Although seizures typically indicate a state of brain dysfunction, there are circumstances in which the biological effects of a seizure may exert therapeutic benefits. The standard technique for inducing controlled therapeutic seizures in humans is electroconvulsive therapy (ECT), a safe and remarkably effective treatment that involves the application of an electrical stimulus to the scalp of a patient under general anesthesia and muscle relaxation. ECT remains a cornerstone of treatment for severe mood disorders and certain other neuropsychiatric conditions, including those in patients with neurologic disorders. In addition, the neurobiological effects of ECT may have beneficial effects on a number of neurologic disorders, including Parkinson disease, epilepsy, and delirium. As with any procedure in medicine, the safety and efficacy of ECT depend critically on appropriate technique and proper patient selection and preparation.
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• The primary diagnostic indications for which ECT is safe and effective include each of the major mood episodes (ie, major depressive, manic, mixed), schizophrenia and schizoaffective disorder, and catatonia (especially malignant variants, such as neuroleptic malignant syndrome).
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• ECT is the single most effective, as well as the most rapidly effective, treatment for major depression.
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• There are no absolute contraindications to ECT.
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• The cognitive side effects of ECT are short-lived, do not cause major functional impairment, and must be distinguished from the symptoms of illness being treated.
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• Misinformation and misunderstanding of these cognitive side effects remain the primary source of stigma and controversy that limit access to and prescription of ECT.
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• Although we have learned a great deal about the neurobiology of ECT, its precise mechanism of action is unknown.
Historical note and terminology
The therapeutic use of seizures began in the early 1900s, when physicians observed that certain patients diagnosed as having schizophrenia appeared to improve after experiencing an unprovoked seizure. After experimenting with various pharmacologic means of inducing seizures (eg, metrazol, insulin), researchers discovered that electric current was the safest and most precise means of eliciting a controlled seizure. Enthusiasm for “electroshock therapy” spread across Europe, and the first use in humans took place in Italy in 1938. For several years, the procedure did not involve anesthesia, leaving some patients to experience intense anxiety and spinal fractures. Modern day ECT bears little resemblance to the electroshock therapy of the early 20th century. General anesthesia with muscle relaxation was introduced in the 1950s, and 2 decades later, brief pulse stimulation (pulse width 0.5-1.0 ms) replaced the far less efficient sine wave stimulation. These 2 major technical advances resulted in vastly improved safety, efficacy, and social acceptance. In today’s world of medication-resistant psychiatric illness, ECT remains the treatment clinicians recommend for their most severely ill patients.