative treatments would be effective, the patient's preference, and a weighing of the risks and benefits.
Some guidelines recommend that cognitive behavioral therapy or other psychotherapy should generally be tried before ECT is used. However, treatment resistance is widely defined as lack of therapeutic response to two antidepressants. The APA states that at times patients will prefer to receive ECT over alternative treatments, but commonly the opposite will be the case.
The APA ECT guidelines state that severe major depression with psychotic features, manic delirium, or catatonia are conditions for which there is a clear consensus favoring early reliance on ECT. The NICE guidelines recommend ECT for patients with severe depression, catatonia, or prolonged or severe mania.
The 2001 APA guidelines support the use of ECT for relapse prevention, but the 2003 NICE guidelines do not.
The 2001 APA ECT guidelines say that ECT is rarely used as a first-line treatment for schizophrenia but is considered after unsuccessful treatment with antipsychotic medication, and may also be considered in the treatment of patients with schizoaffective or schizophreniform disorder. The 2003 NICE ECT guidelines do not recommend ECT for Schizophrenia.
The NICE 2003 guidelines state that doctors should be particularly cautious when considering ECT treatment for women who are pregnant and for older or younger people, because they may be at higher risk of complications with ECT. The 2001 APA ECT guidelines say that ECT may be safer than alternative treatments in the infirm elderly and during pregnancy, and the 2000 APA depression guidelines stated that the literature supports the safety for mother and fetus, as well as the efficacy during pregnancy.
In the UK in 2003 the UK ECT Review Group, led by Professor Geddes of Oxford University, reviewed the evidence and concluded that ECT had been shown to be an effective short-term treatment for depression (as measured by symptom rating scales) in physically healthy adults, and that it was probably more effective than drug treatment. Bilateral ECT was more effective than unilateral, and high-dose was more effective than low-dose. Their conclusions were qualified: most of the trials were old and conducted on small numbers of patients; some groups (for example, elderly people, women with postpartum depression and people with treatment-resistant depression) were under-represented in the trials even though ECT is believed to be especially effective for them.
ECT on its own does not usually have a sustained benefit - virtually all those who remit end up relapsing within 6 months following a course, even when given a placebo. The relapse rate in the first six months may be reduced by the use of psychatric medications or further ECT, but remains high.
Once the decision has been made for a patient to have ECT there is usually a pretreatment evaluation that determines what factors will allow for maximum benefits and minimize risk. Informed consent is also sought before treatment. Patients are informed about the risks and benefits of the procedure. Patients are also made aware of risks and benefits of other treatments and of not having the procedure done at all. Depending on the jurisdiction the need for further inputs from other medical professionals or legal professionals may be required. ECT is usually given on an in-patient basis, although it may also be given on an out-patient basis. Prior to treatment a patient is given a short-acting anesthetic such as methohexital, propofol, etomidate and thiopental, a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation.
Electrodes are usually placed one on either side of the patient's head. This is known as bilateral ECT. Less frequently both electrodes are placed on one side of the head. This is known as unilateral ECT. In bifrontal ECT, an uncommon variation, the electrode position is somewhere between bilateral and unilateral. Unilateral is thought to cause fewer cognitive effects than bilateral but is considered less effective. In the USA most patients receive bilateral ECT. In the UK almost all patients receive bilateral ECT.
The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT. Below these levels treatment may not be effective in spite of a seizure, while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe cognitive impairment without additional therapeutic gains. Seizure threshold is determined by trial and error ("dose titration"). 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. Older men tend to have higher thresholds than younger women, but it is not a hard and fast rule, and other factors, for example drugs, affect seizure threshold.
In the USA, a survey of psychiatric practice in the late 1980s found that an estimated 100,000 people received ECT annually, with wide variation between metropolitan statistical areas. Accurate statistics about the frequency, context and circumstances of ECT in the United States are difficult to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information. One state which does report such data is Texas, where in the mid-1990s ECT was used in about one third of psychiatric facilities and given to about 1,650 people annually. Usage of ECT has since declined slightly; in 2000-01 ECT was given to about 1,500 people aged from 16 to 97 (in Texas it is illegal to give ECT to anyone under sixteen). ECT is more commonly used in private psychiatric hospitals than in public hospitals and minority patients are underrepresented in the ECT statistics. In the United States ECT is usually given three times a week; in the UK it is usually given twice a week. Occasionally it is given on a daily basis. A course usually consists of 6-12 treatments, but may be more or fewer. Following a course of ECT some patients may be given continuation or maintenance ECT with further treatments at weekly, fortnightly or monthly intervals. A few psychiatrists in the USA use multiple-monitored ECT (MMECT) where patients receive more than one treatment per anesthetic. As of 2007, electroconvulsive therapy practice is not officially regulated in the USA, and the education of physicians in its prescription and administration has been described as poor. Electroconvulsive therapy is not a required subject in US medical schools and not a required skill in psychiatric residency training. Privileging for ECT practice at institutions is a local option, no national certification standards are established, and no ECT-specific continuing training experiences are required of ECT practitioners.
In the United Kingdom in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then to about 12,000 per annum. It is still used in nearly all psychiatric hospitals, with a survey of ECT use from 2002 finding that 71 percent of patients were women and 46 percent were over 65 years of age. Eighty-one percent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. Sixteen percent were treated without their consent. In 2003 the National Institute for Clinical Excellence, a government body which was set up to standardize treatment throughout the National Health Service, issued guidance on the use of ECT. Its use was recommended "only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode". The guidance got a mixed reception. It was welcomed by an editorial in the British Medical Journal but the Royal College of Psychiatrists launched an unsuccessful appeal. The NICE guidance, as the British Medical Journal editorial points out, is only a policy statement and psychiatrists may deviate from it if they see fit. Adherence to standards has not been universal in the past. A survey of ECT use in 1980 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 1998 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. A voluntary accreditation scheme, ECTAS, was set up in 2004 by the Royal College, but as of 2006 only a minority of ECT clinics in England, Wales, Northern Ireland and the Republic of Ireland have signed up.
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 Holland and Italy, where its use is severely restricted".
The physical risks of ECT are similar to those of brief general anesthesia; the United States' Surgeon General's report says that there are "no absolute health contraindications" to its use. Immediately following treatment the most common adverse effects are confusion and memory loss. The state of confusion usually disappears after an hour.
A study published in 2004 in the "Journal of Mental Health" reported that 35 to 42% of patients said ECT resulted in loss of intelligence. The study also reported, "There is no overlap between clinical and consumer studies on the question of benefit."
Electroconvulsive Therapy (ECT) increases serum brain-derived neurotrophic factor (BDNF) in drug resistant depressed patients.
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. The patient is then given the opportunity to accept or reject the treatment. The form states how many treatments are recommended and also makes the patient aware that the treatment may be revoked at anytime during a course of ECT. The Surgeon General's report on mental health said that patients should be warned that the benefits of ECT are short-lived without active continuation treatment in the form of drugs or further ECT and that there may be some risk of permanent severe memory loss after ECT. The report advised psychiatrists to involve patients in discussion, possibly with the aid of leaflets or videos, both before and during a course of ECT.
To demonstrate what would be required to fully satisfy the legal obligation for 'informed consent', one psychiatrist, working for an antipsychiatry organisation, has formulated his own 'consent form' using the Texas Legislature as a model. It should be noted that printed or videotaped materials regarding ECT might be commissioned by the manufacturers of the equipment used, and so the possibility of this information leaning towards confirmation bias should be considered. Some question the effects of drugs on the ability to give informed consent.
In the UK in order for consent to be valid it requires an explanation in "broad terms" of the nature of the procedure and its likely effects. One review from 2005 found that only about half of patients felt they were given sufficient information about ECT and its adverse effects, and another survey found that about fifty percent of psychiatrists and nurses agreed with them.
In the USA, the Surgeon General's report on mental health requires a judicial proceeding, at which patients may be represented by legal counsel, prior to initiation of involuntary ECT, stating: "As a rule, the law requires that such petitions are granted only where the prompt institution of ECT is regarded as potentially lifesaving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia."
In England and Wales the Mental Health Act 1983 currently allows the use of ECT on detained patients (with and without capacity) if the treatment is likely to alleviate or prevent deterioration in a condition and is authorized by a psychiatrist from the Mental Health Act Commission's panel. However, proposed amendments to the Mental Health Act (clause 30) will introduce a capacity-threshold for the imposition of ECT. This in effect will mean that ECT may not be given to a patient who has capacity to refuse to consent to it, irrespective of his or her detention under the Act (the treatment may still be given in an emergency under s62). If the treating psychiatrist thinks the need for treatment is urgent they may start a course of ECT before authorization. About 2,000 people a year in England and Wales are treated without their consent under the Mental Health Act, with a small number of informal patients treated in this way under common law. In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 gives patients with capacity the right to refuse ECT.
A study published in 2005 in the "British Journal of Psychiatry" described patients' perspectives of electroshock. The study stated, “About half (45-55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not.” The study also said, “Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form. [deletion] The proportion who feel they did not freely choose the treatment has actually increased over time. The same themes arise whether the patient had received treatment a year ago or 30 years ago. [deletion] Neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ECT, at least in England and Wales.”
Duress in involuntary ECT makes reports about its effects, by patients while under duress, uncertain in their validity. Megara Sanderson, Events & Culture Editor of newspaper "The Flying Horse" reports, "Some speculate that patients may pretend that they are cured of their mental illness so that they no longer have to endure the electro-convulsive treatment."
Involuntary electroshock contravenes the principle of autonomy in medical ethics. The maxim of autonomy is "Voluntas aegroti suprema lex." This rule states that the will of the patient is supreme. It implies that a patient has the right to refuse a medical treatment, such as ECT.
In the early 1940s, in an attempt to reduce the memory disturbance and confusion associated with treatment, two modifications were introduced: the use of unilateral electrode placement and the replacement of sinusoidal current with brief pulse. It took many years for brief-pulse equipment to be widely adopted Unilateral ECT has never been popular with psychiatrists and is still only given to a minority of ECT patients. In the 1940s and early 1950s ECT was usually given in "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones. In the 1940s 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 1951 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 50's to the 70's. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given and, these now antiquated practices contributed to the negative portrayal of ECT in the popular media. The New York Times described the public's negative perception of ECT as being caused mainly by one movie,"For Big Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and in the public mind shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".
In 1976 Dr. 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 some ECT clinics in the US still use sine-wave devices. The 1970s saw the publication of the first American Psychiatric Association task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001). The report endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT. Specifically critics pointed to shortcomings such as noted side effects, the procedure being used as a form of abuse, and uneven application of ECT. The use of ECT declined until the 1980s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression". In 1985 the National Institute of Mental Health and National Institutes of Health convened a consensus development conference on ECT and concluded that, whilst ECT was the most controversial treatment in psychiatry and had significant side-effects, it had been shown to be effective for a narrow range of severe psychiatric disorders.
Due to the backlash noted previously, national institutions reviewed past practices and set new standards. In 1978 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 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task force report in 1990 where specific details on the delivery, education, and training of ECT were documented. Finally in 2001 the American Psychiatric Association released its latest task force report. This report emphasizes the importance of informed consent, and the expanded role that the procedure has in modern medicine.
NICE ECT guidelines report that some individuals consider ECT to have been a beneficial and lifesaving treatment, while others reported feelings of terror, shame and distress, and found it positively harmful and an abusive invasion of personal autonomy, especially when administered without their consent.
Kitty Dukakis, wife of politician Michael Dukakis, reports in a Newsweek article mostly positive effects from electroconvulsive therapy, and regards memory loss as an acceptable price to pay for relief from depression.
American psychotherapist Martha Manning's autobiographical Undercurrents acknowledges the downside of treatment: "I felt like I'd been hit by a truck for a while, but that was, comparatively speaking, not so bad," as well as the upside: "Afterwards, I thought, do regular people feel this way all the time? It's like you've not been in on a great joke for the whole of your life."
In his autobiographical book Electroboy, American writer Andy Behrman describes undergoing ECT as a treatment for bipolar disorder while under house-arrest: "I wake up thirty minutes later and think I am in a hotel in Acapulco. My head feels as if I have just downed a frozen margarita too quickly. My jaws and limbs ache. But I am elated.
Curtis Hartmann, a lawyer in western Massachusetts, stated: "ECT, a treatment of last resort for severe, debilitating depression, is all that has ever worked for me. I awaken about 20 minutes later, and although I am still groggy with anesthesia, much of the hellish depression is gone. It is a disease that for me, literally steals me from myself—a disease that executes me and then forces me to stand and look down at my corpse. Thankfully, ECT has kept my monster at bay, my hope intact".
Negative effects of ECT have been reported by noteworthy individuals.
Ernest Hemingway, American author, committed suicide shortly after ECT treatment at the Menninger Clinic in 1961. He is reported to have said to his biographer, "Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient....
In 2005, "Peggy S. Salters, 60, sued Palmetto Baptist Medical Center in Columbia, as well as the three doctors responsible for her care. As the result of an intensive course of outpatient ECT in 2000, she lost all memories of the past 30 years of her life, including all memories of her husband of three decades, now deceased, and the births of her three children. Ms. Salters held a Masters of Science in nursing and had a long career as a psychiatric nurse, but lost her knowledge of nursing skills and was unable to return to work after ECT. The jury awarded Salters $635,177 in compensation for her inability to work.
Registered nurse Barbara C. Cody reports in a letter to the Washington Post that her life was forever changed by 13 outpatient ECTs she received in 1983. "Shock 'therapy' totally and permanently disabled me. EEGs [electroencephalograms] verify the extensive damage shock did to my brain. Fifteen to 20 years of my life were simply erased; only small bits and pieces have returned. I was also left with short-term memory impairment and serious cognitive deficits. [deletion] Shock "therapy" took my past, my college education, my musical abilities, even the knowledge that my children were, in fact, my children. I call ECT a rape of the soul.
In 2007, a judge canceled a two year old court order that allowed the involuntary electroshock of Simone D., a psychiatric patient at Creedmoor Psychiatric Center in the state of New York. Although Simone spoke only Spanish, she rarely received access to staff fluent in her language. Simone previously had 200 electroshocks. However, she communicated that she did not want more electroshock. Simone stated, "Electroshock causes more pain. I suffer more from shock treatment!"
In 2008, David Tarloff, a psychiatric patient who had received electroshock, assaulted two therapists in the city of New York. Tarloff injured one therapist and murdered the other. One of the therapists was Kent Shinbach, a psychiatrist who had an interest in electroconvulsive therapy. "It is not clear whether Dr. Shinbach played any role in Mr. Tarloff's shock therapy. However, Tarloff told investigators that Shinbach had given Tarloff psychiatric treatment at a psychiatric facility initially in 1991.
In an interview with "Houston Chronicle"in 1996, Melissa Holliday, a former extra on "Baywatch" and model for "Playboy" stated the ECT she received in 1995, "ruined her life". She went on to state, "I've been through a rape, and electroshock therapy is worse. If you haven't gone through it, I can't explain it
Liz Spikol the senior contributing editor of Philadelphia Weekly, wrote of her ECT in 1996, "Not only was the ECT ineffective, it was incredibly damaging to my cognitive functioning and memory. But sometimes it's hard to be sure of yourself when everyone "credible"—scientists, ECT docs, researchers—are telling you that your reality isn't real. How many times have I been told my memory loss wasn't due to ECT but to depression? How many times have I been told that, like a lot of other consumers, I must be perceiving this incorrectly? How many times have people told me that my feelings of trauma related to the ECT are misplaced and unusual? It's as if I was raped and people kept telling me not to be upset—that it wasn't that bad.
A questionnaire survey of 379 members of the general public in Australia indicated that more than 60% of respondents had some knowledge about the main aspects of ECT. Participants were generally opposed to the use of ECT on depressed individuals with psychosocial issues, on children, and on involuntary patients. Public perceptions of ECT were found to be mainly negative.