All about ECT - Electroconvulsive Therapy - for Depression Treatment

What is ECT?

Electroconvulsive therapy (ECT) is a procedure in which a brief application of electric stimulus is used to produce a generalized seizure.  It is not known how or why ECT works or what the electrically stimulated seizure does to the brain.  In the U.S. during the 1940’s and 50’s, the treatment was administered mostly to people with severe mental illnesses.  During the last few decades, researchers have been attempting to identify the effectiveness of ECT, to learn how and why it works, to understand its risks and adverse side effects, and to determine the best treatment technique.  Today, ECT is administered to an estimated 100,000 people a year, primarily in general hospital psychiatric units and in psychiatric hospitals. 

What conditions does electroconvulsive therapy treat?

Electroconvulsive therapy may help people who have the following conditions:

• Severe depression with insomnia (trouble sleeping), weight change, feelings of hopelessness or guilt and thoughts of suicide (hurting or killing yourself) or homicide (hurting or killing someone else).


• Severe depression that does not respond to antidepressants (medicines used to treat depression) or counseling.


• Severe depression in patients who can't take antidepressants.


• Severe mania that does not respond to medication. Symptoms of severe mania may include talking too much, insomnia, weight loss or impulsive behavior.


• Schizophrenia that does not respond to medication.

How does ECT work?

Traditionally, it was believed that ECT works by using an electrical shock to cause a seizure (a short period of irregular brain activity) in the brain. This seizure releases many chemicals in the brain. These chemicals, called neurotransmitters, deliver messages from one brain cell to another. The release of these chemicals makes the brain cells work better. A person's mood will improve when his or her brain cells and chemical messengers work better.



Update 03-19-2012: The recent study revealed absolutely different mechanism of ECT action on the brain affected by depression. The clinical depression causes "over-communication" in
the brain that may make it difficult for people with depression to think and
concentrate, said study researcher Jennifer Perrin, a mental health researcher
at the University of Aberdeen in Scotland. The ECT treatment appeared to turn
down an overactive connection between brain regions responsible for mood and
emotion and those responsible for thinking and concentrating. Perrin likened the mechanism to dialing down a stereo that's too loud.

What steps are taken to prepare a person for ECT treatment?

First, a doctor will perform a physical exam to make sure you're physically able to handle the treatment. If you are, you will meet with an anesthesiologist, a doctor who specializes in giving anesthesia. Anesthesia is medicine used to put you in a sleep-like state so that you don't feel any pain or discomfort. The anesthesiologist will examine your heart and lungs to see if it is safe for you to have anesthesia. You may need to have some blood tests and an electrocardiogram (a test showing the rhythm of your heart) before your first ECT treatment.

How is it administered?

ECT treatment is generally administered in the morning, before breakfast. Prior to the actual treatment, the patient is given general anesthesia and a muscle relaxant.  Electrodes are then attached to the patients scalp and an electric current is applied which causes a brief convulsion.  Minutes later, the patient awakens confused and without memory of events surrounding the treatment.  This treatment is usually repeated three times a week for approximately one month.  The number of treatments varies from six to twelve.  It is often recommended that the patient maintain a regimen of medication, after the ECT treatments, to reduce the chance of relapse.

To maximize the benefits of ECT, it is crucial that the patient’s illness be accurately diagnosed and that the risks and adverse side effects to be weighed against those of alternative treatments.  The risks and side effects involved with the use ECT are related to the misuse of equipment, ill-trained staff, incorrect methods of administration, persistent memory loss, and transient post-treatment confusion.

ECT Approaches: RIGHT UNILATERAL TREATMENT versus BILATERAL ECT TREATMENTS

There are primarily two types of electrode placements used for the delivery of ECT. Differences between these two techniques include the area of the brain stimulated, timing of response and potential side effects.

To generate a seizure with a right unilateral treatment, one electrode is placed on the crown of the head and the other on the right temple. Those receiving the right unilateral treatments may respond somewhat more slowly than those who receive bilateral treatments. This difference is usually no greater than 1 to 2 treatments. Right unilateral treatment is typically associated with less memory side effects. Patients who do not respond to right unilateral treatments may require a switch to bilateral placement.

Bilateral ECT treatment involves placing the electrodes on both temples. This treatment may be associated with more acute memory side effects than right unilateral treatments. Bilateral ECT is indicated for severe mental illnesses including depression with psychosis, manic episodes of bipolar disorder, psychosis related to schizophrenia and catatonia.

You and your doctor will work together to determine which treatment option is best for you. Specific recommendations will be made after carefully evaluating your concerns, medical/psychiatric history, and the severity of your symptoms.

What are some side effects of ECT?

Side effects may result from the anesthesia, the ECT treatment or both. Common side effects include temporary short-term memory loss, confusion, nausea, muscle aches and headache. Some people may have longer-lasting problems with memory after ECT.

Sometimes a person's blood pressure or heart rhythm changes. If these changes occur, they are carefully watched during the ECT treatments and are immediately treated.

The mechanism linking ECT to memory is not well understood, but about one third of patients experience a significant loss. The ability to remember should come back after treatment, but specific memories might not. Research suggests that factors contributing the most to cognitive problems are the use of a high electrical dose and the placement of electrodes on both temples, rather than just on the side of the head associated with the patient's non-dominant half of the brain. The difficulty for practitioners—as well as fuel for debate—is that when both temples are used, a patient might not require as high a dose of electricity to achieve the necessary rejiggering of brain circuitry.

How distressing is ECT to Patients?

While there are certainly patients who perceive the treatment as terrifying and shameful, and some patients who report distress about persistent memory loss, many speak positively of the benefits. An article entitled "Are Patients Shocked by ECT?" reported on interviews with 72 consecutive patients treated with ECT. The patients were asked whether they were frightened or angered by the experience, how they looked back at the treatment, & whether they would do it again. Of the patients interviewed, 54% considered a trip to the dentist more distressing, many praised the treatment, & 81% said they would agree to have ECT again. Those are comforting statistics about a treatment that has an ugly name and unfavorable connotations, while sometimes offering amazing and occasionally even life-saving results.

Why is ECT so controversial?

After 60 years of use, ECT is still the most controversial psychiatric treatment.  Much of the controversy surrounding ECT revolves around its effectiveness vs. the side effects, the objectivity of ECT experts, and the recent increase in ECT as a quick and easy solution, instead of long-term psychotherapy or hospitalization.

Because of the concern about permanent memory loss and confusion related to ECT treatment, some researchers recommend that the treatment only be used as a last resort.  It is also unclear whether or not ECT is effective.  In some cases, the numbers are extremely favorable, citing 80 percent improvement in severely depressed patients, after ECT.  However, other studies indicate that the relapse is high, even for patients who take medication after ECT.  Some researchers insist that no study proves that ECT is effective for more than four weeks.

During the last decade, the “typical” ECT patient has changed from low-income males under 40, to middle-income women over 65.  This coincides with changing demographics. The increase in the elderly population and Medicare, and the push by insurance companies to provide fast, “medical” treatment rather than talk therapy.  Unfortunately, concerns have been raised concerning inappropriate and even dangerous treatment of elderly patients with heart conditions, and the administration of ECT without proper patient consent.

Is ECT an option?

The patient and physician should discuss all options available before deciding on any treatment.  If ECT is recommended, the patient should be given a complete medical examination including a history, physical, neurological examination, EKG and laboratory test.  Medications need to be noted and monitored closely, as should cardiac conditions and hypertension.  The patient and family should be educated and informed about the procedure via videos, written material, discussion, and any other means available before a written consent is signed.

The procedure should be administered by trained health professionals with experience in ECT administration as well as a specifically trained and certified anesthesiologist to administer the anesthesia.  The seizure initiated by the electrical stimulus varies from person to person and should be monitored carefully by the administration team.  Monitoring should be done by an EEG or “cuff” technique.

The nature of ECT, its history of abuse, unfavorable medical and media reports, and testimony from former patients all contribute to the debate surrounding its use.  Research should continue, and techniques should be refined to maximize the efficacy and minimize the risks and side effects resulting from ECT.

Video Presentation:

Electroconvulsive Therapy (ECT)

Sources and Additional Information:

http://www.nmha.org/go/information/get-info/treatment/electroconvulsive-therapy-ect

http://familydoctor.org/online/famdocen/home/common/mentalhealth/treatment/058.html

http://health.usnews.com/articles/health/brain-and-behavior/2009/07/15/brain-stimulation-electroconvulsive-therapy.html

http://www.medhelp.org/lib/ect.htm

http://www.psych.med.umich.edu/ECT/how-does-ECT-work.asp

http://news.yahoo.com/shock-therapys-mystery-closer-being-solved-203609232.html

Theories on Morality of Suicide (Part 1: Ancient and Classic Approaches)

Moral Permissibility

The principal moral issue surrounding suicide has been

1. Are there conditions under which suicide is morally justified, and if so, which conditions?

Several important historical answers to (1) have already been mentioned.

Note that this question should be distinguished from three others:

1. Should other individuals attempt to prevent suicide?


2. Should the state criminalize suicide or attempt to prevent it?


3. Is suicide ever rational or prudent?

Obviously, answers to any one of these four questions will bear on how the other three ought to be answered. For instance, it might be assumed that if suicide is morally permissible in some circumstances, then neither other individuals nor the state should interfere with suicidal behavior (in those same circumstances). However, this conclusion might not follow if those same suicidal individuals are irrational and interference is required in order to prevent them from taking their lives, an outcome their more rational selves might regret. Furthermore, for those moral theories that emphasize rational autonomy, whether an individual has rationally chosen to take her own life may settle all four questions. In any event, the interrelationships among suicide's moral permissibility, its rationality, and the duties of others and of society as a whole is complex, and we should be wary of assuming that an answer to any one of these four questions decisively settles the other three.

Classic Theories on the Morality of Suicide

Although many applied ethics issues emerged only recently, the issue of the moral permissibility of suicide has a long history of philosophical discussion. Plato opposed suicide since it "frustrates the decree of destiny"; he also argued that "the gods are our guardians, and that we are a possession of theirs. ... Then there may be reason in saying that a man should wait, and not take his own life until God summons him, as he is now summoning me".

Aristotle also opposed suicide since it is "contrary to the rule of life". Later Greek and Roman philosophers approved of suicide as a means of ending suffering. For example, the Roman philosopher Seneca (4 BCE - 65 CE) condones suicide in cases in which age takes its toll on us and prevents us from living as we should:

“I will not relinquish old age if it leaves my better part intact. But if it begins to shake my mind, if it destroys my faculties one by one, if it leaves me not life but breath, I will depart from the putrid or the tottering edifice. If I know that I must suffer without hope of relief I will depart not through fear of the pain itself but because it prevents all for which I should live”.

Stoic philosopher Epictetus (60 CE - 120 CE) also endorses suicide. The principal moral theme of Stoic philosophy is that we should resign ourselves to whatever fate has in store for us. Epictetus suggests that, for some of us, there may be limits to what we can endure in this life and, so, when things get too intolerable, we may wish to end our lives.

He describes our options poetically:

“... Above all, remember that the door stands open. Do not be more fearful than children. But, just as when they are tired of the game they cry, "I will play no more," so too when you are in a similar situation, cry, "I will play no more" and depart. But if you stay, do not cry.

... Is there smoke in the room? If it is slight, I remain. If it is grievous, I quit it. For you must remember this and hold it fast, that the door stands open.”

Attitudes about suicide changed in the writings of Christian philosophers. In The City of God, Augustine (354-430) opposes suicide on the grounds that it violates the commandment "thou shalt not kill."

Although Augustine notes some exceptions to this rule, such as divinely ordained wars or government sanctioned executions, self-killing is not is not an exception since it lacks any parallel justification. It is not justified because of personal suffering, fear of possible punishment, or even on more lofty grounds such as high-mindedness. For Augustine, the more high-minded person is the one who faces life's ills, rather than escapes them.

In Summa Theologica, Thomas Aquinas gives three arguments against the permissibility of suicide. The first argument is based on natural law, or the natural purpose of a thing: suicide is wrong since it is contrary to the natural life asserting purpose of humans.

Aquinas's second argument against suicide is a utilitarian type argument: suicide is not justified because of the greater social harm that is done. Aquinas's third argument is that suicide is wrong since it is like stealing from God. Our lives are property that is owned by God, and we are merely the trustees of that property.

Renaissance and modern philosophers such as Montaigne, Montesquieu, and Voltaire wrote in favor of suicide, opposing the medieval arguments of divine providence.

David Hume gives one of the most famous philosophical defenses of suicide from this period in his essay "Of Suicide." The essay was printed for publication in 1757 in a collection of five dissertations, but, for reasons of political pressure, Hume pulled dropped the essay on suicide. The work eventually appeared in 1783, seven years after Hume's death. In this essay, Hume approaches the question of suicide from the standpoint of the traditional duty-based ethics championed by Grotius and Pufendorf.

If suicide is immoral, then it must violate some duty to God, self, or others. Hume systematically goes through each of these possibilities and concludes that we have no such duty. The bulk of his argument focuses on whether suicide violates duties to God.

We can reconstruct Hume's main argument against such a duty as follows:

There is a self-rule established by God in two forces of nature (i.e., physical laws of the natural world, and purposeful action of the animal world)

As a rule, God has given humans the liberty to alter nature for their own happiness

Suicide is an instance of altering the course of nature for our own happiness

There is no good reason this instance should be an exception to the rule

Therefore, suicide does not violate God's plan

Much of Hume's argument focuses on premise four. One possible criticism to premise four is that human life is uniquely important. In response, Hume argues that in the larger scheme of things our lives are of no greater importance than that of an oyster. Hume also considers the criticism that it is up to God to determine when someone should die.

In response, Hume contends that if determining the time of death is entirely up to God, then it would also be wrong to lengthen our lives, such as through medicine. Another possible criticism is that suicide interferes with the natural order of things that God ordains. We build artificial shelters to protect ourselves from harsh weather conditions, we artificially irrigate barren land and we construct artificial means of transportation.

Clearly, we interfere with the natural causal order all the time. For Hume, arguments from providence fails because there is no relevant difference between, say, diverting the Nile river from its natural course and taking one's life by diverting blood from its normal channel. Hume also argues that when life becomes so unbearable, an all good God would not prevent us from ending our miseries through suicide.

Concerning whether suicide violates our duty to others, Hume offers a series of arguments, such as the following argument from social reciprocity:

When we die, we do not harm society, but only cease to do good

Our responsibility to do good is reciprocally related to benefit we receive from society

When I am dead, I can no longer receive the benefits

Therefore, I do not have a duty to do good

He also argues that I am not obliged to do a small good for society at the expense of a great harm to myself.

Using consequentialist reasoning, Hume argues further that if my continued existence is a burden on society, then suicide is permissible. For Hume, most people who kill themselves in such situation.

According to Alan Donagan, if Hume were pushed to his logical conclusion, utilitarianism would require social indigents to kill themselves. And this, Donagan believes, is a decisive refutation of Hume's utilitarian defense of suicide, since requiring suicide is a clear violation of the principle of autonomy.

Tom Beauchamp defends Hume against Donagan's charge by arguing that (a) Hume is a rule utilitarian, and (b) in normal circumstances, no rule requiring suicide could be established which would produce more good than harm for society.

Finally, concerning whether suicide violates a duty to oneself, Hume argues that all suicides have been done for good personal reasons. This is evident since we have such a strong natural fear of death, which requires an equally strong motive to overcome that fear.

In his essay "Suicide," Immanuel Kant argues that suicide is wrong because it degrades our inner worth below that of animals. Kant considers two common justifications of suicide, and rejects them both. First, some may argue that suicide is permissible as a matter of freedom, so long as it does not violate the rights of others.

In response Kant says self-preservation is our highest duty to ourselves and we may treat our body as we please, so long as our actions arise from motives of self-preservation. Some also might give examples from history that imply that suicide is sometimes virtuous.

For example, in Roman history, Cato, who was a symbol of resistance against Caesar, found he could no longer resist Caesar; to continue living a compromised life would disillusion advocates of freedom. Kant argues that this is the only example of this sort and thus cannot be used as a general rule in defense of suicide.

Kant's main argument against suicide is that people are entrusted with their lives, which have a uniquely inherent value. By killing oneself, a person dispenses with his humanity and makes himself into a thing to be treated like a beast. Kant also argues on more consequentialist grounds that if a person is capable of suicide, then he is capable of any crime. For Kant, "he who does not respect his life even in principle cannot be restrained from the most dreadful vices."

Sources and Additional Information:

http://www.utm.edu/research/iep/s/suicide.htm

http://plato.stanford.edu/entries/suicide/

Psychological Theories of Suicide

Emile Durkhem Theory

Durkheim performed a classic study of suicide and published his conclusions in 1897 on the following reasons of the suicide:

1. Egoistic-Not enough Integration. Due to a looser social network or belief system. For example Protestants are more likely to commit suicide than Catholics because the belief system is not as tight.


2. Anomic-Not enough regulation. Society doesn't have enough control over individuals. Often in periods of economic depression does this occur. Because of such change people find it very hard to adapt.


3. Altruistic-Too much integration. The person sacrifices their life for the benefit of others. For example suicide bombers or a recent case in the UK was that a family was set to be deported due to immigration however if the mother was a widow then they could stay so the father killed himself for the family's benefit.


4. Fatalistic-Too much regulation. The individual has little freedom as a result of the control of society. For example slaves.

Thomas Masaryk Theory

Masaryk considered that the main basis of morality in society is religion. An increase in irreligiousity deregulates the social organism, makes people feel unhappy and increases social disorganization. Suicide, as well as mental illnesses, can be seen as a measure of societal disturbances: the suicide rates increase observed during the 19th century, for example, is interpreted by Masaryk as a result of increasing irreligiosity. Religion, he says, is a system that makes psychological life coherent because it offers a structured way of thinking.



Modern education destroys religious perspective without offering anything similar, because science does not include an ethical component. Without a structured and satisfactory perspective on life, people are more likely to take their lives and are higher exposed to mental sicknesses.

Dr. Sigmund Freud Theory

Dr. Sigmund Freud classified suicide as form of built up aggression or tension that causes inward animosity. Or, in other words, it represents a psychological conflict, which cannot be worked out due to the great force of melancholy and depression.

Benjamin Wolman Theory

Benjamin Wolman, a sociologist who theorized on the “anti-culture” of suicide, blamed estrangement and contemporary societal mechanization and alienation for growing suicide rates. Wolman sums up the sociological standpoint in his statement for the main reasons why so many people now tend to hurt one another and to hurt themselves:

1. The estrangement inherent in our way of life;


2. The decline of family ties;


3. The depersonalization in human relations;


4. The loss of the individual in a mass society.

The ability of people to internalize such aggression and turn it into self-criticism and self-hate is one of the most prominent ties between sociology and psychology. While most psychologists do not hold that society is so exceedingly influential in human development and personal motives, the connection is obviously there.

David Malan Theory

David Malan, a psychologist, suggests that suicide is the cause of accumulated trauma. Though it sounds extremely simplistic, most psychologists, to a certain degree, concur with this theory. Many psychiatrists feel suicide is a result of mental and emotional disturbances that are already present and which external circumstances worsen. Rather than outside forces, personality, character, temperament (which is often thought to be inherited, and thus biochemical), and emotional stability are all psychological factors. This shows suicide as being a personal reaction, with external forces merely contributing to the final outcome. Some views stress personality far more than others, however, and the psychological school that seems to have developed the dominant position on suicide is the psychodynamic approach.

Edwin Shneidman Theory

Edwin Shneidman, in an essay evaluating the psychodynamic view, explains most suicides are marked by ambivalence toward life and death, as well as feelings of hopelessness and helplessness. He explains a type of suicide, termed “egotic suicide,” results from a conflict of internal aspects of self to which the only response is the ending of the personality. Such internal aspects are not always as solitarily self-related as egotic conflict, however.

Krauss Theory

Krauss, in a discussion on psychosocial causes of suicide, explained Freud’s view that suicide is often the result of an unachieved goal or dysfunctional relationship, which is similar to the sociological standpoint. Krauss explains, however, in killing oneself one is really killing the internal representation of the unattainable object. The primary dispute between sociology and psychology, then, is whether the external or the internal has more power. Considering the superego is supposedly the internalization of external morals and parental values, all is relative. Internal and external factors are all relevant and the subjectivity is based, again, in terms of “reality”.

Eric Ericson Theory

There is a developmental theory from Erik Erikson in which life occurs in stages and when people perceive to be unsuccessful, the overwhelming feeling of guilt exceeds the ability to cope effectively.  The hopelessness theory is probably one of the more accepted psychological theories.  Hopelessness refers to Aaron Beck's cognitive triad which states an individual has a negative outlook on themselves, the future, and the world in general.

Dr. Joiner Theory

Dr. Joiner has proposed a theory of why people suicide which he believes is more accurate than previous formulations offered by writers like Edwin Schneidman, Ph.D. and Aaron Beck, MD. According to Schneidman's model, the key motivator which drives people to suicide is psychological pain. In Beck's understanding, the key motivator is the development of a pervasive sense of hopelessness. Dr. Joiner suggests that these are correct understandings but are also too vague to be useful for predictive purposes and not capable of offering a complete motivational picture.

Joiner proposes that there are three key motivational aspects which contribute to suicide. These are:

1)      a sense of being a burden to others,

2)      a profound sense of loneliness, alienation and isolation, and

3)      a sense of fearlessness.

All three of these motivations or preconditions must be in place before someone will attempt suicide. Psychological pain and a sense of hopelessness correspond roughly to Joiner's concepts of burdensomeness and alienation, and contribute to the content of much suicidal ideation. These are necessary but not sufficient preconditions for a suicide act, however. So long as a person remains fearful of death and the actions and consequences of the activities that will create death, the actual act of suicide is unlikely.

Sources and Additional Information:

http://www.mentalhelp.net/poc/view_doc.php?type=weblog&id=640&wlid=9&cn=5

http://www.deathreference.com/Da-Em/Durkheim-mile.html

http://en.allexperts.com/q/Psychology-2566/2008/9/suicide-2.htm

http://www.allacademic.com//meta/p_mla_apa_research_citation/0/2/2/1/6/pages22169/p22169-4.php

http://www.newscientist.com/article/mg20126971.900-why-do-some-people-kill-themselves.html