Introduction:
Memory is considered to be the holy grail of neuroscience. Likewise, ECT-Electroconvulsive Therapy (formerly known as electroshock therapy) can be termed as the holy grail in the treatment of psychiatric disorders. Unfortunately, there are a number of myths about the dangers of ECT. These beliefs have no scientific basis, and it is about time that these myths are busted. Bad press and movies were equally responsible for bringing this time-tested treatment into disrepute. The general public and the medical fraternity are largely ignorant about the procedure and its manifold benefits.
An Italian neuropsychiatrist Ugo Cerletti along with Lucio Bini, developed the ECT in 1938 to treat a patient with schizophrenia, hallucinations, and delusions. ECT delivered electrically induced generalized seizures or brief recurrent shocks while chemically (Metrazol) induced convulsions were being employed before ECT was developed to treat schizophrenia. However, ECT came with a drawback that the duration of seizures could not be controlled, and the treatment could not be individualized.
What Are the Types of Electroconvulsive Therapy?
Unmodified or Direct ECT:
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In unmodified or direct ECT, no anesthesia or muscle relaxants are used before the procedure, and shock therapy is carried out while the person is awake.
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This increases the risk of teeth and bone fracture, muscle damage, etc., due to the knocked out effect of the delivered electricity.
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This was termed ''barbaric'' by liberal thinkers and human rights activists.
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The Mental Health Care Act Bill, 2013 prohibits the usage of unmodified ECT.
Modified ECT:
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In modified ECT, anesthesia is first administered, followed by the usage of muscle relaxant.
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Only then is the electrical stimulus applied, which produces convulsions.
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This way, the patient is immune to the pain of the electrical stimulus, and more importantly, is not aware of the seizure episode.
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Administration of an electrical stimulus, along with central seizures, will also cause peripheral seizures, which may result in musculoskeletal injuries.
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To prevent this, a muscle relaxant is used. But these muscle relaxants temporarily affect respiration.
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To overcome this problem, anesthesia is administered prior to the injection of the muscle relaxant, which puts the patient to sleep.
Modern-day ECT suites are equipped with fancy equipment and fancier monitoring systems. All of these serve to minimize the risk to the patients. The components of an ECT suite include a sphygmomanometer to measure the blood pressure, a pulse oximeter to monitor the oxygen saturation levels, a central laminar airflow system, a cardiac defibrillator (if cardiac asystole occurs), an electroencephalogram (EEG), emergency medications, anesthetists, and psychiatrists.
How Does Electroconvulsive Therapy Work?
Mechanism of Action of ECT:
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What is surprising is that, given the tremendous efficacy of the ECT, there has been no discovery of its exact mechanism of action. This may be one of the reasons for the stigma attached to it.
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Proposed mechanisms by which ECTs are believed to work include modulation of the brain structure, function, and neural connectivity.
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ECT also targets the neurotransmitters like monoamines and helps in stabilizing their concentrations.
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Hypothalamic-pituitary-adrenal (HPA) axis dysfunction is frequently seen in depression. This results in an increased concentration of the steroid hormone cortisol. ECT has been shown to reverse this HPA axis dysfunction and thereby suppress cortisol levels, which coincides with marked improvement in depressive symptomatology.
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Then there is evidence to show that ECT modulates gene expression, neurogenesis, and synaptic plasticity. To put it simply, the mechanism of action varies according to the illness, or rather the actions of ECT are multimodal.
Why Is Electroconvulsive Therapy Done?
ECTs are extensively done for the treatment of psychiatric disorders such as,
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Severe and agitated depression along with psychotic symptoms.
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For rapid amelioration of the positive symptoms in schizophrenia.
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Catatonia.
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Patients with psychomotor retardation.
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Uncooperative patients with psychotic symptoms.
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Bipolar disorder with severe depressed phases or mania.
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Severe aggression.
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Parkinsonism.
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Delirium that is resistant to medications and other treatment strategies.
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People with schizophrenia are resistant to treatment.
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Bipolar disorders are resistant to treatment, and possibly PTSD (Post-traumatic stress disorder).
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ECT can be lifesaving in the aforementioned clinical conditions. A patient harboring severe suicidal ideations can be saved by this simple and cost-effective procedure.
What Preparations Are Needed Before Undergoing Shock Therapy?
Before undergoing the shock therapy, the doctor evaluated the patient’s condition completely in the following ways:
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Medical history.
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Complete physical examination.
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Patient’s blood tests.
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Psychiatric assessment.
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Evaluate the risk of anesthesia.
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Electrogram (ECG) to check the heart health.
What Are the Temporary Deficits Or Risk Factors Caused By Electroconvulsive Therapy?
ECTs can cause temporary deficits, and certain conditions are discussed below.
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Clinicians must take responsibility to ease the fear amongst the general public about the supposed dangers of ECT. A vast majority of patients (and surprisingly some doctors too) believe that ECT can cause permanent 'brain damage', which is an idea that is very far-fetched from reality.
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Sure, ECT does cause temporary memory loss in the form of retrograde amnesia (memory loss), which resolves by itself. However, retrograde amnesia is not seen in all the patients, but only a proportion of the patients undergoing ECT.
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The more common cognitive deficits (problems in one’s ability to learn, think, make decisions, and remember) like impaired orientation, disturbances in the autobiographical memory, and executive dysfunction disappear within 15 days of the treatment.
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The treatment with ECT also causes physical side effects in a person, such as headache, nausea, muscle ache, or jaw pain.
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These temporary deficits can be further minimized by spacing out the treatments appropriately. Studies have shown that cognitive deficits are significantly lower for unilateral, twice weekly, low dose ECT as compared to bilateral, thrice weekly, high dose ECT. A baseline bedside clinical assessment of the cognitive functions prior to the administration of ECT is mandatory.
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Hence, it is efficacious in a wide variety of disorders, ranging from depression to schizophrenia (a mental illness affecting behavior, feelings, and thinking). The repertoire of the actions of ECT is mind-boggling by itself.
What Are the Other Brain Stimulating Treatments?
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Vagus Nerve Stimulation (VNS): This method of brain stimulation is used for the treatment of depression when other treatment options, such as ECT or shock therapy are ineffective. VNS is used for stimulating the vagus nerve through electrical pulses by implanting this device.
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Transcranial Magnetic Stimulation (TMS): This type of brain stimulation uses a magnetic field to influence the activity of the brain.
What Are the Advantages of Shock Therapy or ECT?
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It is an effective treatment method for mood-related disorders, such as depression.
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The treatment is considered safe during pregnancy also.
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ECT is considered safe for people who cannot take various medications due to some underlying medical conditions.
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The treatment shows rapid results and improvement in symptoms after two to three therapies, especially if one is suffering from a major depressive disorder.
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The treatment is also effective in combination therapy along with medications and increases the chances of improving the patient's health condition
Conclusion:
Progress in the field of anesthesia has made the procedure all the safer. The benefits outweigh the risks by a huge margin. ECT produces a prompt treatment response that other treatment modalities hardly can. In conditions with rapid amelioration of symptoms, ECT is preferred. No doubt why ECT is considered the 'gold standard' treatment in psychiatry.
