Expert Opinion |
Re-evaluation of Electro-convulsive therapy (ECT)
Colonel (Retd) Professor Md Nurul Azim
The aim of this article is to provide a perspective on Electro Convulsive Therapy (ECT), based on cumulative studies for non-specialists, for those who are prejudiced against it and wish to limit or ban its use. Because it is not uncommon that the patients and family members are unduly concerned that ECT will somehow damage the brain. Even doctors and some psychiatrists are skeptic and afraid of the treatment method.
Anecdotal finding -- epileptics had remission of schizophrenic symptoms after a fit, led Meduna in 1935 to invent convulsive therapy particularly for those cases having acute onset, confusion and mood disturbance. Later on it was found to be most effective in depressive illness with a success rate as high as 90 percent in psychotically depressed patients. It is very potent in acute mania, schizophrenias and catatonia (schizophrenia with intervals of catalepsy and sometimes violence) from almost any underlying cause. At times no option is better than ETC. Broadly speaking it is indicated in acute organic psychosis or serious mental illness of some specific varieties.
There is least doubt regarding the efficacy of the treatment modality. There is no significant side effect other than transient mild confusing state and temporary loss of memory (for 7 days) after a course of therapy. Objective memory testing has also shown normal memory and cognitive functioning at long term post-ECT follow up examinations.
Administration of ECT is not a terrifying experience. Patients do not feel anything whatsoever in the course of treatment. Studies revealed that majority of the patients felt that a visit to the dentist was more distressing, majority agreed with the statement "I wish I had ECT years ago" and 85 percent stated that ECT would be their treatment of choice in future if needed.
It is very rapid in producing response, even cures depression by the time antidepressants initiate intangible improvement in patients. Those drugs are not devoid of side effects too. It is second to none in catatonic, suicidal, drug intolerant, pregnant and drug resistant patients. ECT is about 10 times safer than those during pregnancy. Nevertheless, a complication rate of one in 1400 ECTs were recorded in recent studies, the worst being vertebral compression fracture.
Achievements of ECT can now challenge the common practice of needlessly subjecting the suffering patients to years of futile medication trials before ECT is considered. ECT should be offered as a reasonable choice earlier in the treatment process. This enhances cost effectiveness of treatment by maximising the response and preventing man-hour loss. It is therefore, more suitable in the context of Bangladesh where people live hand to mouth or can not afford to remain out of work, even women out of their domestic responsibilities. Because there is no social support system to feed them and keep them unperturbed. Beside remitting acute phase of the illness, maintenance ECT sustains remission too.
Apart from disruption of time dependent memory, recent brain imaging (CT Scan / MRI) studies failed to reveal any short or long term adverse effect left by ECT on the brain even after giving 1250 ECTs to a patient over 25 years period.
There are different methods of giving ECT suiting a particular case. The choice lies with the personal preference of the principle of the practice of ECT, training background of the psychiatrist and conviction based on own clinical experience. The rapidity and profundity of response rate attract patients as well as their relatives to more ECTs incase of relapses, if necessary. This testifies a most important consideration in risk benefit analysis namely the patient's satisfaction.
We can look forward to further advances. Instead of being discarded as primitive, ECT has established itself as a modern medical procedure. When the "therapy resistant" cases pleaded for any useful intervention, the practitioners who have used ECT earlier but discarded their devices in the enthusiasm for psychotropics recalled their experience and offered ECT again.
All present day prospective, controlled, double blind randomised comparison of ECT versus antidepressants (including combination treatments of depression) favors ECT. Even strict research criteria demonstrated an 86 percent efficacy rate for ETC.
The American Psychiatric Association and The Royal College of Psychiatrists, UK recognise no contra-indication for ECT. Balance will weigh in favor of ECT in patients who are old and has compromised cardiovascular status. Successful ECT was given in patients with hypertension, recent heart attack, after open-heart surgery, major arterial graft, aortic aneurysm, skull defect. Extremes of ages are no contraindication. It is safe during pregnancy as well. Suicide is extremely rare once the ECT is started.
Finally the severity of the condition in which ECT is indicated, particularly during a period of non-responsiveness to other available treatments suffices to go for ECT. The physician's decision to offer ECT to a patient and patient's decision to accept it should be based on consideration of advantages and disadvantages of ECT compared with alternative treatment.