Panel okays ECT, calls for U.S. survey.

Panel okays ECT, calls for U.S. survey

Although it is "the most controversial treatment in psychiatry,' electroshock therapy is effective for a narrow range of psychiatric disorders, particularly severe depression that does not respond to drugs and other treatments, a National Institutes of Health advisory panel reported last week.

Electroshock, or electroconvulsive therapy (ECT), can cause persistent memory gaps for events that occurred during the months surrounding the treatment, adds the 14-member panel, which was composed of psychiatrists, psychologists, a lawyer and a consumer advocate. Their "consensus statement' notes that patients should be informed of risks and benefits involved in ECT throughout the course of treatment. A patient's decision to refuse ECT should be honored, according to the statement.

The panel also calls for a national survey to gauge the quality and extent of ECT use. Little is known about how ECT is administered in the United States and what training is received by those who perform the procedure.

The aim of ECT is to produce a brain seizure. A small electric current, typically lasting one second or less, passes through two electrodes placed on the patient's head. General anesthesia and muscle relaxants are administered before the current is applied, and oxygen is provided during ECT. Patients with severe depression generally receive ECT three times a week for two to four weeks.

It is unclear why brain seizures have powerful antidepressant effects. The panel recommends "much additional research' into how ECT works. Some researchers suggest that the key to ECT's effects lies in the biological process that turns off a seizure (SN: 1/26/85, p. 53).

Despite the mystery surrounding the way it works, the panel says that clinical studies demonstrate ECT to be at least as effective as antidepressant drugs in treating severe depression. ECT is also effective for some cases of mania (excessive elation or activity), say the panelists. The evidence is "not compelling' for using ECT with schizophrenics, they note, especially with those who are chronically ill.

ECT can cut depression short, but it is not a cure, cautions the panel. It is clear that symptoms decrease for up to four weeks after treatment, but long-term studies have not been conducted. Depressed patients who improve after ECT may gradually get worse without continuing medication or psychotherapy. Still, the committee says that ECT is often a valuable last resort for suicidal depressed patients who do not respond to medication.

ECT rarely causes death, notes the report. But it often produces "enduring or permanent gaps in memory' for events occurring an average of six months before and two months after treatment. The extent of memory problems and patients' reactions to them varies widely. The panel heard testimony from several patients treated with ECT: Some opposed the treatment and reported persistent memory problems; others regarded it as a lifesaving therapy.

ECT critics told the committee that the treatment has caused permanent brain damage in animals. The report says, however, that brain cell death has not been demonstrated in animal studies of ECT. Definitive studies of brain metabolism and tissue changes during the treatment have not been done.

Because ECT is a relatively complicated procedure, the panel says that medical schools and psychiatric residency programs should provide training in the technique. Facilities that use ECT should establish review committees to monitor the treatment, it adds.

The panel acknowledges that during the 1940s and 1950s ECT was often overused and misued with a variety of disorders. The best estimate is that 60,000 to 100,000 people per year now receive ECT in the United States, a sharp decline from several decades ago. The typical ECT patient is white, female, middle-aged and relatively well-to-do, with health insurance that covers a course of treatment. ECT is usually performed in private or university hospitals.

The quality of treatment from hospital to hospital is not known, underscoring the need for a national survey of ECT use in the United States.

In England, however, a 1980 survey of 100 ECT clinics revealed a disturbing state of affairs. Less than half met the minimum criteria of the Royal College of Psychiatrists for adequate ECT administration. Many patients were treated with too much electric current on obsolete or improperly maintained machines, and brain seizures often were not noticed by psychiatrists.

The English survey shows that although ECT can be effective when properly used, there may be some substance to public concerns about improper practice, says Max Fink of the State University of New York at Stony Brook. In the Feb. 1983 AMERICAN JOURNAL OF PSYCHIATRY, Fink, a longtime supporter of ECT for depression and mania, asks, ". . . is it not likely that inadequate facilities, poorly trained professional staff and missed seizures are features in many [U.S.] treatment centers?'