Electroconvulsive Therapy (Shock Therapy)

Electroconvulsive Therapy (Shock Therapy)

Electroconvulsive therapy (ECT), previously known as electroshock, is a psychiatric intervention involving the induction of seizures through electrical stimulation in anesthetized patients to achieve therapeutic outcomes. Despite its long history of use, the precise mechanism of action of ECT remains unclear.

Presently, ECT is primarily recommended for severe depression refractory to other treatments and is also employed in managing mania and catatonia. It was first introduced in 1938 by Italian neuropsychiatrists Ugo Cerletti and Lucio Bini and became widely utilized in the 1940s and 1950s.

The origin of ECT traces back to Dr. Cerletti's observation of pigs rendered unconscious but survivable through electrical shocks applied to their temples. Upon testing this method on his mentally troubled patients, Dr. Cerletti found that it induced a subdued and compliant state. Concurrently, large doses of insulin were also employed to induce comas in patients, marking the emergence of these novel therapeutic approaches.

The application of ECT varies in terms of electrode placement, treatment frequency, and electrical waveform, leading to variations in both adverse effects and therapeutic outcomes. Typically, drug therapy is continued post-treatment, and some patients may undergo continuation or maintenance ECT. In the United Kingdom and Ireland, drug therapy is maintained during ECT sessions.

Approximately 70 percent of ECT recipients are women, reflecting their heightened susceptibility to depression. Despite extensive research, the exact mechanism of action of ECT remains elusive, and its standalone efficacy is limited, often necessitating concurrent therapies. Memory loss is a significant risk associated with ECT. Consequently, obtaining written, informed consent from patients before administering ECT is universally recognized as essential. There is ongoing debate regarding whether ECT should be prioritized as a first-line treatment or reserved for patients unresponsive to alternative interventions like medication and psychotherapy.

The primary objective of ECT is to induce a therapeutic clonic seizure, lasting at least 15 seconds, which is believed to potentially "jumpstart" brain activity, although the exact mechanism remains debated. Concerns have been raised by some experts, such as Peter Breggin, regarding the euphoric effects of ECT, likening them to those seen in closed head injuries or traumatic brain injuries. However, direct study of the human brain before and after ECT is challenging, necessitating reliance on animal models of depression and ECT, which have inherent limitations.

Animal studies on electroconvulsive shock (ECS) have revealed synaptic pruning in the hippocampus, a region crucial for mood regulation and memory, particularly in models of depression such as learned helplessness and social defeat.

Guidelines from organizations such as the American Psychiatric Association (APA) and the UK's National Institute for Health and Clinical Excellence (NICE) outline indications for ECT in various psychiatric conditions, including severe depression, mania, catatonia, and psychosis. However, recommendations differ regarding its use as a maintenance therapy due to insufficient long-term data.

ECT may also be considered in certain cases of schizophrenia, although caution is advised, particularly in vulnerable populations such as pregnant women and older or younger individuals, due to potential complications. While the APA suggests ECT may be safer than alternative treatments in select scenarios, NICE guidelines recommend careful consideration of its risks and benefits in specific patient groups.