Electroconvulsive therapy (ECT), formerly known as electroshock

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Electroconvulsive therapy (ECT), formerly known as electroshock, is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown.^[1] The use of electroconvulsive therapy evolved out of convulsive therapy. Long before electric shocks were being administered to induce seizures, doctors were using other drugs and methods to induce seizures as a means of treatment for severe depression and schizophrenia. Today, ECT is most often used as a treatment for clinical depression that has not responded to other treatment, and sometimes for mania and catatonia.^[2] It was first introduced in 1938 by Italian neuropsychiatrists Ugo Cerletti and Lucio Bini, and gained widespread use as a form of treatment in the 1940s and 1950s.^[3][4]
Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and positive outcomes. After treatment, drug therapy is usually continued, and some patients receive continuation/maintenance ECT. In the United Kingdom and Ireland, drug therapy is continued during ECT.^[2]
About 70 percent of ECT patients are women, since they are at twice the risk of depression than are men.^[1][5][6] Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive, and ECT on its own does not usually have a sustained benefit. There is a significant risk of memory loss with ECT.^[7] It is widely acknowledged internationally that obtaining the written, informed consent of the patient is important before ECT is administered.^[8] Experts disagree on when ECT should be used as a first-line treatment or if it should be reserved for patients who have not responded to other interventions such as medication and psychotherapy.^[9]

Adverse effects

Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia; the United States' Surgeon General's report says that there are "no absolute health contraindications" to its use.^[47]:259 Immediately following treatment, the most common adverse effects are confusion and memory loss. The state of confusion usually disappears after a few hours. It can be tolerated by pregnant women who are not suffering major complications. It can be used with diabetic or obese patients, and with caution in those whose cancers are in remission or under control. It can be used in some immunocompromised patients. It must be used very cautiously in people with epilepsy or other neurological disorders because by its nature it provokes small tonic-clonic seizures, and so would likely not be given to a person whose epilepsy is not well controlled.^[49][50] Some patients experience muscle soreness after ECT. This is due to the muscle relaxants given during the procedure and rarely due to muscle activity. ECT, especially if combined with deep sleep therapy, may lead to brain damage if administered in such a way as to lead to hypoxia or anoxia in the patient.^[51][52][53] The death rate due to ECT is around 4 per 100,000 procedures.^[54] There is evidence and rational to support giving low doses of benzodiazepines or else low doses of general anesthetics which induce sedation but not anesthesia to patients to reduce adverse effects of ECT.^[55]

Effects on memory

It is the purported effects of ECT on long-term memory that give rise to much of the concern surrounding its use.^[56] The acute effects of ECT can include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment).^[57] Memory loss and confusion are more pronounced with bilateral electrode placement rather than unilateral, and with outdated sine-wave rather than brief-pulse currents. The use of either constant or pulsing electrical impulses also varied the memory loss results in patients. Patients who received pulsing electrical impulses as opposed to a steady flow seemed to incur less memory loss. A 2007 study on the long term effects of ECT showed that global cognitive impairment followed all forms of ECT in varying extent.^[58] The vast majority of modern treatment uses brief pulse currents.^[57] Research by Harold Sackeim has shown that excessive current causes more risk for memory loss, and using right-sided electrode placement may reduce verbal memory disturbance.^[17] It was his '07 study that also showed global cognitive impairment in all forms of ECT, including the most benign^{[citation needed]}.
Retrograde amnesia is most marked for events occurring in the weeks or months before treatment, with one study showing that although some people lose memories from years prior to treatment, recovery of such memories was "virtually complete" by seven months post-treatment, with the only enduring loss being memories in the weeks and months prior to the treatment.^[59][60] Anterograde memory loss is usually limited to the time of treatment itself or shortly afterwards. In the weeks and months following ECT these memory problems gradually improve, but some people have persistent losses, especially with bilateral ECT.^[1][57] One published review summarizing the results of questionnaires about subjective memory loss found that between 29% and 55% of respondents believed they experienced long-lasting or permanent memory changes.^[61] In 2000, American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with more persistently impaired memory of public events as compared to RUL ECT.^[56]
Some studies have found that patients are often unaware of cognitive deficits induced by ECT.^[62][63] For example, in June 2008, a Duke University study^[62] was published assessing the neuropsychological effects and attitudes in patients after ECT. Forty-six patients participated in the study, which involved neuropsychological and psychological testing before and after ECT. The study documented substantial cognitive impairment after ECT on a variety of memory tests, including "verbal memory for word lists and prose passages and visual memory of geometric designs." Based on their findings, the authors issued the following recommendation:

When ECT is provided to adolescents, the potential impact of such cognitive changes should be discussed with the patients and their parents or guardians in terms of implications for not only the patient's emotional functioning but cognitive functioning as well, particularly upon his or her academic performance. In summary, we argue that an individual cost-benefit analysis should be made in light of the implications of the potential benefits versus costs of ECT upon improving emotional functioning and the impact that potential memory changes may have on real-world functioning and quality of life.^[62]

Severe memory loss from ECT is described in an autobiographical book, Doctors of Deception: What They Don't Want You to Know about Shock Treatment.^[64]