ECT Anonymous - Research Information - May 1999 - ECT Anonymous - May 1999

Written by Juli Lawrence

Variables are related in a complex pattern and metabolic impact is also reported, often agreed to be devastating:

"The failure to find evidence of cerebral hypoxia, anaerobic metabolism, or electrolyte shifts does not imply that cerebral metabolism is normal during seizures. In our patients...there was a rise in venous PCO2 [carbon dioxide tension] without a concomitant fall in oxygen, indicating that the cerebral RQ [respiratory quotient] increased. ... Such findings suggest either that substances other than glucose are being metabolized (e.g. pyruvate) or that substances such as amino acids and proteins are being decarboxylated without being oxidized for energy. Geiger demonstrated a shift in metabolism away from exogenous glucose to endogenous cerebral substances in the perfused cat brain during electrically or chemically induced seizures. He demonstrated a shift to oxidation of nonglucose substances during the seizure and a period of increased glucose uptake postictally, the latter suggesting that endogenous substrates were being replaced. If endogenous substances essential to normal cerebral metabolism are depleted during seizures, one might expect postictal brain dysfunction until repletion even without hypoxia. At some point during repeated seizures, depletion of cerebral substances might become irreversible and permanent brain damage ensue. Thus postictal EEG flattening and coma need not imply cerebral hypoxia." (Posner et al., 'Cerebral Metabolism During Electrically Induced Seizures in Man,' Arch. Neurol., Vol. 20, April 1969)

"ECT causes extracellular retention of sodium and water according to Altschule and Tillotson. This may be responsible for the facial coarsening often noted during ECT. Further, significant changes in sodium and potassium concentrations as well as the resultant shift in water balance would affect neuronal function and personality." (A. M. Sackler, R. R. Sackler, F. Marti-Ibanez and M. D. Sackler, 'The Great Psysiodynamic Therapies,' in 'Psychiatry: an historical reappraisal, Hoeber-Harper, 1956)

Are psychiatrists always careful in their administration of ECT?

"I would like first of all to ask why their electrodes are soaked for 30 seconds? I suggest that they would have fewer failures if they ensured soakings of at least 30 minutes." (L. Rose,'Failure to Convulse With ECT' (Correspondence) Brit. J. Psychiat. (1988), 153)

In fact, although throughout the foregoing the assumption is that ECT is properly administered and monitored, with the welfare and safety of patients the principal concern, this has frequently not been the case.

"...a seizure of only 6-10 minutes' duration can be associated with both metabolic insufficiency and delayed return to baseline neurologic function, even in the presence of apparently adequate oxygenation. ... ...in the more recent technique of multiple monitored ECT, in which two or more EEG-monitored seizures are evoked...prolonged seizures occur on a...frequent basis, lasting as long as an hour. ... The fact that prolonged seizures have been reported only in the presence of EEG monitoring raises the question of whether this phenomenon actually occurs on a more frequent basis." (Richard D. Weiner et al, 'Seizures Terminable and Interminable with ECT,' Am. J. Psychiat., 137:11, November 1980)

"Ectron equipment has not been designed for use with EEG because there has been no demand. EEG monitoring has rarely been used in the UK, unless for research." (John Pippard, 'Audit of Electroconvulsive Treatment in two National Health Service Regions,' Brit. J. Psychiat. (1992), 160

"As early as 1950, Bankhead and colleagues suggested that cardiac ectopic phenomena occur during the 'deepest cyanosis following the convulsion', but the use of oxygen during ECT did not then become routine. In a description of ECT in 1968 the shock was delivered 50 seconds after the relaxant and, following the clonic phase, three hand ventilations were delivered using, 'room air...and never oxygen' (Pitts et al., 1968). As recently as 1979 it has been claimed that oxygenation during ECT is unnecessary (Joshi, 1979), although apnoea after the shock can last for a few minutes, and will cause significant hypoxia if untreated. The present study was designed to monitor oxygenation in the clinical situation during routine anaesthesia and ECT. Significant hypoxia was demonstrated.... ...
As...over 50% of the anaesthesia for ECT is performed by anaesthetists in training, teaching should emphasise the need for adequate oxygenation." (Steven R. Swindells and Karen H. Simpson, 'Oxygen Saturation during Electroconvulsive Therapy,' Brit. J. Psychiat. (1987), 150)

Do the psychiatrists who administer ECT have under control even such variables as the current waveforms and frequency or the voltage and energy involved in delivering electricity to the brain? Seemingly not:

"Electronarcosis is more scientific, because a current of known intensity is passed through the patient. In electric convulsion therapy, on the other hand, the actual current passed through the patient is not known, as the patient's resistance drops during the passage of the current, and these changes are not compensated for as in electronarcosis." (Paterson and Milligan, 'Electronarcosis: a new treatment of schizophrenia,' The Lancet, August, 1947)

"The actual impedance of the skull cannot be measured and the amount of electricity passing through the brain cannot be known for any given setting of the ECT apparatus." (John Pippard, 'Audit of Electroconvulsive Treatment in two National Health Service Regions,' Brit. J. Psychiat. (1992), 160)

"Drs Pippard & Russell [Brit. J. Psychiat. (1988), 152, 712-713] are correct in stating that "the optimum parameter levels for ECT are still uncertain". Indeed, it has been argued that the exact effects, if any, of each parameter are either unknown or, at best, ill understood. This need not be so, however. No other medical treatment is administered "blindly", to use the term of Drs Pippard & Russell, and it would appear that remaining uncertainties in ECT are due more to the inability to fully control dosage.... Now that treatment can proceed in a controlled and repeatable fashion, thanks to computer technology, one can hopefully expect the publication of research results providing more and more information on the effects of duration, frequency, pulse width, potential, current, and energy on the effectiveness of ECT." (Ivan G. Schick, 'Failure to Convulse with ECT,' Brit. J. Psychiat. (1989), 154 (correspondence))

"Shocks higher than the threshold dose will cause cognitive impairment in proportion to the overshock. ... This threshold dose varies 1 to 40 from one patient to the next and clinics have no way of determining this dosage. ... The dose of electricity is given by habit rather than by rational strategy and routine settings vary fourfold between clinics." (extracts from the Pippard Report on ECT)