Shock Therapy Makes a Comeback: States Respond

SHOCK THERAPY MAKES A COMEBACK: STATES RESPOND

Volume 28, Issue 499 September 17, 2007

Carla Curran

After decades of being regarded as a dangerous and sometimes misused procedure, electroconvulsive therapy has been improved since it was first introduced in the 1930s. Today, mental health authorities such as the American Psychiatric Association and Mental Health America say that the therapy can be safe and effective.

Electroshock therapy or ECT is used to treat severely depressed patients when other forms of therapy have not worked. It is widely acknowledged that informed consent is as important in ECT as in other medical treatments. Nevertheless, because the treatment remains controversial, a growing number of states are passing bills to ensure that patients who may be candidates for ECT are protected.

As with all medical procedures, informed consent is a standard of modern electroconvulsive therapy. Nevertheless, in its 2007 session, Illinois enacted Public Act 095-0172 to further safeguard patients. The law requires that all patients be informed in writing of their right to refuse ECT, as well as the risks and benefits of the treatment and alternative remedies. The law also states that only court-appointed guardians may give consent on behalf of an incapacitated individual except for under certain circumstances—for example, if the patient is causing serious harm to himself or others.

Healing Seizures

ECT works by disturbing electrochemical processes in the brain that may be impaired by mental illness. After the patient is given general anesthesia and a muscle relaxant, the patient's brain is stimulated with a series of electric pulses. This causes a seizure in the brain that lasts about a minute. In the 1940s and early 1950s, ECT was usually given without muscle relaxants, and the seizure resulted in a full-scale convulsion, which contributed to its negative reputation. Today, ECT is administered in a series of treatments, usually six to twelve, and it’s estimated that 100,000 people a year in the United States undergo the treatment.

The therapy is controversial because of the possible side effects—which may include temporary confusion and memory loss—and disagreements about its effectiveness. Two recent studies indicate that effectiveness rates are as high as 86 percent. Both studies had similar patient demographics and pretreatment severity of depression. One study found a remission rate of 55 percent and the other, a remission rate of 86 percent. In comparison, the effectiveness rates of four commonly prescribed medications alone range from 21 percent to 30 percent. The studies also looked at relapse rates when patients took a combination of medications following ECT treatments. The rates of relapse at the 6-month point were 39 percent and 32 percent.

In recent years, state legislatures have addressed some of the issues surrounding ECT:

New Hampshire has a law similar to Illinois’, which says the guardian of an incapacitated person may not consent to ECT without court approval;
Texas law states that no surrogate decision-maker may give consent to treatment for ECT;
California mandates that any person detained involuntarily for psychiatric evaluation has the right to refuse ECT.

States also have restricted minors’ access to the procedure. California prohibits minors from consenting to ECT, even though the minor may be able to consent to other medical services. Illinois states that a parent may grant authorization for the procedure only with the consent of a court.

Tennessee provides separate standards for children younger than 14 and those older than 14. Both standards require that all other treatment options be exhausted or the minor's life is in danger before ECT can be administered. The law also requires that a multi-disciplinary team of at least five persons (one of whom is an independent service provider) approves the treatment along with a certified psychiatrist.

Utah's law provides that a due process proceeding be conducted for any child to receive ECT, regardless of whether a parent gives consent. In the past few years, Florida and New York have introduced bills that also would protect minors, but those have not been enacted. The New York bill also banned the use of ECT in those over age 65.