MEDICINE SHOCK THERAPY : Psychiatric Association Issues Guidelines

The country’s largest professional group of psychiatrists announced elaborate guidelines Thursday for the use of electroshock therapy, the controversial treatment for severe depression that is experiencing a resurgence in medical practice.

The guidelines drawn up by the American Psychiatric Assn. were described as among the most detailed ever issued to explain how a therapy should be used--testament to rapid advances in the science of shock therapy and to public pressure for accountability.

“There is no intent to increase or decrease . . . use (of electroshock),” Dr. Richard Weiner, an author of the report, said. “The intent is to maximize the efficacy and safety with which it is provided, to make sure it’s used in the proper fashion.”

Electroshock therapy, also known as electroconvulsive therapy or ECT, uses an electric shock to induce a seizure as a form of psychiatric treatment. By changing the balance of chemicals in the brain, it is used to treat severe depressive illness and mania, usually after drug therapy has failed.

Discovered in the late 1930s, shock therapy was used and abused widely in the 1940s and 1950s. Some patients received dozens of treatments. Its excesses became a subject of Sylvia Plath’s novel, “The Bell Jar,” and Ken Kesey’s “One Flew Over the Cuckoo’s Nest.”

With the discovery of effective antidepressant drugs in the early 1960s, use of electroconvulsive therapy dwindled. After several decades of quiescence, interest was rekindled in the 1980s as a result of research that showed how the therapy could be better used.

“ECT’s effectiveness in rescuing severely ill patients from the despairing depths of depression or the perilous heights of uncontrolled mania is well accepted by psychiatrists,” Dr. Herbert Pardes, president of the APA, said at a news conference Thursday. “However, ECT, like treatments for every other illness, is not 100% effective, it is not a cure and it does have some adverse effects,” he added.

The APA guidelines--filling more than 200 pages and scheduled for publication in book form--cover, among many other things, situations in which ECT may be appropriate or inappropriate and precisely how it should be used.

The guidelines also explore the issue of patient consent, an especially contentious issue in the case of shock therapy. They emphasize the importance of informed consent from all patients capable of giving it and the fact that consent may be revoked at any time.

“You have to give the patient the benefit of the doubt, concerning their right to agree or disagree,” said Weiner, chairman of the APA’s task force on ECT. He said the physician “should express how they feel about it, but it’s up to the patient to decide.”

The report recommends that the primary uses of ECT should be against major depression, mania and some cases of schizophrenia and psychosis. It also might be used in some medical disorders, such as Parkinson’s disease.

The typical course of ECT is six to 12 treatments, administered two to three times a week. The patient receives a mild current that, specialists believe, causes alterations in the brain’s chemistry not dissimilar to those caused by drugs that treat depression.

The APA, which counts its membership at 36,000, spent two years preparing its ECT study. Weiner’s task force sought input from numerous medical professional groups, regulators, the U.S. Food and Drug Administration and lay mental health groups.