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How the use of electroconvulsive therapy changed

This is fine but could also be rephrased – perhaps noticing the effects of epileptic fits could come earlier in the paragraph before starting the testing.

This seems a little confused and muddled. Not sure if you could make it more clear.

Electroconvulsive therapy is "A procedure in which an electric current is used produce a seizure in a patient. This is used to relieve symptoms of depression and other mental disorders"www.psychiatric-disorders.com/dictionary/acutemania-eyemovementdesensitizationandreprocessing.php . Convulsive therapy has been used as a treatment for mental illness since the sixteenth century. However in the 1930's the recognition of shock treatment began to pick up pace quickly. Only three years after the introduction of the already revolutionary Metrazol Convulsive Therapy, Ugo Cerletti, a neuropsychiatrist, used electric shocks to treat a patient with a form of Schizophrenia. One year later, in 1939, it was brought to the United Kingdom. Since then it has travelled a controversial path due to the many ethical issues surrounding its use. The debate stems from its misuse till the 1980s and the consequent effects of memory loss, possible brain damage and in some cases; death. There have also been instances where psychological damage was worsened as some people felt scared and ashamed of undergoing the electroshock treatment. As a result over the past seventy years, its use has dramatically changed, initially rising and in more recent times, ECT has become the treatment of last resort when all else fails.  Legislation has reduced the frequency of use of shock therapy, but it is also because of the development of new psychiatric treatments, that has caused the use of shock treatment to fall. It is still regarded by many psychiatrists however; an effective form of medical treatment.

Though its use has sparked controversy in the last thirty to fourty years, convulsive therapy has been used for hundreds of years to successfully treat psychiatric diseases. Before the advancement of medicine, at around 450BC, people would use plants and herbs which caused convulsions to treat some mental illnesses by "shak[ing] the evil spirits out". Then, in the 1500s, the oral use of camphor (a substance found in the bark of the tree, camphor laurel) was administered to treat mental illness by causing convulsions. Subsequently, in 1785, it was reported that camphor was being used to treat maniaKaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry

http://en.wikipedia.org/wiki/Camphor

 . In 1934, Ladsilaus Meduna begun the use of intramuscular injections of camphor to treat Catatonia. After the fifth seizure the patient was able to talk spontaneously and began to eat and care for himself for the first time in four years makeing a full recovery with three further treatments. It was over two thousand years after the first use of convulsive therapy in which Ugo Cerletti and Lucio Bini first used electroshock treatment on a patient who had catatonic schizophrenia.http://en.wikipedia.org/wiki/Ugo_Cerletti . Sherwin B Nuland, a surgeon, who was treated with ECT, and discussed the event with a firsthand observer, described   "They thought, 'Well, we'll try 55 volts, two-tenths of a second. That's not going to do anything terrible to him.' So they did that...This fellow...sat right up, looked at these three fellows and said, 'What the fuck are you assholes trying to do?' Well, they were happy as could be, because he hadn't said a rational word in the weeks of observation."http://www.ted.com/talks/sherwin_nuland_on_electroshock_therapy.html  Cerletti had got the idea after witnessing pigs being treated with electroshock in an abattoir before being killed. The pigs regained consciousness and were not affected, and so Cerletti and his colleagues began testing on animals and a wide range of patients with conditions such as major depression, acute schizophrenia and other mood disorders. Previously, Cerletti had noticed that his depressive patients who also had epilepsy, would have the depression lifted after a series of epileptic fits. This highlighted the potential benefit of convulsions on depression.

By the 1940's electroconvulsive therapy became the preferred choice of treatment over cardiazol convulsion therapy in mental health instituted in the UK. As it became used for more and more conditions it was later established that it was very effective in the treatment of affective psychosis (which is psychosis characterised mainly by emotional disturbance). All thought its effect on the treating schizophrenia wasn't particularly good, it was still used by many medical practitioners to control institutionalised psychiatric patients who had schizophrenia. In some mental health institutes it was only used to treat depression but in a lot of others it was used to treat a wider range of mental conditions such as schizophrenia, epilepsy, neurosis, and hysteria. By the 1950's the use of ECT has increased by 20 times. The treatment of mental disorders by electrically induced convulsions. Journal of Mental Science

Check grammar/phrasing

 During these early days there was a generally positive view on this revolutionary treatment however the first sign of oppositions came Cyril Birnie and medical superintendent who outlined the potential intellectual deficits that the treatment could have on patientsGolla FL -  Electrically induced convulsions .

Unmodified treatment, the risks and the side effects

So why has the use of Electroconvulsive therapy been so controversial? In its early years, ECT was found to be used in psychiatric hospitals to calm and control patients who were becoming difficult to handlehttp://www.cerebromente.org.br/n04/historia/shock_i.htm . They were often not properly sedated and restrained and sometimes underwent the treatment several times in one day. Since ECT was cheap and easy to administer, it quickly became popular and by the 1950s was firmly established as a common method to treat depression. When ECT was unmodified, the procedure was often terrifying for patients because it was administered without anaesthetics or muscle relaxants, and the uncontrolled seizures lead to breaking of bones and other injuries due to the violent nature of the muscle contractions caused by the convulsionsOxford Handbook of Psychiatry . During the 1940's the use of curare (a poison from South America which paralyses the muscles) was experimented with to make the procedure more safe however the drug itself was dangerous due to its toxic properties. However the introduction of succinylcholine in 1951 solved this problem since it was a safer alternative. In 1957 a patient who had fractures to both hips whilst undergoing ECT took legal action. Even though he lost the case it had great consequences as it encouraged the issue about ECT techniques to be debated which led to the abandonment of the use of unmodified ECT in hospitals in England.

Since the beginning of its use in the 1930s, patients have complained about many side effects including headache, temporary confusion and some loss of short term memory. Depressed patients with bipolar mood (affective) disorder may become manic as a

You could explain and expand a bit on bi and uni lateralresult of the treatment. Patients who underwent bilateral ECT were more likely to complain of impaired memory than those who underwent unilateral ECT. Although confusion usually occurs after treatment, it is not regarded as persistent in all patients however memory loss is persistent in some patients. A patient describes their experience of memory loss after treatment: "It took a long time for my memory to return properly, and I still get frustrated at being unable to recall events or things I learned". From this patient it is clear to see that the treatment has caused her a great deal of distress and some harm. Personal memories are invaluable to most people since they are irreplaceable and the loss of them can be devastating for a patient and perhaps therefore lead to further frustration and sadness. Another example of a patient who suffered memory losss is Susan; "I had headaches following the procedure and loss of memory. I got to #3 and refused the other 3 - I was sure the doc was trying to kill me. There are periods of time I cannot recall. My daughter was admitted to the hospital and I don't remember taking her"http://bipolar.about.com/od/ect/a/sfe_shock1.htm .

A recent patient describes their use of ECT; "Although I was seriously ill at the time, and in a psychiatric hospital, I can honestly say that the whole experience of ECT was incredibly traumatic. I hated the pads being put on my head (in fact I tried to pull them off while I was going under the anaesthetic) and I hated the awful disorientation after the treatment".http://www.bbc.co.uk/dna/h2g2/A840700   Although, the use of ECT has become safer and more controlled, this patient's description vividly describes some of the worries and emotions going through a patients mind before undergoing the procedure. Before the introduction muscle relaxants and anaesthesia it would be accurate to say that ECT would have been a lot more frightening than it is now. Supporters of ECT have always defended it and their reasoning behind this is that "it works". This argument however ignored the negative consequences such as memory impairment and also medicine being an evidence based field, it can be considered hypocritical to argue that it works, when there is insufficient evidence for this and there is insufficient evidence explaining how it works. Also, what does it mean when health professionals say "it works"? What is the criteria for success?

"At age 16 I was raped. I suffered severe post-traumatic shock and was taken to a psych ward. I was in a non-verbal state and the psychiatrist upon admission misdiagnosed my condition as catatonic schizophrenia. After only four days of observation I was started on a course of 10 shock treatments - which in and of themselves were as traumatizing as the rape. When I awoke after each treatment I felt completely broken, like a walking zombie.

I experienced ECT as invasive, cruel and terrifying. Today, 25 years later, my memory and abilities to comprehend and learn are still greatly disabled. I have permanent brain damage from this form of "therapy." Shock treatment was the most horrific experience in my life"http://bipolar.about.com/od/ect/a/sfe_shock1.htm . It is stories like these which have shocked outsiders. The potential long term effects are identified vividly. Health professionals may however argue that this is an example of ECT on a young person so whether or not an adult would experience the same effects is questionable. From this case however it is unquestionable, that ECT can have devestating effects on a persons life. Every day in medicine, doctors weigh up the potential risks with the potential benefits, and this is the main ethical issue which has to be considered. With Chloe, the benefits are evidently not existant.

In a survey from the APA task force on ECT, psychiatrists were asked, “Is it likely that ECT produces slight or subtle brain damage?” 41 percent voted yes, with only 26 percent voting no.http://www.ect.org/psychiatrists-private-views-on-ect/  

Misuse of ECT and the resulting legislation

Aside from the side effects, there has been much publicity regarding its use on patients without their consent. It can be witnessed in the film One Flew Over the Cuckoo's Nest where Jack Nicholson is shown to be forced to undergo shock therapy. The violent nature of the convulsions is one of the reasons why the issue is stigmatised and looked upon as an inhumane treatment. It is thought that one of they key reasons why ECT is identified as “psychiatric wickedness” in the public mind is the media, films and books such as the one mentioned. This extract describes what happened to Ruckly, one of the characters in the book when he underwent ECT:

 

They brought him back to the ward two weeks later, bald and the front of his face an oily purple bruise and two little button-sized plugs stitched one above each eye. You can see by his eyes how they burned him out over there; his eyes all smoked up and gray and deserted inside like brown fuses. All day now he won’t do a thing but hold an old photograph up in front of that burned-out face, turning it over and over in his cold finders, and the picture wore gray as his eyes on both sides with all his handling till you can’t tell any more what it used to be.One Flew Over the Cuckoo's Nest by Ken Kesey  

 

The extract portrays a very earie and inhumane image of ECT. It is an extract from a novel so doesn't necessarily portray what the treatment actually involved however it was a very popular book and the subesequent film was also a huge hit and this is what influenced the general public. This publicity may have had negative impacts on patient care - as L Clarke noted in his book that "decisions about ECT are fraught with social considerations". This suggests doubts about whether the patient's health is considered most important as the social issued of ECT may affect the decision making of medical practitioners.

In a UK study in 1992 it was revealed that of the seven hundred patients detained and had ECT, fifty nine percent had not consented to the treatment. Helen Crane has undergone ECT treatment on two occasions and has suffered side effects including memory loss, slurred speech and loss of co-ordination. Mrs Crane agreed to treatment after suffering from depression a few years ago. She now gets lost around her home town where she has lived for many years. She said; "I think the fact that patients are treated without consent is barbaric. If there was an orthopaedic treatment like this, for example, there would be a huge outcry. I think ECT should be a last-resort treatment." It is also thought that standards of psychiatric workers were not adequate and patients were not fully informed of the risks of ECT treatment and some of the risks were played down in the consent forms. The Royal College of Psychiatrists did a study in 1980 and found that at least half of all cinics were rated below their standards required for provision of ECT treatment. Patient Thomas Sanderson, who suffered from long term memory loss after his treatment said that "People need to know that it is a definite possibility that you can lose your memory, you can lose your self, you can lose the ability to do the work you do everyday of your life. Is the risk worth it?". Although he wasn't directly forced to undergo the treatment, he said that he felt he was strongly encouraged and was not told of the risks. He was told that there was "perhaps a risk of 1 in 200 of long term memory loss". When questioned, the doctor said that the key word was "perhaps"http://www.youtube.com/watch?v=fBK5Y5rmAy0&feature=related . However after much protest, there has been the introduction of legislation which has made sure that patients who are able to consent, must sign if they want to undergo the treatment.

The study by the Royal College of Psychiatrists revealed that in quite a few clinics, ECT was being used by "bored and uninterested staff with obsolete machines operated by ignorant and uncaring psychiatrists".Pippard J and Ellam L (1981). Electroconvulsive treatment in Great Britain, 1980. London: Gaskell  In one clinic it was noted that staff described a 30 year old ECT machine fixed using sticking plaster as "old is gold". In 1980 it was reported that about 27,000 patients had recieved electroconvulsive therapy which is estimated to be half of the number during the early 1970s. There was quite a bit of variation in its use around the UK: Jersey and Guernsey were reported to have used ECT the most where ECT was used at least five times as much as it was in Oxford, where ECT was used the least. Although few psychiatrists decided not to use ECT on any of their patients; there were others others thought that ECT should only be used in psychotic or endogenous depression; and yet there were others that believed that ECT should be used on a very wide range of mental ilnesses. The survey also found that a small number of clinics were still, in 1980, occasionally using unmodified ECT (i.e. without anaesthesia).

Legislation is a key reason why the use of ECT reduced for a while and its use became more controlled and as a result more accepted. Conversely, it can be argued that some legislation was introduced in response to patients’ rights groups as a sort of knee jerk reaction, ignoring therefore; its benefits. As a result a lot of the legislation didn’t come into effect. In 1967, UTA became the first American state to pass legislation regarding the control of ECT and by 1983, twenty six states has passed statures about the issue. In 1974, a bill was passed in the state of California which prohibited ECT altogether. Even when a patient had volunteered, it could only be used after a review panel appointed by the community medical authorities agreed to it, and after all other psychiatric treatments has been used and failed. If a doctor were to break this rule then they would have their licence removed. The bill was later rejected. In 1982, a coalition in the city of Berkley gathered the one thousand four  hundred signatures required to ban ECT. In 1995, the banning of ECT was introduced into the Texas legislature. Both bans however were overturnedThe History of Pscyhiatry by Edward Shorter . Training for the administration of ECT did however disappear from medical school programmes between 1960 to 1980 as a result of this public opposition. In recent years however, regulation has come into effect successfully. In 2001, the state of New York introduced the following bill; "Requires every facility which administers electroconvulsive therapy to provide full disclosure of the benefits and side effects of such therapy, gain the written consent of the patient to such therapy, include a copy of such disclosure and consent in the patient`s records, and establish a protocol for determining patients' capacity". In the UK, the mental health Act has changed the way in which ECT has been administered. Section 58A of the mental health act covers ECT and any medication given as part of the ECT treatment. The rules apply to adult detained patients and to all patients under 18 including those who aren't detained. The act says that no patient may be given ECT without approval of a Second Opinion Appointed Doctor (SOAD). Furthermore, ECT is not permitted to to be used on an adult unless the patient has consented and either the approved clinician in charge of it or a SOAD has certified in writing that the patient is capable of understanding its nature, purpose and likely effects and has then consented to it. It can also be administered however if a SOAD has certified in writing that the patient is not capable of understanding the nature, purpose and likely effect of the treatment and that it is appropriate for the treatment to be given and that this will not conflict with a valid and applicable advance decision made by a donee or a deputy or the Court of ProtectionMental Health Law in England and Wales - Paul Barber . On top of this, the SOAD must have consulted two other professionals who have been involved with that patient's care. One of the consulted professionals has to be a nurse while the other cannot be a nurse of registered medical practitioner. Quite clearly, there has been a heavy amount of legislation concerning ECT. It mostly deals with the issue of forced treatment which has been the primary concern of most people. It also requires quite a length process if ECT is given without consent (in the case where a patient isn't able to understand the treatment and therefore make a valid decision). Legislation is therefore one of the key reasons why the use of ECT has changed. Although in some countries, laws have reduced its administration, the fundamental change is that it is now no longer unnecessarily forced up on people. At least this what the laws have aimed to set right, whether or not this is being followed in hospitals is another question altogether.

However it was revealed in 1980 that ECT had been used without any anaesthitics to control a patient's behaviour in Broadmoor HospitalCommons Hansard, 26 January 1981, col 744-750 . Although this was defended by the Royal College of Psychiatrists and the Department of Health; if true, then it highlights that even by 1980, ECT was still being misused to control patients as a form of punishment. On top of that, it highlights that a lot of the legislation introduced prior to this had not been enforced properly. The fact that it was used without anaesthetics further reveals the slow enforcement of legislation by this time.

Introduction of new treatments and medicines

During the 1950's and 1960's more and more medicines were being developed to help cure psychiatric illness. How during these years, the fequency of ECT use still remained high. However, after mental health practicioners started using these new drugs more and more, they realised their effectiveness and thus prescribed them more and more resulting in ECT being used less and less. It was not till the 1980's in which the use of ECT began to significantly fall. In the early 1970s there were an estimated 50,000 courses of ECT per year in the UK and by the mid 1980's this had dropped to roughly 24,000. It can therfore be interpreted that the introduction of new medication was in fact the trigger which resulted in the fall of ECT use in hospitals.

The new drugs included neuroleptics (psychotropic drugs used mainly in the treatment of schizophrenia, having also a tranquilizing effect)www.zentiva.cz/default.aspx/en/consumers/glossary/group-indication , antidepressants (psychotropic drugs used for the treatment of various forms of depression) and benzodiazipines (medication used to sedate, to control anxiety, and to stop seizures)www.cbtf.org/learn/glossary . These drugs were very effective in treating depression, bipolar, schizophrenia and to control anxiety. ECT was never found to have been particularly effective to treat schizophrenia so the role of treating this condition was quite quickly taken up by neuroleptics. In the UK, a report was published stating that "The current state of the evidence does not allow the general use of ECT in the management of schizophrenia to be recommended"http://www.ect.org/wp-content/uploads/2006/08/59ectfullguidance.pdf . However, many mentally ill patients didin't respond well to antipsychotic drugs and so as a result ECT was still very commonly used and is commonly used today.

Even these drugs however had their own risks and side effects including drowsiness, shaking, trembling, spasms, blurred vision, headache and anxietyhttp://www.clinical-depression.co.uk/dlp/treating-depression/side-effects-of-antidepressants/ .

So why is Electroconvulsive therapy still used within out health service?

As we have discovered, electroconvulsive therapy has reduced in use since its introduction in the early 20th century however it as not completely dissapeared. Why? As discussed earlier, psychiatrists say that shock therapy works! In fact, in recent years, its use is believed to have increased slowly as this argument has become more and more accepted. It is also important to remember that the risk factor of ECT has reduced since eighty years ago due to the inrtrodction of anaesthetics and muscle relaxants. In the 1940's and 1950's the death rate of patients undergoeing the treatment was estimated to be one in a thousand. However a recent study suggests that the current death rate is now 4.5 deaths per 100,000 treatmentshttp://www.essortment.com/all/whatiselectroc_riek.htm . Today, the treatment can be hugely beneficial when rapid treatment response is required (e.g. during pregnancy), when a patient refuses food which could lead to other health complications, when other treatments and medication does not work and to treat people who are are a severe risk of suicidehttp://www.webmd.com/depression/guide/electroconvulsive-therapy . Medication such as antidepressants often take months to work properly and many patients don't have this amount of time and so ECT is a very good option for them.

 

Perhaps most importantly however, ECT can save people's lives. The following patient (named Melissa) described her experience of the treatment:

"I have had numerous ECT treatments. I had bilateral treatments in 1995-96 that did nothing except destroy my memory. However, in the past two years, I have had several courses of ECT to treat psychotic, suicidal depression and believe me, ECT was the only thing that helped at all. My psychiatrist at Barnes-Jewish Hospital in St. Louis recommended that I do maintenance treatments, which I did for about 3-4 months. Three months after my last maintenance treatment, my moods are stable and I am a successful graduate student. I have told my psychiatrist that he saved my life with the ECT. I hate to admit it because I find the treatments abhorrent, but I truly believe that this awful treatment has saved my life more than once"http://bipolar.about.com/od/ect/a/sfe_shock1.htm  

Although the patient describes that she found the treatment "abhorrent", she is happy that she had it since it helped her. Many may argue "Isn't that the main purpose of medicine? ...To save lives?". In general psychiatrists appreciate the benefits of ECT and see patients like Melissa benefit from the treatment and therefore support the treatment. In 2003 The Royal College of Psychistrists were unhappy that ECT treatments were to be restricted to those people who have severe symptoms and not available to people with moderate symptoms http://www.ect.org/news/2003-3-26_MINDrelease.html . The treatment is supported by psychiatrists, so much so that they want it to be available for use on patients with less severe symptoms. Since they are the ones who treat patients and have professional and academic experience, it is only logical to listen to and somewhat agree with what they say.

There has also been much debate on the use of electroconvulsive therapy on young people. Maybe it should be used more on younger people? In a study done in 1980 in the USA it was estimated that 500 cases were treated with ECT. Overall the results suggested beneficial outcomes particularly with depressed and catatonic patients. This does raise some ethical concerns. If the benefits of ECT are confirmed and potential risks such as cognitive deficits and prolonged seizure activity are minimised, why is treatment used so sparingly? It would seem to be unethical to withold a potentially helpful treatment. ECT brings a lot of historical "baggage" with its name and malpractive insurance premiums for practioners have affected its application too. However none of this factors achieve the ethical duty of doctors of providing beneficial treatments.

Conclusion

To summarise, the changes in the use of ECT can be categorised into two main ways; one being the frequency of its use since its introduction in the 1930s and secondly, the way in which ECT is used i.e. in what situations it is now used in. In terms of the frequency of its use, shock therapy rapidly began to grow after its introduction in the 1930's and throughout the 1950's and 1960's. It was seen as a revolutionary treatment and was used to treat most psychiatric conditions from moderate depression to schizophrenia. After the late 1980's and 1990's, legislation resulted in the use of ECT being reduced and there was a huge stigma associated with the treatment. The legislation was a consequence of the highly common side effects of memory impairment and head aches, it was also a result of discovering that it was misused as a punishment for psychiatric patients. The development of new drugs such as antidepressants further reduced the need of ECT. However, in recent years, perhaps due to the release of this stigma and the fact that research has found that the treatment is extremely effective, the use of ECT has increased again. In terms of the way ECT is used, it has changed, again due to legislation which has prevented patients from having the treatment forced upon them. It has also changed in the sense that there are more precautions such as muscle relaxants and anaesthetics which has reduced some of the side effects such as bone damage and other injuries.

Yes the past mistakes should not be forgotton. However, both the pass and current benefits of ECT should also not be forgotten. From the evidence from health professionals and patients, it is clear that electroconvulsive therapy has been hugely beneficial in treating patients with conditions such as major depression. It saves lives. It improves quality of life. Like every drug and from every procedure, there is a risk, though the potential benefits are undoubtedy; even greater.

This is fine Dip.

You must go through it in great detail, checking your spelling and grammar all the way through (I stopped after a while – you can do that!)

Without encouraging you to write too much more, which you don’t need to do, you could explain the difference between unilateral and bilateral and point out that this is another reason its use has increased – because if only one hemisphere is being shocked it reduces the effect of memory loss, etc.

Be careful what you say about young people. I haven’t checked this out but I think in the UK it is not used on those under 16 as it has been found to cause severe memory loss in children and young people. You need to some extent to be clear about what age you mean by ‘young’.

You do need to work more on splitting some of your paragraphs, however you have ordered it quite logically and not been too repetitive.

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