Different methods treat schizophrenia. The main ones are drug therapy and psychotherapy sessions. In severe cases, when nothing helps, insulin injections are prescribed, and the patient is put into a hypoglycemic coma. ECT in schizophrenia is not prescribed often but only as a radical way to combat the disease. Let’s consider the features of this procedure – indications, counter-indications, pros, cons, stages, and complications.
Features of ECT
Electroconvulsive (ECT) or electroconvulsive shock therapy (ECT) was developed in 1938 as a treatment for psychiatric disorders. Its essence is the following: the patient is passed through the brain current to cause a seizure.
At one time, such therapy proved effective, but more gentle methods replaced it. The fact is that the mechanism of the effect of electric shock on the brain has not been thoroughly studied. As long as there is an opportunity to use other therapies, it will not be prescribed. In addition, there are contraindications to its use, and complications are possible after its implementation.
Therefore, ECT is used only in extreme cases when no other methods, mainly drug therapy, bring a positive effect. Only when adequately established electroconvulsive therapy becomes a fast and effective way to improve the patient’s condition.
Often electroshock is used for severe forms of depression, when the patient falls into a stupor, does not eat anything, and does not experience any desires. The procedure is also prescribed for:
- Bipolar disorder;
- Manic disorder;
Specialists worldwide argue about the effectiveness of the technique and its harm. Likely, they will not be able to come to a consensus yet. It is because this therapy has not yet been thoroughly studied. Most physicians believe that electroshock can be used only at:
- Depression in the case of drug resistance;
- Complete intolerance to medication;
- Severe neurosis and high risk of suicide;
- Febrile catatonia.
The method is also advisable after an earlier course if it has been successful. As for schizophrenia, electroshock should not be prescribed as the primary method in its treatment if other methods have not been tested. It can use after unsuccessful therapy with drugs (mainly antipsychotics), which usually have a positive effect.
British scientists do not recommend using ECT in schizophrenia, which is explained by the meta-analysis (analysis of complex trials on the same topic) conducted at the National Institute, which shows a complete lack of result or a slightly positive result, comparable to placebo.
However, there is also evidence in favor of ECT. Several research studies show that shock therapy has an antipsychotic effect after drugs of similar action.
Approximately 1 million people a year receive 6-12 sessions of ECT.
We can conclude that the prescription of ECT is based on the following principle. If other treatment methods fail and the patient’s condition worsens without electroconvulsive therapy, it is more appropriate to administer ECT than to do nothing. In other words, the therapy method is determined by the specific case of schizophrenia.
Not to say that there are many limitations to ECT, given physicians’ conflicting attitudes toward it. Among the main ones are high intracranial pressure and recent heart attack or stroke. Electroshock is prescribed with care for patients. If it (or another neurological disease) is poorly controlled, it is better to refuse the procedure.
Before therapy, the patient undergoes a comprehensive examination. The number of doctors he will have to visit depends on the underlying pathology, the presence or absence of comorbidities, age, etc. It is necessary to exclude intracranial pressure, cerebrovascular insufficiency, cardiovascular pathology, and severe osteoporosis. There is only one absolute limitation – high blood pressure; the others are relative.
An ophthalmologist must also examine patients. Some limitations of ECT could be glaucoma with increased intraocular pressure and severe myopia with a high risk of retinal detachment.
As for age contraindications, they are also entirely conditional. Studies show that electroshock in children and adolescents has the same effectiveness as in adults. Usually, the procedure is not used to treat very young patients, i.e., those younger than adolescence. But the possibility of using the method is not wholly excluded. Usually, in such cases, consult a psychiatrist already experienced in ECT treatment of children.
The upper age threshold is also not very strict. But at a very advanced age, when the risk of heart or vascular disease is much higher, ECT can be detrimental. Again may decide the strategy if the attending physician deems it appropriate.
Electroshock and Pregnancy
Many treatments and medications are contraindicated during pregnancy. However, electroconvulsive therapy is not on the list of limitations. The amount of data in this area is small since doctors, in principle, do not often encounter patients with schizophrenia who are pregnant with a fetus. But the likelihood of a positive effect from electroshock is not that low.
Depending on the gestational age, may implement additional safety measures. A gynecological obstetrician is involved in the examination. A doctor who has already performed ECT on pregnant women should be consulted. Maternal and fetal monitoring begins several weeks before the procedure and continues after treatment. Electroshock after delivery is not prescribed before 20 weeks.
Principles of conduct
The preparation stage includes examining the procedure’s need and ruling out contraindications. Consent to ECT must be given in writing by the patient (or guardians/representatives). Several weeks before therapy, anticonvulsants are withdrawn. Anesthesia is done on an empty stomach.
There is no specific protocol for administering electroconvulsive therapy. The doctor selects a particular method, depending on the patient’s condition. The parameters such as electrode location, pulse width, the number and frequency of sessions, and the electricity dose are essential. The latter depends on the individual seizure threshold.
The course of the procedure
First, tests are done to determine the minimum dosage needed. After that, it can be increased depending on the situation. Usually, the treatment follows this algorithm:
- The patient is positioned on the couch, after which the equipment is connected to him;
- The duration of the first treatment is about 4-6 seconds;
- The minimum duration of a seizure should be observed for 25 seconds;
- If this period is shorter, the current strength is doubled;
- For prolonged convulsions, i.e., over a minute, the voltage is reduced by 10%.
It is a general scheme. It is somewhat more complicated, as medics calculate the parameters by formulas to correctly position the electrodes and determine the initial current strength.
Anesthesia is one of the most critical aspects of ECT. Both the procedure itself and the recovery period depend on it. Basic principles:
- Continuous seizure monitoring;
- Optimization of lung ventilation;
- Minimizing the risk of respiratory depression;
- Reducing the effect of anesthesia on cognitive function;
- Consideration of the risks of arrhythmia.
Physiological parameters are closely monitored throughout the procedure.
One reason electroconvulsive therapy is rarely used in treating schizophrenia is the presence of side effects and complications. Not all of them are studied. Some have been named suspects based on the available brain and the body’s general characteristics.
Short-term effects of ECT include memory impairment. Usually, this is reversible, and the person returns to normal after a few days or weeks. However, more severe disorders are also possible. We will consider this issue separately later.
The mortality rate is low, about 4 cases per 100,000. However, death is caused by anesthesia, not by electricity.
Also, possible short-term functional psychosis manifested in confusion and disorder of spatial orientation. It is observed only in 0.5% of cases. It lasts from a few minutes to 2-3 hours. But longer disorientation, lasting many days, is also possible, which is extremely rare.
Among the frequently diagnosed side effects of electroshock:
- Nausea and vomiting;
- The impaired concentration of attention;
- Asthenopic signs.
Delirium is also possible after anesthesia, but such effects are uncommon. Only some patients experience derealization and depersonalization, problems with speech and movement coordination.
Respiratory and cardiovascular system disorders are possible after ECT:
- Respiratory problems;
- Arrhythmia or tachycardia;
- Lung abscesses and pneumonia.
People with epilepsy, who are rarely diagnosed with schizophrenia, may fall into prolonged uncontrolled seizures. Bipolar depression can lead to mania and hypomania. Doctors often warn the patient about everything if unpredictable effects occur and are prepared for almost any scenario.
Memory disturbances after ECT can be both short-term and more severe, up to severe disorders like Korsak’s syndrome, in which no drug therapy is effective. It means that, hypothetically, memory could be irreversibly impaired, which is what is feared in the first place.
There are reasons to be afraid. Medicine knows of cases where electroshock therapy hurt long-term memory, and the adverse effects persisted for six months. Such cognitive impairment can cause many difficulties, including in work or study. Students must take “unpaid leave,” and adults must take extended leave, which not every employer will decide. There is also a chance that a patient will be given a disability.
Memory impairment usually occurs in patients who have had frequent ECT sessions. The likelihood of such complications also increases if the current dose is exceeded. However, doctors often encounter retrograde amnesia when a patient forgets the events of the last two weeks or months (less often, years). Gradually it decreases and passes, though not always. The memory is restored in full. If irreversibly, the events that preceded ECT, i.e., the week before the procedure, disappear.
See Also: Remission in schizophrenia.
As for anterograde amnesia, in which the ability to remember new information is lost, which noticeably affects a person’s life, it is limited to a short period. Usually, memory is restored a couple of weeks after a fully completed course. Although, if we look objectively, there are sad cases in medical practice. Some patients had retained anterograde amnesia for 8, 10, and even 15 years after the treatment.
Ernest Hemingway underwent ECT, after which he stopped writing books. The writer himself attributed it to cognitive problems.
One more critical point. According to studies, 29 to 55% of people who have undergone ECT complain of memory impairment. However, neuropsychological tests, which include memory tests, show that patients talk about themselves. Although they think their memory is terrible, they do well on the tests, and people without signs of cognitive impairment.
They consider that ECT for schizophrenia is prescribed only as a last resort when doctors have no other way to help the patient. Usually, in such situations, his cognitive functions are already severely impaired. There is a risk of complete disintegration of the personality, due to which the person may lose touch with reality. He will be recognized as disabled and left under the care of medical personnel forever.
If electroconvulsive therapy gives any chance to avoid such complications, then the side effects of the procedure are of secondary importance.
Schizophrenia is one of the most challenging diagnoses in psychiatry. Its true causes are unknown, and it is impossible to completely rid a person of this pathology. Even if he had just one attack, the disease stays with him for the rest of his life. The patient’s task is to follow the doctor’s recommendations, not only during inpatient treatment but also during remission.