Bill. J. P@ychiat.(1975), 127, 6og—ii
Subjective
Side-Effects ByJOAN
Summary.
The incidence ofside-effects
of ECT
GOMEZ
present 24 hours after electroconvulsive
therapy was studied in 96 patients who between
them received
500 treatments
a consecutive series. None of the side-effects occurred frequently:
headache
in
was
experienced after 2@6 per cent and subjective memory impairment after 3 per cent of treatments. None of the unwanted effects held any serious physical threat. The aspect of ECT most disliked by the patients in this study, and men
tioned by i6 per cent of them, was the fear of permanent
INTRODUCTION
Electroconvulsive
therapy
effective treatment
(ECT)
in 8o patients (420 treatmentS) and unilateral in i6 (8o treatments). In the morning-after
is the most
in selected psychiatric
tions (Granville-Grossman,
condi
interview,
1971) and substan
tial use is made of it. Short-acting anaesthesia and muscle-relaxants
presence
intravenous have long
incidence
and
severity
patient pain,
was
asked
headache,
about nausea,
the sore
third or fourth treatment, each patient was asked what, ifanything, she most disliked about ECT, and also whether it was better, worse, or
ECT with horror. In this context, it was decided the
each of muscle
throat or nasal congestion, and about memory disturbance, including a feeling of muddle; and was invited to mention any other symptom which had not been present before the treat ment. On one occasion only, usually after the
since removed the early barbaric aspects of this therapy, and the risk of dangerous sequelae is very small (Sargant and Slater, 1972), yet many patients and their relatives view the prospect of to investigate
memory upset.
of
subjectively experienced side-effects in un selected patients receiving routine ECT in a large modern psychiatric hospital.
the same as expected.
Top-ranking
complaints
only were counted, and grouped. RESULTS
PATIENTS AND METHODS
Side-effectspresent 24 hours after treatment (Table I)
Patients were interviewed between 7 and 9 a.m. on the morning after ECT from 19 bi
Side-effectspresent 24 hours after ECT
weekly
sessions
comprising
500
TABUt I
(n = 500)
consecutive
treatments. Ninety-six patients, of whom 6o were female, were involved. Their ages ranged from I 7 to 91 yearS, with 34 aged under 30; 32
aged
30
to 50;
four patients
30
more
were depressives
others schizophrenics catatonic
aged
than
50.
..418@2—generalized pain ..
Seventy
..
2@6Upper .. Headache .. symptoms9i@8Nausea respiratory
and most of the
with marked
0/
/0Muscle
affective or
symptomatology.
In the majority of cases a flexible plan for six treatments had been made, but was subject to
..7I@4Confusion ..
..
..I0@2Subjective ..
..
..
..5
13I@0
memoryimpairment
..
continuous review. Methohexitone was the anaesthetic employed in all cases, and suxethonium bromide the muscle relaxant. Bilateral electrodes were used
..153@0
Mnscle pain occurred 4! times. In 5 cases there was generalized pain and stiffliess, such as follows severe exercise; 609
all in patients
under
25,
6io
SUBJECTWE
SIDE-@EFFECTS OF ECT
all having received their first treatment, 3 female and 2 male. Of the others, 7 had pain in the masseters
only,
but
uncomfortable,
and
enough the
rest
to had
make aching
in
Of the 4! cases of muscle after
occurred
the
first
treatment,
with none after the fourth or subsequent treat ment. In 28 cases the patient was under 30 ; only one was over 50. However, 7 patients in the over 50 range mentioned exacerbation of pre existing backache, and 3 patients complained of toothache ; neither of these categories was
included under muscle pain. @
(g6 patients)
the
pain,
Anticipatory anxieties Permanent memory impairment Entering ECT room .. Death or serious damage .. Waiting for treatment .. Injection .. .. .. Confusion on coming round Sundry or irrelevant .... i6Total
.. (7@%)No
Headache was mentioned on i occasions, and in 3 patients receiving unilateral ECT it was
localized to the side on which the electrodes were applied. Xausea. Seven complaints were made, but 2 individuals accounted for 4 of these. Upper respiratoiy symptoms. Nine patients
had
mild symptoms, one was pyrexial, but none developed more than simple coryza. Patients suffering
headache,
nausea
or muscle
pain
had
lost their symptom by the next day. Memoty impairment and muddle. One lady of 6o who was hypertensive was still disorientated the morning after treatments. Complaints
ECT,
and was given
no further
impairment
parti
cularly affecting details of the day before treatment were made on I 5 occasions, mainly in the middle of the course of treatment. The 10 patients
involved
had treatment
were
all over 45, and
7 had
in the past.
Other complaints.
Difficulty
in focussing
was
mentioned by 4 patients, but on enquiry it appeared that this had been present before treatment and was probably related to the antidepressant medication. What patients disliked about ECT
(Table
II)
The aspects of ECT disliked by patients after they had experienced at least three treatments all centred on fear, although none found it worse than they had anticipated
and So per cent
found it better. The top-ranking fear (in 16 of the 96 patients) was of permanent memory or other intellectual
..
impairment,
even among those
who had experienced no subjective memory up set during the study. Vague, unpleasant im
..
ii
..
10 9
.. ..
5 5
.. .. ..i6
....72
special fear of dislike of ECT..24(25%) pressions of the ECT room, such as screens, a rubber mouth gag, someone's noisy breathing, were most disliked by i i per cent of patients.
Sixteen patients mentioned personal fears, or thoughts connected with their illness, while a quarter of the dislikeof ECT.
patients
now
felt
no special
DISCUSSION
The most striking feature of these results was the low incidence of side-effects, none of which endangered
of memory
through a
courseof ECT
eating
neck and shoulders. 35
TABui II Aspects most disliked by patients partway
health.
None
48 hours
after
exception
of memory
of them was present
treatment,
with
the possible
impairment.
It has been
demonstrated by objective tests that some memory disturbance is common after ECT (Dornbush and Williams, i@7@)but Cronholm and Ottosson (1963) found that patients treated by ECT were unable to judge their memory accurately and that a favourable response was associated with fewer complaints, even
where
there
was
objective
evidence
of
impairment. In our study, most patients had little recollection of the time between waiting
in the waiting room and having coffee after treatment
; but
in
general
bered least of this period memory
those
who
complained
remem
least of
loss.
Non-dominant unilateral ECT is said to produce less memory upset than bilateral (d'Elia, 1970), but in the present study sub jective complaints were not significantly less frequent in those having unilateral treatment; this may have been partly due to their selection.
6i i
BY JOAN GOMEZ
Other side effects were not significantly corre lated with either type of electrode placement. Suxethonium
relaxants Enderby,
is the
least
likely
pain were young than most.
Indeed
the adverse effects are
few.
of muscle
to be associated with pain (Hale 1959), and it is noteworthy that the
patients who experienced presumably more active
greatly reduced.
AcKNOWLEDGEMENTS
I thank Dr. Morris Markowe and all the Consultants at Springfield Hospital, whose patients were studied.
and REFERENcES
CRoiusou@,B. & OTIOSSON, J. 0. (I3)
Side-effects
after ECT
The experience
of memory function after electroconvulsive
CONCLUSIONS
are relatively
infre
therapy.
British Journal ofP@ychietry,iou, 251-8.
quent, mild and short-lived. The incidence of muscle pain might be reduced if all patients
DORNBUSH, R. L. & Wiu.u@s,
were encouraged to rest on return to their wards, especially after a first treatment. While
D'Eu@, G. (editor) (‘970)Unilateral ECT. Ada Psj chiatricaScandinavica,Supplement 215. Gavui@-GRosus@, K. (ig7i) Recent Advances in ClinicalP@YC/iiaIrJ. London: @Jhurchill.
efforts
to reduce
real memory
impairment
after
ECT continue, involving electrical, anaesthetic and other manoeuvres, subjective complaints appear to relate importantly to the patient's
HALE ENDERBY, J. minor
retrospect, when they have experienced a few treatments as given nowadays, most patients find that the fears they had beforehand are
current
affective
state.
(i@@@) Low
incidence
of muscle
pain
after suxethonium compared with suxamethonium in 530.
and
and
New York: John Wiley.
In
expectations
M. (1974) Memory
ECT. In P@ychobiolo@ ofECT (edited by Fink et a!.).
SA1tG@urr,
operations.
W.
&
British
[email protected],
JOUrnOJ
E.
(1972)
of Anaesthesia,
An
35,
Introduction
12,
to
Physical Methods of Treatment in [email protected] edition, Ohapter H. London: Churchill Livingstone.
Joan Gomez, M.B., M.R.C.PSyCL.,Springfield Hospital, London, S. W. 17 (now Registrar, Westminster Hospital London, S.W.i.)
(Received ‘¿4 March 1975)
Subjective
Side-Effects ByJOAN
Summary.
The incidence ofside-effects
of ECT
GOMEZ
present 24 hours after electroconvulsive
therapy was studied in 96 patients who between
them received
500 treatments
a consecutive series. None of the side-effects occurred frequently:
headache
in
was
experienced after 2@6 per cent and subjective memory impairment after 3 per cent of treatments. None of the unwanted effects held any serious physical threat. The aspect of ECT most disliked by the patients in this study, and men
tioned by i6 per cent of them, was the fear of permanent
INTRODUCTION
Electroconvulsive
therapy
effective treatment
(ECT)
in 8o patients (420 treatmentS) and unilateral in i6 (8o treatments). In the morning-after
is the most
in selected psychiatric
tions (Granville-Grossman,
condi
interview,
1971) and substan
tial use is made of it. Short-acting anaesthesia and muscle-relaxants
presence
intravenous have long
incidence
and
severity
patient pain,
was
asked
headache,
about nausea,
the sore
third or fourth treatment, each patient was asked what, ifanything, she most disliked about ECT, and also whether it was better, worse, or
ECT with horror. In this context, it was decided the
each of muscle
throat or nasal congestion, and about memory disturbance, including a feeling of muddle; and was invited to mention any other symptom which had not been present before the treat ment. On one occasion only, usually after the
since removed the early barbaric aspects of this therapy, and the risk of dangerous sequelae is very small (Sargant and Slater, 1972), yet many patients and their relatives view the prospect of to investigate
memory upset.
of
subjectively experienced side-effects in un selected patients receiving routine ECT in a large modern psychiatric hospital.
the same as expected.
Top-ranking
complaints
only were counted, and grouped. RESULTS
PATIENTS AND METHODS
Side-effectspresent 24 hours after treatment (Table I)
Patients were interviewed between 7 and 9 a.m. on the morning after ECT from 19 bi
Side-effectspresent 24 hours after ECT
weekly
sessions
comprising
500
TABUt I
(n = 500)
consecutive
treatments. Ninety-six patients, of whom 6o were female, were involved. Their ages ranged from I 7 to 91 yearS, with 34 aged under 30; 32
aged
30
to 50;
four patients
30
more
were depressives
others schizophrenics catatonic
aged
than
50.
..418@2—generalized pain ..
Seventy
..
2@6Upper .. Headache .. symptoms9i@8Nausea respiratory
and most of the
with marked
0/
/0Muscle
affective or
symptomatology.
In the majority of cases a flexible plan for six treatments had been made, but was subject to
..7I@4Confusion ..
..
..I0@2Subjective ..
..
..
..5
13I@0
memoryimpairment
..
continuous review. Methohexitone was the anaesthetic employed in all cases, and suxethonium bromide the muscle relaxant. Bilateral electrodes were used
..153@0
Mnscle pain occurred 4! times. In 5 cases there was generalized pain and stiffliess, such as follows severe exercise; 609
all in patients
under
25,
6io
SUBJECTWE
SIDE-@EFFECTS OF ECT
all having received their first treatment, 3 female and 2 male. Of the others, 7 had pain in the masseters
only,
but
uncomfortable,
and
enough the
rest
to had
make aching
in
Of the 4! cases of muscle after
occurred
the
first
treatment,
with none after the fourth or subsequent treat ment. In 28 cases the patient was under 30 ; only one was over 50. However, 7 patients in the over 50 range mentioned exacerbation of pre existing backache, and 3 patients complained of toothache ; neither of these categories was
included under muscle pain. @
(g6 patients)
the
pain,
Anticipatory anxieties Permanent memory impairment Entering ECT room .. Death or serious damage .. Waiting for treatment .. Injection .. .. .. Confusion on coming round Sundry or irrelevant .... i6Total
.. (7@%)No
Headache was mentioned on i occasions, and in 3 patients receiving unilateral ECT it was
localized to the side on which the electrodes were applied. Xausea. Seven complaints were made, but 2 individuals accounted for 4 of these. Upper respiratoiy symptoms. Nine patients
had
mild symptoms, one was pyrexial, but none developed more than simple coryza. Patients suffering
headache,
nausea
or muscle
pain
had
lost their symptom by the next day. Memoty impairment and muddle. One lady of 6o who was hypertensive was still disorientated the morning after treatments. Complaints
ECT,
and was given
no further
impairment
parti
cularly affecting details of the day before treatment were made on I 5 occasions, mainly in the middle of the course of treatment. The 10 patients
involved
had treatment
were
all over 45, and
7 had
in the past.
Other complaints.
Difficulty
in focussing
was
mentioned by 4 patients, but on enquiry it appeared that this had been present before treatment and was probably related to the antidepressant medication. What patients disliked about ECT
(Table
II)
The aspects of ECT disliked by patients after they had experienced at least three treatments all centred on fear, although none found it worse than they had anticipated
and So per cent
found it better. The top-ranking fear (in 16 of the 96 patients) was of permanent memory or other intellectual
..
impairment,
even among those
who had experienced no subjective memory up set during the study. Vague, unpleasant im
..
ii
..
10 9
.. ..
5 5
.. .. ..i6
....72
special fear of dislike of ECT..24(25%) pressions of the ECT room, such as screens, a rubber mouth gag, someone's noisy breathing, were most disliked by i i per cent of patients.
Sixteen patients mentioned personal fears, or thoughts connected with their illness, while a quarter of the dislikeof ECT.
patients
now
felt
no special
DISCUSSION
The most striking feature of these results was the low incidence of side-effects, none of which endangered
of memory
through a
courseof ECT
eating
neck and shoulders. 35
TABui II Aspects most disliked by patients partway
health.
None
48 hours
after
exception
of memory
of them was present
treatment,
with
the possible
impairment.
It has been
demonstrated by objective tests that some memory disturbance is common after ECT (Dornbush and Williams, i@7@)but Cronholm and Ottosson (1963) found that patients treated by ECT were unable to judge their memory accurately and that a favourable response was associated with fewer complaints, even
where
there
was
objective
evidence
of
impairment. In our study, most patients had little recollection of the time between waiting
in the waiting room and having coffee after treatment
; but
in
general
bered least of this period memory
those
who
complained
remem
least of
loss.
Non-dominant unilateral ECT is said to produce less memory upset than bilateral (d'Elia, 1970), but in the present study sub jective complaints were not significantly less frequent in those having unilateral treatment; this may have been partly due to their selection.
6i i
BY JOAN GOMEZ
Other side effects were not significantly corre lated with either type of electrode placement. Suxethonium
relaxants Enderby,
is the
least
likely
pain were young than most.
Indeed
the adverse effects are
few.
of muscle
to be associated with pain (Hale 1959), and it is noteworthy that the
patients who experienced presumably more active
greatly reduced.
AcKNOWLEDGEMENTS
I thank Dr. Morris Markowe and all the Consultants at Springfield Hospital, whose patients were studied.
and REFERENcES
CRoiusou@,B. & OTIOSSON, J. 0. (I3)
Side-effects
after ECT
The experience
of memory function after electroconvulsive
CONCLUSIONS
are relatively
infre
therapy.
British Journal ofP@ychietry,iou, 251-8.
quent, mild and short-lived. The incidence of muscle pain might be reduced if all patients
DORNBUSH, R. L. & Wiu.u@s,
were encouraged to rest on return to their wards, especially after a first treatment. While
D'Eu@, G. (editor) (‘970)Unilateral ECT. Ada Psj chiatricaScandinavica,Supplement 215. Gavui@-GRosus@, K. (ig7i) Recent Advances in ClinicalP@YC/iiaIrJ. London: @Jhurchill.
efforts
to reduce
real memory
impairment
after
ECT continue, involving electrical, anaesthetic and other manoeuvres, subjective complaints appear to relate importantly to the patient's
HALE ENDERBY, J. minor
retrospect, when they have experienced a few treatments as given nowadays, most patients find that the fears they had beforehand are
current
affective
state.
(i@@@) Low
incidence
of muscle
pain
after suxethonium compared with suxamethonium in 530.
and
and
New York: John Wiley.
In
expectations
M. (1974) Memory
ECT. In P@ychobiolo@ ofECT (edited by Fink et a!.).
SA1tG@urr,
operations.
W.
&
British
[email protected],
JOUrnOJ
E.
(1972)
of Anaesthesia,
An
35,
Introduction
12,
to
Physical Methods of Treatment in [email protected] edition, Ohapter H. London: Churchill Livingstone.
Joan Gomez, M.B., M.R.C.PSyCL.,Springfield Hospital, London, S. W. 17 (now Registrar, Westminster Hospital London, S.W.i.)
(Received ‘¿4 March 1975)
