Electroconvulsive Therapy

Electroconvulsive Therapy, 3rd Edition

Richard Abrams

New York: Oxford University Press; 1997. 382 pp

ISBN 0-19-510944-9

The dust jacket describes this textbook on electroconvulsive therapy (ECT) as “indispensable.” I agree. Now in its third edition, this book is unique in the field. It is written entirely by the author — a practising clinician with expertise in ECT, a scholar (this book has 73 pages of references; about 125 references have been added since the second edition in 1992) and a researcher whose contribution to the scientific literature goes back more than 30 years. Written in an engaging style, this book reflects the author’s intimate knowledge of an indispensable psychiatric treatment.

The chapter headings are the same as those in the second edition, but new material has been incorporated throughout (sometimes with new subheadings). The result is a refined and up-to-date disquisition on a complex and multifaceted subject. I recommend it for psychiatrists — particularly those who prescribe or administer ECT, for residents, for clinical psychologists and for anyone else with clinical or research interests in ECT. Supplemented by some recent research papers, this book would provide an ideal structure on which to base a course on ECT for residents. With such a knowledge base complementing supervised experience in the administration of ECT, a trainee would quickly acquire the expertise needed to deliver ECT.

Despite the favourable overall impression the book makes, there are some minor points with which one might reasonably take issue. For example, the advice to use ECT before drugs to treat pregnant women (page 29) seems unbalanced, especially in view of recent studies showing the safety of a number of medications, even during the first trimester. Although there is certainly a place for the use of ECT during pregnancy, there is also a place for the judicious use of psychoactive medication. Another point of contention is the statement that “despite manufacturers’ claims, no significant progress in the pharmacological treatment of major depression has occurred since the introduction of imipramine in 1958″ (page 9), which is made to support the continued use of ECT. In fact, there has been considerable progress in this area, and indeed the author does go on to mention lithium augmentation of tricyclic antidepressants (page 16). This style of making strong, unequivocal statements at least lets the reader know where the author stands and should, in fact, make it easier for critical readers to draw their own conclusions.

The book begins with the history of ECT and then reviews studies on efficacy, including those employing a sham ECT control group. The third chapter deals with predictors of successful outcome, and the fourth reviews the physiology of ECT. A later chapter on the high-risk patient will be very useful to practitioners considering ECT for severely depressed patients who have had a recent stroke, myocardial infarction or other serious medical problem, and who may also be on more than one medication. This chapter, supplemented by a MEDLINE search, will help the clinician make the best treatment decision in such cases.

There is a chapter devoted to the ECT stimulus, a critical variable affecting the response to treatment. Another chapter reviews the issue of unilateral treatment. The author concludes that high-dose (i.e., several times seizure threshold) right unilateral ECT should generally be the method of choice, at least initially. This recommendation may indeed improve the general standard of ECT, but the practitioner should also consider alternative electrode placements and levels of stimulation. Some patients may receive excessive doses with the high-dose unilateral approach. Of course this is an evolving area, and clinicians administering ECT must be aware of the issues regarding electrode placement and stimulus level when they make treatment decisions. They must also take into account side effects and clinical response as the series of ECT progresses.

Two chapters comprehensively cover the technique of ECT, and another covers the issue of memory and cognitive functioning after ECT (and contains descriptions of the important studies in the area). In the chapter on neurochemical correlates, Dr. Abrams concludes that “modern ECT researchers, regardless of their species of predilection, do not have any more of a clue about the relation between brain biological events and treatment response in ECT than they did when the first edition of this book was published — which is to say, none at all. Moreover, modern theories of the action of ECT — even as formulated by sophisticated investigators with impeccable credentials — have not surpassed in conceptual elegance the 18th century claim that things burned because they contained phlogiston; “ECT awaits its Lavoisier” (page 268). Thus there is plenty of scope for further research, but new researchers would be wise to understand the history of basic research in this field, particularly animal-based research, before embarking on their own.

The last chapter is on patients’ attitudes, legal-regulatory issues and informed consent. It is of interest that the history of ECT regulation in the US includes a 1982 ordinance, approved in a referendum by the citizens of Berkeley, California, that made the administration of ECT in city hospitals a crime punishable by a fine, 6 months in prison, or both! (The regulation was later reversed by a court decision on a technical point of law.) ECT continues to be a controversial treatment, despite its safety and proven efficacy. Perhaps because of its safety, ECT is surprisingly unlikely to result in malpractice claims. The best protection against the minimal risk of complaints or litigation is good clinical practice and fully informed consent. A sample consent form is presented in the appendix.

Much refined over the years, ECT will continue to be an important part of our therapeutic armamentarium in the foreseeable future. Apart from the mechanism of action of ECT, which remains an intriguing mystery, other promising areas for research include magneto-convulsive therapy (with induction of electrical currents by magnetic fields), new approaches to the control of ECT-induced increases in pulse and blood pressure, effects of bifrontal ECT on autobiographical memory, maintenance ECT (which appears to be increasingly prescribed) and stimulus variables.

This comprehensive review of a complex and sometimes controversial topic by one of the leading researchers in the field is highly recommended for both the clinician and researcher.