May 2009  << Back  

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Electroconvulsive Therapy. A Guide for Professionals A Guide for Professionals and Their Patients

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Since its inception, electro-convulsive therapy (ECT) has been praised as an effective treatment and maligned as inhumane torture of psychiatric patients. The fact is that ECT is 1 of the most effective treatments—if not the most effective—for some psychiatric conditions and disorders. Sadly, the media’s portrait of ECT usually is grossly unfair, neglecting that times have changed and ECT is effective and safe and used in an ethical and dignified manner. Despite all that, ECT remains the most stigmatized among stigmatized treatments and needs to be constantly defended and explained. Many researchers and clinicians have defended this effective treatment, but who could better defend and explain it than Max Fink, who has been practicing, studying, popularizing, and publishing about ECT for more than half a century? He revised and restructured his decade-old classic text on ECT, providing patients, their families, and mental health professionals with “everything you need and want to know about electroconvulsive therapy” in this slight volume, Electroconvulsive Therapy. A Guide for Professionals and Their Patients.

By Max Fink; Oxford University Press; New York, New York; 2009; ISBN: 978-0-19-536574-0; pp 162; $17.95 (paperback).

Besides Preface and Acknowledgements, the book consists of 13 brief chapters addressing issues such as “What is electroconvulsive therapy?,” “The patient’s experience,” “The treatment technique,” “Side effects and memory issues,” “Depressive mood disorders,” “Manic mood disorders,” “Movement disorders,” “Other uses: psychosis, pregnancy, and status epilepticus,” “Pediatric ECT,” “How does ECT work?,” “How did convulsive therapy originate?,” “Is brain stimulation an alternative to ECT?,” and “Is ECT practice ethical?” Two appendices summarize “Diagnoses in which ECT is considered effective” and “Diagnoses in which ECT is considered ineffective,” and the third provides a “Sample ECT consent form.” The book also features extensive notes and bibliography and includes powerful and moving clinical vignettes.

Dr. Fink emphasizes that “electroconvulsive therapy has undergone fundamental changes since its introduction 75 years ago. It is no longer the bone-breaking, memory-stealing, fearsome treatment pictured in films. Anesthesia, controlled oxygenation, and muscle relaxation make the procedure so safe that the risks are less than those accompanying the use of several psychotropic drugs. Indeed, for the elderly, the systemically ill, and pregnant women, ECT is a safer treatment for mental illness than alternatives.” I guess that many— hopefully all—psychiatrists will say “we know that,” yet the public and media do not or deny it.

The chapters’ text is succinct, brief, and straight to the point, yet addresses all the important points one would like to know about, such as who is ECT appropriate and useful for, when might ECT be considered, what conditions respond to ECT, what conditions interfere with effective ECT, what preparation for ECT looks like, what happens during ECT, what are the restrictions in behavior after treatment, what the frequency of treatments is, what is continuous ECT treatment, what are the treatment outcomes, what the various techniques are, etc. Mentioning all the questions the author addresses is beyond the scope of this review, but I hope that the examples listed give the reader an idea of how thorough Dr. Fink is in his covering the entire area of ECT.

When discussing side effects and addressing misconceptions, Dr. Fink emphasizes that, “the risk of death during ECT is very low, less than that of women delivering spontaneous births” (p 34). The review of memory problems associated with ECT reminds us of anesthesia’s effect on memory, that high oxygenation minimizes the ill effects of ECT, and that memory is affected by the patient’s age, duration and severity of the illness, presence and seriousness of bodily disorders, and technical factors such as current intensity, electrode placement, and frequency and number of treatments.

Chapters addressing various disorders and conditions in which ECT is effective are, like the rest of the book, comprehensive and informative. The pediatric ECT chapter is especially interesting because the treatment is rarely used in this population and therefore little is known about it. Dr. Fink addresses issues of ECT in adolescents, prepubertal children, catatonic children (also in catatonic autistic children), intellectually disabled, and children and adolescents with self-injurious behavior. The chapter on how ECT works is interesting, but we all know that we do not know how it works. Nevertheless, theories of the mechanism of action presented in this chapter are interesting. The history of ECT’s origin is thought provoking, but basically a footnote about the astute and observant clinicians of the past. A brief discussion of transcranial magnetic stimulation, magnetic seizure therapy, vagus nerve stimulation, and deep brain stimulation and their comparison to the efficacy of ECT reminds that none of these new therapies is as effective as ECT.

The book ends with an interesting discussion of whether ECT practice is ethical. Discussing the 4 basic principles of an ethical relationship—beneficence (do good), nonmaleficence (do not harm), autonomy (respect for individual wishes), and justice (equal opportunity regardless of age, gender, color, religion, or wealth)—Dr. Fink concludes that ECT is beneficent, not an infringement of the principle of nonmaleficence, and not an infringement of autonomy, but does not meet the principle of justice. The reasons for not meeting the principle of justice are numerous, eg, lack of properly trained personnel in all psychiatric hospitals, especially in community-supported facilities treating the poor, elderly, and children, and the fact that ECT frequently is discouraged in adolescents, the mentally retarded, pregnant women, and elderly patients. Dr. Fink also emphasizes that “the prevailing practice that considers ECT as the last resort is unjust, as it consigns patients to weeks, months, and even years of inadequate care” (p 118).

Although a small volume, this is a powerful and useful educational text about ECT. As noted (p viii) it is written for those faced with decisions about using ECT and it is meant to complement available DVDs that educate patients about what to expect. I believe all patients, their families, and their treating mental health professionals considering this treatment will appreciate this text. As such, this book should be a resource in the library of all clinical psychiatrists, whether or not they practice ECT.