Principles and Practice of Electroconvulsive Therapy

August 2019

BOOK REVIEWS: Principles and Practice of Electroconvulsive Therapy

Aug
2019
Vol. 31. No. 3
Richard Balon, MD

Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University School of Medicine
Detroit, Michigan, USA

Electroconvulsive therapy (ECT) is unquestionably the most effective treatment modality used in psychiatry. Most psychiatrists feel that because they know a little bit about ECT, or at least know when to refer for this form of treatment, that they do not need to know much more. When I received this book, I thought, “Three hundred pages about electroconvulsive therapy? That seems a lot of reading in this world of shorter and shorter guides to various forms of treatment, especially about something as simple as ECT.” Nevertheless, I started to read and soon found that I was mistaken, both about there being too much information about ECT and the simplicity of ECT. The book was much more interesting than I expected.

Dr. Keith G. Rasmussen’s Principles and Practice of Electroconvulsive Therapy consists of 10 chapters: 1) Introduction to ECT; 2) Patient Selection for ECT; 3) Patient Education and Informed Consent for ECT; 4) The Pre-ECT Medical Workup; 5) Anesthesia for ECT; 6) ECT Technique, Part I: Managing the Individual Treatment; 7) ECT Technique, Part II: Managing the Course of Treatments; 8) Preventing Relapse after ECT: Maintenance ECT and Pharmacotherapy; 9) Cognitive Effects of ECT; and 10) ECT Versus Other Neuropsychiatric Treatments. The chapters are well written, comprehensive and well referenced (the book includes 46 pages of references).

The first chapter is fairly standard coverage of what ECT is, its history, and the fact that we all know that we do not know how ECT works. The second chapter is another standard discussion of patient selection/indications for ECT, and it provides a solid review of the evidence of ECT’s efficacy in various indications. It includes a useful table summarizing factors favoring the use of ECT in depressed patients, and factors weighing against the use of ECT in these patients.

I found the chapter on patient education and informed consent very useful. It discusses issues such as broaching ECT with a patient (including specific suggestions of what to say); generic templates of ECT descriptions for patients and families; and patient and family education (pros and cons of written brochures and videos), including a reference to Max Fink’s book for patients and families.1 Furthermore, this chapter reviews obtaining informed consent, and the capacity to consent to ECT. As Dr. Rasmussen notes, “Capacity can be conceptualized as a set of abilities, including cognitive, emotional, behavioral, and ideational factors, any one of which may interfere with what physicians perceive as needed mental health care” (p 48). Dr. Rasmussen also emphasizes that the ECT clinician will need to be guided by local laws and hospital policies. He also suggests that an “ECT consent form can easily cover no more than the front side of one standard piece of paper, with a place for signatures by the patient and the physician” (p 50). These examples highlight how detailed and practical this book is. The chapter on pre-ECT workup is again very clinically useful, going into interesting details, such as that patients with glaucoma should have their intraocular pressure checked before an ECT course if it has not been checked recently.

The chapter on ECT anesthesia is similarly detailed and educational for anyone who does not know much about this topic.

The 2 chapters on ECT technique include useful tables—one on the steps to take for conducting an ECT treatment, and another on the tasks of the psychiatrist managing a course of ECT treatments—as well as useful illustrations (electrode placements; EEG artifacts). Dr. Rasmussen also discusses concomitant use of various medications during the course of ECT, and issues such as whether to start a new medication during the course of ECT, cognitive monitoring, and monitoring of other adverse effects. The chapter on preventing relapse not only covers maintenance ECT, but also maintenance pharmacotherapy after index ECT. Dr. Rasmussen notes that virtually all post-ECT patients will be treated with some form of maintenance pharmacotherapy, even if maintenance ECT is also used.

The discussion on the cognitive effects of ECT is quite detailed and touches on issues such as work and school performance and driving vehicles (patients should not drive for at least 24 hours after a treatment). The final part of this chapter emphasizes that ECT does not cause brain damage and reviews all evidence supporting this statement.

The last chapter discusses the efficacy of ECT vs other neuromodulation treatments, such as transcranial magnetic stimulation (which is weak and not good for acute treatment), magnetic seizure therapy (why did it disappear in spite positive results?), transcranial direct current stimulation, focal electrically administered therapy, focal electrically administered seizure therapy, vagus nerve stimulation (“it has not exactly taken the psychiatric community by storm” [p 251]), and deep brain stimulation. As Dr. Rasmussen writes at the end, “As it now stands, ECT is the most effective neuropsychiatric treatment modality, better for more clinical circumstances than medications or any one of the abovelisted neuromodulatory alternatives being investigated” (p 254).

This is an excellent compendium of everything the psychiatrist who is practicing ECT or plans to practice ECT needs to know. It is very well written, useful, and well referenced— a definite buy for anyone interested in administering ECT, or teaching about it. I enjoyed reading this book much more than I expected. 

REFERENCE
1. Fink M. Electroconvulsive therapy: a guide for professionals and their patients. New York, NY: Oxford University Press, Inc.: 2010.

CORRESPONDENCE

Richard Balon, MD
Wayne State University
Detroit, Michigan, USA

REFERENCES

By Keith G. Rasmussen; Washington, DC; American Psychiatric Publishing; 2019; 978-1-61537-241-6; pp 322; $60 (paperback).