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Electroconvulsive or electroshock therapy: how it works

Electroconvulsive or electroshock therapy: how it works


The  electroconvulsive therapy  is among the most dramatic and controversial treatments. Commonly known as electroshock , it is a therapeutic technique used only in those cases that do not respond to drug treatments.

Today, in hospital facilities and mental health centers, both bilateral electroshock (with electrodes placed on both sides of the head) and unilateral electroshock (with electrodes placed only on one side of the head) are performed. The latter treatment is preferred as it appears to cause fewer side effects than bilateral treatment.

Content hide 1 Electric shock: what is it for? 2 Electroconvulsive therapy 2.1 How is it done? 2.2 Duration 2.3 Side effects 3 Electroconvulsive therapy in Italy 4 Electroshock and depression 5 Ethical implications of electroconvulsive therapy 6 Testimonials

Electroshock: what is it for?

The effective effectiveness of  electroconvulsive therapy  is still highly debated. Its use is recommended only in cases of  chronic depression , bipolar disorder, catatonia that do not respond to drugs. Electroshock can be used to treat the symptoms of schizophrenia and in psychotic depression. Treatment is rarely used in cases of autism spectrum disorder.

Electroshock is also used in cases where suicidal conduct has been observed and intervention times (pharmacological or psychotherapeutic) would be too long for the patient’s precarious conditions. Other applications are found in cases where depression is associated with a serious illness or  pregnancy , where treatment with antidepressants would put the mother or fetus at risk.

The  electroconvulsive therapy  is induction of a deliberate  seizure  with temporary  loss of consciousness

Electroconvulsive therapy

Electroconvulsive therapy (TEC) is considered by clinicians to be a responsible choice only when other therapies fail and / or only when the risk of suicide is high. Compared to a few decades ago, the benefits of treatment outweigh the risks of associated side effects.

The electric discharge administered with the treatment is of an intensity between 70 and 130 volts. The effects of this discharge are not yet fully known, however several studies have correlated the repeated application of the treatment to an improvement of the serotinonercic system.

TEC appears to sensitize two serotonin receptor subtypes by improving signal transmission.

How is it done?

At one time, electroconvulsive therapy was called  bilateral  because an electrode was applied to each side of the forehead. Today a single electrode is applied to one side of the forehead, to the non-dominant cerebral hemisphere (usually the right one).

In the past, the person remained awake until the moment of discharge, when the current triggered the  seizure ; the electric shock caused frightful contortions to the point of causing bone fractures. Today, before applying the current, the patient is administered an anesthetic in addition to a powerful muscle relaxant, that is, a drug capable of strongly relaxing the muscles of the whole body so as to avoid contortions related to the passage of the electric discharge.

During  electroconvulsive therapy , muscle spasms are barely noticeable to the observer and the person wakes up a few minutes later without  remembering anything about the treatment .

Duration

Each therapy is studied by itself, however the protocols provide between 6 and 12 applications of ECT  (acronym from the English electroconvulsive therapy) a few days apart from each other. Clinicians agree with a wait of at least 24 between treatments. Typically 2 to 3 treatments per week are expected until symptoms are reduced.

The approximately 800 milliamps of direct current pass through the central nervous system for a duration ranging from 100 milliseconds to 6-8 seconds. The discharge goes from side to side of the head in the bilateral ECT or from front to back of the head in the unilateral ECT.

At the end of the electroshock cycle, the patient follows a drug therapy with antidepressants. Drug therapy is aimed at preventing relapses (relapses).

Side effects

To reduce side effects, the electric current administration treatment is applied to only one hemisphere and is combined with the use of muscle relaxants.

Despite progress, the majority of specialists agree that those who undergo ECT run the risk of developing mental confusion and temporary memory loss.

Among the  testimonials  of patients undergoing treatment, it is quite common to detect amnesia of varying intensity. Generally, people subjected to TEC report that they have no memory of the period in which they received the discharge and sometimes even of the weeks that preceded and followed the treatment.

The appliance that emits the electric shock is able to trigger an epileptic seizure lasting 30-50 seconds. The device simultaneously returns the patient’s electroencephalogram.

From a cognitive point of view (including memory), the effects of electroconvulsive therapy (electroshock) are lighter when it comes to unilateral ECT. The effects on memory are more relevant in the case of bilateral ECT. Nevertheless, unilateral electroconvulsive therapy is also associated with cognitive deficits (mental confusion, memory problems, disorientation …) which can still occur six months after treatment (Sakeim, Prudic, Fuller et al., 2007).

The extent of the effects on memory are variable, even the timing for full cognitive recovery varies from individual to individual.

Other side effects are related to the use of general anesthesia – the patient undergoes an already unconscious electroshock – and the muscle relaxant.

Electroconvulsive therapy in Italy

L ‘ electroshock  is a discovery all Italian. At the beginning of the twentieth century, Ugo Carletti, an epilepsy scholar, sought methods to induce epileptic seizures and found it by applying electrical discharges to the sides of the head. Thus was born the electric shock. Only later, in 1939, electroshock was used on a person suffering from schizophrenia and subsequently its use made its way among patients with severe depression.

According to Ignazio Marino, President of the Senate Commission of Inquiry on the National Health Service, there are 91 structures in Italy that practice electroshock (updated 2013 data). According to AITEC (Italian Association for electroconvulsive therapy), the numbers are very different and electroconvulsive therapy in Italy is much less widespread. According to the association, in Italy there are only 11 structures that perform the TEC, 6 belonging to the National Health Service and 5 private clinics affiliated with the NHS.

Electric shock and depression

As mentioned, electroshock is used in cases of drug-resistant disorders, in particular, to treat the manic or depressive episode in bipolar disorder, severe depression with or without psychotic episodes, catatonia, schizophrenia …

In 2012, a meta-analysis was conducted on the effectiveness of  electroconvulsive therapy  in the treatment of  depression  (unipolar and bipolar). The results indicated that although patients (depressed with bipolar diagnosis and depressed with major depressive disorder diagnosis) responded to medical treatment differently, they achieved comparable positive relapses.

The procedure saw a remission of depressive symptoms with a success of 50.9% for patients with severe major depression and 53.2% for patients with bipolar depression. The follow-up studies, albeit limited, show that about 50% of the patients who have obtained benefits from the treatment show a relapse within 12 months; about 37% of relapses occur within the first 6 months (Jelovac, Kolshus, McLoughlin, 2013). This means that any beneficial effects of electroshock are not long lasting and the patient will have to undergo multiple cycles.

The risk of relapse increases when the patient does not take antidepressants following treatment.

Ethical implications of electroconvulsive therapy

The controversies about ECT not only concern the potential efficacy and the mechanism of action (still unknown) of the therapy, there is also a legal and ethical implication.

In 2005, the World Health Organization stated that electroconvulsive therapy should only be performed on patients who have accepted treatment by  informed consent. This means that patients must be made aware of the risks and possible side effects of therapy.

It is important to underline that patients in a manic state, catatonic patients, with psychotic, schizophrenic symptoms or severe depressive symptoms, are only rarely able to give a real conscious consent .

In these circumstances it is important that a legal guardian capable of making this decision is indicated as the patient’s informed consent may be legally ineffective due to his own mental state.

Testimonials

Thanks to the TEC “I freed myself from the burden of suffering: the therapy restored my lucidity, and made me want to live again”. These are the words that Giampietro Ferrari reported to L’Espresso journalists. In this case, the patient was diagnosed with bipolar disorder and before the age of 37 he had attempted suicide nine times and led a life that was extremely compromised by manic episodes. The patient’s psychopathology was refractory to a pharamcological approach.

An unforgettable testimony on electric shock is certainly that of Alda Merini, who writes: “every now and then they would crowd us into a room and make us those horrible bills. I called them invoices because they only served to brutalize our spirit and our minds. The electroshock room was a very cramped and terrible room; and even more terrible was the anteroom, where they prepared us for the sad event. […] Once I got to take the head nurse by the throat, on behalf of all my companions. The result was that I was subjected to electroshock first, and without preliminary anesthesia, so that I felt everything. And still I keep the atrocious memory of it ”. Fortunately, the protocol today provides for total anesthesia before the treatment which is not painful.