Electroconvulsive therapy
Encyclopedia
Electroconvulsive therapy (ECT), formerly known as electroshock, is a psychiatric
Psychiatry
Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...

 treatment in which seizure
Seizure
An epileptic seizure, occasionally referred to as a fit, is defined as a transient symptom of "abnormal excessive or synchronous neuronal activity in the brain". The outward effect can be as dramatic as a wild thrashing movement or as mild as a brief loss of awareness...

s are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown. Today, ECT is most often recommended for use as a treatment for severe depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...

 that has not responded to other treatment, and is also used in the treatment of mania
Mania
Mania, the presence of which is a criterion for certain psychiatric diagnoses, is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression...

 and catatonia
Catatonia
Catatonia is a state of neurogenic motor immobility, and behavioral abnormality manifested by stupor. It was first described in 1874: Die Katatonie oder das Spannungsirresein ....

. It was first introduced in 1938 by Italian neuropsychiatrists Ugo Cerletti
Ugo Cerletti
Ugo Cerletti was an Italian neurologist who discovered the method of electroconvulsive therapy in psychiatry. Electroconvulsive therapy is a procedure in which electric currents are passed through the brain, deliberately triggering a brief seizure...

 and Lucio Bini
Lucio Bini
Lucio Bini was an Italian psychiatrist and professor at the University of Rome La Sapienza, Italy. Together with Ugo Cerletti, a neurophysiologist, he researched and discovered the method of electroconvulsive therapy, a kind of shock therapy for mental diseases.-References:*Kalinowsky, LB: Lucio...

, and gained widespread use as a form of treatment in the 1940s and 1950s.

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.

Informed consent
Informed consent
Informed consent is a phrase often used in law to indicate that the consent a person gives meets certain minimum standards. As a literal matter, in the absence of fraud, it is redundant. An informed consent can be said to have been given based upon a clear appreciation and understanding of the...

 is a standard of modern electroconvulsive therapy. According to the Surgeon General, involuntary treatment is uncommon in the United States and is typically only used in cases of great extremity, and only when all other treatment options have been exhausted and the use of ECT is believed to be a potentially life saving treatment. However, caution must be exercised in interpreting this assertion as, in an American context, there does not appear to have been any attempt to survey at national level the usage of ECT as either an elective or involuntary procedure in almost twenty years. In one of the few jurisdictions where recent statistics on ECT usage are available, a national audit of ECT by the Scottish ECT Accreditation Network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent.

Despite the fact that the majority of psychiatric clinicians regard ECT as a safe and effective procedure, surveys of public opinion, the testimony of former patients, legal restrictions on its use and disputes as to the efficacy, ethics and adverse effects of ECT within the psychiatric and wider medical community indicate that the use of ECT remains controversial. This is reflected in the recent decision by the FDA's Neurological Devices Advisory Panel to maintain ECT devices in the Class III device category for high risk devices except for patients suffering from catatonia. This will result in the manufacturers of such devices having to do controlled trials on their safety and efficacy for the first time. In justifying their position panelists referred to the memory loss associated with ECT and the lack of long-term data.

History

As early as the 16th century, agents to produce seizures were used to treat psychiatric conditions. In 1785, the therapeutic use of seizure induction was documented in the London Medical Journal. Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna
Ladislas J. Meduna
Ladislas J. Meduna was a Hungarian neurologist and neuropathologist noted for his development of shock treatment for persons suffering from schizophrenia.Meduna was born to a well-to-do family in Budapest, Hungary, in 1896...

 who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures with first camphor
Camphor
Camphor is a waxy, white or transparent solid with a strong, aromatic odor. It is a terpenoid with the chemical formula C10H16O. It is found in wood of the camphor laurel , a large evergreen tree found in Asia and also of Dryobalanops aromatica, a giant of the Bornean forests...

 and then metrazol (cardiazol). In 1937, the first international meeting on convulsive therapy was held in Switzerland by the Swiss psychiatrist Muller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide. Italian Professor of neuropsychiatry Ugo Cerletti
Ugo Cerletti
Ugo Cerletti was an Italian neurologist who discovered the method of electroconvulsive therapy in psychiatry. Electroconvulsive therapy is a procedure in which electric currents are passed through the brain, deliberately triggering a brief seizure...

, who had been using electric shocks to produce seizures in animal experiments, and his colleague Lucio Bini
Lucio Bini
Lucio Bini was an Italian psychiatrist and professor at the University of Rome La Sapienza, Italy. Together with Ugo Cerletti, a neurophysiologist, he researched and discovered the method of electroconvulsive therapy, a kind of shock therapy for mental diseases.-References:*Kalinowsky, LB: Lucio...

 developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1937, experimented for the first time on a person. Sherwin B. Nuland
Sherwin B. Nuland
Dr. Sherwin Nuland is an American surgeon and author who teaches bioethics, history of medicine, and medicine at the Yale University School of Medicine and, upon occasion, bioethics and history of medicine at Yale College...

, having discussed the matter with a first-hand observer in the 1970s, gave the following description of the results of the first use of ECT on a person:
"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 — remember, he wasn't even put to sleep — after this major grand mal convulsion, 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."


ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening and more convenient. Cerletti and Bini were nominated for a Nobel Prize
Nobel Prize
The Nobel Prizes are annual international awards bestowed by Scandinavian committees in recognition of cultural and scientific advances. The will of the Swedish chemist Alfred Nobel, the inventor of dynamite, established the prizes in 1895...

 but did not receive one. By 1940, the procedure was introduced to both England and the US. In Germany and Austria it was promoted by Friedrich Meggendorfer
Friedrich Meggendorfer
Friedrich Meggendorfer was a German psychiatrist and neurologist.- Life :Born in Bad Aibling, Bavaria, he was intended to take over the local colonial goods store of his ancestors. He enjoyed an excellent international education aimed at preparing him for this role...

. Through the 1940s and 1950s the use of ECT became widespread. ECT is the only form of shock treatment
Shock Treatment
Shock Treatment is a 1981 musical-black comedy film and a follow-up to the film The Rocky Horror Picture Show. While not an outright sequel, the movie does feature several characters from the movie portrayed by different actors and several Rocky Horror actors portraying new characters...

 still performed by modern medicine.

In the early 1940s, in an attempt to reduce the memory disturbance and confusion associated with treatment, two modifications were introduced: the use of unilateral electrode placement and the replacement of sinusoidal current with brief pulse. It took many years for brief-pulse equipment to be widely adopted Unilateral ECT has never been popular with psychiatrists and is still only given to a minority of ECT patients. In the 1940s and early 1950s ECT was usually given in "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones. In the 1940s psychiatrists began to experiment with curare
Curare
Curare is a common name for various arrow poisons originating from South America. The three main types of curare are:* tubocurare...

, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction of suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to the more widespread use of "modified" ECT. A short-acting anesthetic was usually given in addition to the muscle relaxant in order to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants.

The steady growth of antidepressant use along with negative depictions of ECT in the mass media led to a marked decline in the use of ECT during the 1950s to the 1970s. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given, and that "these now-antiquated practices contributed to the negative portrayal of ECT in the popular media." The New York Times described the public's negative perception of ECT as being caused mainly by one movie. "For Big Nurse in One Flew Over the Cuckoo's Nest
One Flew Over the Cuckoo's Nest (film)
One Flew Over the Cuckoo's Nest is a 1975 American drama film directed by Miloš Forman and based on the 1962 novel of the same name by Ken Kesey....

,
it was a tool of terror, and, in the public mind, shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".

In 1976, Dr. Blatchley demonstrated the effectiveness of his constant current, brief pulse device ECT. This device eventually largely replaced earlier devices because of the reduction in cognitive side effects, although some ECT clinics in the US still use sine-wave devices. The 1970s saw the publication of the first American Psychiatric Association task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001). The report endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT. Specifically critics pointed to shortcomings such as noted side effects, the procedure being used as a form of abuse, and uneven application of ECT. The use of ECT declined until the 1980s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression". In 1985 the National Institute of Mental Health
National Institute of Mental Health
The National Institute of Mental Health is one of 27 institutes and centers that make up the National Institutes of Health...

 and National Institutes of Health
National Institutes of Health
The National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...

 convened a consensus development conference on ECT and concluded that, whilst ECT was the most controversial treatment in psychiatry and had significant side-effects, it had been shown to be effective for a narrow range of severe psychiatric disorders.

Due to the backlash noted previously, national institutions reviewed past practices and set new standards. In 1978, The American Psychiatric Association released its first task force report in which new standards for consent were introduced and the use of unilateral electrode placement was recommended. The 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task force report in 1990 where specific details on the delivery, education, and training of ECT were documented. Finally in 2001 the American Psychiatric Association released its latest task force report. This report emphasizes the importance of informed consent, and the expanded role that the procedure has in modern medicine.

Mechanism of action

The aim of ECT is to induce a therapeutic clonic seizure
Seizure
An epileptic seizure, occasionally referred to as a fit, is defined as a transient symptom of "abnormal excessive or synchronous neuronal activity in the brain". The outward effect can be as dramatic as a wild thrashing movement or as mild as a brief loss of awareness...

 (a seizure where the person loses consciousness and has convulsions) lasting for at least 15 seconds. Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive. The main reasons for this are that the human brain can not be studied directly before and after ECT and therefore scientists rely on animal models of depression and ECT, with major limitations. While animal models are acknowledged to model merely aspects of depressive illness, human and animal brains are very similar at a molecular level, enabling detailed study of the molecular mechanisms involved in ECT.

There is a vast literature on the effects of Electroconvulsive Shock (ECS) in animals. In animal models of depression, particularly "Learned helplessness
Learned helplessness
Learned helplessness, as a technical term in animal psychology and related human psychology, means a condition of a human person or an animal in which it has learned to behave helplessly, even when the opportunity is restored for it to help itself by avoiding an unpleasant or harmful circumstance...

" and "Social defeat
Social defeat
Social defeat refers to losing a confrontation among conspecific animals, or any kind of hostile dispute among humans, in either a dyadic or in a group-individual context, generating very significant consequences in terms of control over resources, access to mates and social...

", there is evidence of pruning of normally dense synaptic
Synaptic
Synaptic may refer to:*Synapse, part of the nervous system*Synapsis, the pairing of two homologous chromosomes*Synaptic , a Linux graphical package management program for APT See also...

 connections in the hippocampus
Hippocampus
The hippocampus is a major component of the brains of humans and other vertebrates. It belongs to the limbic system and plays important roles in the consolidation of information from short-term memory to long-term memory and spatial navigation. Humans and other mammals have two hippocampi, one in...

, a richly connected area deep in the temporal lobe
Temporal lobe
The temporal lobe is a region of the cerebral cortex that is located beneath the Sylvian fissure on both cerebral hemispheres of the mammalian brain....

 which is vital in controlling both mood and memory. ECS has been shown to increase levels of Brain-derived neurotrophic factor
Brain-derived neurotrophic factor
Brain-derived neurotrophic factor, also known as BDNF, is a protein that, in humans, is encoded by the BDNF gene. BDNF is a member of the "neurotrophin" family of growth factors, which are related to the canonical "Nerve Growth Factor", NGF...

 (BDNF) and Vascular Endothelial Growth Factor
Vascular endothelial growth factor
Vascular endothelial growth factor is a signal protein produced by cells that stimulates vasculogenesis and angiogenesis. It is part of the system that restores the oxygen supply to tissues when blood circulation is inadequate....

 (VEGF) in the rodent hippocampus. This reverses the toxic effects of depression on this area of the brain, increasing both new synapse formation and the formation of new brain cells (hippocampal neurogenesis
Neurogenesis
Neurogenesis is the process by which neurons are generated from neural stem and progenitor cells. Most active during pre-natal development, neurogenesis is responsible for populating the growing brain with neurons. Recently neurogenesis was shown to continue in several small parts of the brain of...

). Both these effects have been noted to be present in antidepressant-treated animals, however they are neither necessary nor sufficient for antidepressant response. ECT is a more robust inducer of these neuroplastic effects than antidepressants. Electroconvulsive Therapy (ECT) has also been shown to increase serum brain-derived neurotrophic factor
Brain-derived neurotrophic factor
Brain-derived neurotrophic factor, also known as BDNF, is a protein that, in humans, is encoded by the BDNF gene. BDNF is a member of the "neurotrophin" family of growth factors, which are related to the canonical "Nerve Growth Factor", NGF...

 (BDNF) in drug resistant depressed patients. This suggests a common molecular mechanism of action, albeit in need of much further study.

Guidelines for treatment

Experts disagree on whether ECT is an appropriate first-line treatment or if it should be reserved for patients who have not responded to other interventions such as medication and psychotherapy.

The American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...

 (APA) 2001 guidelines give the primary indications for ECT among patients with depression as a lack of response to, or intolerance of, antidepressant
Antidepressant
An antidepressant is a psychiatric medication used to alleviate mood disorders, such as major depression and dysthymia and anxiety disorders such as social anxiety disorder. According to Gelder, Mayou &*Geddes people with a depressive illness will experience a therapeutic effect to their mood;...

 medications; a good response to previous ECT; and the need for a rapid and definitive response (e.g. because of psychosis
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...

 or a risk of suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...

). The decision to use ECT depends on several factors, including the severity and chronicity of the depression, the likelihood that alternative treatments would be effective, the patient's preference and capacity to consent, and a weighing of the risks and benefits.

Some guidelines recommend cognitive behavioral therapy or other psychotherapy
Psychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...

 before ECT is used. However, treatment resistance is widely defined as lack of therapeutic response to two antidepressants at adequate doses for an adequate duration and with good compliance. The APA states that at times patients will prefer to receive ECT over alternative treatments, but commonly the opposite will be the case.

The APA ECT guidelines state that severe major depression with psychotic features, manic delirium, or catatonia
Catatonia
Catatonia is a state of neurogenic motor immobility, and behavioral abnormality manifested by stupor. It was first described in 1874: Die Katatonie oder das Spannungsirresein ....

 are conditions where there is a clear consensus favoring early ECT. The UK's National Institute for Health and Clinical Excellence
National Institute for Health and Clinical Excellence
The National Institute for Health and Clinical Excellence is a special health authority of the English National Health Service , serving both English NHS and the Welsh NHS...

 (NICE) guidelines recommend ECT for patients with severe depression, catatonia
Catatonia
Catatonia is a state of neurogenic motor immobility, and behavioral abnormality manifested by stupor. It was first described in 1874: Die Katatonie oder das Spannungsirresein ....

, or prolonged or severe mania
Mania
Mania, the presence of which is a criterion for certain psychiatric diagnoses, is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression...

. It did not recommend the use of ECT as a maintenace therapy in depressive illness as "the long-term benefits and risks ... had not been clearly established". Due to a lack of data, The NICE Guidelines for the Treatment and Management of Adult Depression (2009) issued no updated treatment recommendation for the use of maintenance or relapse prevention ECT. The 2001 APA guidelines support the use of ECT for relapse prevention.

The 2001 APA ECT guidelines say that ECT is rarely used as a first-line treatment for schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...

 but is considered after unsuccessful treatment with antipsychotic medication, and may also be considered in the treatment of patients with schizoaffective or schizophreniform disorder. The 2003 NICE ECT guidelines do not recommend ECT for schizophrenia, and this has been supported by meta-analytic evidence showing no or little benefit versus placebo
Placebo
A placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient...

, or in combination with antipsychotic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...

 drugs, including Clozapine
Clozapine
Clozapine is an antipsychotic medication used in the treatment of schizophrenia, and is also used off-label in the treatment of bipolar disorder. Wyatt. R and Chew...

.

The NICE 2003 guidelines state that doctors should be particularly cautious when considering ECT treatment for women who are pregnant and for older or younger people, because they may be at higher risk of complications with ECT. The 2001 APA ECT guidelines say that ECT may be safer than alternative treatments in the infirm elderly and during pregnancy, and the 2000 APA depression guidelines stated that the literature supports the safety for mother and fetus
Fetus
A fetus is a developing mammal or other viviparous vertebrate after the embryonic stage and before birth.In humans, the fetal stage of prenatal development starts at the beginning of the 11th week in gestational age, which is the 9th week after fertilization.-Etymology and spelling variations:The...

, as well as the efficacy during pregnancy.

Non-clinical patient characteristics

About 70 percent of ECT patients are women. This is almost entirely due to women being at twice the risk of depression. Older and more affluent patients are also more likely to receive ECT. The use of ECT treatment is "markedly reduced for ethnic minorities."

Duration of effect

ECT on its own does not usually have a sustained benefit. Half those who remit then relapse within six months. This is similar to the rate of relapse after discontinuing antidepressant medication, and is a function of the usual severity and chronicity of pre-existing illness rather than ECT itself. The relapse rate in the first six months is reduced by the use of psychiatric medications or further ECT, but remains high.

Probability of remission

The 1999 U.S. Surgeon General's Report on Mental Health summarized psychiatric opinion at the time about the effectiveness of ECT. It stated that both clinical experience and published studies had determined ECT to be effective (with an average 60 to 70 percent remission rate) in the treatment of severe depression, some acute psychotic states, and mania
Mania
Mania, the presence of which is a criterion for certain psychiatric diagnoses, is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression...

. Its effectiveness had not been demonstrated in dysthymia, substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...

, anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...

, or personality disorder
Personality disorder
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors. Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR of the American Psychiatric Association.Personality disorders are...

. The report stated that ECT does not have a long-term protective effect against suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...

 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.

A 2004 large multicentre clinical follow-up study of ECT patients in New York
New York
New York is a state in the Northeastern region of the United States. It is the nation's third most populous state. New York is bordered by New Jersey and Pennsylvania to the south, and by Connecticut, Massachusetts and Vermont to the east...

—describing itself as the first systematic documentation of the effectiveness of ECT in community practice in the 65 years of its use—found remission rates of only 30 to 47 percent, with 64 percent of those relapsing within six months. However, when patients with co-morbid personality disorders or who were suffering from schizoaffective disorder
Schizoaffective disorder
Schizoaffective disorder is a psychiatric diagnosis that describes a mental disorder characterized by recurring episodes of elevated or depressed mood, or of simultaneously elevated and depressed mood, that alternate with, or occur together with, distortions in perception.Schizoaffective disorder...

 were removed from the analysis, the remission rates climbed to 60-70%.

Degree of effectiveness

All systematic published reviews of the literature have concluded that ECT is effective in the treatment of depression. In 2003, The UK ECT Review group published a systematic review and meta-analysis comparing ECT to placebo and antidepressant drugs. This meta-analysis demonstrated a large effect size for ECT versus placebo, and versus antidepressant drugs.
In 2006, research psychiatrist Colin A. Ross
Colin A. Ross
Colin A. Ross is a psychiatrist of Canadian origin and professional training. Ross attended medical school at the University of Alberta, Edmonton, Canada and completed his training in psychiatry at the University of Manitoba, Winnipeg, Canada...

 reviewed the placebo-controlled trials one-by-one and found that no single study showed a significant difference between real and placebo
Placebo
A placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient...

 ECT at one month post-treatment. Dr. Ross was highly critical of other published reviews, which concluded that ECT is effective, and Ross stated that these reviews often relied primarily on studies that were not placebo-controlled.

In a 2010 review of placebo controlled studies Bentall and Read found ECT to give slightly higher recovery/remission rates to sham-ECT during treatment but equal rates on follow up after treatment. Their conclusions are as follows: "Given the strong evidence of persistent and, for some, permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and the evidence of a slight but significant increased risk of death, the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified."

Related experimental therapeutics

Recent research has investigated whether implantable devices such as DBS (deep brain stimulation
Deep brain stimulation
Deep brain stimulation is a surgical treatment involving the implantation of a medical device called a brain pacemaker, which sends electrical impulses to specific parts of the brain...

) could result in clinical improvements for patients with treatment-resistant depression. However, in North America, DBS has not been authorized as an approved, effective therapy for treatment-resistant depression.

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. 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. Some patients experience muscle soreness after ECT. This is due to the muscle relaxants given during the procedure and rarely due to muscle activity.
The death rate due to ECT is around 4 per 100,000 procedures.

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. The acute effects of ECT can include amnesia
Amnesia
Amnesia is a condition in which one's memory is lost. The causes of amnesia have traditionally been divided into categories. Memory appears to be stored in several parts of the limbic system of the brain, and any condition that interferes with the function of this system can cause amnesia...

, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment). However, the vast majority of these effects are short lived. 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 vast majority of modern treatment uses brief pulse currents. 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.

Retrograde amnesia
Retrograde amnesia
Retrograde amnesia is a loss of access to events that occurred, or information that was learned, before an injury or the onset of a disease....

 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. Anterograde memory loss
Anterograde amnesia
Anterograde amnesia is a loss of the ability to create new memories after the event that caused the amnesia, leading to a partial or complete inability to recall the recent past, while long-term memories from before the event remain intact. This is in contrast to retrograde amnesia, where memories...

 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. 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. 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.

Some studies have found that patients are often unaware of cognitive deficits induced by ECT. For example, in June 2008, a Duke University study 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." The study further found that a significant number of patients believed that their memory had improved after ECT despite the fact that neuropsychological testing clearly showed the opposite. As stated by the researchers, "Indeed, there was a slight trend towards [patients reporting] improved memory functioning, despite the objective neuropsychological data indicating significantly lower recognition and delayed recall." Based on their findings, the authors issued the following recommendation:
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.

Controversy over long-term effects on general cognition

According to prominent ECT researcher Harold Sackeim, "despite over fifty years of clinical use and ongoing controversy", until 2007 there had "never been a large-scale, prospective study of the cognitive effects of ECT." In this first-ever large-scale study (347 subjects), Sackeim and colleagues found that at least some forms (namely bilateral application and outdated sine-wave currents) of ECT "routine[ly]" lead to "adverse cognitive effects," including global cognitive deficits and memory loss, that persist for up to six months after treatment, suggesting that the induced deficits may be permanent. The authors also warned that their findings did not suggest that right-unilateral ECT did not also lead to chronic cognitive deficits. However, the several limitations of this study include the lack of a depressed control group with which to compare memory decay over 6 months. The measure of autobiographical memory used, the Columbia Autobiographical Short-Form (AMI-SF) is not capable of showing memory improvement, with scores at followup expressed as percentages of baseline.

Harold Sackeim can be seen in a videotaped deposition briefly discussing the findings of this study and why, in his opinion, earlier studies had failed to find evidence of long-term harm from ECT. Despite over fifty years of clinical use, Sackeim states that prior to 2001, "the field itself never really had an opportunity to have a discussion about patients who have complaints about long-term memory loss." In this video clip, Sackeim also reveals that at a California ECT conference with 200 practitioners present, when polled as to whether they think ECT can lead to chronic cognitive deficits, two-thirds raised their hands. Sackeim says this was "almost a watershed moment for the field", and was the "first time publicly that the field itself said 'no' to the position that it can't happen."

In July 2007, a second study was published concluding that ECT routinely leads to chronic, substantial cognitive deficits, and the findings were not limited to any particular forms of ECT. The study, led by psychiatrist Glenda MacQueen and colleagues, found that patients treated with ECT for bipolar disorder show marked deficits across multiple cognitive domains. According to the researchers, "Subjects who had received remote ECT had further impairment on a variety of learning and memory tests when compared with patients with no past ECT. This degree of impairment could not be accounted for by illness state at the time of assessment or by differential past illness burden between patient groups." Despite the findings of chronic, global cognitive deficits in post-ECT patients, MacQueen and colleagues suggest that it is "unlikely that such findings, even if confirmed, would significantly change the risk–benefit ratio of this notably effective treatment."

Six months after the publication of the Sackeim study documenting routine, long-term memory loss after ECT, prominent ECT researcher Max Fink
Max Fink
Max Fink is an American psychiatrist best known for his work on ECT .-Early life, marriage and qualifications:...

 published a review in the journal Psychosomatics concluding that patient complaints of memory loss after ECT are "rare" and should be "characterized as somatoform disorders, rather than as evidence of brain damage, thus warranting psychological treatment for such disorders." Based on his findings, Fink suggests that, "Instead of endorsing these reports as the direct consequence of ECT, especially in patients who have recovered from their depressive illness, lost their suicidal drive, and have improved social functioning, is it not more useful to accept the complaint as a somatoform disorder, explore the basis in the individual’s history and experience, and offer appropriate supportive treatment?"

Most recent reviews of the literature and other articles continue to characterize ECT as safe and effective. For example, in June 2009, Portuguese researchers published a review on the safety and efficacy of ECT in an article entitled, Electroconvulsive Therapy: Myths and Evidences. In their review, the researchers conclude that ECT is an "efficient, safe and even life saving treatment for several psychiatric disorders." In 2008, Yale researchers published a review on the safety and efficacy of ECT in elderly patients. According to the authors, "ECT is well established as a safe and effective treatment for several psychiatric disorders." And in a June 2009 article published in the Journal of ECT, Iranian researchers observe that, "Despite the wide consensus over the safety and efficacy of electroconvulsive therapy (ECT), it still faces negative publicity and unfavorable attitudes of patients and families."

Psychiatrist Peter Breggin
Peter Breggin
Peter Roger Breggin is an American psychiatrist and critic of biological psychiatry and psychiatric medication. In his books, he advocates replacing psychiatry's use of drugs and electroconvulsive therapy with humanistic approaches, such as psychotherapy, education, and broader human...

, chief editor of the journal Ethical Human Psychology and Psychiatry, is a leading critic of ECT who believes the procedure is neither safe nor effective. In a published article reviewing the findings of Harold Sackeim's 2007 study on the cognitive effects of ECT, Breggin accuses Max Fink
Max Fink
Max Fink is an American psychiatrist best known for his work on ECT .-Early life, marriage and qualifications:...

 and other pro-ECT researchers of having a history of "systematically covering up damage done to millions of [ECT] patients throughout the world." He disagrees with the position that findings of chronic, global cognitive deficits should have no bearing on the risk-benefit ratio of ECT, and he believes it's important to address the "actual impact of these losses on the lives of individual patients." In a section of his paper entitled Destroying Lives, Dr. Breggin writes, "Even when these injured people can continue to function on a superficial social basis, they nonetheless suffer devastation of their identities due to the obliteration of key aspects of their personal lives. The loss of the ability to retain and learn new material is not only humiliating and depressing but also disabling. Even when relatively subtle, these activities can disrupt routine activities of living."

A study published in 2004 in the Journal of Mental Health reported that 35 to 42% of patients responding to a questionnaire reported ECT resulted in loss of intelligence. The study also reported, "There is no overlap between clinical and consumer studies on the question of benefit."

Doctors of Deception: What They Don't Want You to Know About Shock Treatment reports before-and-after IQ testing of persons receiving ECT, including the author, that show 30 to 40 point losses.

A recent opinion article by a neuropsychologist and a psychiatrist in Dublin suggests that ECT patients who experience cognitive problems following ECT should be offered some form of cognitive rehabilitation. The authors say that the failure to attempt to rehabilitate patients may be partly responsible for the negative public image of ECT. The article speculates on what aspects of such rehabilitation might be useful, without reviewing the literature on its presence or absence.

Effects on brain structure

Considerable controversy exists over the effects of ECT on brain tissue although a number of mental health associations, including the American Psychiatric Association, have concluded that there is no evidence that ECT causes structural brain damage. A 1999 report by the United States Surgeon General states, "The fears that ECT causes gross structural brain pathology have not been supported by decades of methodologically sound research in both humans and animals". However, the word "gross" is a synonym for major, leaving the possibility open for real brain damage which the US Surgeon General considers minor. However, not all experts agree that ECT does not cause brain damage, and two studies have been published since 2007 finding that at least some forms of ECT may result in widespread, persisting, generalized cognitive dysfunction, which might support claims that ECT causes brain damage.

A leading critic of ECT, psychiatrist Peter Breggin
Peter Breggin
Peter Roger Breggin is an American psychiatrist and critic of biological psychiatry and psychiatric medication. In his books, he advocates replacing psychiatry's use of drugs and electroconvulsive therapy with humanistic approaches, such as psychotherapy, education, and broader human...

 has published books and journalistic reviews of the literature purporting to show that ECT routinely causes brain damage as evidenced by a considerable list of studies in humans and animals. In particular, Dr. Breggin asserts that animal and human autopsy studies have shown that ECT routinely causes ‘widespread pinpoint hemorrhages and scattered cell death.’ According to Dr. Breggin, the 1990 APA task force report on ECT ignored much of the scientific literature pointing out the negative effects of electroshock therapy. For example, in 1952 Hans Hartelius conducted and published an animal study on cats entitled Cerebral Changes Following Electrically Induced Convulsions in which a double-blind microscopic pathology examination showed that it was possible to distinguish the 8 shocked animals from the 8 non-shocked animals with remarkable accuracy based on statistically significant structural changes to the brain, including vessel wall changes, gliosis
Gliosis
Gliosis is a proliferation of astrocytes in damaged areas of the central nervous system . This proliferation usually leads to the formation of a glial scar....

, and nerve cell changes. Based on the detection of shadow cells and neuronophagia, Hartelius determined that there was irreversible damage to neurons associated with electroshock.

Proponents argue that the addition of hyperoxygenation and refinement in technique in the last thirty years has made ECT safe, and a majority of published reviews in recent decades have reflected this position. In a 2004 study designed to evaluate whether modern ECT techniques lead to identifiable brain damage, twelve monkeys underwent daily electroshock for six weeks under conditions meant to simulate human ECT; the animals were then sacrificed and their brains were compared to monkeys undergoing anesthesia alone. According to the researchers, "None of the ECT-treated monkeys showed pathological findings."

There are recent animal studies that have documented significant brain damage after an electroshock series. For example, in 2005, Russian researchers published a study entitled, Electroconvulsive Shock Induces Neuron Death in the Mouse Hippocampus: Correlation of Neurodegeneration with Convulsive Activity. In this study, the researchers found that after an electroshock series, there was a significant loss of neurons in parts of the brain and particularly in defined parts of the hippocampus where up to 10% of neurons were killed. The researchers conclude that "the main cause of neuron death is convulsions evoked by electric shocks." In 2008, Portuguese researchers conducted a rat study aimed at answering the question of whether an electroshock series causes structural changes in vulnerable parts of the brain. According to the authors, "This study answers positively the question of whether repeated administration of ECS seizures can cause brain lesions. Our data are consistent with findings from other animal models and from human studies in showing that neurons located in the entorhinal cortex and in the hilus of the dentate gyrus are particularly vulnerable to repeated seizures." However, they question the applicability of their own research with respect to Electroconvulsive therapy in humans: "An important caveat of our results is that it is unclear to what extent they are relevant to the use of electroconvulsive therapy in psychiatry, because the protocol employed in this study is different from that used clinically. Evidence from previous studies (Gombos et al., [1999]; Vaidya et al., [1999]) and from our pilot experiments indicates that treating rats either with five to ten widely spaced ECS (at 24- or 48-hr schedules) or with two stimulations only 2 hr apart does not lead to loss of hippocampal neurons".

Many expert proponents of ECT maintain that the procedure is safe and does not cause brain damage. Dr. Charles Kellner, a prominent ECT researcher and former chief editor of the Journal of ECT states in a recent published interview that, "There are a number of well-designed studies that show ECT does not cause brain damage and numerous reports of patients who have received a large number of treatments over their lifetime and have suffered no significant problems due to ECT." Dr. Kellner cites specifically to a study purporting to show an absence of cognitive impairment in eight subjects after more than 100 lifetime ECT treatments. One of the authors of the cited study, Harold Sackeim, published a large-scale study less than a month after this interview concluding that the type of ECT used in the eight patients receiving the 100 lifetime treatments, bilateral sine wave, routinely leads to persistent, global cognitive deficits (discussed above). Dr. Kellner states that, "Rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness."

Effects in pregnancy

If steps are taken to decrease potential risks, ECT is generally accepted to be relatively safe during all trimesters of pregnancy, particularly when compared to pharmacological treatments. Suggested preparation for ECT during pregnancy includes a pelvic examination
Pelvic examination
A pelvic examination, also pelvic exam, is a physical examination of the female pelvic organs.Broadly, it can be divided into the external examination and internal examination.It is also called "Bimanual Exam" & "Manual Uterine Palpation"....

, discontinuation of nonessential anticholinergic
Anticholinergic
An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system. An example of an anticholinergic is dicycloverine, and the classic example is atropine....

 medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate antacid
Antacid
An antacid is a substance which neutralizes stomach acidity.-Mechanism of action:Antacids perform a neutralization reaction, increasing the pH to reduce acidity in the stomach. When gastric hydrochloric acid reaches the nerves in the gastrointestinal mucosa, they signal pain to the central nervous...

. During ECT, elevation of the pregnant woman's right hip, external fetal cardiac monitoring, intubation
Intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...

, and avoidance of excessive hyperventilation
Hyperventilation
Hyperventilation or overbreathing is the state of breathing faster or deeper than normal, causing excessive expulsion of circulating carbon dioxide. It can result from a psychological state such as a panic attack, from a physiological condition such as metabolic acidosis, can be brought about by...

 are recommended. Much of the medical literature in this area is composed of case studies of single or twin pregnancies, and although some have reported serious complications, the majority have found ECT to be safe. ECT is not performed on the fetus.

Administration

Informed consent is sought before treatment. Patients are informed about the risks and benefits of the procedure. Patients are also made aware of risks and benefits of other treatments and of not having the procedure done at all. Depending on the jurisdiction the need for further inputs from other medical professionals or legal professionals may be required. ECT is usually given on an in-patient basis. Prior to treatment a patient is given a short-acting anesthetic such as methohexital
Methohexital
Methohexital, also called methohexitone, is a drug which is a barbiturate derivative. It is classified as short-acting, and has a rapid onset of action...

, etomidate
Etomidate
Etomidate is a short acting intravenous anaesthetic agent used for the induction of general anaesthesia and for sedation for short procedures such as reduction of dislocated joints, tracheal intubation and cardioversion...

, or thiopental, a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine
Atropine
Atropine is a naturally occurring tropane alkaloid extracted from deadly nightshade , Jimson weed , mandrake and other plants of the family Solanaceae. It is a secondary metabolite of these plants and serves as a drug with a wide variety of effects...

 to inhibit salivation.

Both electrodes can be placed one on the same side of the patient's head. This is known as unilateral ECT. Unilateral ECT is used first to minimize side effects (memory loss). When electrodes are placed on both sides of the head, this is known as bilateral 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. In the UK almost all patients receive bilateral ECT.

The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold
Seizure threshold
A seizure threshold is the balance between excitatory and inhibitory forces in the brain which affects how susceptible one is to seizures. Those diagnosed with epilepsy or certain other neurological conditions are vulnerable to sudden new seizures if the threshold is upset, and so must be...

: 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
Mental function
Mental processes, mental functions and cognitive processes are terms often used interchangeably to mean such functions or processes as perception, introspection, memory, creativity, imagination, conception, belief, reasoning, volition, and emotion—in...

 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.

ECT machines

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 or Ireland.
Typically, the electrical stimulus used in ECT is about 800 milliamps and has up to several hundred watt
Watt
The watt is a derived unit of power in the International System of Units , named after the Scottish engineer James Watt . The unit, defined as one joule per second, measures the rate of energy conversion.-Definition:...

s, and the current flows for between one and 6 seconds. In the USA, ECT machines are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and Mecta
Mecta
Mecta is an American corporation in Portland, Oregon, that makes and sells electroconvulsive therapy machines.-History:The Mecta ECT machine was developed at Oregon Health Sciences University in 1973 by Dr. Paul Blachley, for the treatment of major depression unresponsive to pharmaceuticals.Expert...

. The Food and Drug Administration
Food and Drug Administration
The Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...

 has classified the devices used to administer ECT as Class III medical devices.
Class III is the highest-risk class of medical devices.
In the UK, the market for ECT machines was long monopolized 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.

Variations in international practice

There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists. International practice varies considerably from widespread use of the therapy in many western countries to a small minority of countries that do not use ECT at all, such as Slovenia. Guidelines on the use of ECT are stringent in the USA and the UK. Modern standards are not always followed throughout the world and not all countries that use ECT have written technical standards. The use of both anesthesia and muscle relaxants is universally recommended in the administration of ECT. If anesthesia and muscle relaxants are not used the procedure is called unmodified ECT. In a minority of countries such as Japan, India, and Nigeria, ECT may be used without anesthesia. WHO has called for a worldwide ban on unmodified ECT and the topic is currently being debated in countries like India. The practice has been recently abolished in Turkey's largest psychiatric hospital
Psychiatric hospital
Psychiatric hospitals, also known as mental hospitals, are hospitals specializing in the treatment of serious mental disorders. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialise only in short-term or outpatient therapy for low-risk patients...

. A major difficulty for developing countries in eliminating unmodified ECT is a lack of trained anesthesiologists available to administer the procedure. A small minority of countries never seek consent before administering ECT. This significantly uneven application of ECT around the world continues to make ECT a controversial procedure.

Sarah Hall reports, "ECT has been dogged by conflict between psychiatrists who swear by it, and some patients and families of patients who say that their lives have been ruined by it. It is controversial in some European countries such as the Netherlands and Italy, where its use is severely restricted".

United States

In the United States, 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.
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.
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). 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. A few psychiatrists in the USA use multiple-monitored ECT (MMECT) where patients receive more than one treatment per anesthetic. Electroconvulsive therapy is not a required subject in US medical schools and not a required skill in psychiatric residency training. Privileging for ECT practice at institutions is a local option, no national certification standards are established, and no ECT-specific continuing training experiences are required of ECT practitioners.

United Kingdom

In the United Kingdom in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then 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 percent of patients were women and 46 percent were over 65 years of age. Eighty-one percent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. Sixteen percent were treated without their consent. In 2003, the National Institute for Clinical Excellence, a government body which was set up to standardize treatment throughout the National Health Service in England
England
England is a country that is part of the United Kingdom. It shares land borders with Scotland to the north and Wales to the west; the Irish Sea is to the north west, the Celtic Sea to the south west, with the North Sea to the east and the English Channel to the south separating it from continental...

 and Wales
Wales
Wales is a country that is part of the United Kingdom and the island of Great Britain, bordered by England to its east and the Atlantic Ocean and Irish Sea to its west. It has a population of three million, and a total area of 20,779 km²...

, 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".
The guidance received a mixed reception. It was welcomed by an editorial in the British Medical Journal but the Royal College of Psychiatrists launched an unsuccessful appeal. 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. 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 Republic of Ireland have signed up.

India

The Union Health Ministry of India has decided in the Mental Health Care Bill of 2010 that they will no longer use direct ECT. The Health Ministry recommended a ban on the whole procedure.

Informed consent

It is widely acknowledged internationally that obtaining the written, informed consent
Informed consent
Informed consent is a phrase often used in law to indicate that the consent a person gives meets certain minimum standards. As a literal matter, in the absence of fraud, it is redundant. An informed consent can be said to have been given based upon a clear appreciation and understanding of the...

 of the patient is important before ECT is administered. The World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

, in its 2005 publication "Human Rights and Legislation WHO Resource Book on Mental Health," specifically states, "ECT should be administered only after obtaining informed consent."

In the US, this doctrine places a legal obligation on a doctor to make a patient aware of: the reason for treatment, the risks and benefits of a proposed treatment, the risks and benefits of alternative treatment, and the risks and benefits of receiving no treatment. The patient is then given the opportunity to accept or reject the treatment. The form states how many treatments are recommended and also makes the patient aware that the treatment may be revoked at anytime during a course of ECT. The Surgeon General's Report on Mental Health states that patients should be warned that the benefits of ECT are short-lived without active continuation treatment in the form of drugs or further ECT, and that there may be some risk of permanent, severe memory loss after ECT. The report advises psychiatrists to involve patients in discussion, possibly with the aid of leaflets or videos, both before and during a course of ECT.

To demonstrate what he believes should be required to fully satisfy the legal obligation for informed consent, one psychiatrist, working for an anti-psychiatry organisation, has formulated his own consent form
using the consent form developed and enacted by the Texas Legislature as a model.

In the UK, in order for consent to be valid it requires an explanation in "broad terms" of the nature of the procedure and its likely effects. One review from 2005 found that only about half of patients felt they were given sufficient information about ECT and its adverse effects and another survey found that about fifty percent of psychiatrists and nurses agreed with them.

A 2005 study published in the British Journal of Psychiatry described patients' perspectives on the adequacy of informed consent before ECT. The study found that, "About half (45–55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not." The authors also stated:

Involuntary ECT

Procedures for involuntary ECT vary from country to country depending on local mental health law
Mental health law
Mental health law is the area of the law that applies to persons with a diagnosis or possible diagnosis of mental illness, and to those involved in managing or treating such people.-Mental health law in general:...

s. Legal proceedings are required in some countries, while in others ECT is seen as another form of treatment that may be given involuntarily as long as legal conditions are observed. Involuntary electroshock contravenes the principle of autonomy in medical ethics
Medical ethics
Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine. As a scholarly discipline, medical ethics encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, and sociology.-History:Historically,...

. The maxim of autonomy is "Voluntas aegroti suprema lex." This rule states that the will of the patient is supreme. It implies that a patient has the right to consent to, or to refuse a medical treatment, such as ECT. Persons considered not to be of sound mind are in many jurisdictions considered incapable of giving true consent. In such a case, the patient's "assent" may be sought; opinions are divided as to whether this should be routinely done, or whether a patient who is not competent to consent to therapy should retain the right to refuse it.

Citizens in western societies often undergo emergency medical procedures when they have lost the capacity to consent (such as neurosurgery after head injury). Under these circumstances, the principles of benificence and non-maleficence must be adhered to.

United States

In most states in the USA, a judicial order following a formal hearing is needed before a patient can be forced to undergo involuntary ECT. Patients may be represented by legal counsel at the hearing. According to the Surgeon General's Report on Mental Health, "As a rule, the law requires that such petitions are granted only where the prompt institution of ECT is regarded as potentially lifesaving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia
Catatonia
Catatonia is a state of neurogenic motor immobility, and behavioral abnormality manifested by stupor. It was first described in 1874: Die Katatonie oder das Spannungsirresein ....

." However, there are legal loopholes that thwart strict adherence to this principle. For example, an American citizen was being forced to undergo ECT against his will in 2009, even though his life was not in danger. In this March 17, 2009 video, the man, his mother, and advocates, speak out against his forced ECT. The description of the video states that "Though Sandford, 54, is not charged with any crime, he has received over 40 such rounds of shocks on an outpatient basis so far – even after his original mental problems have long since subsided and he has repeatedly asked for the shocks to stop. Over the objections of Sandford, his mother and friends, his legal conservator at Lutheran Social Service of MN (LSSMN) has gone to court and succeeded in mandating a continuation of the procedure." Twin Cities Indymedia asserts "Like all other USA states, Minnesota has [legal] loopholes allowing [its] citizens to receive electroshock over their expressed wishes."

Great Britain

Until 2009 in England and Wales, the Mental Health Act 1983
Mental Health Act 1983
The Mental Health Act 1983 is an Act of the Parliament of the United Kingdom which applies to people in England and Wales. It covers the reception, care and treatment of mentally disordered persons, the management of their property and other related matters...

 allowed the use of ECT on detained patients whether or not they had capacity
Capacity (law)
The capacity of both natural and legal persons determines whether they may make binding amendments to their rights, duties and obligations, such as getting married or merging, entering into contracts, making gifts, or writing a valid will...

 to consent to it, so long as the treatment was likely to alleviate or prevent deterioration in a condition and was authorized by a psychiatrist from the Mental Health Act Commission's panel. However, following amendments
Mental Health Act 2007
The Mental Act 2007 is an Act of the Parliament of the United Kingdom. It amends the Mental Health Act 1983 and the Mental Capacity Act 2005. It applies to people in England and Wales. Most of the Act was implemented on 3 November 2008....

 which took effect in 2009, ECT may not be given to a patient who has capacity to refuse to consent to it, irrespective of his or her detention under the Act, although treatment may still be given to capacious patients in an emergency under Section 62 of the Act
Mental Health Act 1983
The Mental Health Act 1983 is an Act of the Parliament of the United Kingdom which applies to people in England and Wales. It covers the reception, care and treatment of mentally disordered persons, the management of their property and other related matters...

. If the treating psychiatrist thinks the need for treatment is urgent they may start a course of ECT before authorization. About 2,000 people a year in England and Wales are treated without their consent under the Mental Health Act. In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 also gives patients with capacity the right to refuse ECT.

Patient experience

The APA ECT taskforce guidelines report findings that most patients find ECT no worse than going to the dentist, and many found it less stressful than the dentist. They report that other research finds that most patients would voluntarily receive ECT again if needed.

NICE ECT guidelines report that some individuals consider ECT to have been a beneficial and lifesaving treatment, while others reported feelings of terror, shame and distress, and found it positively harmful and an abusive invasion of personal autonomy, especially when administered without their consent.

Individual positive depictions

Kitty Dukakis
Katharine D. Dukakis
Katharine Dickson Dukakis , known as Kitty Dukakis, is the wife of former Massachusetts governor and U.S. presidential candidate Michael Dukakis.-Life and career:...

, wife of politician Michael Dukakis
Michael Dukakis
Michael Stanley Dukakis served as the 65th and 67th Governor of Massachusetts from 1975–1979 and from 1983–1991, and was the Democratic presidential nominee in 1988. He was born to Greek immigrants in Brookline, Massachusetts, also the birthplace of John F. Kennedy, and was the longest serving...

, reports in a Newsweek
Newsweek
Newsweek is an American weekly news magazine published in New York City. It is distributed throughout the United States and internationally. It is the second-largest news weekly magazine in the U.S., having trailed Time in circulation and advertising revenue for most of its existence...

article mostly positive effects from electroconvulsive therapy, and regards memory loss as an acceptable price to pay for relief from depression.
American psychotherapist Martha Manning's autobiographical Undercurrents acknowledges the downside of treatment: "I felt like I'd been hit by a truck for a while, but that was, comparatively speaking, not so bad," as well as the upside: "Afterwards, I thought, do regular people feel this way all the time? It's like you've not been in on a great joke for the whole of your life."

In his autobiographical book Electroboy, American writer Andy Behrman
Andy Behrman
Andy Behrman was born 1962 and is an American writer of non-fiction as well as a mental health advocate and national speaker who maintains a website at www.electroboy.com. He is the author of Electroboy: A Memoir of Mania, a chronicle about his experiences with Manic Depression, published by Random...

 describes undergoing ECT as a treatment for bipolar disorder while under house-arrest: "I wake up thirty minutes later and think I am in a hotel in Acapulco. My head feels as if I have just downed a frozen margarita too quickly. My jaws and limbs ache. But I am elated."

Curtis Hartmann, a lawyer in western Massachusetts, stated: "ECT, a treatment of last resort for severe, debilitating depression, is all that has ever worked for me. I awaken about 20 minutes later, and although I am still groggy with anesthesia, much of the hellish depression is gone. It is a disease that for me, literally steals me from myself—a disease that executes me and then forces me to stand and look down at my corpse. Thankfully, ECT has kept my monster at bay, my hope intact".

Beverley Callard
Beverley Callard
Beverley Jane McEwan is an English actress, best known for her role as Liz McDonald in ITV's Coronation Street, and Flo Henshaw in BBC Three's Two Pints of Lager and a Packet of Crisps.-Early life:Beverley Jane Moxon was born in Leeds on 28 March 1957 to Clive and Mavis Moxon...

 is a British actress, best known for her role as Liz McDonald
Liz McDonald
Elizabeth "Liz" Jayne McDonald is a fictional character in the UK television ITV soap opera, Coronation Street. Portrayed by actress Beverley Callard, the character first appeared onscreen during the episode airing on 27 October 1989 and remained on the series until Callard opted to leave in 1998...

 in Coronation Street
Coronation Street
Coronation Street is a British soap opera set in Weatherfield, a fictional town in Greater Manchester based on Salford. Created by Tony Warren, Coronation Street was first broadcast on 9 December 1960...

. In her recently published autobiography titled "Unbroken", she describes her experience with ECT for severe depression, stating that the treatment was responsible, in part for her recovery.

Depictions of severe long-term, permanent memory loss

Ernest Hemingway
Ernest Hemingway
Ernest Miller Hemingway was an American author and journalist. His economic and understated style had a strong influence on 20th-century fiction, while his life of adventure and his public image influenced later generations. Hemingway produced most of his work between the mid-1920s and the...

, American author, committed suicide shortly after ECT at the Mayo Clinic in 1961. He is reported to have said to his biographer, "Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient...."

In a poem, The Hanging Man, by Sylvia Plath
Sylvia Plath
Sylvia Plath was an American poet, novelist and short story writer. Born in Massachusetts, she studied at Smith College and Newnham College, Cambridge before receiving acclaim as a professional poet and writer...

 ECT is described:

By the roots of my hair some god got hold of me.

I sizzled in his blue volts like a desert prophet.

The nights snapped out of sight like a lizard's eyelid:

A world of bald white days in a shadeless socket.

A vulturous boredom pinned me in this tree.

If he were I, he would do what I did.

In a letter to the editor published in the Washington Post in December, 2000, registered nurse Barbara C. Cody wrote that her life was forever changed by 13 outpatient ECTs she received in 1983. She wrote,
"Shock 'therapy' totally and permanently disabled me. EEGs [electroencephalograms] verify the extensive damage shock did to my brain. Fifteen to 20 years of my life were simply erased; only small bits and pieces have returned. I was also left with short-term memory impairment and serious cognitive deficits. ... Shock 'therapy' took my past, my college education, my musical abilities, even the knowledge that my children were, in fact, my children. I call ECT a rape of the soul."

Similarly, writer Johnanton Cott claims to have completely lost 15 years of memory in On the Sea of Memory: A Journey from Forgetting to Remembering.

Despite former patients having reported devastating, permanent amnesia and cognitive impairment since ECT was first invented, the first lawsuit for ECT amnesia, Marilyn Rice v. John Nardini, was not brought until 1975; dozens of suits followed. While there have been a few settlements, including one for half a million dollars, no former patient had won a case until 2005. In a 2005 South Carolina court proceeding, Peggy S. Salters became the first ECT survivor to win a jury verdict and compensation. Ms. Salters sued Palmetto Baptist Medical Center in Columbia, as well as the three doctors responsible for her care, for an intensive course of outpatient ECT that she received in 2000, at age 55 years old, that caused her to lose all memories of the past 30 years of her life, including all memories of her husband of three decades, then deceased, and the births of her three children. She held a Masters of Science in nursing and, prior to the ECT, had a long career as a psychiatric nurse; but, as a result of the ECT, lost her knowledge of nursing skills and was unable to return to work. The jury awarded Salters $635,177 in compensation for her inability to work. The judgement was upheld upon appeal in an unpublished opinion.

Accounts of severe cognitive diminishment

Liz Spikol, the senior contributing editor of Philadelphia Weekly
Philadelphia Weekly
Philadelphia Weekly , is an award-winning alternative newspaper in Philadelphia, Pennsylvania, published every Wednesday.The paper was founded in 1971 as a sister publication to the South Philadelphia Press. In 1995, the paper became Philadelphia Weekly...

, wrote of her ECT in 1996,
"Not only was the ECT ineffective, it was incredibly damaging to my cognitive functioning and memory. But sometimes it's hard to be sure of yourself when everyone 'credible' — scientists, ECT docs, researchers — are telling you that your reality isn't real. How many times have I been told my memory loss wasn't due to ECT but to depression? How many times have I been told that, like a lot of other consumers, I must be perceiving this incorrectly? How many times have people told me that my feelings of trauma related to the ECT are misplaced and unusual? It's as if I was raped and people kept telling me not to be upset—that it wasn't that bad."

Involuntary or other problems in administrating ECT

In 2007, a judge canceled a two-year-old court order that allowed the involuntary electroshock of Simone D., a psychiatric patient at Creedmoor Psychiatric Center
Creedmoor Psychiatric Center
Creedmoor Psychiatric Center is a psychiatric hospital in Queens Village, Queens, New York, United States that provides inpatient, outpatient and residential services for severely mentally ill patients...

 in the state of New York. Although Simone spoke only Spanish, she rarely received access to staff fluent in her language. Simone previously had 200 electroshocks. However, she communicated that she did not want more electroshock. Simone stated, "Electroshock causes more pain. I suffer more from shock treatment! "

In 2008, David Tarloff, a psychiatric patient who had received electroshock, assaulted two therapists in the city of New York. Tarloff injured one therapist and killed the other. One of the therapists was Kent Shinbach, a psychiatrist who had an interest in electroconvulsive therapy. "It is not clear whether Dr. Shinbach played any role in Mr. Tarloff's shock therapy". However, Tarloff told investigators that Shinbach had given Tarloff psychiatric treatment at a psychiatric facility initially in 1991.

Other descriptions

In an interview with Houston Chronicle
Houston Chronicle
The Houston Chronicle is the largest daily newspaper in Texas, USA, headquartered in the Houston Chronicle Building in Downtown Houston. , it is the ninth-largest newspaper by circulation in the United States...

in 1996, Melissa Holliday
Melissa Holliday
Melissa Deanne Holliday was Playboy magazine's Playmate of the Month for January 1995....

, a former extra on Baywatch
Baywatch
Baywatch is an American action drama series about the Los Angeles County Lifeguards who patrol the beaches of Los Angeles County, California, starring David Hasselhoff. The show ran in its original title and format from 1989 to 1999, sans the 1990-1991 season, of which it was not in production...

and model for Playboy
Playboy
Playboy is an American men's magazine that features photographs of nude women as well as journalism and fiction. It was founded in Chicago in 1953 by Hugh Hefner and his associates, and funded in part by a $1,000 loan from Hefner's mother. The magazine has grown into Playboy Enterprises, Inc., with...

stated the ECT she received in 1995, "ruined her life." She went on to state, "I've been through a rape, and electroshock therapy is worse. If you haven't gone through it, I can't explain it."

Public perception and mass media

A questionnaire survey of 379 members of the general public in Australia
Australia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...

 indicated that more than 60% of respondents had some knowledge about the main aspects of ECT. Participants were generally opposed to the use of ECT on depressed individuals with psychosocial issues, on children, and on involuntary patients. Public perceptions of ECT were found to be mainly negative.

Fictional examples

Electroconvulsive therapy has been depicted in fiction and works based on true experiences. These include A Clockwork Orange, The Snake Pit
The Snake Pit
The Snake Pit is a 1948 American drama film directed by Anatole Litvak. The film tells the story of a woman who finds herself in an insane asylum and cannot remember how she got there, and stars Olivia de Havilland, Mark Stevens, Leo Genn, Celeste Holm, Beulah Bondi, and Lee Patrick.The film was...

, Quantum Leap (TV series), Frances
Frances
Frances is a 1982 American drama film starring Jessica Lange, Kim Stanley, and Sam Shepard. When it was released this film was advertised as a purportedly true account of actress Frances Farmer's life but the script was largely fictional and sensationalized...

, Requiem for a Dream, the novel One Flew Over the Cuckoo's Nest
One Flew Over the Cuckoo's Nest (novel)
One Flew Over the Cuckoo's Nest is a novel written by Ken Kesey. Set in an Oregon asylum, the narrative serves as a study of the institutional process and the human mind, as well as a critique of Behaviorism and a celebration of humanistic principles. Written in 1959, the novel was adapted into a...

by Ken Kesey
Ken Kesey
Kenneth Elton "Ken" Kesey was an American author, best known for his novel One Flew Over the Cuckoo's Nest , and as a counter-cultural figure who considered himself a link between the Beat Generation of the 1950s and the hippies of the 1960s. "I was too young to be a beatnik, and too old to be a...

 as well as the movie adaptation
One Flew Over the Cuckoo's Nest (film)
One Flew Over the Cuckoo's Nest is a 1975 American drama film directed by Miloš Forman and based on the 1962 novel of the same name by Ken Kesey....

, Melrose Place, A Beautiful Mind
A Beautiful Mind (film)
A Beautiful Mind is a 2001 American drama film based on the life of John Nash, a Nobel Laureate in Economics. The film was directed by Ron Howard and written by Akiva Goldsman. It was inspired by a bestselling, Pulitzer Prize-nominated 1998 book of the same name by Sylvia Nasar...

, The Caretaker
The Caretaker
The Caretaker is a play by Harold Pinter. It was first published by both Encore Publishing and Eyre Methuen in 1960. The sixth play that Pinter wrote for stage or television production, it was his first significant commercial success...

, The Best of Youth
The Best of Youth
The Best of Youth , is a 2003 Italian film directed by Marco Tullio Giordana. Originally planned as a four-part mini-series, it was presented at the 2003 Cannes Film Festival where it won the prestigious Un Certain Regard award. It was then given a theatrical release in Italy in two three-hour...

, House
House (TV series)
House is an American television medical drama that debuted on the Fox network on November 16, 2004. The show's central character is Dr. Gregory House , an unconventional and misanthropic medical genius who heads a team of diagnosticians at the fictional Princeton-Plainsboro Teaching Hospital in...

; The Bell Jar
The Bell Jar
The Bell Jar is American writer and poet Sylvia Plath's only novel, which was originally published under the pseudonym "Victoria Lucas" in 1963. The novel is semi-autobiographical with the names of places and people changed...

by Sylvia Plath
Sylvia Plath
Sylvia Plath was an American poet, novelist and short story writer. Born in Massachusetts, she studied at Smith College and Newnham College, Cambridge before receiving acclaim as a professional poet and writer...

, Shine
Shine (film)
Shine is a 1996 Australian film based on the life of pianist David Helfgott, who suffered a mental breakdown and spent years in institutions. It stars Geoffrey Rush, Lynn Redgrave, Armin Mueller-Stahl, Noah Taylor, John Gielgud, Googie Withers, Justin Braine, Sonia Todd, Nicholas Bell, Chris...

, the film version of Girl, Interrupted
Girl, Interrupted (film)
Girl, Interrupted is a 1999 drama film about a teenager's 18-month stay at a mental institution, starring Winona Ryder, Brittany Murphy, Angelina Jolie, Whoopi Goldberg and Vanessa Redgrave, with Jolie winning an Academy Award for her performance....

, Insanitarium
Insanitarium
Insanitarium is a 2008 psychological horror starring Jesse Metcalfe, Kiele Sanchez, Kevin Sussman, Olivia Munn, Carla Gallo and Peter Stormare. The film is directed by Jeff Buhler.-Storyline:...

, Changeling, Ciao! Manhattan
Ciao! Manhattan
Ciao! Manhattan is a 1972 American avant garde film starring Edie Sedgwick, one of Andy Warhol's Superstars. Although not a documentary, the film centers around a character very closely based on Sedgwick, and deals with the pain of addiction and the lure of fame.-Film overview:Written and directed...

, Next to Normal, Return to Oz, Private Practice, Ghost Whisperer
Ghost Whisperer
Ghost Whisperer is an American television supernatural drama, which ran on CBS from September 23, 2005 to May 21, 2010.The series follows the life of Melinda Gordon , who has the ability to see and communicate with ghosts...

, From Beyond
From Beyond (film)
From Beyond is a 1986 American science fiction/ body horror film directed by Stuart Gordon, loosely based on the short story of the same title by H. P. Lovecraft, and was written by Dennis Paoli, Gordon and Brian Yuzna...

, the novel Zen and the Art of Motorcycle Maintenance
Zen and the Art of Motorcycle Maintenance
Zen and the Art of Motorcycle Maintenance: An Inquiry into Values is a 1974 philosophical novel, the first of Robert M. Pirsig's texts in which he explores his Metaphysics of Quality.The book sold 5 million copies worldwide...

, Helen
Helen (film)
Helen is a 2009 drama starring Ashley Judd and directed by Sandra Nettelbeck. It follows a professor who overcomes severe depression after a massive breakdown, with the help of new friend Matilda...

, Oz
Oz (TV series)
Oz is an American television drama series created by Tom Fontana, who also wrote or co-wrote all of the series' 56 episodes . It was the first one-hour dramatic television series to be produced by premium cable network HBO. Oz premiered on July 12, 1997 and ran for six seasons...

, Six Feet Under, House on Haunted Hill
House on Haunted Hill (1999 film)
House on Haunted Hill is a 1999 American horror film, directed by William Malone and starring Geoffrey Rush, Famke Janssen, Taye Diggs, Ali Larter and Jeffrey Combs. It also includes a cameo appearance by Peter Graves...

, Royal Pains
Royal Pains
Royal Pains is a USA Network television series that premiered on June 4, 2009, starring Mark Feuerstein, Paulo Costanzo, Jill Flint and Reshma Shetty. The series is based in part on actual concierge medicine practices of independent doctors and companies...

, and "The Wolfman (2010 film)."

See also

  • Anti-psychiatry
    Anti-psychiatry
    Anti-psychiatry is a configuration of groups and theoretical constructs that emerged in the 1960s, and questioned the fundamental assumptions and practices of psychiatry, such as its claim that it achieves universal, scientific objectivity. Its igniting influences were Michel Foucault, R.D. Laing,...

  • DSM-IV Codes
    DSM-IV Codes
    Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as DSM-IV-TR, is a manual published by the American Psychiatric Association that includes all currently recognized mental health disorders...

  • Harold A. Sackeim
    Harold A. Sackeim
    Dr. Harold A. Sackeim is an American psychologist and proponent of electroconvulsive therapy, . He has been chief of the department of biological psychiatry at New York State Psychiatric Institute and professor of clinical psychology at Columbia University...

  • Insulin shock therapy
    Insulin shock therapy
    Insulin shock therapy or insulin coma therapy was a form of psychiatric treatment in which patients were repeatedly injected with large doses of insulin in order to produce daily comas over several weeks...

  • History of electroconvulsive therapy in the United Kingdom
    History of electroconvulsive therapy in the United Kingdom
    Electroconvulsive therapy is a controversial psychiatric treatment in which seizures are induced with electricity...

  • Psychiatric survivors movement
    Psychiatric survivors movement
    The psychiatric survivors movement is a diverse association of individuals who are either currently clients of mental health services , or who consider themselves survivors of interventions by psychiatry, or who identify themselves as ex-patients of mental health services...

  • List of people who have undergone electroconvulsive therapy

External links

The source of this article is wikipedia, the free encyclopedia.  The text of this article is licensed under the GFDL.
 
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