The place of ECT in mental health care: the use of electroconvulsive therapy has been dogged by controversy, misuse and abuse. But it has its place in mental health care, particularly in the treatment of those suffering from catatonia.

Electroconvulsive therapy (ECT) is one of the most controversial treatments in medicine. (1) It has a chequered history of misuse and abuse. Some of those who recall having had unmodified ECT, ie without anaesthetic or muscle relaxant, retain nightmare memories of the treatment. Some people remember being given ECT as a punishment for perceived poor behaviour, or to coerce them to conform to acceptable "normal'" behaviours. In 2001, 95 people who had been patients in Lake Alice Hospital near Wanganui, received $6.5 million in compensation for the abuse they suffered. (2) Many who received compensation had been given unmodified shock treatment, and when describing their experiences today, they use the term "torture" in relation to ECT. Popular culture has tended to portray the procedure and outcomes of ECT negatively. Many people's understanding of the treatment is based on the 1975 film, One Flew Over the Cuckoo's Nest. (3) Seldom does one read or hear of the positive effects of ECT for those who present with a life-threatening mental disorder. An exception was an article published in the New Zealand listener in 2003. (4) This presented evidence and views from experts both in favour of, and against ECT.

Electroconvulsive therapy is no longer used indiscriminately, as was the case in the 1950s and 1960s. It has proven to be an effective treatment for catatonia and catatonic states. "Catatonia is a state of apparent unresponsiveness to external stimuli in a person who is apparently awake, and is difficult to differentiate from diffuse encephatopathy and non-convulsive status epitepticus.... Diagnostic criteria for catatonia include motoric immobility, excessive motor activity, extreme negativism or mutism, peculiarities of voluntary movement, and echolalia or echopraxia. (5) Two of these symptoms are required to diagnose catatonia in schizophrenia and mood disorder. Only one is required to diagnose catatonia in general medical conditions. Catatonia can present in an immobile state (apparently stuporose) and is potentially life-threatening, unless nutrition is administered parentally. (5)

Extreme excitability in a catatonic state presents a risk of injuring self and/or others, with ensuing autonomic disturbances, such as tachycardia and hypertension, and can result in collapse. (5) Catatonia is not related to any specific age group or gender. Children as young as eight have received ECT to relieve them of this condition when all other treatments have failed. (6)

Case study in use of ECT

I was closely involved in caring for a client for whom ECT treatment for catatonia was successful. Trevor (not his real name) had no previous known psychiatric disorder and there was no family history of mental ill health. Trevor had experienced a traumatic incident at work. During the following four weeks his mood progressively deteriorated, with a decrease in responsiveness and activity. He presented to a medical ward in a severe catatonic state, resistive to physical examination, adamantly but mutely refusing to open his eyes or mouth, and combative when nurses attempted to reposition him.

To eliminate other diagnoses, the patient underwent a thorough medical and physical investigation but nothing abnormal was discovered. These investigations included a chest x-ray; an electrocardiograph; a full blood screen; lumbar puncture for cerebral-spinal fluid abnormality; a EAT brain scan; a magnetic resonance imaging brain scan; electroencephalograph; thyroid function tests; toxicology screening; and syphilis serology. He was given intravenous (IV) fluids for nutrition, as he was not taking any food or drink. He resisted oral cares, clenching his jaws tightly. A neurology review showed no evidence of any neurological disorder.

A referral was sent to the mental health team for an assessment of his mental health status. Since delirium had been ruled out, a diagnosis of a catatonic state was made. Because Trevor had no previous psychiatric history, a definitive diagnosis of catatonic schizophrenia could not be established. The mental health team advised ECT, as this has been used successfully to treat catatonia, "effectively releasing the patient from an apparent state of stupor to one of recovery and the resumption of a normal active life". (7)

Next of kin or other family members cannot give consent for ECT and, as Trevor was not able to give informed consent for the treatment, he was placed under the Mental Health Act (MHA) Section 11. This is a five-day compulsory assessment and treatment order and ECT is prescribed and administered under section 60(b) of the MHA. A second opinion from a suitably appointed psychiatrist must be sought and assessment conducted and recorded using a particular legal form.

The ECT nurse plays a crucial role in all issues involving the administration of ECT. She is a co-ordinator, an educator, she liaises with other services and families, and is a point of contact about ECT within the mental health service generally and in the ECT unit in particular.

Information for the family

The nurse caring for Trevor on the medical ward contacted the ECT nurse for information regarding the treatment and the MHA. This was provided in as much detail as was required. The family had been fully informed of the proposed treatment, the risks involved, potential side-effects and the anticipated benefits. The family was given a comprehensive information booklet about ECT and was invited to ask any questions in relation to the treatment. The family was satisfied with the information and agreed that Trevor should receive ECT.

Escorted by his nurse and the ECT nurse, Trevor was taken from the medical ward in his bed to the ECT suite for his first three treatments. In the suite he was greeted warmly by the ECT team and was given step-by-step verbal information about the procedure, despite his apparent semi-comatose state. The ECT nurse remained with him, holding his hand by way of reassurance, white the anaesthetist and the psychiatrist explained to Trevor exactly what they were doing. Trevor recovered quickly from the ECT treatment, with no untoward events and was returned to the medical ward. Response after the first ECT treatment was minimal but evident. Trevor was able to specify which drink he wanted when his nurse asked him to nod or shake his head to indicate what drink he wanted. He accepted sips of water and co-operated with mouth cares; however he continued to refuse to eat or to open his eyes.

After the second ECT treatment his condition showed little improvement, although Trevor did continue to comply with oral cares and accept fluids. Naso-gastric feeding was to be considered if his nutritional intake did not improve after the third ECT treatment.

The turning point

The third treatment proved to be the turning point. In the recovery room, Trevor opened his eyes. He was wheeled back to the medical ward where he ate a full breakfast. He was able to respond verbally and tater got up from his bed to walk quite steadily around the ward. The mental health team conducted a further assessment and agreed that Trevor could be transferred from the medical ward to the mental health unit, as he no longer required intensive medical and nursing cares.

During an interview in the mental health unit with a psychiatrist and a mental health primary nurse, Trevor denied any thoughts of self-harm or suicide and said he was feeling slightly better. Despite this, he appeared low in mood, his responses were restricted, poverty of thought and speech were evident, and he made only fleeting eye contact. He spoke in a quiet monotone and was extremely retarded in his responses to questions, appearing somewhat preoccupied and guarded throughout the interview. There was evidence of paranoia, as he intimated that people were talking about him and putting him down in relation to the incident at work. He denied any alcohol or illegal substance abuse. He indicated that his family was extremely supportive and anxious for his recovery and return home. Trevor was fully orientated to time, place and person but was hesitant in his responses, apparently unable to concentrate on the questions being asked.

A course of ECT

The plan was for Trevor to continue with a course of ECT and to commence anti-depressants. His primary nurse was responsible for gathering information from other members of the team, including occupational and art therapists, and for recording and reporting these and her findings to the multi-disciplinary team. Trevor was to be observed for any psychotic features; his food and fluid intake and his ability with activities of dairy living (ADL) were to be monitored. Participation in ward social activities was to be encouraged and family contact maintained.

Over the next three weeks, Trevor received a total of eight ECT treatments and improved with each treatment. On the ward Trevor continued to took preoccupied at times but stated he was "thinking" when asked about this by his nurse. His family had described Trevor as a shy, introspective young man, who had no special relationships outside the family circle, so he was assessed as being naturally quiet. However, he gradually became less isolated, joined others in spontaneous group activities, as well as organised group work, and his appetite improved to the point where he looked forward to meats and wanted snacks in between. Trevor went home to his family on leave twice and on his return to the ward reported that art had gone well.

Just before his discharge, the ECT nurse made an appointment with Trevor and his primary nurse to conduct an assessment of his level of depression, using the revised version of the Montgomery and Asberg Depression Rating Scale (MADRAS). This is a ten-point questionnaire with ratings of 0-6 on nine questions and 0-5 on one question, with the higher number indicating the most severe depression. Trevor scored five out of a potential 59, which signified minimal depression. During the assessment he appeared a little sad and made little eye contact. He reported occasional feelings of anxiety; poor steep at times; occasional difficulties with concentrating; and some sluggishness when having to embark on his ADLs. Due to Trevor's initial catatonic state it had not been possible to conduct a baseline assessment before ECT started, therefore there was no way of comparing the severity of his depression pre- and post-treatment. Trevor was discharged home with a minor depression which did not interfere with his normal functioning and he was showing signs of enjoying the once again.

Accepted part of treatment

Despite the adverse publicity ECT has received, in the past decade it has re-emerged as a safe and effective treatment for major depressive disorders, with the greatest interest in research and use being in the United States (US). It is an accepted part of psychiatric practice in the Scandinavian countries, Great Britain, Ireland, Australia and New Zealand, and use is similar to that in the US. (9)

As the case study of Trevor demonstrates, ECT can be a very effective treatment for a potentially life-threatening condition.

This article was reviewed by Kai Tiaki Nursing New Zealand's editorial review committee in December 2004.

REFERENCES

(1) Journal of American Medical Association. (2001) www.heatthyplace.com/Comrnunities/Depression/ treatment/ect/article_jama.asp. Retrieved 22/07/04.

(2) http://www.thedoctorslounge.net/clmlounge/ procedures/neurology/ect.htm. Retrieved 22/07/04.

(3) http://www.healthyplace.com/Communities/ Depression/treatment/ect/article_jama.as p. Retrieved 22/07/04.

(4) Spence, A. (2003) Positive and Negative. New Zealand listener; 189: 3292.

(5) http://www.emedicine.com/neuro/topic708htm. Retrieved 22/07/04.

(6) http://www.healthyplace.com/Communities/ Depression/treatment/ect/paediatric ect.asp. Retrieved 22/07/04.

(7) http://www.mhsource.com/exclusive/pedect.html Retrieved 22/07/04.

(8) Mental Health (Compulsory Assessment and Treatment) Act (1992). Wellington: New Zealand Government.

(9) Fink, M. (1999) Electroshock--Restoring the Mind. New York Oxford Publications; and http://www.questai.com. Retrieved 25/07/04.

Val Flint, RN, works as the ECT RN for Waikato District Health Board. She also works as staff nurse at the Henry Bennett Centre at Waikato Hospital in Mental Health Services for the Older Person.