Hall and Bensing (2005), Fink (2004), and Sadock and Sadock (2003) provide an excellent overview of the discovery and evolution of ECT. Although electric eels were used to ease headaches and camphor-induced seizures were used to treat psychosis as early as the 16th century, most histories of ECT start in 1934, when catatonia and other schizophrenic symptoms were successfully treated with pharmacologically induced seizures. Before the introduction of ECT, intramuscular injections of camphor suspended in oil and then the intravenous administration of pentylenetetrazol were used to induce seizures. In 1938, Cerletti and Bini introduced electroshock therapy (EST), but it later became known as ECT. In 1940, the first documented treatment of ECT was administered in the United States. An American psychiatrist, Abram E. Bennett, suggested the use of spinal anesthetics and the use of the muscle relaxant curare to reduce the incidence of fractures. In 1951, succinylcholine (Anectine) became the muscle relaxant of choice during ECT.

Between 1960 and 1970, during the advent of more effective neuroleptics, deinstitutionalization of the
mentally ill, and complaints of ECT misuse, the use of ECT declined. Complaints about ECT misuse resulted in the development of ECT task forces by the Commissioner of Mental Health in Massachusetts, the American Psychiatric Association (APA), and the International Psychiatric Association. Between 1985 and 1990, the National Institute of Mental Health (NIMH) and the APA combined efforts to develop guidelines for patient selection and treatment. Although the Surgeon General released a report on mental health favoring the use of ECT in 1999, some well-intentioned activists who received ECT inappropriately suffered side effects that their doctors did not explain, or who were told that the effects of ECT were always permanent, attacked the treatment itself when the doctor who delivered the treatment was at fault. As a result of such complaints, the New Freedom Commission Report released in 2003 cited the need for mental health care reform in the United States. In 2004, the World Health Organization and Mind Freedom cited ECT as a violation of the rights of mental health clients.

These allegations have been countered by the publication of educational articles such as Clinical Science Versus Controversial Perceptions and the National Institutes of Health Consensus Statement on ECT. Although the National Association of the Mentally Ill (NAMI) does not endorse particular forms of treatment, it believes that informed individuals with neurobiologic disorders have the right to receive NIMH-approved treatments such as ECT from properly trained practitioners. NAMI opposes actions intended to limit this right (Papolos & Devanand, 2005).

Electroconvulsive therapy (ECT) uses electric currents to induce convulsive seizures in neurons in the entire brain to alleviate symptoms such as major depression, acute manic episodes, or schizophrenia. Although the exact mechanism of ECT is unclear, four main theories exist: the neurotransmitter theory (the correction of biochemical abnormalities of peptide and neurotransmitters such as serotonin and dopamine produce effects similar to that of tricyclic antidepressants or selective serotonin reuptake inhibitors); neuroendocrine theory (a release of hormones by the hypothalamus or pituitary produce antidepressant effects); anticonvulsant theory (the treatment itself minimizes or eliminates symptoms); and the frontal lobe theory (ECT minimizes or eliminates symptoms of mood or behavioral disorders that originate in the frontal lobe) (Hall & Bensing, 2005; Sadock & Sadock, 2003).

With ECT, electrodes are applied to the client’s scalp. Two types of electrode placements, bitemporal or bilateral (BL; one electrode placed on each temporal area) and right unilateral nondominant temporal (RUL; two electrodes placed on the right temporal area), are commonly used during the procedure (Figure 17-1). The left hemisphere is dominant in most persons; therefore, unilateral electrode placement is almost always over the right hemisphere. If a person exhibits right-hemisphere dominance, the polarity of electrode stimulation should be alternated during successive treatments. RUL placement has been described as more advantageous than BL placement because the negative effects on the client’s cognition and memory after treatment are lessened. However, clinical efficacy is lower, with at least a 15% greater failure rate compared with BL placement (Fink, 1999; Sadock & Sadock, 2003).

A third type of placement, bifrontal (BF), in which the electrodes are placed on the forehead immediately above each eye, has been studied recently. Ongoing studies of BF placement find equal efficacy to BL placement. BF may be a useful alternative to BL placement (Fink, 1999; Fink, Abrams, Bailine, & Jaffe, 1996). Electronarcosis is a type of ECT that produces a sleep-like state without the presence of convulsions. Anesthetics and muscle relaxants are used to prohibit the development of convulsions during electrostimulation.