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Electro-convulsive therapy (ECT) was introduced in 1938 and has been in continuous use since then as a tool for therapeutic neuromodulation in the treatment of various psychiatric disorders. ECT celebrates its 74th birthday this year and is neither tired nor retired as a treatment modality. It remains an important component in the armamentarium of biological therapeutic tools in psychiatry. ECT remains invaluable, and can be termed life saving, in the management of patients with acute suicidal risk, severely retarded depression, catatonia, etc.
ECT differs from psychopharmacology in several clinically relevant aspects: action on electrical depolarization and not at receptors at synapses, independent of renal clearance, hepatic metabolism, compliance of patient, drug interactions, etc. As of today there is no single unifying explanation how ECT works so well in a variety of conditions.
Since its introduction in 1938 there were several advances in the practice of ECT with introduction of modified ECT, brief pulse and ultrabrief pulse current, unilateral electrode placement, seizure threshold titration, etc. with the goal to increase efficacy and minimize the risk, special focus being on minimizing cognitive side effects. Risk of death with ECT is relatively low at 1 in 10,000 patients. At Asha hospital, Hyderabad, about 30,000 patients received ECT in the last 8 years, mostly modified, without any mortality (oral communication). Amnesia, both anterograde and retrograde, remains a significant troublesome side effect. Generally it is transient but some reports comment on many patients having incomplete recovery in retrograde amnesia. The reasonable safety of unmodified ECT has been well described.[3–7] The safety profile of ECT remains neighbors's (other biological treatments) envy. Scalia et al. reported the case of a 92-year-old woman who had received 91 ECTs in her lifetime and showed no pathological effects at postmortem examination of her brain when she died of other causes. Dwork et al. reported no evidence of any significant neuro-pathological lesions in nonhuman primates after receiving multiple ECTs.
Broadly ECT can be categorized based on the phase of treatment:
ECT is used in the management of depression and every psychotic disorder in psychiatry, though depression remains the most common indication. The Consortium for esearch in ECT (CORE) reported a 75% remission in depression which is supported by the UK ECT Review group. Patients with psychotic subtype of depression respond much higher. But there are reports that success rates in community hospital settings have been less at 30-45% as reported by Prudic et al.. There was another report by Sackeim et al. that documented remission rates in depression with ECT at 54%. Another interesting component of this study was that without any form of maintenance treatment 84% of patients relapsed at the end of 6-month follow-up. The CORE group also reported 46% relapse at the end of 6 months. One of their recommendations underscores the need to “treat to wellness” and not prematurely terminate the acute course of ECT. The clinical utility of continuation ECT and maintenance ECT was well discussed by Andrade et al. and Kellner et al.
Most guidelines recommend ECT only for resistant depression and at a much later stage in the treatment process. The National Institute for Clinical Excellence (NICE) guidelines recommend restriction of ECT only for patients with severe depression and state that ECT is not recommended as maintenance therapy.
ECT is underutilized as a treatment modality by some psychiatrists, at some institutions and in some geographical locations of the world. Similarly with some psychiatrists, at some institutions and in some geographical locations, ECT is an overused, rather abused, treatment modality. Each group has its own rationalizations and justifications.
The Grand Old Lady of the biological treatments in psychiatry stood the test of time for three quarters of a century and is going strong, a standing testimonial to its therapeutic benefits.
“In all affairs it is a healthy thing now and then to hang a question mark on the things you have long taken for granted.”
After having said so a few lingering thoughts/doubts cross my mind, which I thought, I will share with you all:
If an young/old scientist takes up any “doubt” as a research project, I salute him. If somebody leaves it as the ramblings of another “Doubting Thomas,” I will not be unhappy with him.
Truth is the goal at which the gradual process of corrected error aims.