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BACKGROUND

The use of Electroconvulsive Therapy (ECT) has been a subject of controversy since it was first introduced in 1938. The process of sending an electrical shock into a person's brain in order to produce an epileptic grand mal seizure does not appear as a safe process to many people, including health care professionals and mental health experts. Further, the fact that mental health experts do not fully understand how ECT works, coupled with its indiscriminate use to treat a variety of mental illnesses following the first few decades of its introduction, have contributed to the ongoing controversy. The lack of federal testing of ECT devices, as well as an absence of federal or state regulation of ECT protocols and demographic and statistical data related to ECT use, have also contributed to the Iongstanding controversy surrounding its safety and efficacy.

The following reflects opinions from well known established organizations addressing mental health concerns in New York State and nationwide:

NATIONAL INSTITUTES OF HEALTH CONSENSUS STATEMENT, JUNE, 1985

In June 1985. the National Institutes of Health (NIH) published a Consensus Statement regarding ECT. NIH Consensus Statements are prepared by a non-advocate, non-federal panel of experts and reflect the panel's assessment of medical knowledge available at the time the statement was written. Following are excerpts from the NIH statement.

Electroconvulsive therapy is the most controversial treatment in psychiatry. The nature of the treatment itself, its history of abuse, unfavorable media presentations, compelling testimony of former patients, special attention by the legal system, uneven distribution of ECT use among practitioners and facilities, and uneven access by patients all contribute to the controversial context in which the consensus panel has approached its task... To prevent misapplication and abuse, it is essential that appropriate mechanisms be established to ensure proper standards and monitoring of ECT (NIH, pgs. I I - 12).

Electroconvulsive Therapy (ECT) is a treatment for severe mental illness in which a brief application of electrical stimulus is used to produce a generalized seizure. In the United States in the 1940s and 1950s. the treatment was often administered to the most severely disturbed patients residing in large mental institutions. As often occurs with new therapies, ECT was used for a variety of disorders, frequently in high doses and for long periods. Many of these efforts proved ineffective and some even harmful. Moreover, its use as a means of managing unruly patients, for whom other treatments were not then available, contributed to the perception of ECT as an abusive instrument of behavioral control for patients in mental institutions for the chronically mentally ill. (NIH, p. 2).

Although ECT has been in use for more than 45 years, there is continuing controversy concerning the mental disorders for which ECT is indicated, its efficacy in their treatment, the optimal methods of administration, possible complications, and the extent of its usage in various settings. These issues have contributed to concerns about the potential for misuse and abuse of ECT and the desire to ensure the protection of patient's rights. At the same time, there is concern that the curtailment of ECT use in response to public opinion and regulation may deprive certain patients of a potentially effective treatment (NIH, p. 2). To maximize the benefits of ECT and minimize the risks, it is essential that the patient's illness be correctly diagnosed, that ECT be administered only for appropriate indications, and that the risks and adverse effects be weighed against the risks of alternative treatments (NIH. p.5).

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NEW YORK STATE PROTECTION AND ADVOCACY FOR INDIVIDUALS WITH MENTAL ILLNESS ADVISORY COUNCIL (PAIMI), MARCH 15,1996 RESOLUTION

The Protection and Advocacy for Individuals with Mental Illness Amendments Act of 1991 (Public Law \ 100-509) provides legal advocacy supports for individuals who have been diagnosed as mentally ill and who reside in any residential facility which provides care and treatment, or who are in the process of being admitted or recently discharged from such facility. The PAIMI system investigates complaints about abuse, neglect and violation of rights, and provides both legal and non-legal advocacy on behalf of individuals. On March 15, 1996, PAIMI, a federally funded arm of the New York State Commission on Quality of Care for the Mentally Disabled, issued a resolution requesting that New York State consider development of legislation that would provide for monitoring of the provisions of ECT, as well as for informed consent of ECT recipients. According to PAIMI:

Electroconvulsive therapy (ECT) is a procedure that continues to he the subject of serious controversy and disagreement, even within the psychiatric profession.

There is a growing body of evidence that there is substantial potential for irreversible brain damage and permanent memory loss.

No standards exist which pertain to the mechanical safety of equipment used to administer ECT or to the certification of the operators of such equipment.

No State regulation or policy exists which governs the manner in which ECT is administered.

No safeguard exists which assures truly informed consent.

When contacted by Committee staff prior to the first public hearing on ECT, PAIMI reaffirmed its support of its I 1996 resolution.

ECT PRACTICES IN THE COMMUNITY (an unpublished report)

In a 1997 study, funded in part by the National Institute of Mental Health, the New York State Psychiatric Institute and Columbia University conducted a survey of 86 facilities in the greater New York Metropolitan area that used ECT. Responses were received from nearly 70% (59) of these facilities.

The survey revealed that facilities varied considerably in many aspects of ECT practice, including frequent departures from field standards. It further found that the more intensive the form of ECT used at the facilities, the less likely cognitive status was assessed following the course of treatment. The survey concluded that. "the marked departures from the field standards of care and the wide variability in how ECT is conducted, undoubtedly raise public health concerns." (Prudic, Olfson and Sackeim, p. 8)

TASK FORCE REPORT OF THE AMERICAN PSYCHIATRIC ASSOCIATION, 2001

The Practice of Electroconvulsive Therapy, Recommendations for Treatment, Training, and Privileging, Second Edition is a Task Force report of the American Psychiatric Association. Following are some key excerpts:

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The decision to recommend the use of ECT derives from a risk/benefit analysis for the specific patient.

ECT should not be reserved for use only as a last resort.

The likely speed and efficacy of ECT are factors that influence its use as a primary intervention. Additional considerations for the first line use of ECT relate to the patient's medical status, treatment history and treatment preference.

ECT is most often used in patients who have not responded to other treatments.

There are no diagnoses that should automatically lead to treatment with ECT.

To some extent, medical adverse events can be anticipated.

Continuation therapy has become the rule in contemporary practice ... the risk of relapse after ECT is very high, particularly during the first few months ... the need for aggressive continuation therapy... is compelling and should be instituted as soon as possible.

After ECT, concern over recurrence of illness is so great ... that maintenance therapy should be initiated for virtually all patients receiving continuation therapy. At present, no applicable data indicate how long maintenance therapy should be sustained after ECT.

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