Tuesday, 12 January 2021

Reflections about electroconvulsive therapy

Today's post is by Emiliano Loria (Universit√† La Sapienza, Roma). Here he summarises a recent paper he wrote, "A desirable convulsive threshold: Some reflections about electroconvulsive therapy", published open access in a special issue of the European Journal of Analytic Philosophy on Bounds of Rationality.

Emiliano Loria

Long-standing psychiatric practice confirms the pervasive use of pharmacological therapies for treating severe mental disorders. Nevertheless, we are far from triumphal therapeutic success. Despite the advances made by neuropsychiatry, this medical discipline remains lacking in terms of diagnostic and prognostic capabilities when compared to other branches of medicine. 

An ethical principle remains as the guidance of therapeutic interventions: improving the quality of life for patients. Unfortunately, psychotropic drugs and psychotherapies do not always result in an efficient remission of symptoms. I corroborate the idea that therapists should provide drug resistant patients with every effective and available treatment, even if some of such interventions could be invasive, like Electroconvulsive Therapy (ECT).

ECT has an almost centennial history that began in Rome (Italy) in 1938, at the Clinic of Nervous and Mental Diseases, run at the time by (psychiatrist) Ugo Cerletti. ECT still represents one of the most important and controversial therapeutic discoveries in the field of psychiatry. ECT carries upon its shoulders a long and dramatic history that should be better investigated to provide new insights. 

From the examination of the Archives of Pediatric Neuropsychiatry in Rome - a section of the Roman Clinic specifically dedicated to minors - I discovered t the first child ever administered with ECT (September 18, 1940), a 7-year-old boy diagnosed with “dementia praecocissima”, a diagnostic category introduced by Sante De Sanctis, who was Ugo Cerletti’s predecessor to the direction of the Roman Clinic, as well as the one who established the first department of Neuropsychiatry.

ECT has attracted renewed interest in recent years. This is due to the fact that antidepressant drugs in younger patients show often scarce effectiveness and unpleasant side-effects. Moreover, thanks to modern advances, ECT may work as a successful form of treatment for specific and rare cases, such as severe depression (with suicide attempts) and catatonia. 

When pharmacotherapy fails to improve depressive symptoms, then, response rates of about 50–60% can be achieved by ECT. For this reason, particularly in depressed patients at high risk of suicide, ECT should be recommended earlier than its conventional “last resort” position. In fact, the risks of suicide have been shown to relieve quickly through ECT, when administered in continuity with previous treatments, that are essential to sustain its benefits.

The ethical puzzle that I raise is the following. Is it possible to administer a therapy to help severely suffering patients (be them adults or minors)? If the answer is yes, at least for some types of severe diseases, why should we prolong the severity of the symptoms by making the life of patients and their family members unbearable? One therapy for the improvement of some severe psychotic symptoms exists and is practicable. ECT is such a therapy. In this sense, ECT does not constitute an alternative model of treatment, but an additional therapeutic tool that does not replace, but rather integrates pharmacotherapy and psychotherapy.

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