Richard D. Weiner, M.D., Ph.D.
Andrew D. Krystal, M.D.
Electroconvulsive therapy (ECT) is the use of electrically induced seizures for therapeutic purposes. Now, more than 60 years since its first use, ECT continues to play an important role in the management of severe mental disorders, particularly episodes of major depression (American Psychiatric Association 1994a). Despite its portrayal by some as controversial, there is evidence of increasing interest in and use of this treatment. It behooves all mental health practitioners to be aware of the indications, risks, benefits, and methodology of ECT.
The roots of ECT lie in a now-disproven hypothesis that schizophrenia and epilepsy are incompatible. In 1934, this hypothesis led the Hungarian psychiatrist Ladislaus von Meduna to chemically induce a series of seizures in patients with schizophrenia. Because at that time there were no effective treatments for schizophrenia (or for other major mental disorders), Meduna’s partial success with this new “pharmacoconvulsive therapy” soon led to its widespread use (Meduna 1990).
With the arrival of pharmacoconvulsive therapy in Italy in the mid-1930s, the neuropsychiatrist and epileptologist Ugo Cerletti was struck both by its efficacy and by the technical difficulties involved in generating a seizure. By using an electrical stimulus to produce the seizure, a technique that he and others had developed as an experimental model of grand mal epilepsy, Cerletti and his colleague, Lucio Bini, developed this new “electroconvulsive” therapy, which offered a more controlled and reliable means of seizure induction (Endler 1988). The clinical significance of this innovation was rapidly appreciated around the world, and within a few years ECT had become the dominant somatic treatment not only for schizophrenia but for major mood disorders as well.
The state of knowledge about indications for ECT rapidly moved forward via clinical studies carried out during an early period of somewhat indiscriminate use. It soon became clear that ECT was most effective in major mood disorders, with a lesser degree of efficacy in patients with certain types of schizophrenia (as will be discussed later in this section). Beginning in the mid-1950s, following the discovery of antidepressant, antipsychotic, and antimanic psychotropic agents, the utilization of ECT began to decline, and many practitioners believed that this treatment modality would no longer be necessary.
This decrease in utilization was in part also due to powerful negative portrayals of ECT in the media (e.g., the movie One Flew Over the Cuckoo’s Nest), which often cast ECT as a crude and inhumane means of behavior control and played upon the rather horrific image engendered by the traditional unmodified ECT technique. Given such portrayals, it is not surprising that ECT was viewed by the public in a negative way.
Perhaps partly in reaction to such concerns, a series of scientific advances in ECT methodology—for example, use of general anesthesia, muscular relaxation, oxygenation, brief-pulse stimuli, unilateral electrode placement, and seizure monitoring (to be discussed later in this chapter)—were made. These advances have made modern ECT a state-of-the-art medical procedure, in which both efficacy and safety can be optimized. With these developments, along with a realization that the challenges of medication-resistant and medication-intolerant patients remain, there has been a resurgence of interest in the use of ECT, and the historical decline in utilization rate appears to have leveled out (Thompson et al. 1994).
In recent years the value of ECT has been endorsed by the American Psychiatric Association (American Psychiatric Association 1993; American Psychiatric Association Committee on ECT 2000), by a joint National Institutes of Health and National Institute of Mental Health Consensus Development Panel (Consensus Conference 1985), and within a mental health report by the U.S. Surgeon General. There is also evidence for a more positive attitude about ECT on the part of patients and their families (as evidenced by statements made by the National Depressive and Manic Depressive Association and the National Mental Health Association), as well as a tendency toward a more open-minded handling of ECT by the media.
This chapter focuses on the use of ECT in contemporary practice. Specifically, the indications for and risks associated with ECT are discussed, along with coverage of how treatments should be administered. For more detailed information, readers are referred to several recent book-length treatises on this topic. The American Psychiatric Association work is of particular importance because it provides comprehensive clinical recommendations covering all aspects of ECT, including training and privileging.
Antidepressant and Antimanic Medications
Combined Medication and Psychotherapy
Treatment-Resistant Mood Disorders
Treatment of Mood Disorders in the Medically Ill Patient
Strategies and Tactics in the Treatment of Depression
Revision date: July 9, 2011
Last revised: by Andrew G. Epstein, M.D.