A Case for Electro-Convulsive Therapy: The Never Ending Contraversy

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A Case for Electro-Convulsive Therapy: The Never Ending Contraversy

Electroconvulsive therapy is the treatment of choice for severe depressive episodes. Although little definitive research exists to explain its effectiveness, since its development in 1938 it has proven effective for the treatment of depression with psychotic features and suicidal ideation. The procedure is explained and implications for the mental health counselor are discussed.

Changes in professional understanding of mental illness have led to the increasing use of somatic, or biological, therapy as part of the successful treatment of some of the more common disorders. Somatic therapies are physical in nature, and the most commonly used of these are medication and electroconvulsive therapy (ECT). Many psychiatrists returned to the biological model in the 1980s and use both medication and ECT to treat the more severe or serious illnesses: (a) depression, (b) mania, (c) schizophrenia, (d) severe anxiety disorders, and (e) dementia. These disorders are common, handicapping, and often resistant to treatments other than ECT (Rey & Walter, 1997). In addition, they are the most likely disorders to have biological causes, and somatic therapies are seen as correcting an underlying biological imbalance.

Electroconvulsive therapy is widely used today, but continues to attract controversy (Baldwin & Jones, 1998; Johnstone, 1999). Even by the 1970s many standard psychiatric texts did not address ECT with children or adolescents, while others included brief references to possible clinical indications for administration. A paucity of training courses regarding ECT exists for health professionals as well as nonmedical mental health workers, who often hold responsible clinical or administrative positions (Kramer, 1999). Education and experience in the use of ECT result in a more positive attitude toward ECT as a viable treatment option for clients with refractory mood disorders and psychotic disorders (Baldwin & Jones, 1998; Finch, Sobin, Carmody, DeWitt, & Shiwach, 1999; Gass, 1998; Hermann, Ettner, Dowart, Hoover, & Yeung, 1998).

The belief held by many outside the mental health professions that ECT is dangerous, unnecessary, and misused is erroneous. Dr. Daniel Dye was a psychiatric resident with the diagnosis of bipolar disorder. He took lithium regularly after an initial course of ECT for severe depression. He is quoted by Restak (1988) in a case study as saying that ECT is "the gold standard" (p. 188). He felt that ECT broke through his depression and stopped it. Research supports the efficacy, safety, and economic savings of the use of ECT; however, the use of ECT varies widely and depends on geographic location (Irvin, 1997; Olfson, Marcus, Sackeim, Thompson, & Pincus, 1998; Salzman, 1998; Sherman, 2000; Wheeldon, Robertson, Eagles, & Reid, 1999). Rey & Walter (1997) suggest that more research and education of professionals and the public are needed, since information is necessary in order to accept or reject the opinions and criticisms of those who wish to limit the use of ECT. The purpose of this article is to provide basic information on ECT to mental health counselors for use in developing and providing more effective services to clients considering, receiving, or completing a course of ECT.

When ECT was developed it was often given without adequate sedation beforehand and without the use of muscle relaxants to prevent violent seizures. ECT was a frightening and risky procedure. As a result of this, ECT was frequently portrayed inappropriately in films as a form of punishment with which to control unruly patients (Salzman, 1998).

Convulsive therapy as a treatment for schizophrenia was introduced by von Meduna and reported in 1934. His reasoning for such an approach was based on two observations long noted by mental hospital physicians. The first was that patients would suddenly lose their symptoms when they had a convulsion. The second was the belief, now known to be erroneous, that epilepsy and schizophrenia rarely occurred in the same patient (Restak, 1988).

Von Meduna's work followed that of another Hungarian, Nyiro, who treated schizophrenic patients with the blood from epileptic patients (Restak, 1988). This treatment proved unsuccessful, so von Meduna induced actual convulsions in patients with schizophrenia by injecting camphor in oil intramuscularly. This was found to be unreliable, since it was not possible to predict when the first convulsion would occur. Some patients would have several convulsions, and some patients would have no convulsions at all. Von Meduna changed to a soluble synthetic camphor preparation, Metrazol (pentylenetetrazol), which was injected intravenously. In the majority of cases, this produced a convulsion within 30 seconds (Butcher, Carson, & Coleman, 1988). Several pharmacological convulsive agents were used after Metrazol was introduced. Usage of only one continued; hexaflourodiethyl ether, or Indoklin, produces a tonic-clonic seizure when inhaled (Freedman, Kaplan, & Sadock, 1975).

In 1938, two Italian workers, Cerletti and Bini, used electrically induced convulsions in place of pharmacological convulsive therapy. Bini built a simple apparatus using alternating current. Most machines used today are still based on his model. Other machines have been introduced over the years, and there is much controversy over whether modified currents produce less confusion and reduce memory impairments seen in patients after a course of electroconvulsive therapy than machines based on Bini's design. Today, ECT machines are classified as Class III devices by the Federal Food and Drug Administration (FDA), which means that ECT is an experimental procedure, classified in the highest risk category by the FDA. The machines have not gone through the rigorous FDA testing required of medical devices, including safety testing and efficacy assessments (Breeding, 2000). Regulation of ECT is done by each state and varies widely. The American Psychiatric Association offers guidelines for the use of ECT, and research is ongoing to determine efficacy, electrode placement, and optimum stimulus intensity (Bailine, Rifkin, Kayne, & Selzer, 2000; Prudic, Haskett, Mulsant, & Malone, 1996; Rey & Walter, 1997).

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Originally used to treat schizophrenia, ECT was largely replaced by the use of antipsychotic drugs in the 1950s. Today, fewer than 20% of the clients given ECT are diagnosed as having schizophrenia. ECT is still used in the emergency treatment of some intractable psychotic patients, but probably does not change the course of the illness (Reid, 1989). It may benefit those with major depression, bipolar disorder, and some forms of schizophrenia, including catatonia (Hermann, Dorwart, Hoover, & Brody, 1995). It is useful for several types of schizophrenic episodes, but most clinicians feel that pharmacological treatment is preferable at all ...

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