Electroconvulsive Therapy: History and Modern Use

This assignment delves into the historical evolution of electroconvulsive therapy (ECT), examining its initial development and controversial past alongside its current applications in treating various mental health conditions. It explores both the therapeutic benefits and potential risks associated with ECT, addressing ethical considerations and contemporary practices surrounding this treatment modality.

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ELECTROCONVULSIVE THERAPY AND NURSING CARE MANAGEMENT
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Table of Contents
Contents Page
Introduction....................................................................................................................3
A brief history of ECT...................................................................................................3
Epidemiology of ECT....................................................................................................6
Indications of ECT.........................................................................................................8
Major depression........................................................................................................8
Mania..........................................................................................................................9
Bipolar Disorder.........................................................................................................9
Schizophrenia...........................................................................................................10
Theories on Mechanism of Action...............................................................................10
Nursing Role................................................................................................................10
Pre-ECT....................................................................................................................11
Post ECT..................................................................................................................12
Conclusion....................................................................................................................12
References....................................................................................................................14
Appendices...................................................................................................................17
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Introduction
Electroconvulsive therapy (ECT) is the deliberate inducing of a modified generalized
seizure in an anaesthetized patient under medically-controlled conditions to produce a
therapeutic effect (Kavanagh & McLoughlin, 2009). To achieve this, an electric
charge is passed through the brain between two electrodes that are placed on the scalp
of the anaesthetized patient. Electroconvulsive therapy is used to cause changes in the
chemistry of the brain so as to reverse the symptoms of some mental conditions. It is
often referred when other treatments are unsuccessful. When compared to
pharmacotherapy, ECT has evidenced as an effective treatment for depression. It is
actually preferred as an effective treatment option for the acute treatment of
depression with psychotic symptoms (Petrides, et al., 2001). ECT plays a critical role
in contemporary mental health care, and nurses play a very pivotal role in which they
have to deliver on when a patient undergoes electroconvulsive therapy.
This resource reviews ECT and its developmental history, epidemiology, indications
and its mechanism of action.
A brief history of ECT
The history of electroconvulsive therapy can be traced back to the 1500s on the basis
of the practice in which mental illness was treated with convulsions. The initial
practice involved inducing convulsions by orally taking camphor. The Swiss
physician Paracelsus successfully induced seizures through oral administration of
camphor to treat psychiatric illness (Sadock & Sadock, 2007). The first report to
published on the use of camphor to induce seizures for the treatment of mania was in
1785. Oral camphor was later replaced with intramuscular injection as demonstrated
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by the Hungarian neuropathologist Ladislas Joseph von Meduna in 1934 for the
treatment of catatonic schizophrenia (Sadock & Sadock, 2007). Treating mental
conditions with chemically-induced seizures came along with an equal share of
distressing and prolonged preictal effects which served as a precursor for the
exploration of new methods to induce therapeutic seizures.
Modern ECT can be traced back to 1938 when electricity was used to induce seizures
for the successful treatment of a catatonic patient by the neurologist Ugo Cerletti and
psychiatrist Lucio Bini (Kalapatapu, 2015). In 1939, ECT was introduced in the US
(Pandya, et al., 2007). However, the lack of adequate anaesthetic procedures or
muscle relaxation measures during ECT procedures led to dislocations and fractures,
and also the lack of adequate knowledge pertaining to dose parameters of electrical
stimulation to severe cognitive adverse effects (Pandya, et al., 2007). To counter such,
curare was used as a muscle relaxant during ECT procedures (Sadock & Sadock,
2007). Insulin shock therapy and lobotomy were the only viable alternatives to ECT
until the 1950s when effective antipsychotic drugs were developed.
Electroconvulsive therapy as a procedure was first scientifically researched in the
1950s. psychiatrist Max Fink applied rigorous scientific research methods to study the
efficacy and the ECT procedure (Taylor, 2007). It is in the same year in which
succinylcholine, a depolarizing muscle relaxant was introduced and used alongside a
short-acting anaesthetic during ECT procedures so as to prevent injuries and also
numb the patient from feeling the ECT procedure. According to Sadock and Sadock
(2007), randomised clinical trials conducted on the efficacy of ECT compared to other
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medications for the treatment of mania, the response rates were significantly higher in
ECT.
As a measure to reduce abuse and misuse of the procedure, in 1978, the American
Psychiatric Association published the first Task Force Report on ECT which outlined
standard ECT procedures which were in-line with scientific evidence. This report was
later revised in 1990 and 2001. The development of ECT was further boosted by the
endorsement by the National Institutes of Health and National Institute of Mental
Health Consensus Conference on ECT, which also called for additional research and
national standards of practice (Sadock & Sadock, 2007). Towards the end of the 20th
century, randomised controlled clinical trials of ECT versus lithium were carried out
and the results indicate that both have equal efficacy in the treatment of mania. In the
early 21st century, Sarah Lisanby and colleagues from the Columbia University
successfully demonstrated inducing convulsive treatment using magnetic stimulation
(Sadock & Sadock, 2007).
The development of ECT was characterised by two eras. One was an era oof
therapeutic optimism in psychiatry, and the other was an era of almost indiscriminate
use (Glass, 2001). The initial era of therapeutic optimism occurred when there was no
alternative to ECT. However, during the mid-20th century, ECT was almost
indiscriminately used and the consequences of this period were the anti-psychiatry
movement which exaggerated the negative aspects of ECT and hospital care,
alongside negative portrayal in media such as “One Flew Over The Cuckoo’s Nest”
(Swaine, 2011). These actions cast a shadow on the efficacy of ECT. In the current
times, there is some stigma and fear that accompanies contemporary ECT (Dowman,
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et al., 2005). This inhibits the potential of administering effective treatment on
individuals suffering from severe mental illness in two forms. First, it is the reluctance
of treating teams to prescribe the treatment and second are the unwillingness of
patients to accept it when prescribed. To overcome such stigma, Glass (2001),
recommends that healthcare professionals need to be aware of the facts surrounding
the contemporary ECT practice, alongside efficacy, indications and adverse effects.
Epidemiology of ECT
Electroconvulsive therapy was initially indicated in the treatment of schizophrenia as
early as 1941. However, the utilization of the procedure declined on the 1970s and
80s following the introduction of pharmaceutical products for the treatment of severe
mental disorders (McCall, et al., 1992). As a result, ECT mainly became indicated as
a last-resort option for patients who exhibited resistance to medication and those who
exhibited severe life-threatening illness (Eranti & McLoughlin, 2003). This notion
was however rectified following the guidelines by the National Institutes of Health
and National Institute of Mental Health Consensus Conference on ECT which
recommended that ECT should not be used as a last resort.
The spread of ECT from Europe to other continents including the US occurred rapidly
following the displacement of psychiatrists during World War II (Shorter, 2009).
There are an estimated one million patients worldwide who receive electroconvulsive
therapy each year (Hermann, et al., 1995). According to Swartz (2009), ECT stands
out as a widely available treatment modality for persons with mental disorders across
all continents. Regardless of the common international guidelines (Enns, et al., 2011)
developed for the practice, there are large differences in the practice among regions
and countries. In addition, there are variations in ECT utilization across the various
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divides. For instance, according to a 2009 study by Van Waarde and colleagues on the
utilization of ECT in the previous decade, the utilisation of ECT in the US was
estimated 4.9 persons per 10,000 resident population per year as of 1995 (van
Waarde, et al., 2009). Further, according to a 2012 review, there are indications of
sparse utilisation in the continents of Latin America and Africa (Leiknes, et al., 2012).
ECT is abundantly practiced in Europe, Asia, and America.
Regardless of the wide utilisation in Europe, America, and Asia, there are variations
in the utilization rates and clinical practice between the regions and countries.
Notably, unmodified ECT (ECT administered without anaesthesia) is substantially in
use mainly in Asia with an over 90% prevalence, in Latin America, Africa, and some
countries in Europe (Spain, Russia, and Turkey) (Leiknes, et al., 2012).
In Australia, the United States, New Zealand and Europe, ECT is mainly utilised by
elderly female patients exhibiting depressive disorders. In other parts of the world
(Africa Asia, Russia, Latin America), where unmodified ECT is still administered, the
predominant users are younger male patients presenting with schizophrenia (Leiknes,
et al., 2012). Baghai, et al., (2005) and Moksnes, et al., (2006) agree with this
observation, noting that the predominance of patients who receive ECT in the first tier
of countries are elderly female with affective disorder. The same profile is applicable
to Pakistan and Saudi Arabia except for age being younger. Western Australia also
exhibits higher ECT treatment rates among Caucasian white ethnicity (Teh, et al.,
2005).
Pertaining the provision of ECT by psychiatric institutions, there are significant
variations. Asia demonstrates the highest (59-78%), followed by Australia at 66%, 23-
51% in Europe and 6% in the United States (Leiknes, et al., 2012). Chanpattana,
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(2007), agrees with this observation, noting that in Australia, the procedure is
provided by 66% institutions whereas training on ECT is provided by 73% of the
institutions.
An analysis of reports on the side effects, adverse effects and mortality rates related to
ECT reveals a sparse database. Nevertheless, Thailand reports the highest mortality
rate (0.08%) followed by Texas (14 deaths per 100.000 treatments) (Chanpattana &
Kramer, (2004); Scarano & Felthous, (2000). However, there are no indications of
whether these ECT-related deaths are as a result of either anaesthetic complications,
comorbid somatic illnesses or as a result of lethal side effects such as cardiac
arthymia.
Pertaining to the consent of administration of ECT, the procedure is largely
administered involuntarily or under guardian consent conditions across all regions of
the world.
Indications of ECT
ECT is an ideal nonpharmacologic biological treatment with a proven high
effectiveness predominantly for depression, schizophrenia and other indications. ECT
is particularly an important alternative option in the treatment of therapy-resistant
psychiatric disorders which result after medication treatment failures.
Major depression
Electroconvulsive therapy is an effective and rapid-acting option for the treatment of
severe depression. It is indicated in cases of major depression when antidepressant
therapy stands out to be ineffective or intolerable or in events where the symptoms are
quite severe to warrant a rapid response (O'Reardon, et al., 2011). Due to its rapid
response, it is often a preferred treatment modality for patients with highly severe
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psychotic, or suicidal depression. For these categories of patients, waiting for
antidepressants is unfeasible. ECT is recognised to be quite effective and safe
treatment in psychiatry. The drawback is that the effects of the treatment usually do
not last and it often warrants further treatment.
Mania
The use of ECT as the primary treatment option for mania has declined in recent
times as a result of the availability of atypical antipsychotics, classical neuroleptics,
lithium and other mood stabilizers which exhibit better antimanic effectiveness.
Regardless, randomised controlled trials and study reviews have indicated good
efficacy of ECT. ECT has indicated high remission or improvement rate (Baghai &
Möller, 2008).
Bipolar Disorder
Acute depression that is characteristic of bipolar disorder often does not rapidly or
adequately respond to pharmacological agents particularly antidepressants (can
precipitate the switching phase of the illness) or mood stabilizers, (with the exception
of lithium, quetiapine, lamotrigine). It is thus recommended that ECT should be
considered for clients with bipolar disorder in the depressive state, especially if they
exhibit unresponsiveness to any medication in either category of mood stabilisers or
antidepressants. The preference for ECT over antidepressants is that ECT does not
precipitate switching. Contrary to common misconceptions, ECT is an ideal
alternative especially for the elderly, and those patients with bipolar disorder and co-
morbid medical presentations (Brooks, 2015).
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Schizophrenia
ECT was initially adopted in the management of schizophrenia as early as in 1938 by
Cerletti and Bini. The procedure has demonstrated efficacy in the treatment of
patients with schizophrenia and schizoaffective disorder (Chanpattana, et al., 2010).
This is regardless of a decline in its use for this condition in the 1950s after the
introduction of neuroleptics. ECT stands out as an effective option for persons
suffering from schizophrenia, and it is recommended for persons with the conditions
and who have shown nil or minimal response to antipsychotics, and also those having
a co-morbid status which makes this alternative a safer alternative (Phutane, et al.,
2011).
Theories on Mechanism of Action
Studies on the mechanism of action of ECT using animal models have revealed that
there is the need for repeated administration of the procedure in order to entrain a
series of molecular and structural changes in the brain which are proposed to be
relevant to its antidepressant effect (Kavanagh & McLoughlin, 2009). These changes
include the upregulation of neuronal growth factors which enhance the survivability
of neurones and plasticity or the manner in which neurones can adapt to enhance the
way they connect with each other. Notably, ECT also increases the number of new
nerve cells in the hippocampus (Grover, et al., 2005). The hippocampus is concerned
with memory and mood regulations. According to Kavanagh and McLoughlin (2009),
the effect produced by antidepressants is much lesser compared to ECT.
Nursing Role
Psychiatric nursing care for ECT has evolved from the traditional supportive and
adjunctive practice to the existing practice of collaborative and independent nursing
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actions (Burns & Stuart, 1991). In the current practice, nursing in ECT encompasses a
number of nurses including an ECT nurse, a ward nurse, operating department
assistant, nurse coordinator and a recovery nurse.
Pre-ECT
The ECT nurse plays the role of coordinating the service and is also tasked with the
responsibility of managing the ECT clinic and caring for the patient (IECT
Accreditation Service, 2016). ECT nurses are charged with developing protocols
which are in line with best practice guidelines. The ECT nurse in entirety ensures that
both the medications, equipment, and environment for ECT are adopted in line with
the best practice guidelines (Kavanagh & McLoughlin, 2009).
Whereas the actual administration of electroconvulsive therapy is the primary
responsibility of the anaesthetist and the psychiatrist, the ECT nurse plays a very
critical role in addressing the psychological needs of the client undergoing the
procedure. This involves but not limited to educating the patient about their condition,
the reasons why the procedure has been recommended, the initial and through the
treatment process, addressing the patient's or family's fears pertaining the procedure
and using scientific evidence and facts to direct them (Queensland Health, 2017).
With such, the patient is educated, a therapeutic relationship is also formed between
the nurse and the patient, it reduces anxiety and also dispels myths and negative
premonitions formed. The nurse plays a critical role in this element as (s)he makes the
process less intrusive and more positive and these encourage the patients to persist
through the process regardless of the adverse effects.
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Before the treatment, the nurse undertakes a pre-treatment checklist and ensures the
patient is ready for anaesthesia and the procedure itself. The nurse is also in charge of
the patient’s prevailing mental, legal and medical status (Kavanagh & McLoughlin,
2009)
Post ECT
The recovery nurse plays an important role following the ECT treatment course.
These nurses are equipped with knowledge in advanced life support and are also
conversant with the ECT treatment process and all possible adverse events. Following
the treatment, the nurse will maintain the integrity of the patient’s airway, monitor the
vitals and also administer prescribed medications to counter the side effects. The
nurse’s role in the recovery room persists until the patient regains his orientation and
the anaesthetist gives a clean bill of health (Queensland Health, 2017).
Conclusion
Electroconvulsive therapy (ECT is considered the most effective treatment for the
management of severe mental illness. The process has undergone tremendous
development dating back to 1938 when it was adequately developed to treat
schizophrenia. Even though there is a significant amount of stigma associated with the
process, there is a significant amount of evidence base that supports its efficacy and
safety in modern medicine.
Nurses currently play a very important role in the provision of ECT. This is opposed
to the earlier role that was just a supportive one. Currently, nurses play a multifaceted
role ranging from the ECT nurse, ward nurse, recovery nurse and the anaesthetist’s
assistant. It is therefore of great significance to lay emphasis on the education of
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nurses in ECT so as to enhance the central role they play in the enhancement and
development of the therapy.
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References
Baghai, T. C. & Möller, H.-J., 2008. Electroconvulsive therapy and its different
indications. Dialogues Clin Neurosci, 10(1), pp. 105-117.
Baghai, T., Marcuse, A., ller, H. & Rupprecht, R., 2005. Electroconvulsive therapy at
the Department of Psychiatry and Psychotherapy, University of Munich.
Development during the years 1995–2002. Nervenarzt, Volume 76, pp. 597-612.
Brooks, M., 2015. ECT Beats Drug Therapy for Resistant Bipolar Depression.
[Online]
Available at: http://www.medscape.com/viewarticle/839049
[Accessed 4 september 2017].
Burns, C. & Stuart, G., 1991. Nursing care in electroconvulsive therapy.. Psychiatr
Clin North Am, 14(4), pp. 971-88.
Chanpattana, W., 2007. A questionnaire survey of ECT practice in Australia.. J. ECT.
, Volume 2007, pp. 89-92.
Chanpattana, W. & Kramer, B., 2004. Electroconvulsive therapy practice in Thailand.
J. ECT, Volume 20, pp. 94-98.
Chanpattana, W. et al., 2010. A survey of the practice of electroconvulsive therapy in
Asia.. J ECT., Volume 26, pp. 5-10.
Dowman, J., Patel, A. & Rajput, K., 2005. Electroconvulsive therapy: attitudes and
misconceptions. J ECT, 21(2), pp. 84-7.
Enns, M., Reiss, J. & P, C., 2011. Electroconvulsive therapy [Position Paper 1992–
27-R1]. s.l.:s.n.
Eranti, S. & McLoughlin, D., 2003. Electroconvulsive therapy—state of the art. Br. J.
Psychiatry, Volume 182, pp. 8-9.
Glass, R., 2001. Electroconvulsive therapy: time to bring it out of the. JAMA, 285(10),
pp. 1346-8.
Grover, S., Mattoo, S. K. & Gupta, N., 2005. Theories on Mechanism of Action of
Electroconvulsive Therapy. German Journal of Psychiatry, pp. 70-84.
Hermann, R., Dorwart, R., Hoover, C. & Brody, J., 1995. Variation in ECT use in the
United States. Am. J. Psychiatry, Volume 152, pp. 869-875.
IECT Accreditation Service, 2016. Standards for the administration of ECT. 3rd ed.
London: Royal College of Psychiatrists.
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Kalapatapu, R. K., 2015. Addiction Psychiatry. [Online]
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%2BgpbZkL0sQA5MVsQnXkdlGtuko%2BqF90%2Fo
%2FWHsf1SXToM9t2GZJwKsZeuU%3D
[Accessed 4 September 2017].
Kavanagh, A. & McLoughlin, D. M., 2009. Electroconvulsive therapy and nursing
care. Brritish Journal of Nursing, 18(22), pp. 1371-1377.
Leiknes, K. A., Schweder, L. J.-v. & Høie, B., 2012. Contemporary use and practice
of electroconvulsive therapy worldwide. Brain Behav, 2(3), pp. 283-344.
McCall, W., Weiner, R., Shelp, F. & Austin, S., 1992. ECT in a state hospital setting.
Convuls. Ther., Volume 8, pp. 12-18.
Moksnes, K., Vatnaland, T., Eri, B. & Torvik, N., 2006. Electroconvulsive therapy in
the Ullevaal region of Oslo 1988–2002. Tidsskr. Nor. Laegeforen, Volume 126, pp.
1750-1753.
O'Reardon, J. P. et al., 2011. Electroconvulsive Therapy for Treatment of Major
Depression in a 100-Year-Old Patient with Severe Aortic Stenosis: A 5-year follow
up report. J ECT, 27(3), pp. 227-230.
Pandya, M., Pozuelo, L. & Malone, D., 2007. Electroconvulsive therapy: whta the
internist needs to know. Cleve Clin J Med, 74(9), pp. 679-85.
Petrides, G. et al., 2001. ECT remission rates in psychotic versus nonpsychotic
depressed patients: a report from CORE. J ECT, 17(4), pp. 244-53.
Phutane, V. H. et al., 2011. Why do we prescribe ECT to schizophrenia patients?.
Indian J Psychiatry, 53(2), pp. 149-151.
Queensland Health, 2017. The Administration of Electroconvulsive Therapy. 1st ed.
Queensland: State of Queensland.
Sadock, B. & Sadock, V., 2007. Brain Stimulation Methods. In: Kaplan & Sadock,
eds. Kaplan & Sadock's Synopsis of Psyhciatry: Behavioral Sciences/Clinical
Psychiatry. Philadelphia: Lippincott Willians and Wilkins.
Scarano, V. & Felthous, A., 2000. The state of electroconvulsive therapy in Texas.
Part I: reported data on 41,660 ECT treatments in 5971 patients. J. Forensic Sci,
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Shorter, E., 2009. History of electroconvulsive therapy.. In: C. Swartz, ed.
Electroconvulsive and neuromodulation therapies. New York: Cambridge Univ.
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Press, pp. 167-79.
Swaine, J., 2011. How 'One Flew Over the Cuckoo's Nest' changed psychiatry.
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Taylor, S., 2007. Electroconvulsive therapy: a review of history, patient selection,
technique, and medication management. South Med J, 100(5), pp. 494-8.
Teh, S., Xiao, A., Helmes, E. & Drake, D., 2005. Electroconvulsive therapy practice
in Western Australia. J. ECT, Volume 145-150, p. 21.
van Waarde, J., Verwey, B., van den Broek, W. & van der Mast, R., 2009.
Electroconvulsive therapy in the Netherlands: a questionnaire survey on
contemporary practice. J ECT, Volume 25, pp. 190-194.
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Appendices
Source: ‘The Not-So-Shocking Facts about ECT’ by Peter Chan,
http://www.heretohelp.bc.ca/visions/seniors-mental-health-no15/the-not-so-shocking-facts-about-ECT
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Source: Opportunities and Challenges for Electroconvulsive Therapy by Donna Ecklesdafer,
http://www.meetingproceedings.com/2012/posters/apna/SplitViewer.asp?PID=ODAyODE2MDA
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Source: (Kavanagh & McLoughlin, 2009)
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