Task Force Reports This is the fourteenth in a series of reports approved by the Board of Trustees of the American Psychiatric Association to give wider dissemination to the findings of APA's many commissions, committees, and task forces that are called upon to evaluate the state of the art in a problem area of current concern to the profession, to related disciplines, and to the public. The findings, opinions, and conclusions of the report do not necessarily represent the views of the officers, trustees, or all members of the Association. Each report, however, does represent the thoughtful judgment and findings of the task force of experts who composed it. These reports are considered a substantive contribution to the ongoing analysis and evaluation of problems, programs, issues, and practices in a given area of concern. Jules H. Masserman, M.D. President, APA, 1978-79 September 1978 Library of Congress Catalogue No. 78-69521 Copyright 1978 by the American Psychiatric Association 1700 18th Street, N.W., Washington, D.C. 20009 ELECTROCONVULSIVE THERAPY Report of the Task Force on Electroconvulsive Therapy of the American Psychiatric Association Fred H. Frankel, M.B.Ch.B., D.P.M. Chairperson T. George Bidder, M.D. Max Fink, M.D. Michel R. Mandel, M.D. Iver F. Small, M.D. George J. Wayne, Ph.D., M.D. Larry R. Squire, Ph.D., Consultant Edward N. Dutton, M.D., Falk Fellow Lee Gurel, Ph.D., Staff Liaison Approved for Publication by the Council on Research and Development Lester Grinspoon, M.D. Chairperson Edward Joel Sachar, M.D. Vice-Chairperson John M. Davis, M.D. Charles Gaitz, M.D. Frank DeLeon-Jones, M.D. Leigh Roberts, M.D., Assembly Liaison Louis Linn, M.D., Board Liaison Henry H. Work, M.D., Staff Liaison Publication authorized by the Board of Trustees May 1978 AMERICAN PSYCHIATRIC ASSOCIATION 1700 18th Street, N.W. Washington, D.C. 20009 THE AUTHORS and TASK FORCE MEMBERS Fred H. Frankel, M.B.Ch.B., D.P.M. Chairperson Department of Psychiatry, Beth Israel Hospital and Harvard Medical School, Boston, Mass. T. George Bidder, M.D. Department of Psychiatry, UCLA School of Medicine and Sepulveda VA Hospital, Los Angeles, Calif. Max Fink, M.D. Department of Psychiatry and Behavioral Science, School of Medicine, State University of New York at Stony Brook Michel R. Mandel, M.D. Department of Psychiatry, Massachusetts General Hospital and Har- vard Medical School, Boston, Mass. Iver F. Small, M.D. Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana George J. Wayne, Ph.D., M.D. Department of Psychiatry, UCLA School of Medicine and Edgemont Hospital, Los Angeles, Calif. Larry R. Squire, Ph.D. Consultant Veterans Administration Hospital, San Diego, Calif. Department of Psychiatry, University of California, San Diego, at La Jolla, Calif. Edward N. Dutton, M.D. Falk Fellow Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, Ohio Lee Gurel, Ph.D., Staff Liaison American Psychiatric Association ii ACKNOWLEDGEMENTS The Task Force gratefully acknowledges the advice, assistance, con- sultation and contributions of the following: Gregory Asnis, M.D. H. Richard Beresford, M.D. David Boehm, B.A. Rosmary Krispinsky Cheesman, R.N. N. Jeanne Cooper, L.P.N. Jane E. Edgerton Theodore W. Lorei, M.S.W. Doris T. Pearsall, M.A. Psychotherapy Institute and Continuing Education Program, Psychiatry Service, Beth Israel Hospital, Boston Loren H. Roth, M.D., Member of the Commission on Judicial Action, APA Sue Saferstein, B.A. Sibley Memorial Hospital, Washington, D.C. Pam C. Slater Era Smith Caroline Starcher, R.N. Alan A. Stone, M.D. Chairperson, Commission on Judicial Action, APA James J. Strain, M.D. Zebulon Taintor, M.D. Ann Tom, B.A. Richard D. Weiner, M.D., Ph.D. The members of the A.P.A. who responded to the Questionnaire; and those who addressed the Hearings in Miami, May, 1976 These contributions were aided, in part, by grants MH-15561, 20872, and 24600 from the National Institute of Mental Health; by the International Association for Psychiatric Research, Inc; by Veterans Administration Clinical Inves- tigatorship 808 4C. iii This page intentionally left blank CONTENTS Introduction .................................... vii Chapter I. A Survey of the APA Membership on the Use of ECT .......................... 1 Chapter II. Efficacy in Affective Disorders and Schizo- phrenia' .......................... 13 Chapter III. ECT in Mental Illness other than Schizo- prenia and the Affective Disorders ........ 31 Chapter IV. Adverse Effects of ECT .............. 57 Section I. Memory and ECT ........ 57 Section II. CNS Sequelae of ECT: Risks of Therapy and their Prophylaxis ............... 72 Section III. ECT: Possible Neurological Side-effects .............. 87 Chapter V. ECT: Methods of Administration .......... 92 Chapter VI. Physiological and Biochemical Concomitants of ECT .......................... 122 Chapter VII. Social, Ethical, and Legal Aspects of ECT . 132 Chapter VIII. Training and Education .............. 151 Chapter IX. Future Research ................... 157 Chapter X. Recommendations Regarding the Use of ECT ........................... 161 Appendices Description of ECT for Informed Consent . 174 APA Questionnaire .................. 179 v This page intentionally left blank INTRODUCTION This report on Electroconvulsive Therapy contains few simple solu- tions. We will be pleased if it helps to lead to a rational perspective. An examination of the published literature since the early 1940s reveals the mixed reception accorded ECT since its introduction in 1938. Attitudes surrounding it capture the essence of the struggle between the rival philosophical approaches to emotional and mental illness, namely the psychological, the biological, and the social. We believe that what follows in this report affirms that the last word has yet to be written on the etiology and treatment of psychiatric illness, as well as on the most useful role for government and the courts in attempting to prevent or manage it. Those who disagree have misled us in the past by exaggerating a single viewpoint; they will no doubt attempt to do so again. In the fall of 1974, the Council on Research and Development resolved to establish a task force on ECT "with tenure of about two years, to have liaison with the Commission on Judicial Action and to include in its study consideration of legislative issues, consent, indications for its use and possible increasing use because of short- ened length of stay in hospital." The Task Force assembled for the first time in September 1975, with the following mandate approved by the Council: Mandate to the APA Task Force on ECT The task force is enjoined to: (1) Review the current use of ECT, both typical and atypical, the prevailing criticisms of its use, and the recent and current research on the subject with special but not exclusive refer- ence to studies of: (a) its indications in different clinical entities; (b) its benefits in relation to its adverse effects; (c) treatment techniques designed to minimize adverse ef- fects, particularly memory loss and confusion; (d) the effectiveness of associated drug therapy; (e) associated neurochemical and neurophysiological changes; (f) long term effects, both beneficial and adverse; (g) comparisons with other treatment methods; vii Task Force Report 14 (h) comparable treatments with flurothyl; (i) associated cerebral and behavioral events; (j) induced seizures and convulsive shock in animals. (2) Report its conclusions regarding the benefits of ECT in relation to the risks involved. (3) Describe the indications for its use and the contraindications. (4) Make recommendations regarding: (a) general clinical considerations; (b) pretreatment investigations and precautions; (c) the use of anesthesia and related measures to reduce the dangers of treatment; (d) techniques with reference to apparatus, schedules of administration including those of multiple and single treatments, appropriate numbers of treatments, location of electrodes, and after-care procedures; (e) the simultaneous use of drug therapy; (f) criteria of improvement and indications for the termina- tion of treatment. (5) Consider the civil liberties of patients and informed consent in the management of treatment programs. (6) Comment and advise on related legislative issues. (7) Recommend directions for future research and study. (8) Report on any other issues it considers relevant. In all, the Task Force held five two-day meetings through the two years, as well as an evening meeting and a two-day open forum at the time of the annual meeting in Miami in 1976. Because the published literature, although considerably more helpful in recent years than previously, still provides only a limited number of well controlled studies, it was thought essential that the empirical evidence available be evaluated and given serious con- sideration. The members therefore decided on exploring four main avenues in order to accumulate the information needed by them to discharge their mandate. The methods selected were: (1) a search of the literature; (2) a national survey of a 20% random sample of the approxi- mately 20,000 APA members to provide data on the extent of the use of ECT, the indications for its use, the methods and techniques in general use, and the general experience of its viii ELECTROCONVULSIVE THERAPY effectiveness; these data were to provide the context within which to consider the questions raised in the mandate; (3) an open forum for the discussion of ECT at the annual meeting in 1976. As not more than 20% of the membership would be polled in the national survey, an opportunity was to be provided for members generally to report on their views and experience to the members of the Task Force if they so wished. Announcements in Psychiatric News extended an invitation to the membership to arrange for an appointed time at which they could address the Task Force. Twenty four individuals had an opportunity to communicate personally in this way with the committee. Invitations were extended to a few highly experienced clinicians to share their views with us, as well as to two colleagues in neurology known to hold strong views against the use of ECT.