ELECTROCONVULSIVE THERAPY: CHARACTERISTICS, EFFECTS AND APPLICATIONS - ECONOMÍA - 2024

The electroconvulsive therapy, electroconvulsive therapy electroconvulsoterpia or a psychiatric treatment in which seizures are induced by cerebral electricity. This therapeutic tool is used to treat different psychological disorders. The most common are major depression, bipolar disorder, and schizophrenia.

The use of electroconvulsive therapy has been established since the 30s of the last century and, today, it continues to be a highly used therapy in the treatment of severe mental disorders. It is estimated that approximately one million people receive electroconvulsive therapy each year, according to the World Health Organization.

Electrodes in electroconvulsive therapy. BruceBlaus

Both its characteristics and its effects cause some controversy about society. Many people perceive and classify it as a highly harmful technique. However, upon detailed analysis of its qualities, it immediately becomes clear that electroconvulsive therapy is a necessary therapy in several cases. Like any other treatment, its application has advantages and disadvantages.

In fact, the scientific community agrees that electroconvulsive therapy is one of the main treatments available and used in psychiatry for serious mental illnesses.

Electroconvulsive therapy characteristics

Electroconvulsive therapy machine MECTA spECTrum 5000Q. Author: Soggybread, wikimedia commons

Electroconvulsive therapy is a treatment designed to relieve acute depression, bipolar disorder, schizophrenia, and other severe mental illnesses. For many patients, this treatment provides significant relief from their pathology. More importantly, in some cases it is the only therapy that provides therapeutic effects.

For its application an electrical energy device is required, which sends electrical impulses directly to the brain. To do this it is necessary to place a series of electrodes in specific regions of the skull.

The electrical discharge produced on the brain is very brief (a few seconds). The application of the shock produces a brief and controlled cerebral seizure, which lasts between 30 seconds and 2 minutes, depending on each case.

In order to apply this therapy, general anesthesia must be used. In other words, the patient must be totally asleep before its application. Likewise, it is necessary to apply a muscle relaxant and a dental protector to avoid possible damage during the seizure.

It should be noted that the electroconvulsive therapy intervention is remarkably brief. The discharge itself lasts a few seconds and the full effect of the anesthesia lasts for a few minutes.

Thus, despite the fact that this treatment requires all the care prior to the administration of anesthesia, it does not require hospitalization. In fact, electroconvulsive therapy can be applied to both inpatients and outpatients.

Applications

Patient receiving electroconvulsive therapy

Electroconvulsive therapy is a highly used mental health treatment that is essential in some cases of serious psychiatric disorders. Mainly, it is used for the treatment of depression, schizophrenia, mania and catatonia, since these are the psychopathologies in which it has been shown to be effective.

However, this therapy is considered today as a second-line treatment. Electroconvulsive therapy is used to treat subjects with these conditions that do not respond to medications or other therapies.

Specifically, the American Psychiatric Association (APA) recommends the use of electroconvulsive therapy as a therapeutic option in patients with the following characteristics:

1. Pharmacotherapy has not been effective in treating the first episode or preventing relapses of the disorder.
2. Pharmacotherapy cannot be administered safely or the patient has some characteristic that makes its application difficult.
3. The patient prefers electroconvulsive therapy to drug treatment.

Thus, electroconvulsive therapy is not the first-choice treatment for any pathology, since at present there is a clear preference for the use of psychotropic drugs.

However, the low efficacy and the application problems that drugs present in some cases of severe mental disorder, make electroconvulsive therapy a highly used technique.

Likewise, electroconvulsive therapy has shown that it does not present a therapeutic efficacy inferior to many of the psychotropic drugs used for the treatment of major depression, schizophrenia or bipolar disorder.

What is electroconvulsive therapy for?

The Food and Drug Administration (FDA) postulates six different pathologies for which the use of electroconvulsive therapy is indicated: unipolar and bipolar depression, schizophrenia, manic and mixed bipolar disorder, schizoaffective disorder, schizophreniform disorder and mania.

Depression

Major depression is the pathology par excellence that is treated with electroconvulsive therapy. In fact, the cure rate of this therapy for each depressive episode is 70%. Thus, especially in patients with depression who do not respond to either drug therapy or psychotherapy, the use of electroconvulsive therapy should be considered.

Likewise, electroconvulsive therapy is an especially relevant treatment to intervene psychotic depressions, subjects with high suicidal risk and patients who refuse to eat or present a state of high inactivity.

In fact, electroconvulsive therapy is much more effective in the treatment of psychotic depression (92-95% effective) than in the intervention of melancholic depression (55-84% effective).

Finally, it has been shown how the combination of electroconvulsive therapy and drugs promotes a better prognosis. A recent study showed that the combination of both techniques reduced relapses by 45% more than the single use of drugs.

Schizophrenia

The use of electroconvulsive therapy in schizophrenia is subject to the combination of drugs. In fact, there is no evidence to show that electroconulsive therapy alone is effective in treating this condition.

Regarding the combination of drugs and electroconvulsive therapy, it is found that the integration of both techniques presents between 50 and 70% of efficacy.

These data show that electroconvulsive therapy can be a good therapeutic option in the treatment of schizophrenia. Especially in those cases in which antipsychotic treatment is insufficient to guarantee a good prognosis.

Schizoaffective disorder and schizophreniform disorder

Both schizoaffective disorder and schizophreniform disorder are pathologies very similar to schizophrenia. Thus, the efficacy of electroconvulsive therapy for these disorders is very similar to that discussed above.

Specifically, it is argued that electroconvulsive therapy may be an option especially indicated for schizoaffective disorder, since it constitutes a psychotic disorder with altered mood, which is why it benefits from the effects that electroconvulsive therapy produces on both alterations.

Mania

Electroconvulsive therapy is an excellent treatment option in cases where drug treatment is not fast enough. In patients with high levels of agitation or extreme physical exhaustion, it is a quick and effective intervention.

Likewise, electroconvulsive therapy is also indicated in cases in which drug treatment fails to completely remit the manic episode; presents a response rate close to 80% in the treatment of mania.

Action mechanisms

Electroconvulsive therapy machine on display at the Glenside Museum. Rodw

The mechanism of action of electroconvulsive therapy is still under investigation today. In general, there are four theories or possible mechanisms through which this type of therapy carries out its therapeutic effects.

These four mechanisms are: effects on the monoamine system, neuroendocrine effects, neurotropic effects, and anticonvulsant effects.

-Effects on the monoaminergic system

The electrical discharges produced by electroconvulsive therapy cause an alteration and modification of the functioning of various neurotransmitters.

Specifically, it is thought that the functioning of serotonin and norepinephrine would be the ones that are most influenced by electric shocks.

Increased serotonergic transmission

Electroconvulsive therapy has been shown to modify the postsynaptic functioning of the serotonergic system. Specifically, serotonin receptors type 1A and 2A increase in cortical regions and in the hippocampus after application.

The relationship between serotonin and depression is well established, so this mechanism of action would explain its therapeutic potential for this pathology. Likewise, antidepressants tend to decrease postsynaptic receptors, which is why electroconvulsive therapy is more effective than drugs in some cases.

Inhibition of noradrenergic transmission

The effects of electroconvulsive therapy shocks are similar to the effects of antidepressants. This therapy increases the level of norepinephrine and the sensitivity of alpha 1 adrenergic receptors. Likewise, it decreases alpha 2 receptors and the sensitivity to beta adrenergic receptors.

-Neuroendocrine effects

Electroconvulsive therapy shocks result in increased release of various hormones and neuropeptides. Specifically, after electroconvulsive therapy, prolactin, cortisol, oxytocin, and vasopressin are increased.

This increase in hormones occurs due to an acute decrease in dopaminergic inhibition in the hypothalamus. This factor would contribute to explain the therapeutic effects of electroconvulsive therapy in improving the motor manifestations of Parkinson's disease.

-Neurotropic effects

Theories suggest that electroconvulsive therapy increases the expression of brain-derived neurotrophic factor (BDNF). Thus, therapy could prevent and reverse BDNF deficits.

BDNF is a neurotrophin whose deficiency is implicated in the pathophysiology of stress and depression. Thus, by increasing the expression of this factor, therapeutic effects could be achieved for different mental disorders.

-Anticonvulsant effects

Electroconvulsive therapy itself acts as an anticonvulsant, since its application produces seizures and increases the seizure threshold as more therapy sessions are applied.

Positron emission tomography (PET) studies show that during electroconvulsive therapy, cerebral blood flow, use of glucose and oxygen, and permeability of the blood-brain barrier increase.

Likewise, some studies show that electroconvulsive therapy also causes an increase in GABA levels in the brain.

In this way, electroconvulsive therapy would not only be effective in directly attenuating the symptoms of psychopathologies, but it also allows increasing the effectiveness of drug treatment, which is why in many cases both treatments are combined.

Side effects

Electroconvulsive therapy is a therapy that is cumbersome. In fact, it is socially interpreted as an extravagant treatment that causes multiple side effects. However, its side effects are not excessively superior to those caused by antipsychotic drugs or other medications.

The side effects that electroconvulsive therapy can cause are:

Cardiovascular

At the start of the shock the body responds with bradycardia (slowing of breathing). Later, tachycardias, hypertension, and other tachycardia occur.

In the long term, some cases of mild ischemia have been described, especially in patients who already suffered from caridovascular diseases previously.

Cognitive damage

This is probably the main side effect of electroconvulsive therapy. However, there are individual variations in cognitive impairments. In most cases, subjects experience a period of ictal confusion lasting about 30 minutes.

Memory loss can appear in the long term, but the use of unilateral electrodes reduces memory compromise.

Spontaneous seizures

Only between 0.1 and 0.5% of subjects who undergo electroconvulsive therapy develop spontaneous seizures, an incidence slightly higher than in the general population.

Contraindications

Electroconvulsive therapy is strongly discouraged in patients with intracranial hypertension. Likewise, patients with occupational brain injuries, acute myocardial infarction, recent stroke, and pheochromacytoma cannot receive this therapy.

On the other hand, there are other pathologies that can increase the risk of suffering side effects with electroconvulsive therapy. These are considered relative contraindications and are:

• Perform anticoagulant treatment.
• Congestive heart failure.
• Severe lung injury
• Severe osteoporosis
• Long bone fracture.
• Retinal detachment.

References

1. Arrufat F, Bernardo M, Navarro V, Salva J. Relationship between the anticonvulsant properties of ECT and its therapeutic action. Archives of Neurobiology 1997; 600 (1): 37-54.
2. American Psychiatric Association: The practice of ECT: recommendations for Treatment, Training, and Privileging. A Task Force Report of the American Psychiatric Association, Washington DC, 1990.
3. Bernardo M, Pigem J. Electroconvulsive Therapeutics. In: Gutierrez M, Ezcurra J, Pichot P ed. Advances in Psychopharmacology. Barcelona, ​​Editions in Neurosciences. 1994.
4. Calev A, Fink M, Petrides G, Francis A. Phenomenologic augmentation of ECS: Neurochemistry. Convulsive Ther 1993; 9:77.
5. Drafting Committee of the American Psychiatric Association. The practice of electroconvulsive therapy, recommendations for treatment, education and training. Psychiatry Editores, SL. 2002.
6. Granero Lázaro, A; Arredondo Fernández, A; Bleda García, F; Other authors. Action guide for the patient treated with electroconvulsive therapy. Goals, number 42, February 2002.