Information About ECT

It is the position of the Office of Mental Health (OMH) that individuals with psychiatric needs should have access to all clinically effective and approved treatment services, including electroconvulsive therapy (ECT) when it is indicated as clinically appropriate. Based upon the conclusions the American Psychiatric Association, the American Medical Association, the National Institute of Mental Health and similar organizations in Canada, Great Britain and many other countries, ECT is a safe and effective medical treatment for certain psychiatric disorders.

Although the exact process that underlies the effectiveness of ECT is uncertain, it is known that its benefits depend on producing a seizure in the brain. Biological changes that result from the seizure are believed to result in a change in brain chemistry which is believed to be the key to restoring normal function. Considerable research is being conducted to isolate these critical biochemical processes. During the procedure, patients are under general anesthesia and are given muscle relaxant to prevent movement and to insure that there are only minimal contractions of the muscles during the seizure. The course of treatment is 2 to 3 ECT procedures per week, over several weeks, provided by a qualified clinical team which is led by a psychiatrist. The public perception of ECT is often based on inaccurate representations which portray it as a painful procedure, used to control or punish patients. These portrayals have no resemblance to modern ECT practiced according to accepted professional guidelines.

OMH facilities provide access to ECT, either on-site in OMH psychiatric centers or at community hospitals. ECT is used for a limited number of patients served in OMH’s inpatient psychiatric centers who require, and are appropriate for, this treatment. Such patients usually have severe disorders that can be potentially life-threatening (either major depression or bipolar disorder), medication-resistant schizophrenia and schizo-affective disorder, or severe catatonia (a relatively rare condition).

ECT’s major side effect can be transient cognitive impairment, which takes the form of a very short-term confusion and some memory loss. The memory loss generally pertains to events preceding the treatments, and may be expected to clear over a period of days to weeks (Sackeim, 1992). In rare cases, this impairment may last for a considerably longer period--weeks to months to years. Even in such cases, the memory impairment does not interfere with mental functioning or cause persistent deficits in the formation of new memories or disrupt with basic cognitive functions, such as intelligence (Sackeim et al., 1992, 1993, 2000). There is a clear absence of any evidence that ECT causes damage to neurons or other brain cells (Devanand et al., 1994).

In New York State, persons treated by ECT must be given an explanation of the proposed procedure and course of treatment, including a discussion of the expected benefits, reasonable foreseeable risks, and any reasonable alternative to the proposed treatment. New York’s law and regulations state that no patient may be treated with ECT over his or her objection as long as s/he retains the capacity to make a reasoned decision concerning treatment. Where there is reason to believe that the patient may lack capacity, the treatment team may appeal to the court for permission to administer ECT, when the treating physician determines that this treatment would be of greatest benefit to the patient.

In these cases, a court must determine that the person lacks capacity and must balance whether or not the proposed treatment is sufficiently justified; this decision is based on the circumstances of the individual case including the patient’s best interest, the benefits to be gained, potentially adverse side effects and consideration of any less intrusive alternative treatments. OMH adheres to NYS law and regulations in all cases where treatment is sought when the patient lacks capacity.

In order to maximize effectiveness and minimize side-effects, OMH is committed to ensuring that practitioners administering ECT in New York State follow the latest (second edition, 2001) guidelines published by the American Psychiatric Association’s (APA) Task Force on ECT. OMH psychiatric centers which provide ECT adhere to the APA’s Guidelines regarding its administration.

These detailed guidelines address the following:

• Clinical indications for use of ECT, including primary and secondary use.
• Determination of medical risk factors including risk evaluation and specific medical conditions associated with increased risk.
• Identification and treatment of special populations including pregnant women, the elderly, persons with heart conditions, etc.
• Reduction of, recognition of and response to adverse effects including heart complications, reduced oxygen levels, prolonged seizures, memory loss, etc.
• Appropriateness and interaction of medications during the ECT treatment period, including a full review of all prescribed medications.
• Procedures for obtaining written consent for the administration of ECT for patients who possess the capacity to consent.
• Staff requirements, including medical disciplines, privileging, training and specific treatment responsibilities.
• Treatment procedures during all phases of ECT administration, including patient preparation, pre-treatment, recovery and post-treatment.
• Description of ECT devices, including identification of preferred equipment, routine maintenance, and equipment calibration.
• Description of medical equipment required to monitor and manage patients during the ECT process, including equipment to monitor vital signs and provide initial management of medical emergencies.
• Continued evaluation of patient’s therapeutic response and review of adverse effects, including cognitive changes and identification of any new risk factors.

Data on the use of ECT in inpatient settings in New York State:

• Five of OMH’s 27 psychiatric centers currently provide on-site ETC (Creedmoor, Manhattan, Pilgrim and Rockland PCs, and NYS Psychiatric Institute). Twelve psychiatric centers reported ECT treatment using community hospitals during calendar year 2000. Ten psychiatric centers report no ECT procedures during the year 2000.
• A total of 134 (1.3%) individuals of the approximately 10,000 adult patients served in OMH’s inpatient service (adult and forensics) received ECT during calendar year 2000.
• Of the 134 individuals receiving ECT, 95 (approximately 71%) were treated in on site and 39 (29%) were treated by a community provider.
• The number of individuals in OMH psychiatric centers receiving ECT has increased from 74 in 1990 to 134 in 2000 (45%).
• Of the 134 individuals in OMH psychiatric centers receiving ECT in 2000, 35 (26%) were court ordered. The number of court ordered ECT procedures has increased by 52% since 1998, when 23 individuals received court ordered ECT.
• According to SPARCS data from the Department of Health, the rate of ECT for individuals receiving ECT in non-OMH facilities is 1.8% of the total number of persons served. This is higher than the rate of 1.3% in OMH facilities.

REFERENCES:

American Psychiatric Association [Weiner, R.D.; Coffey, C.E.; Fochtmann, L.; Greenberg, R.; Isenberg, K.E.; Moench, L.; and Sackeim, H.A.]. The Practice of ECT: Recommendations for Treatment, Training and Privileging. Second Edition. Washington, D.C. American Psychiatric Press, 2001.

Devanand, D.P.; Dwork, A.J.; Hutchinson, E.R.; Bolwig, T.G., and Sackeim, H.A. Does ECT alter brain structure? Am J Psychiatry. 1994 July; 151(7):957-70.

Sackeim, H.A. The cognitive effects of electroconvulsive therapy. In: Moos, W.H.; Gamzu, E.R., and Thal, L.J., eds. Cognitive Disorders: Pathophysiology and Treatment. New York: Marcel Dekker; 1992; pp. 183-228.

Sackeim, H.A.; Freeman, J.; McElhiney, M.; Coleman, E.; Prudic, J., and Devanand, D.P. Effects of major depression on estimates of intelligence. J Clin Exp Neuropsychol. 1992 Mar; 14(2):268-88

Sackeim, H.A.; Prudic, J.; Devanand, D.P.; Kiersky, J.E.; Fitzsimons, L.; Moody, B.J.; McElhiney, M.C.; Coleman, E.A., and Settembrino, J.M. Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med. 1993 Mar 25; 328(12):839-46.

Sackeim, H.A.; Prudic J.; Devanand, D.P.; Nobler, M.S.; Lisanby, S.H.; Peyser, S.; Fitzsimons, L.; Moody, B.J., and Clark, J. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry. 2000 May; 57(5):425-34.