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INDICATIONS ECT is used predominantly as a treatment for depression. It is generally reserved for use as a second-line treatment for patients who have not responded to drugs. The first-line use of treatment is for situations where immediate clinical intervention is needed or alternative treatments are not advisable. About seventy percent of ECT patients are women.This is largely, but not entirely, due to the fact that women are more likely to receive treatment for depression. Older and more affluent patients are also more likely to receive ECT. The use of ECT treatment is "markedly reduced for ethnic minorities."http://www.ectjournal.com/pt/re/ject/abstract.00124509-200612000-00002.htm;jsessionid=GxLJLWpHRbCyhMfQJVYGC5Xgd5Q1YQW8QNkrHphsp9SzXJjgPZJT!1267112738!181195629!8091!-1 ECT is also sometimes used in the treatment of other disorders, for example, Schizophrenia , Mania , and Catatonia . ADMINISTRATION There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists. International practice varies considerably with widespread use of the therapy in many western countries to a small minority of countries that do not use ECT such as Slovenia. See the Slovenian government website for information about ECT in Slovenia. Modern standards are not always followed throughout the world. The use of both anesthesia and muscle relaxants is universally recommended in the administration of ECT. In countries such as Japan,Motohashi, N ''et al.'' (2004) "A questionnaire survey of ECT practice in university hospitals and national hospitals in Japan". ''Journal of ECT'' 20:21-23. Turkey,Mental Disability Rights International (2005). ''Behind Closed Doors: Human Rights Abuses in the Psychiatric Facilities, Orphanages and Rehabilitation Centres of Turkey'' . Washington, 1-10. India,Chanpattana, W ''et al.'' (2005) "Survey of the practice of electroconvulsive therapy in teaching hospitals in India". ''Journal of ECT'' '''21''':100-104. and Nigeria,Ikeji, OC (1999). "Naturalistic comparative study of outcome and cognitive effects of unmodified electro-convulsive therapy in schizophrenia, mania and severe depression in Nigeria". ''East African Medical Journal'' '''76''':644-650. ECT is still used without anesthesia in some hospitals unlike the USA and the UK where guidelines on the use of ECT are stringent. In the USA, a survey of psychiatric practice in the late 1980s found that an estimated 100,000 people received ECT annually, with wide variation between metropolitan statistical areas.1 Accurate statistics about the frequency, context and circumstances of ECT in the United States are difficult to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information.2 One state which does report such data is Texas, where in the mid-1990s ECT was used in about one third of psychiatric facilities and given to about 1,650 people annually. Usage of ECT has since declined slightly; in 2000-01 ECT was given to about 1,500 people aged from 16 to 97 (in Texas it is illegal to give ECT to anyone under sixteen).Texas Department of State (2002) Electroconvulsive therapy reports . ECT is more commonly used in private psychiatric hospitals than in public hospitals and minority patients are underrepresented in the ECT statistics. In the United States ECT is usually given three times a week; in the UK it is usually given twice a week. Occasionally it is given on a daily basis. A course usually consists of 6-12 treatments, but may be more or fewer. Following a course of ECT some patients may be given continuation or maintenance ECT with further treatments at weekly, fortnightly or monthly intervals. Some patients, as a result of repeat courses or continuation/maintenance ECT may receive large numbers of treatments.Reid, WH ''et al.'' (1998). "ECT in Texas: 19 months of mandatory reporting." ''Journal of Clinical Psychiatry'' 59: 8-13. PMID 9491059. A few psychiatrists in the USA use multiple-monitored ECT (MMECT) where patients receive more than one treatment per anesthetic. In the United Kingdom in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since thenPippard, J and Ellam, L (1981). ''Electroconvulsive treatment in Great Britain, 1980''. London: Gaskell. to about 12,000 per annum. It is still used in nearly all psychiatric hospitals, with a survey of ECT use from 2002 finding that 71 per cent of patients were women and 46 per cent were over 65 years of age. Eighty-one per cent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. Sixteen per cent were treated without their consent. Electro convulsive therapy: survey covering the period from January 2002 to March 2002 , '' Statistical Bulletin 2003/08 ''. Department of Health. In 2003 the National Institute For Clinical Excellence , a government body which was set up to standardize treatment throughout the National Health Service, issued guidance on the use of ECT. Its use was recommended "only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode".NICE (2003). ''Guidance on the use of electroconvulsive therapy'' London: Nice, 5. The guidance got a mixed reception. It was welcomed by an editorial in the British Medical JournalCarney, S & Geddes, J (2003). "Electroconvulsive therapy: recent recommendations are likely to improve standards and uniformity of use". ''British Medical Journal'' 326: 1343-4. but the Royal College of Psychiatrists launched an unsuccessful appeal.NICE (2003). Appraisal of electroconvulsive therapy: decision of the appeal panel . London: NICE. The NICE guidance, as the British Medical Journal editorial points out, is only a policy statement and psychiatrists may deviate from it if they see fit. Adherence to standards has not been universal in the past. A survey of ECT use in 1980 found that more than half of ECT clinics failed to meet minimum standards set by the Royal College of Psychiatrists, with a later survey in 1998 finding that minimum standards were largely adhered to, but that two-thirds of clinics still fell short of current guidelines, particularly in the training and supervision of junior doctors involved in the procedure.Duffett, R and Lelliot, P (1998). "Auditing electroconvulsive therapy: the third cycle". ''British Journal of Psychiatry'' '''172''':401-405. A voluntary accreditation scheme, ECTAS, was set up in 2004 by the Royal College, but as of 2006 only a minority of ECT clinics in England, Wales, Northern Ireland and the Irish Republic have signed up.Royal College of Psychiatrists (2006). ECTAS newsletter issue 5. ECT is usually given on an in-patient basis, although it may also be given on an out-patient basis. Prior to treatment a patient is given a short-acting anesthetic such as (succinylcholine), and occasionally Atropine to inhibit salivation. Electrodes are usually placed one on either side of the patient's head. This is known as bilateral ECT. Less frequently both electrodes are placed on one side of the head. This is known as unilateral ECT. In bifrontal ECT, an uncommon variation, the electrode position is somewhere between bilateral and unilateral. Unilateral is thought to cause fewer cognitive effects than bilateral but is considered less effective. In the USA most patients receive bilateral ECT.Prudic, J, Olfson, M, Sackeim, HA (2001). "Electroconvulsive therapy practices in the community." ''Psychological Medicine'' 31: 929-934. PMID 11459391. In the UK almost all patients receive bilateral ECT.Duffett, R and Lelliott, P (1998). "Auditing electroconvulsive therapy: the third cycle". ''British Journal of Psychiatry'' '''172''': 401-405. Stimulus levels in excess of an individual's seizure threshold are therefore recommended: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT. Below these levels treatment may not be effective in spite of a seizure, while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe Cognitive Impairment without additional therapeutic gains. Seizure threshold is determined by trial and error ("dose titration"). Some psychiatrists use dose titration, some still use "fixed dose" (that is, all patients are given the same dose) and others compromise by roughly estimating a patient's threshold according to age and sex. Older men tend to have higher thresholds than younger women, but it is not a hard and fast rule, and other factors, for example drugs, affect seizure threshold. Most modern ECT machines deliver a brief-pulse current, which is thought to cause fewer cognitive effects than the sine-wave currents which were originally used in ECT. A small minority of psychiatrists in the USA still use sine-wave stimuli. Sine-wave is no longer used in the UK. Typically, the electrical stimulus used in ECT is about 800 milliamps, and the current flows for between one and 6 seconds.Lock, T (1995). "Stimulus dosing". In C Freeman (ed.) ''The ECT Handbook''. London: Royal College of Psychiatrists, 72-87. In the USA, ECT machines are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and MECTA. The .Federal Register (1979), p. 51776 Class III is the highest-risk class of medical devices. In the UK the market for ECT machines was long monopolised by Ectron Ltd, although in recent years some hospitals have started using American machines. Ectron Ltd was set up by psychiatrist Robert Russell, who together with a colleague from the Three Counties Asylum, Bedfordshire, invented the Page-Russell technique of intensive ECT. EFFECTIVENESS In the US the Surgeon General's report on mental health summarised current psychiatric opinion about the effectiveness of ECT. It stated that both clinical experience and controlled trials had determined ECT to be effective (with an average 60 to 70 per cent response rate) in the treatment of severe depression, some acute Psychotic states, and Mania . Its effectiveness had not been demonstrated in Dysthymia , Substance Abuse , Anxiety , or Personality Disorder . The report stated that ECT does not have a long-term protective effect against suicide and should be regarded as a short-term treatment for an acute episode of illness, to be followed by continuation therapy in the form of drug treatment or further ECT at weekly to monthly intervals.Surgeon General (1999). ''Mental Health: A Report of the Surgeon General'' , chapter 4. A large multicentre clinical follow-up study of ECT patients in New York found response rates of 30-47 per cent (depending on criteria), with 64 per cent of those relapsing within six months.Prudic, J ''et al''. (2003). "Effectiveness of electroconvulsive therapy in community settings". ''Biological Psychiatry'' 55:301-12. A survey of New York psychiatrists found that they thought that 85 per cent of their patients benefited from ECT. In the UK in 2003 the UK ECT Review Group, led by Professor Geddes of Oxford University, reviewed the evidence and concluded that ECT had been shown to be an effective short-term treatment for depression (as measured by and people with treatment-resistant depression) were under-represented in the trials even though ECT is believed to be especially effective for them.The UK ECT Review Group (2003)."Efficacy and safety of electroconvulsive therapy in depressive disorders: a systemic review and meta-analysis". ''Lancet'' 361:799-808. A recent survey in the UK found that 83 per cent of psychiatrists thought that ECT was more likely to be beneficial than harmful – this figure fell to 69 per cent of mental health nurses and 14 per cent of psychologists.Lutchman, RD ''et al''. (2001). "Mental health professionals' attitudes towards and knowledge of electroconvulsive therapy." ''Journal of Mental Health'' 10(20):141-150. Meanwhile a survey in Australia found that 72 per cent of the public thought that ECT would be harmful for someone who was depressed, causing the authors to advocate better education of the public to aid acceptance of evidence-based mental health care.Jorm, AF ''et al''. (1997). "Mental Health Literacy: a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment". ''The Medical Journal of Australia'' '''166'''(4):182-6. PMID 9066546Jorm AF. Mental health literacy. Public knowledge and beliefs about mental disorders. Br J Psychiatry. 2000 Nov;177:396-401. PMID 11059991 ADVERSE EFFECTS The 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. Immediately following treatment the most common side effects are confusion and memory loss. The state of confusion usually disappears after an hour. Rarely this state of disorientation leads to a state of delirium.Benbow, SM (2004) "Adverse effects of ECT". In AIF Scott (ed.) ''The ECT Handbook, second edition.'' London: The Royal College of Psychiatrists, 170-174. It is the effects of ECT on long-term memory, that give rise to much of the concern surrounding its use.Lisanby, SH (2000). "The effects of electroconvulsive therapy on memory of autobiographical and public events". ''Archives of General Psychiatry'' 57:581-90.The acute effects of ECT include 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.Benbow, SM (2004) "Adverse effects of ECT". In AIF Scott (ed.) ''The ECT Handbook, second edition.'' London: The Royal College of Psychiatrists, 170-174. One review of paitent self-reporting found that between 29 percent and 55 percent (depending on the study) of people who had undergone ECT reported persistent memory loss.Rose, D ''et al''. (2003). "Patients' perspectives on electroconvulsive therapy: systematic review". ''British Medical Journal'' 326:1363-1365.. In 2000 American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with persistent impairment for memory of public events as compared to RUL ECT.Lisanby, SH (2000). "The effects of electroconvulsive therapy on memory of autobiographical and public events". ''Archives of General Psychiatry'' '''57''':581-90. A recent large study, (published January 2007) by Harold Sackeim and colleagues found that some forms of ECT "routine {Link without Title} " causes "adverse cognitive effects," including cognitive dysfunction and memory loss, that can persist for an extended period.Sackeim, HA ''et al.'' (2007). "The Cognitive Effects of Electroconvulsive Therapy in Community Settings." ''Neuropsychopharmacology'' 32(1):244-254. PMID 16936712. Full Text: http://www.nature.com/npp/journal/v32/n1/pdf/1301180a.pdf Formal neuropsychological testing has documented permanent neuropsychological deficits in patients who receive certain types of ECT treatment,FDA, Docket #82P-0316 |
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