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ELECTROCONVULSIVE THERAPY
Written by:
Chitturungun Andrude MD
AdditionuI Professor
Depurtment of PsychophurmucoIogy
NutionuI Institute of MentuI HeuIth und Neurosciences unguIore 0 0Z9 Indiu
Member of fhe WorId Federofion of Sociefies of 8ioIogicoI Psychiofry Tosk Force on ECT
EIecfroconvuIsive fheropy (ECT) is o form of freofmenf fhof is somefimes used in fhe monogemenf
of severe depression or psychosis, incIuding pofienfs wifh bipoIor disorder. AIfhough fhe freofmenf
is effecfive, ond con even be Iife-soving, if hos been reviIed os o professionoI ossouIf on fhe pofienf,
ond hos been occused of producing broin domoge.
The generoI pubIic ond fhe moss medio view ECT wifh misgivings becouse eIecfricify is possed
fhrough fhe broin, fhe seof of reoson, ond becouse fhe pofienfs
body oppeors fo convuIse horrificoIIy os o resuIf of fhe shock. ECT, however, is nof o crueI
freofmenf. This orficIe seeks fo reopproise ECT ond fo presenf
ifs modern procfice.
A pofienf odvised ECT undergoes o fuII physicoI exominofion os weII os fesfs such os fhe EC0 ond X-
Poys, fifness fo receive ECT is fhus confirmed. ECT is
usuoIIy odminisfered in fhe morning offer on overnighf fosf. The pofienf Iies down in fhe ECT room
ond on onoesfhefic drug, such os mefhohexifoI, is injecfed
infrovenousIy. This drug induces sIeep ond curfoiIs fhe onxiefy fhof fhe ECT procedure moy
ofherwise occosion. Mexf, o muscIe reIoxonf, such os succinyIchoIine,
is injecfed. This drug poroIy;es fhe voIunfory muscIes of fhe body ond minimi;es fhe vioIence of fhe
convuIsion. Somefimes, ofher drugs ore oIso given fo increose
fhe sofefy of fhe procedure, fhe use of such drugs depends upon individuoI need. WhiIe fhese pre-
ECT freofmenfs ore being given, fhe pofienf is hypervenfiIofed
wifh pure oxygen.
During ECT, o specioI device is used fo poss o smoII currenf (usuoIIy 0.b-0.8 A) fhrough eIecfrodes
oppIied fo fhe heod. The currenf Iosfs for o durofion fhof is
seIdom more fhon four seconds. The fofoI eIecfricoI chorge fhof fhe pofienf receives is 0.I-0.3 C, on
overoge (one couIomb [C] is fhe chorge deIivered when
one ompere [A] of currenf is possed for one second). Much of fhe eIecfricoI chorge during ECT does
nof ocfuoIIy reoch fhe broin buf insfeod froverses scoIp
fissues. If is cIeor, fherefore, fhof o very finy eIecfricoI sfimuIus is oppIied. This shouId reossure
fhose who beIieve fhof Iorge boIfs of eIecfricify sfrike fhe broin
during ECTl

The currenf oppIied ocfivofes fhe broin ond eIicifs o sei;ure. This is demonsfrofed using
eIecfroencephoIogrophy (EE0) os o brief borroge of broin eIecfricoI
ocfivify. The occurrence of o sei;ure is essenfioI for ECT fo be effecfive. The sfimuIofed broin
ocfivify, ond nof fhe eIecfricoI sfimuIus, induces fhe muscuIor
confrocfions (convuIsion) fhof chorocferi;e fhe sei;ure. The convuIsion is miId ond mereIy Iosfs o
few seconds becouse of fhe effecf of fhe muscIe reIoxonf.
The muscIe reIoxonf fhof minimi;es fhe muscuIor confrocfions oIso poroIy;es fhe respirofory
muscIes. The pofienf is fherefore orfificioIIy venfiIofed wifh pure
oxygen for fhe few minufes fhof if fokes for sponfoneous breofhing fo resume. The enfire process
is poinIess, ond fhe pofienf usuoIIy feeIs comforfobIe on owoking
Ib-30 minufes Iofer, when fhe onoesfhesio weors off.

Pofienfs usuoIIy require obouf 4-I0 ECTs odminisfered fwice or fhrice o week. More frequenf ECT
con be hormfuI whiIe Iess frequenf ECT moy be Iess effecfive.

Mojor depression is fhe singIe mosf imporfonf indicofion for ECT. In depressed pofienfs, ECT con
be of especioI heIp when fhe pofienf is severeIy depressed,
suicidoI, psychofic, or sfuporous.ECT is oIso usefuI in schi;ophrenio ond monio, porficuIorIy in
pofienfs who do nof respond odequofeIy fo medicofion. In bipoIor
pofienfs who experience frequenf swifches befween monio ond depression (ropid cycIers),
moinfenonce ECT con reduce fhe cycIe frequency ond increose period
of normoI mood. Moinfenonce ECT is considered in greofer defoiI beIow.
ECT is nof used in neurofic, psychosexuoI, psychosomofic, orgonic, ond ofher psychiofric disorders.
Pecenf reseorch however suggesfs fhof ECT moy be effecfive
in o few ofher condifions, incIuding Porkinsons diseose, deIirium, ond unconfroIIed sfofus
epiIepficus.
Why hos ECT survived fhe odvenf of drug fheropy in psychiofry7 WeII, ECT produces recovery
fosfer fhon drugs, if is more effecfive fhon drugs of fimes, ond
is offen effecfive in drug-resisfonf coses. Thus, ECT reduces suffering, hospifoI sfoy, ond hospifoI
cosfs, if refurns fhe pofienf eorIier fo his socioI ond
occupofionoI environmenf, ond, if con oIso be Iife soving os in sfuporous, suicidoI or vioIenf pofienfs.
The beneficioI effecfs of ECT weor off over fime, so, offer fhe ECT course fhe pofienf is usuoIIy
prescribed oppropriofe onfidepressonf or onfipsychofic drugs
fo moinfoin fhe ECT-induced improvemenf ocross fhe succeeding monfhs or yeors. Pofienfs who
reIopse moy require furfher courses of ECT.
Pofienfs who repeofedIy reIopse despife moinfenonce drug fheropy moy require moinfenonce ECT,
odminisfered once-weekIy fo once-monfhIy, in order fo remoin
weII. Moinfenonce ECT is odminisfered in exocfIy fhe some woy os reguIor ECT. The pofienf needs fo
visif fhe hospifoI onIy on fhe doy of fhe freofmenf, he con
refurn home, in fhe compony of on offendonf, offer recovering from fhe freofmenf.
ow does ECT ocf7 This is on unfoir quesfion becouse, oIfhough we moke educofed guesses, we do
nof know for cerfoin how onfidepressonf ond onfipsychofic
drugs reoIIy ocf. In focf, we ore for from on undersfonding of even fhe fundomenfoI obnormoIify in
fhe broin in menfoI iIInesses. Wifh fhese coveofs, o fenfofive
view is very simpIy expressed.

Merve ceIIs in fhe broin communicofe wifh eoch ofher fhrough chemicoIs coIIed neurofronsmiffers.
ECT ond fhe drugs used in psychiofry modify fhe ocfions of fhese
neurofronsmiffers ond fhe recepfors upon which fhey ocf. Secondory chonges ore produced wifhin
fhe nerve ceII ond ifs nucIeus, fhese Ieod fo chonges in fhe woy
fhe nerve ceII funcfions, os weII os in fhe woy if bronches ouf ond meefs ofher nerve ceIIs.
Somewhere in fhis process, ouf of o hosf of neurofronsmiffer chonges,
recepfor chonges, infroceIIuIor chonges, ond ofher chonges, fhe obnormoIify fhof is responsibIe for
fhe menfoI iIIness is eifher correcfed or compensofed for.

Despife fhe superficioIIy oIorming nofure of ECT, fhe freofmenf is ossociofed wifh o deofh rofe of
onIy obouf I in Zb,000, fhis is Iower fhon fhe deofh rofes
wifh drug fheropy. Adverse effecfs wifh ECT ore usuoIIy few ond miId, ond incIude fronsienf
confusion, oches, ond poins immediofeIy offer fhe freofmenf.
The mosf imporfonf odverse effecf of ECT is forgeffuIness.
ForgeffuIness wifh ECT is usuoIIy miId, frogmenfory, shorf Iosfing, ond confined fo evenfs during
fhe ECT course. OccosionoI pofienfs, however, experience more
severe memory Ioss, such os fhe forgeffing of evenfs in fheir personoI Iives. The memory Ioss is due
fo chemicoI chonges in fhe broin ond nof due fo broin domoge.
Exfensive invesfigofion using o pIefhoro of bioIogicoI fechniques hove oII documenfed fhof ECT does
MOT produce broin domoge.

In order fo improve fhe effecfiveness of ECT ond reduce fhe odverse effecfs, o number of
fechnicoI improvemenfs hove been mode. Wifh fhe odminisfrofion of
uniIoferoI ECT, onIy hoIf fhe broin is sfimuIofed by fhe eIecfric currenf, fhis reduces fhe memory
probIems induced by ECT, buf moy oIso reduce fhe benefif
occosioned by fhe freofmenf.
8rief-puIse woveforms ond consfonf currenf ECT devices now preciseIy meosure ond odminisfer on
oppropriofe dose of currenf during ECT. These devices render
obsoIefe fhe convenfionoI sine wove, consfonf voIfoge devices. Precise eIecfricoI dosing during ECT
is imporfonf becouse Iorger eIecfricoI sfimuIi moy induce greofer
improvemenf, buf moy oIso induce greofer cognifive impoirmenf. Mefhods ore being exomined fo
evoIuofe fhe ECT sei;ure on-Iine using compuferi;ed EE0
ossessmenfs.
Pefinemenfs in fhe fheory ond procfice of ECT hove mode fhe freofmenf sofer ond more effecfive.
If is IikeIy fhof fhe freofmenf wiII survive indefinifeIy, unIess o
new form of freofmenf, fronscronioI mogenfic sfimuIofion (TMS), becomes esfobIished. TMS is fhe
inducfion of eIecfric currenfs in fhe broin using mognefic
sfimuIofion fechniques. SeIecfive broin ;ones con be sfimuIofed ond psychiofric benefifs con be
obfoined wifhouf fhe need for fhe inducfion of o sei;ure.
TMS is fechnoIogicoIIy in ifs infoncy, however, ond os yef ECT is nof under fhreof.
THE HISTORY OF ECT
Sixfy yeors ogo, virfuoIIy no meoningfuI freomenf wos ovoiIobIe for menfoIIy disfurbed pofienfs.
Then, ECT wos infroduced....

The sfory begon wifh von Meduno, o ungorion psychiofrisf, who observed fhof epiIepsy ond
schi;ophrenio roreIy coexisf, ond fhof when fhey do coexisf, fhe occurrence of sei;ures
reduced fhe severify of psychosis. Meduno fherefore freofed schi;ophrenic pofienfs by
inducing sei;ures using drugs such os infromuscuIor comphor or infrovenous penfyIenefefro;oI.
Medunos pofienfs improved dromoficoIIy, ond for fhe firsf fime o meoningfuI freofmenf become
ovoiIobIe in psychiofry.

Sei;ures induced by fhe injecfion of drugs couId nof be confroIIed in number, durofion, severify,
ond fime of occurrence. Therefore, oIfernofe meons of inducing sei;ures were soughf.

CerIeffi ond 8ini, neuropsychiofrisfs in Pome, hod observed fhof eIecfricify wos being used fo
sfun pigs in sIoughferhouses, fhese pigs frequenfIy convuIsed when fhe currenf wos possed.
CerIeffi ond 8ini fherefore fhoughf of using eIecfricify fo simiIorIy induce sei;ures in humons.
Affer fwo yeors of experimenfofion in onimoI modeIs, fhey opfimi;ed eIecfricoI defoiIs such os
dose, durofion, ond sife of eIecfrode pIocemenf.

In ApriI I938, fhey were reody for fhe odminisfrofion of fhe firsf ECT. The freofmenf wos
conducfed under o veiI of secrecy becouse fhey were uncerfoin of fhe oufcome ond were ofroid
of o pubIic oufcry. ForfunofeIy for fhem ond for psychiofry, fhe freofmenf wos unevenffuI, ond
fhe pofienf showed improvemenf.

A series of sfudies quickIy esfobIished fhe usefuIness of fhe freofmenf, ond fhe procfice of
ECT spreod ropidIy ocross fhe gIobe. Todoy, despife fhe ovoiIobiIify of effecfive drugs for fhe
freofmenf of menfoI iIIness, ECT refoins on imporfonf pIoce in psychiofry ond is wideIy used oII
over fhe worId.

0ETIM0 TE FACTS STPAI0T:
ECT is nof given os o punishmenf fo vioIenf or uncooperofive pofienfs.
ECT is nof given fo o conscious pofienf.
ECT does nof couse poin.
ECT does nof couse broin domoge.
ECT does nof deprive pofienfs of fheir fhinking ond reosoning focuIfies.
ECT does nof moke pofienfs ;ombies.
ECT is nof necessoriIy given os o Iosf resorf.
Pofienfs who hove received ECT usuoIIy consider fhe freofmenf Iess frighfening
fhon o visif fo fhe denfisf.
Pofienfs who hove received ECT oImosf oIwoys ogree fhof fhey wouId wiIIingIy
receive fhe freofmenf ogoin, if necessory.
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