Journal of Psychiatry Sakauye et al.

, J Psychiatry 2014, 17:6

http://dx.doi.org/10.4172/Psychiatry.1000177

Research Article Open Access

Safety and Benefit of Five Times per Week Electroconvulsive Therapy

Kenneth Sakauye1*, Farzana Badrun2, Andrew Elliott3 and William N Yetter4
1 Department of Psychiatry ,University of Tennessee Health Sciences Center, College of Medicine, USA
2 Department of Preventive Medicine , University of Tennessee Health Science Center, USA
3University of Tennessee Health Science Center, USA
4University of Tennessee Health Sciences Center, College of Medicine, USA
*Corresponding author: Kenneth Sakauye, Department of Psychiatry, University of Tennessee Health Sciences Center, College of Medicine, USA, Tel: 9014484572;
E-mail: Kenneth.Sakauye2@va.gov
Received Date: September 18, 2014, Accepted Date: October 20, 2014, Published Date: October 27, 2014
Copyright: © 2014, Kenneth Sakauye et al., This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Objective: The study aimed to test whether there was more rapid response with daily Electroconvulsive Therapy
(ECT) (5 times per week right unilateral) and shorter lengths of stay (LOS) without an increase in adverse effects
compared to ECT administered in a routine fashion of 2-3 times/week.

Methods: This is a retrospective chart review study of inpatient ECT cases performed over a two year period in a
general psychiatric unit. Different practitioners used 5 times/week right unilateral (RUL) ECT, 2-3 times/week right
unilateral ECT, or bilateral (BL) ECT. All inpatient records of patients, who received inpatient ECT in a general
hospital with 80 psychiatric adult beds, were reviewed in the two year study period. Due to a variation in the quality
of documentation, the analysis used proxy variables for improvement and side effects of ECT: LOS following the first
ECT to discharge, total treatments in the series, and switches in treatment parameters that indicating poor response
or adverse effects.

Results: 78 patients received inpatient ECT. 35 cases were started with RUL ECT in the standard 3 times/week
frequency. 32 cases were started with 5 times/week frequency. 11 cases continued BL ECT placement 3 times per
week for a repeat ECT series. Diagnosis was not factor in lead placement or frequency of treatment. 90% of patients
had major depression, and 10% were treated for bipolar disorder or schizophrenia. The number of treatments in a
successful series was roughly equivalent irrespective of starting lead placement. 5 times/week RUL lead placement
did not lead to significant morbidity based on switch rates. The findings show a trend supporting the use of 5 times/
week RUL ECT as a means to shorten the course of ECT without increasing cognitive morbidity.

Keywords: Electroconvulsive Therapy; Safety; ECT
Background
Electroconvulsive Therapy (ECT) remains the most effective
treatment for depression and many other major psychiatric disorders.
Although ECT has long been associated with complaints of memory
dysfunction, risk factors for who will develop post-ictal confusion or
long-term memory problems have not been definitively identified
[1,2], and seem to be transient. Prevention of cognitive side effects has
focused mainly on non-dominant hemisphere lead placement [3,4]. In
naturalistic clinical practice there is a huge variation in lead placement,
stimulus parameters, case selection, acceptable health co morbidities,
concurrent medications, and frequency of treatments, although the
general consensus is to start with right unilateral lead placement, with
brief biphasic pulses of square wave stimulations at three to five times
threshold [5,6]. Measurement of cognitive impairment and depression
outcomes are still generally measured by global impression of change.
Cognitive change, in particular is generally measured by meta memory
assessment since baseline cognitive function before depression, is not
verifiable [7]. Bilateral ECT has consistently been associated with more
subjective memory complaints than unilateral ECT, including
complaints of persistent memory problems even in the absence of
objective cognitive deficits on post-ECT testing [8,9].
How often ECT should be administered has been seen as a trade-off
between speed of response and minimizing confusion [10]. Three
times per week has been the norm, but more or less treatments per
week have largely been a matter of clinical judgment. Multiple
monitored ECT was often done in the 1980’s where several treatments
were given in a session. Clinical Procedural Codes (CPT) once
included a code for multiple monitored ECTs. Initial comparisons of
multiple monitored versus routine treatment showed no difference in
effectiveness or safety and had a significantly more rapid course of
treatment [11]. However, multiple monitored ECT was subsequently
abandoned due to an overall higher rate of cognitive impairment with
the dominant mode of bilateral lead placement, and the CPT code has
been removed. However, the controversy over the number of ECT per
week is still open. The current range of ECT frequency has been five
times per week [12] to two to three times per week [10,13] depending
upon severity of symptoms. It would be a significant issue for hospitals
and insurance if more frequent ECT administration can shorten
lengths of stay (LOS) and provide good outcomes without increasing
in morbidity. Patients should also find the shorter course of treatments
reassuring.

J Psychiatry Volume 17 • Issue 6 • Psychiatry-14-146

Journal of Psychiatry, an open access
Citation: Sakauye K, Badrun F, Elliott A, Yetter WN (2014) Safety and Benefit of Five Times per Week Electroconvulsive Therapy . J Psychiatry
17: 1000177. doi:10.4172/Psychiatry.1000177
Methods
The present study is a retrospective chart review of patterns of ECT
administration used by practitioners in an urban general hospital with
80-psychiatric beds. This was a naturalistic outcome study. The data
was manually reviewed since electronic medical records were not yet
available, and entered into SAS statistical software (SAS Institute, Inc.)
for data analysis the decision tree for ECT lead placements and
frequency of treatment used by practitioners is listed in Figure 1.
Lead Placement: Initial ECT series utilized right unilateral (RUL)
lead placement. Modified right unilateral (Mod RUL) ECT was used if
right unilateral seizures seemed focal or of short duration. Bilateral
Figure 1: Treatment Decision Tree
Paper-based records were manually reviewed and tallied. Since
improvement and adverse effects were rated by global clinical
impression and were often implicit, proxy measures were used to
provide less subjective measures for improvement and emergent side
effects. End of treatment was used as a measure of efficacy. Change in
lead placement from unilateral to bilateral was used as a measure of
lack of efficacy. Reduction in frequency of administration was used as
a measure of clinically significant cognitive complaints. No cases were
terminated because of a medical complication.
The following variables were available: demographic information,
diagnostic codes, initial lead placement, change in lead placement,
number of treatments per week, motor and Electroencephalogram
(EEG) based seizure duration, total length of stay, and length of stay
following the first ECT.
J Psychiatry
Journal of Psychiatry, an open access
Page 2 of 4
lead placement was used if there was poor response to unilateral
treatments or if a prior series required bilateral lead placement for
efficacy. If confusion became evident, the frequency of administration
was reduced or ECT was discontinued.
Treatment Parameters: The selection of initial frequency of
treatments was based on provider preference. One practitioner used
RUL 5 times/week routinely while others used 2-3 times/week
routinely. Stimulus parameters were empirically determined. Right
unilateral ECT generally used 3-5x threshold stimulation and bilateral
ECT generally threshold stimulation. ECT was administered with a
MECTA Spectrum 5000Q device.
All inpatient records of patients who received inpatient ECT in a
general hospital between July 2009 and July 2011 were reviewed. The
hospital records pertaining to ECT and psychiatry were not part of an
electronic medical record system so information was manually
extracted and entered into SAS Statistical Software (SAS Institute,
Inc.).
Results
35 cases were started with right unilateral ECT in the standard 3
times/week frequency. 32 cases were started with 5 times/week
frequency. 11 cases continued bilateral ECT placement 3 times/week
for a recurrent ECT series. Diagnosis was not used by the clinicians as
a factor in lead placement or frequency of treatment. Most patients
had major depression, but 10% were treated for bipolar disorder or
Volume 17 • Issue 6 • Psychiatry-14-146
Citation: Sakauye K, Badrun F, Elliott A, Yetter WN (2014) Safety and Benefit of Five Times per Week Electroconvulsive Therapy . J Psychiatry
17: 1000177. doi:10.4172/Psychiatry.1000177

Page 3 of 4

schizophrenia. Univariate pair wise comparisons of group outcomes bilateral placement was used as a proxy for lack of efficacy of the
were performed since group sizes and characteristics were not original treatment. None of the 3 times/week patients were switched.
normally distributed (Shapiro-Wilk, W=0.913669, p 0.4899). However six of the 5 times/week patients were switched to either
modified right unilateral or bilateral lead placement to improve seizure
There was no significant difference in age, gender, or diagnosis
response or efficacy. The latter was more typical of what was expected
between the 5 times/week unilateral and 3 times/week unilateral
because of the lower efficacy rate for unilateral lead placement overall.
groups.
Table 1 shows the average number of treatments and switch rates.
The number of switches of RUL placement to Modified RUL or

Starting Lead and N (%) Switch N (%) Ave Treatments in Series LOS in days
frequency
Switching (range)

RUL 2-3 times /wk 30 (39.5%) No switches 29 (96.6%) 5.75 (SD 3.43) 12.0 (3-44)

Mod RUL 1 (3.33%) 4 (SD 0.00) 24.0 (0)

Bilateral 0 (0%) 0 0

RUL 5x/week 27 (35.5%) No switches 16 (59.2%) 7.19 (SD 2.4) 12.66 (4-31)

Mod RUL 3 (11.1%) 7.0 (SD 3.46) 9.33 (5-16)

Eventual Bilateral ECT 6 (22.2%) 8.83 (SD 2.22) 22.83 (10-46)

Bilateral ECT 3x/week 11 (14.5%) No changes 0 (100%) 7.45 (SD 4.13) 22.45 (6-88)

Reduced Frequency or 0 (0%) 0 0

terminated ECT

Table 1: Switch Rates, LOS (Length of stay) is from treatment #1 until discharge, RUL = Right Unilateral lead placement, Mod RUL = Modified
Right Unilateral lead placement

The average number of treatments in a series differed unexpectedly
for the 3 times/week group. Table 2 shows the 5 times/week RUL
group was 7.19 treatments, and bilateral ECT was 7.45 treatments as
opposed to 5.75 for the 3times/week RUL group. Usually a RUL ECT
series requires more treatments than a course of Bilateral ECT.
The average LOS of the combined right unilateral ECT groups was
half the LOS of the bilateral ECT patients.
Initial Lead Placement Significance
RUL 3x/wk LOS vs. RUL 5x/week LOS p= 0.4269
Bilat 3x/wk LOS vs RUL 5x/wk LOS p=0.0816
Bilat 3x/wk LOS vs Mod RUL 3x/wk LOS p=0.0090
Bilat 3x/wk LOS vs Mod RUL 5x/wk LOS p=0.0953
Bilat 3x/wk LOS vs RUL 3x/wk LOS p=0.0193
Table 2: Length of Stay (LOS), RUL=Right Unilateral lead placement,
~x/week=times per week, Bilat=Bilateral lead placement
No early termination of bilateral ECT was observed and no
reduction of frequency of RUL treatments was observed, suggesting no
clinically significant cognitive morbidity in any group.
Discussion
The findings showed a trend supporting the use of 5 times / week
RUL ECT as a means to shorten the course of ECT without increasing
cognitive morbidity. The number of treatments in a successful series is
roughly equivalent irrespective of starting lead placement, but doing
ECT more frequently shortens the time frame. RUL lead placement
allows clinically significant improvement without an increase in
cognitive impairment (based on switch rates).
In this study, an odd observation was that 3 times/week RUL ECT
seemed superior to either 5 times/week ECT or bilateral ECT in terms
of fewer number of treatments in a series, no switches to bilateral ECT,
or LOS for the course of treatment. This seemed odd in light of
purported lower efficacy of RUL ECT compared to BL. This prompted
a qualitative chart review of the 2-3 times/week cases. Non-
standardized documentation and lack of detail in the 2-3 times/week
cases many charts did not allow any secondary analysis. We concluded
that treatment parameters used by the psychiatrists using 2-3 times/
week ECT differed from published American Psychiatric Association
(APA) guidelines in terms of inclusion criteria and endpoints for
treatment. Our expectation was that the number of treatments in a
series would be roughly identical in all groups, and that length of stay
would be wholly dependent upon the frequency of treatments.
In looking at 5x/week RUL ECT group alone, about 20% of the
patients required modification in lead placement to improve efficacy.
The modifications were switch to modified right unilateral ECT to
improve the quality of seizures, or to bilateral lead placement if
Modified RUL lead placement was still suboptimal. The comparison in
lengths of stay of 5 times/week RUL cases with Bilateral ECT cases (3
times/week) seemed to be a more useful comparison because of the 2-3
times/week RUL cases seemed so atypical. Of those that completed 5
times/week ECT, the number of treatments was about the same as a BL
ECT series, and a trend toward shorter lengths of stay for 5 times/week
was seen. No evidence for significant cognitive impairment from

J Psychiatry Volume 17 • Issue 6 • Psychiatry-14-146

Journal of Psychiatry, an open access
Citation: Sakauye K, Badrun F, Elliott A, Yetter WN (2014) Safety and Benefit of Five Times per Week Electroconvulsive Therapy . J Psychiatry
17: 1000177. doi:10.4172/Psychiatry.1000177
treatment was seen, based on further reducing the frequency of ECT
throughout the series.
The limitation to this chart review study was the lack of
standardized records or scales. Proxy measures for efficacy and
adverse effects had to be used because of limitations in the quality of
documentation. The quality and reliability of chart data should
improve as the Hospital moves toward an electronic Medical Record
System. Deviations from practice guidelines by some psychiatrists
were an inadvertent finding that is being corrected by the Hospital.
In conclusion, 5 times/week RUL ECT seems to be well tolerated
and can shorten the length of a series of ECT.
References
1. Kikuchi A, Yasui Furukori N, Fujii A, Katagai H, Kaneko S (2009)
Identification of predictors of post-ictal delirium after electroconvulsive
therapy. Psychiatry and Clinical Neurosciences, 63: 180-185.
2. Hausner L, Sartorius DM, Frolich L (2011) Efficacy and Cognitive Side
Effects of Electroconvulsive therapy (ECT) in depressed elderly inpatients
with coexisting mild cognitive impairment of dementia. Journal of
Clinical Psychiatry 72: 97-7.
3. Abrams R (2007) Does Bilateral ECT Cause Persistent Cognitive
Impairment. Journal of ECT. 23: 61-62.
4. Crowley K, Pickle J, Dale R, Fattal O (2008) A Critical Examination of
Bifrontal Electroconvulsive Therapy: Clinical Efficacy, Cognitive Side
Effects, and Directors for Future Research. Journal of ECT 24: 268-271.
5. Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, et al.
(2000) A Prospective, Randomized, Double-blind Comparison of
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Bilateral and Right Unilateral Electroconvulsive Therapy at Different
Stimulus Intensities. Archives of General Psychiatry 57: 425-434.
6. Weiner RD, Fink M, Hammersley DW, Small IF, Moench LA, et al.
(1990) The American Psychiatric Association Task Force on
Electroconvulsive Therapy, The Practice of Electroconvulsive Therapy:
Recommendations for Treatment, Training, and Privileging, American
Psychiatric Association, Washington DC.
7. Brakemeier EL, Berman R, Prudic J, Zwillenberg K, Sackheim HA (2008)
Self-evaluation of the cognitive effects of electroconvulsive therapy. Brain
Stimulation, 1: 16-26.
8. Squire LR, Chance PM (1975) Memory functions six to nine months after
electroconvulsive therapy. Archives of General Psychiatry 32: 1557-64.
9. Prudic J, Peyser S, Sackeim HA (2000) Subjective Memory Complaints: A
Review of Patient Self-Assessment of Memory after Electroconvulsive
Therapy. The Journal of ECT 16:121-132.
10. Shapira B, Tubi N, Lerer B (2000) Balancing Speed of Response to ECT in
Major Depression and Adverse Cognitive Effects: Role of Treatment
Schedule. The Journal of ECT 16:109.
11. Berens ES, Yesavage JA, Leirer VO (1982) A Comparison of Multiple and
single electroconvulsive therapy. Journal of Clinical Psychiatry 43: 126-8.
1.
12. Hirose S, Ashby CR, Mills MJ (2001) Effectiveness of ECT Combined
with Risperidone Against Aggression in Schizophrenia. The Journal of
ECT 17: 22-26.
13. Charlson F, Siskind D, Doi SAR, Mc Callum E, Broome A, et al. (2011)
ECT efficacy and treatment course: A systematic review and meta-
analysis of twice vs thrice weekly schedules. Journal of Affective
Disorders.
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By Donna Jackel

Every smoker is familiar with the strong mix of feelings that nicotine addiction elicits: you long for that
next cigarette, but you’re haunted by the knowledge that your habit is placing you—and your loved ones
—at risk. (/winter-2019/)

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The health facts are indisputable. According to the World Health Organization (WHO), 5.4 million people
WINTER 2019
globally die from smoking tobacco each year—an average of one death every six seconds. Smoking also
substantially increases the risk of heart disease and lung diseases, such as emphysema.

The stakes are disproportionately high for people with bipolar (/bringing-bipolar-into-focus/). About 31
percent smoke compared to about 21 percent of the general population, according to the U.S.
government-funded “Systematic Treatment Enhancement Program for Bipolar Disorder(STEP-BD),” the
most in-depth study of its kind.

And while the average smoker has a one in four chance of quitting, a smoker with bipolar has a one in 10
chance, says Tony George, MD, professor in addiction psychiatry at the University of Toronto. George is
working on developing effective medications for treating tobacco addiction in people with bipolar
(/bringing-bipolar-into-focus/). “We need to learn how to treat it,” he says. “The lead reason why people
with bipolar die is smoking-related illnesses.”

Nicotine is an addictive drug that acts on specific receptors on the brain to cause the release of
neurotransmitters, such as serotonin or dopamine. Smoking may therefore interfere with the
effectiveness of many medications for bipolar, since these drugs work by blocking the activity of the same
neurotransmitters that are increased by smoking (/smoking-and-bipolar-can-e-cigarettes-help-you-
quit/). As evidence of this, a 2008 study out of the University of Melbourne found that nonsmokers taking
antipsychotic drugs for acute mania (http://www.bphope.com/mania/)showed significantly greater
improvement in symptoms than the smokers in the group.
The relationship between nicotine and mental illness is complex. George and colleagues found that
nicotine eases some of the attention deficit that occurs with schizophrenia. A similar chemical interaction
may occur with bipolar (/bringing-bipolar-into-focus/) and nicotine, but there are other theories why
people with bipolar smoke. Nicotine may reduce some of the unpleasant side effects of psychiatric Please see Important Safety Information,
including Boxed Warnings, below and full
Prescribing Information.
medications. And the nature of bipolar may increase one’s vulnerability to smoking, says Ivan D. Montoya,
MD, of the National Institute on Drug Abuse (NIDA).

During mania, people may increase alcohol intake, indulge in illicit drugs, and smoke more, says Montoya.
As drugs or alcohol lower one’s inhibitions, health concerns about smoking may be reduced. Nicotine may
Is your
also reduce the anxiety produced by mania, he adds. As for depression, the stimulation produced by
bipolar
nicotine can help a sluggish person get moving. They may find that smoking gives some structure to the
depression
day and reduces boredom, Montoya says.
affecting
life’s little
moments?
Kicking the habit—again

Calvin of Ontario, was 12 when he smoked his first cigarette (http://www.bphope.com/acceptance-and-

commitment-therapy-may-help-to-quit-smoking/). Thirty-six years later, he still remembers lighting up IMPORTANT SAFETY
INFORMATION AND INDICATIONS
FOR LATUDA
with his pals in a neighbor’s backyard. INCREASED MORTALITY IN
ELDERLY PATIENTS WITH
DEMENTIA-RELATED PSYCHOSIS;
“It made me high. Even though I got sick, I enjoyed it. A couple of days later, I tried it again and I didn’t get and SUICIDAL THOUGHTS AND
BEHAVIORS

sick.” Calvin was soon addicted. “I needed to have that smoke. It took away my nervousness. It was really Increased risk of death in elderly
people with dementia-related
psychosis. Medicines like LATUDA
important to me to fit in with some kind of crowd.” can raise the risk of death in
elderly people who have lost touch

Barb B. of Kansas, started smoking in high school, but it wasn’t until she got to college that she began
smoking heavily. “It was stress and anxiety (/the-tension-tango/) that made me turn to smoking,” Barb
says. “Looking back, I’m sure the bipolar played an important part. When I smoked, I felt less confusion. I
could concentrate better.”

Barb married, became a mother, and gave up cigarettes for almost 20 years. When her children became
teenagers, she started graduate school and took a job. With the stress, she returned to her old habit.
“Smoking was always there when I was up or down in my bipolar. It was something I turned to for
security.” Each time she quit, she started again. Each time she resumed, she smoked more than the last
time.

Many smokers quit (http://www.bphope.com/smoking-and-bipolar-can-e-cigarettes-help-you-quit/)

multiple times before succeeding. Nicotine withdrawal is usually the culprit. Possible symptoms include
(/kids-children-teens-cat/)
irritability, craving, sleep disturbances, and increased appetite. “You have to learn how to surf through the
urge to pick up a cigarette,” says William Riley of the National Institute of Mental Health. “If you can get
through that 15 or 30 minutes, the urge will go away.”

There are steps you can take to increase your chances of quitting. For starters, pick a specific quit date, let
loved ones know you’re quitting, and ask for their support. Instead of going it alone, George recommends
using nicotine replacement therapy—such as sprays, gums, or a patch—or one of the newer smoking
cessation drugs. It’s important to make your psychiatrist part of your team, as the absence of nicotine can
destabilize one’s mood. It’s also recommended you attend an anti-smoking group for reinforcement.

George predicts that if every smoker with bipolar had these supports, the rate of success for smoking
cessation would “probably quadruple.”

Answers to why we smoke

Calvin, who was diagnosed with bipolar disorder (/bringing-bipolar-into-focus/) in 1998, regularly thinks
about giving up cigarettes. But he’s not ready. Instead, he’s cut down from a pack a day to eight to 10
cigarettes.
Researchers are hopeful that there will be better solutions for smokers who want to quit. Studies are
underway to determine why people with bipolar are more vulnerable to nicotine and what types of
cessation medications and behavioral therapies might be most effective for them.

As for Barb, she quit last summer using a nicotine replacement therapy nasal spray. She’s hoping that,
this time, it’s for good.

“I wanted to see my grandkids grow up, I didn’t want to smell like smoke around my husband, and I
wanted to breathe better. I just didn’t want to be dependent on something like that anymore.”

Barb urges smokers not to beat themselves up if the first—or fifth—attempt to quit fails. “If you relapse,
you can always try a different medication or patch or gum. The main thing is not to give up. It doesn’t
mean you are worthless. You can always quit again.”

* * * * *

Quitting time

Here are some strategies to overcome a nicotine addiction.

Distract yourself. When the urge to light up hits, keep your hands busy. Bowers distracted herself by
cleaning her closets and cupboards, for example.
Circle the date
date. It’s easier to have a fixed date for quitting.
Get help. Your health care provider can direct you to what’s best for you.
Change your habits. Instead of drinking caffeine or alcohol, which may spark a nicotine craving, switch
to juice or water.
Fight that fixation. Longing for a cigarette? Pop in sugarless gum, hard candy, carrot sticks, or sunflower
seeds.
De-stress. Exercise, take a hot bath, or read a book.
Breathe deeply. Inhale and picture your lungs filling with clean air. This will not only relax you, but
remind you of why you’re quitting.

* * * * *

Printed as “Your Habit… Up in Smoke“, Winter 2009 (http://www.bphope.com/winter-2009/)

$ ADDICTION (HTTPS://WWW.BPHOPE.COM/TAG/ADDICTION-2/), SMOKING

(HTTPS://WWW.BPHOPE.COM/TAG/SMOKING/), WINTER 2009 (HTTPS://WWW.BPHOPE.COM/TAG/WINTER-2009/)

ABOUT THE AUTHOR

Donna Jackel (/author/donnajackel)

Donna Jackel is a health writer based in Upstate New York whose work has been featured
in Gannett Newspapers and The Bark, Rochester and Her magazines.

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Tracy February 21, 2019 at 7:47 pm Reply

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You are here: Home » ECT Information » Modified multiple-monitored Electroconvulsive therapy

Modified multiple-monitored Electroconvulsive

therapy
Modified multiple-monitored Electroconvulsive therapy. (Letters to the Editor).
(Abstract)(Brief Article)

Journal of the American Academy of Child and Adolescent

Psychiatry; 7/1/2002

To the Editor:

Electroconvulsive therapy (ECT) has been available in the United States for more than 50 years, and its
safety in adults is well documented; the mortality rate is approximately 0.000045% (Consensus Conference,
1985). In the 1940s significant numbers of children were first treated with ECT. However, in 1980 only 1.5%
of 33,384 ECT patients were younger than 21 (Thompson and Blame, 1987). Reluctance to recommend ECT
in youths may be due to a lack of experience rather than the results of systematic studies or untoward
outcomes.

A 1997 review of the child literature by Walter and Rey revealed no double-blind controlled studies
comparing ECT with other traditional treatments. Nevertheless, ECT has been used to treat many child and
adolescent mental illnesses, including bipolar disorder, depression, and schizophrenia. Some reports have
found that the efficacy and safety is similar to that in adults (Walter and Rey, 1997), with complications being
typically brief in duration: disorientation, memory impairment, excitation, disinhibition, and alteration of
seizure threshold.

In contrast to conventional ECT, with one seizure induced per session, MMECT (multiple-monitored
electroconvulsive therapy) involves the induction of multiple, closely spaced seizures during a single session.
ECT and MMECT are similar in safety and clinical efficacy when total seizure duration is equal (Maletzky,
1986). The advantages of MMECT include shorter treatment duration, fewer hospital days and thus lower
costs, and less exposure to the risks of anesthesia. Roemer et al. (1990) found that double-seizure induction
offered a more rapid resolution of depressive symptoms; however, these patients also experienced more
posttreatment confusion, disorientation, and memory loss. A search of the literature reveals virtually no
reports on MMECT in the child and adolescent population. We report on the use of MMECT in an
adolescent.

Adam is a 14-year-old white male with a 2-year history of refractory depression and psychosis. His prenatal
history and developmental course were unremarkable. At age 4 he had the onset of Tourette’s syndrome and
was subsequently placed in emotionally handicapped classes because of his attention-deficit/hyperactivity
disorder and behavioral problems. At age 12, Adam became markedly depressed following his parents’
divorce and required psychiatric hospitalization for mutism, refusal to eat (requiring a nasogastric tube for
nutrition), and paranoid delusions (he believed that his food was poisoned). Over the next 2 years he
remained hospitalized because of paranoia, auditory hallucinations, depressed mood, ritualized touching,
vocal and facial motor tics, and little spontaneous speech. Regressed behaviors included encopresis, enuresis,
and fecal smearing. Trials of antipsychotics, lithium, benzodiazepines, and antidepressants (tricyclic
antidepressants, a monoamine oxidase inhibitor, and fluoxetine) were unsuccessful. Computed tomography
head scans, magnetic resonance imaging (MRI) head scans, and multiple electroencephalograms (EEGs)
were unremarkable.

Adam was discharged at age 14, but he required readmission shortly thereafter because of a recurrence of
symptoms. He believed that people were planning to kill him, was preoccupied with death, and claimed that
he received satanic messages from “heavy metal” music, which he listened to constantly. Adam would smear
feces on walls, engage in coprophagia, gorge himself with food until he vomited, strip, and publicly
masturbate. He also compulsively touched walls and objects as frequently as 100 times each minute.

Results of additional tests (repeated MRI head scan, human immunodeficiency virus test, rapid plasma
reagin, ceruloplasmin level, and a lumbar puncture) were negative. The patient’s haloperidol dose was
increased to 40 mg, but symptom improvement was minimal. An 8-week course of clomipramine did not
improve the repetitive touching or depression. ECT was ultimately recommended. MMECT was used with
the hopes that it would more expeditiously improve Adam’s depression and psychotic behavior. The pre-
MMECT workup was no different from that for traditional ECT; the American Academy of Child and
Adolescent Psychiatry is in the process of establishing guidelines for the use of ECT in adolescents.

Ten ECT treatments with double-seizure induction during treatments 4 through 7 were performed over a
period of 3 weeks. The MECTA SR-2 device was used (MECTA Corp., Tualatin, OR). This machine
delivers a constant bidirectional square-wave brief pulse stimulus. Standard bifrontotemporal electrode
placement was used. Methohexital was used for induction, and succinylcholine was used for muscle
relaxation. Both EEG monitoring and the sphygmomanometer “cuff method” for assessment of motor
convulsive activity were used to monitor seizure duration. Increasing stimulus strength parameters were
necessary for adequate seizure length, with final MECTA settings as follows: pulse width 2.0 milliseconds,
frequency 90 hertz, duration 2.0 seconds, current 0.8 amperes. Intravenous caffeine 500 mg was given during
the latter three ECT treatments to promote adequate seizure duration. The total seizure duration for the 10
treatments was 699 seconds.

Haloperidol 30 mg daily was maintained during MMECT treatment. Within two treatments a marked
decrease in depressive symptoms was noted, with virtual remission by treatment’s end. Adam did not have
significant memory loss or confusion during or after MMECT based on serial mental status examinations. His
compulsions did not improve; however, the daily fecal smearing decreased to two to three times per week. Of
interest, his tics almost completely remitted, but they gradually returned to pretreatment levels over the 4
weeks following treatment.

In this report, we describe the use of modified MMECT (two seizures per session for part of ECT course) to
treat refractory depression in an adolescent. These modifications were precautionary because of the lack of
data about MMECT in youths. Adam’s mood and tic symptoms responded well to the MMECT. Assessment
of improvement in psychotic symptoms was difficult; however, less frequent fecal smearing and
improvement in social interaction indicate some objective measure of improvement.

The literature is nearly quiet on the use of ECT for tic disorders. In general, ECT has been shown to be
ineffective. Swerdlow et al. (1990) described a case of a 59-year-old man with major depression and
refractory motor tics, unresponsive to haloperidol and pimozide. After receiving four sessions of ECT, both
mood symptoms and motor tics improved. Swerdlow et al. (1990) suggested that the improvement in tics
might have been an indirect effect of the improvement in mood symptoms, as mood and anxiety symptoms
can exacerbate tics. This may also have been the case with Adam, although his tic improvement was
temporary.

The use of MMECT has not been robust, likely because of concerns that adequate second and third seizure
times may be difficult to generate and may worsen postictal confusion. In our case, we found that the second
seizure time was comparable with the first. The benefits of MMECT–more favorable side effect profile,
shorter duration of hospitalization, and lower treatment costs–have been documented. Nevertheless,
controlled studies assessing ECT versus MMECT in children and adolescents are lacking. Caution should be
exercised before MMECT is considered for the treatment of severe or refractory illnesses in this population.

Wade Myers, M.D.

Mathew Nguyen, M.D.

Division of Child and Adolescent Psychiatry University of Florida, Gainesville

Consensus Conference (1985), Electroconvulsive therapy. JAMA 254:2103-2108

Maletzky BM (1986), Multiple-Monitored Electroconvulsive Therapy. Boca Raton, FL: CRC Press

Swerdlow NR, Gierz M, Berkowitz A, Nemiroff R, Lohr J (1990), Electro-convulsive therapy in a patient
with severe tic and major depressive episode. J Clin Psychiatry 51:34-35

Roemer RA, Dubin WR, Jaffe R, Lipschutz L, Sharon D (1990), An efficacy study of single versus double
seizure induction with ECT in major depression. J Clin Psychiatry 51:473-478

Thompson JW, Blaine JD (1987), Use of ECT in the United States in 1975 and 1980. Am J Psychiatry
144:557-562

Walter G, Rey JM (1997), An epidemiological study of the use of ECT in adolescents. J Am Acad Child
Adolesc Psychiatry 36:809-815

Added: July 25, 2006 at 6:26 pm

Categories: ECT Information, Studies

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Find a Therapist (City or Zip) Verified by Psychology Today

Nigel Barber Ph.D.

The Human Beast

Smoking: Most effective

quitting technique little known
Guess which method of quitting works best
Posted Feb 17, 2010

Smoking is a powerful addiction as I know from personal experience. It remains

one of the biggest causes of preventable health problems. There are many
useful products and drugs that help smokers to quit. Yet, the most effective
technique is virtually unknown.

When a smoker wakes up to the fact that they have a dangerous addiction and
decide to quit, what are their chances of success? For most, failure is more
likely than success.

ARTICLE CONTINUES AFTER ADVERTISEMENT

 ARTICLE CONTINUES AFTER ADVERTISEMENT

IMPORTANT SAFETY INFORMATION

TRELEGY is not for asthma. TRELEGY contains
vilanterol. Long-acting beta2-adrenergic agonist (LABA)
medicines such as vilanterol when used alone increase
the risk of hospitalizations and death from asthma
problems. TRELEGY contains an inhaled corticosteroid
(ICS), an anticholinergic, and a LABA. When an ICS

According to voluminous research distilled in the U.S. public health services

report, "Treating tobacco use and dependence," a person's chances of
remaining tobacco free a year after quitting independently are only one in
twenty. By using nicotine replacement (whether patch, gum, lozenges, nasal
spray, or inhaler) a person trebles their chance of quitting - to 15 percent, or
approximately one person in seven. Combining the nicotine patch and inhaler
boosts the success rate to one in five (19.5 percent).

Substantially better results are produced by using Zyban, a prescription

antidepressant that has a success rate of 30 percent. This provides an
interesting insight into why people smoke. Combining the antidepressant with
nicotine replacement boosts success to 35.5 percent. Another prescription
drug, Chantix, acts on nicotine receptors in the brain and has received adverse
publicity as a possible suicide risk. Its one-year success rate is 22 percent.

Interestingly, many smokers have never even heard of the most effective
quitting approach - aversion therapy. If smoking persists because it is
pleasurable, associating puffing with mild electric shock, and nausea, takes the
pleasure out of it in a procedure known as counter conditioning that is offered
by the Schick-Shadel Treatment Centers in Seattle.
After Shick-Shadel aversion therapy, 52.5 percent of 327 people were still off
tobacco after a year. Unfortunately, due to its unpleasant connotations, drug
companies and treatment facilities seem unwilling to promote it. Other studies
of aversion therapy produced more modest results.

To date, aversion therapy using shock and nausea is the only technique of
quitting that offers decent gambling odds. For all others, substantially more
quitters fail than succeed. Still there are no limits on how often a person can try
to quit. With persistence anyone can give up smoking.

ARTICLE CONTINUES AFTER ADVERTISEMENT

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About the Author

Nigel Barber, Ph.D., is an evolutionary psychologist as well as

the author of Why Parents Matter and The Science of
Romance, among other books.

View Author Profile

 U.S.

Kitty Dukakis, a Beneficiary

of Electroshock Therapy,
Emerges as Its Evangelist
By Katharine Q. Seelye

Dec. 31, 2016

BROOKLINE, Mass. — When Michael Dukakis lost the presidential election in 1988,
his wife, Kitty, felt as if she had been squashed in a compactor, all the air forced out of
her. Her even-keeled husband went back to work as governor of Massachusetts; she
started binge drinking.

“An alcoholic can contain himself for only so long,” Mrs. Dukakis would later write.
“When a crisis hits, the restraints snap.”

Her drinking masked a long-smoldering depression that eventually led her to receive
electroconvulsive therapy, also known as electroshock therapy or ECT.

Like most people, she had no idea that the procedure was still used. She thought it a
relic, scrapped after it was depicted as an instrument of torture in the 1975 movie
“One Flew Over the Cuckoo’s Nest.”

But Mrs. Dukakis was desperate. Rehabilitation, talk therapy and antidepressants
had failed to ease her crippling depression, so in 2001, at age 64, she turned to shock
therapy.

To her amazement, it helped.

After the first treatment, Mrs. Dukakis wrote, “I felt alive,” as if a cloud had lifted —
so much so that when Mr. Dukakis picked her up at Massachusetts General Hospital,
she astonished him by proposing that they go out to dinner.

“I was so shocked I almost drove off Storrow Drive,” Mr. Dukakis recalled. “I had left
this wife of mine at the hospital a basket case just the night before.”

Now, 15 years later, the Dukakises have emerged as the nation’s most prominent
evangelists for electroconvulsive therapy.

Truth be told, there is not much competition. Few boldface names who have had the
treatment will acknowledge as much; the stigma is still too great. Exceptions include
Carrie Fisher, the actress and writer who died Tuesday, and Dick Cavett, the talk-
show host; both have openly discussed their positive experiences.

Electroconvulsive therapy is not a one-and-done procedure. Mrs. Dukakis, 80, still

receives maintenance treatment every seven or eight weeks. She said that she had
minor memory lapses but that the treatment had banished her demons and that she
no longer drank, smoked or took antidepressants.

She went public with her use of electroshock in 2006 in her book, “Shock: The
Healing Power of Electroconvulsive Therapy,” which she wrote with the journalist
Larry Tye.
 Treatment electrodes connected to an electroconvulsive therapy
device at McLean Hospital in Belmont, Mass., where Mrs. Dukakis
receives her maintenance therapy.
M. Scott Brauer for The New York Times

These days she and her husband — who is 83 and still teaching full time at
Northeastern University — devote their time to promoting ECT.
They hold support groups at their Victorian home outside Boston here; manage a
website, ecttreatment.org; and answer inquiries from people seeking guidance.
Their efforts include trying to persuade the Department of Veterans Affairs to make
the procedure more accessible. Mrs. Dukakis also gives speeches around the country
and abroad.

As they bear witness, the Dukakises face decades of prejudice against a treatment
that Mrs. Dukakis credits with saving her life.

“I have lots to be grateful for,” she says, snuggling her cockapoo puppy. “And lots to
look forward to.”

Wary of Treatment
During the 1988 campaign, Mrs. Dukakis said, she generally limited herself to one
shot of vodka at night, though she did go on a couple of benders that forced her to
cancel appearances. All that changed with the election, when her husband lost 40
states to George Bush.

Two days later, her long-masked depression came roaring back; she lost herself in
the bottle and spent the next several years in and out of rehab.

In the mornings, she would see her husband off to work, then drink, retreat to her
room and pass out. Her family sometimes found her passed out in her vomit.

“Once I came home and couldn’t find her,” Mr. Dukakis recalled. “I finally went up to
the third floor, and I saw what I thought was a bunch of rags on the floor. It was my
wife. This beautiful …” His voice broke off. “Jesus,” he said.

Though she and her husband had heard about electroconvulsive therapy, they were
wary. Mr. Dukakis’s older brother, Stelian, had had an ECT session in 1951 and was
never the same.
Mrs. Dukakis’s sister’s husband also had ECT therapy in the 1950s but had kept it
secret. When he learned that Mrs. Dukakis was considering it, he told her that he
had had a positive outcome; he lost some memory, but his psychosis was gone.

Benefits, With Risks

No one knows exactly how electroshock eases depression, if only temporarily, in
many people. It sends an electrical current to the brain that triggers a brief seizure.
The result is like rebooting a computer, say those who have had positive results.

Shock therapy was developed in 1938. Back then, patients were not given anesthesia,
and the electrical current was much stronger. It was in fairly wide use by the 1960s.
Patients included Sylvia Plath, the poet; Clementine Churchill, the wife of Winston
Churchill; and Senator Thomas F. Eagleton of Missouri, the 1972 Democratic vice-
presidential candidate, who was booted off the ticket when his treatment was made
public.
“Depression is a chronic and recurring illness that requires good lifetime management,” Dr. Charles
Welch, Mrs. Dukakis’s psychiatrist, said.

M. Scott Brauer for The New York Times

But electroshock fell out of favor with the growth of antidepressants and the release
of “Cuckoo’s Nest.”

Critics say proponents deliberately minimize the dangers — starting with their use of
sanitizing nomenclature like “ECT.”

Among the criticisms: that memory problems can be far more severe than doctors
say; that relapses are almost inevitable; and that the procedure causes brain
damage, a point in sharp dispute.

Jonathan Cott, a writer and editor, wrote in his 2005 book, “On the Sea of Memory: A
Journey From Forgetting to Remembering,” that his shock therapy had wiped out 15
years of memories. They included events like the murder of John Lennon, whom Mr.
Cott had interviewed just three days before the shooting. Mr. Cott forgot books he
had written and edited and friends listed in his address book.

“The pact with the devil that is ECT,” he wrote, “requires that one trade certain
memory loss (short-term, long-term or both), possible brain damage and cognitive
dysfunction for the temporary relief of depression.”

Despite its negative image, ECT has remained the go-to option for severely
depressed people who do not respond well to antidepressants or other treatments. It
is usually fast acting, which can mean the difference between life and death in
patients who are suicidal.
“Public awareness of the use of ECT has waxed and waned, but in medical practice,
we have continuously used it,” said Dr. Sarah Lisanby, a specialist in ECT at the
National Institute of Mental Health.

In the old days, patients convulsed during therapy sessions, sometimes so violently
that they broke their bones or teeth. Today, with anesthesia and muscle relaxants,
such reactions are rare.

“ECT is the single most efficacious treatment that we have and the treatment of
choice if you absolutely had to get someone out of a severe depression within a day
or two,” said Steven D. Hollon, a professor of psychology at Vanderbilt University,
who has studied the treatment of depression.

But, he added, electroconvulsive therapy can potentially cause serious side effects,
most notably long-term memory problems, some of which are temporary. Even
patients whose depression goes into remission almost always need maintenance
treatment, with ECT, antidepressants or both.

A National Institute of Mental Health study conducted in 2014 and released this year
found that new ECT techniques designed to better protect memory, in combination
with antidepressants, fully relieved symptoms in 61 percent of severely depressed
elderly patients; some were still well six months later. (Of the others, 28 percent
dropped out and 10 percent did not improve.)

Mrs. Dukakis receives her maintenance therapy at McLean Hospital in suburban

Boston, one of the world’s largest and most renowned psychiatric hospitals. McLean
does about 10,000 such treatments a year, up from 2,500 treatments in 1999, Dr.
Stephen Seiner, McLean’s director of ECT, said. Each patient generally receives eight
to 20 treatments.
Mrs. Dukakis, right, hosting an electroconvulsive therapy support group at her home in December.
M. Scott Brauer for The New York Times

“For most patients,” said Mrs. Dukakis’s psychiatrist, Dr. Charles Welch, “depression
is a chronic and recurring illness that requires good lifetime management.”

Varied Experiences
It was a frosty Sunday night in December, and Mrs. Dukakis, stylishly dressed in a
starched white blouse and royal blue sweater with pearls, was seated on her living
room couch. Her husband, in a flannel shirt and khakis, sat beside her.

Nine others, who make up part of their ECT support group, sat in a circle. Three
women had had shock therapy and came with their husbands; another woman and
two men came on behalf of deeply depressed family members and wanted to learn
more.
As the meeting began, Mrs. Dukakis explained that she and her husband would be
celebrating “my 50th birthday.” People chuckled, assuming she was joking about her
age, but she did not appear to be, prompting Mr. Dukakis to remind her that it would
be her 80th.

Two women who had received ECT spoke positively about it. A third, a doctor named
Barrie Baker, had a very different experience.

“After the first time, I couldn’t remember the season or the year,” Dr. Baker said. “I
don’t know if I’ve ever fully recovered.”

She said she preferred being treated with medications.

“You can stop a medication, and the side effects will go away,” she said. “But the
things that happen with ECT can take months to go away.”

The group discussed whether it was better to hold off on ECT as a last resort or seek
it sooner if drugs did not help immediately.

“Given Kitty’s experience,” Mr. Dukakis said, “I can’t support the notion that you try
everything else before you try ECT. Those 17 years before we finally got to ECT were
brutal.”

A woman named Deborah, who came on behalf of her husband and did not want her
last name used, said her husband had been so depressed, she had dropped a letter in
Mrs. Dukakis’s mailbox several months ago seeking help.

Mrs. Dukakis arranged for the man to meet with Dr. Welch. He received ECT but
remains severely depressed. Still, Deborah is grateful to the Dukakises.

“They call to find out how my husband is,” she said. “They have been there for him.
They have hundreds of people like that in their life, and they never stopped caring.”

A version of this article appears in print on Jan. 1, 2017, on Page A13 of the New York edition with the headline: Beneficiary of Electroshock
Therapy Emerges as Its Leading Evangelist
 Letters to the Editor
Emily Shao, MBBS, MPH
Royal Brisbane and Women's Hospital
Brisbane, Australia
emilyxshao@gmail.com
Rachael Moore, MBBS
John Linnane, MBBS, FRANZCP
Metro North Mental Health
Royal Brisbane and Women's Hospital
Brisbane, Australia
The authors have no conflicts of inter-
est or financial disclosures to report.
Downloaded from https://journals.lww.com/ectjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3wX04VDhDA65ooX9oONiHEOfB6mrcmBxERBFO9JNTNtQ= on 02/22/2019
REFERENCES
1. Mehta V, Mueller PS, Gonzalez-Arriaza HL,
et al. Safety of electroconvulsive therapy
in patients receiving long-term warfarin
therapy. Mayo Clin Proc. 2004;79:
1396–1401.
2. Australian Medicines Handbook. 2016.
Available at: https://amhonline.amh.net.au/
chapters/chap-07/anticoagulants/
other-anticoagulants/warfarin.
Accessed January 5, 2017.
3. Bauer KA. Pros and cons of new oral
anticoagulants. Hematology Am Soc Hematol
Educ Program. 2013;2013:464–470.
4. Shuman M, Hieber R, Moss L, et al. Rivaroxaban
for thromboprophylaxis in a patient receiving
electroconvulsive therapy. J ECT. 2015;31:
e19–e20.
5. Schmidt ST, Lapid MI, Sundsted KK, et al.
Safety of electroconvulsive therapy in
patients receiving dabigatran therapy.
Psychosomatics. 2014;55:400–403.
Sylvia Plath Recovered
Completely by
Electroconvulsive Therapy
at the Age of 21 Years
and Might Have Been Saved
by Another Series
9 Years Later
To the Editor:
ax Fink1 recently reviewed the pos-
M itive experiences of electroconvul-
sive therapy (ECT) reported by 8 personal
witnesses and 4 negative and widespread
“stigmatizing voices.” He is right in pointing
out that we, as a profession, have failed to
present the favorable experiences to offset
the negative images that limit the use of
ECT. Therefore, I will emphasize that one
of those behind the “stigmatizing voices,”
e26 www.ectjournal.com
Journal of ECT • Volume 33, Number 3, September 2017
Sylvia Plath, also is a positive witness, be-
cause she has described a successful ECT
series after the failed one.
Electroconvulsive therapy is the cen-
terpiece in Plath's autobiographical novel
The Bell Jar.2 Fink quotes her frightening
description of the first ECT course in chap-
ter 12 of the novel. An unknown number of
ECTs was given ambulatory without nar-
cosis and a muscle relaxant (unmodified
ECT), from July 29, 1953. The stimulus
dose may have been too low since she felt
the stimulus and/or her bodily reaction in-
stead of being immediately unconscious,
and did not improve. Later, she was admit-
ted to McLean Hospital, Massachusetts,
where she met Dr Ruth Beuscher, with
whom she made a lifelong bond.3,4 In
chapter 15 of the novel, she describes the
first ECT course to her doctor (“the blue
flashes… the jolting… the noise”), who
comments, “That was a mistake… It's not
supposed to be like that… If it's done prop-
erly… it's like going to sleep.” Plath was
persuaded to a second course of ECT and
had 5 treatments from December 15 to
Christmas 1953.5 This is described very
positively in chapter 17 and 18 of the novel:
“…and darkness wiped me out like chalk
on a blackboard… I woke out of a deep,
drenched sleep… All the heat and fear
had purged itself. I felt surprisingly at
peace. The bell jar hung, suspended, a few
feet above my head. I was open to the circu-
lating air.”
Plath had a long-term remission
following this second course of ECT,
documented in several biographies, for
example, “Almost immediately after these
treatments, Sylvia began to recover. During
the Christmas holidays, her depression
seemed to disappear”4 and “Plath recov-
ered fully, and by early February 1954
was able to return to Smith College where
she had brilliantly completed her degree,
written an honors theses, and led an active
social life.”3 She may herself have seen
her deliverance from madness by ECT as
a poetic rebirth, and wrote in her poem
The Hanging Man: “By the roots of my
hair some god got hold of me, I sizzled in
his blue volts like a desert prophet.”5
Sylvia Plath most probably had a bi-
polar disorder. However, she had no serious
relapse until January 1963. As in 1953, this
came after a very energetic and creative
period with little sleep. Dr Beuscher was
not available as Sylvia lived in London.
Her doctor visited her daily, administered
an antidepressant, but did not succeed in
finding a place for her and her 2 small
children in a psychiatric department. On
February 11, 1963, she committed suicide.
She might have been saved by another
ECT series.
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Per Bergsholm, MD, PhD
Department of Psychiatry
District General Hospital of Førde
Førde, Norway
per.bergsholm@gmail.com
The author has no conflict of interest
or financial disclosures to report.
Supported by funds from the District
General Hospital of Forde, Norway.
Copyright © 2017 The Author(s). Pub-
lished by Wolters Kluwer Health, Inc. This
is an open-access article distributed under
the terms of the Creative Commons
Attribution-Non Commercial-No Deriva-
tives License 4.0 (CCBY-NC-ND), where it
is permissible to download and share the
work provided it is properly cited. The work
cannot be changed in any way or used
commercially without permission from
the journal.
REFERENCES
1. Fink M. Bearing witness: personal and poetic
descriptions of seizure therapy. J ECT. 2016;32:
13–16.
2. Plath S. The Bell Jar. London, United Kingdom:
William Heinemann Limited 1963/Faber and
Faber Limited; 1966.
3. Middlebrook D. Her husband: Hughes and
Plath—A Marriage. New York, NY:
Penguin; 2003.
4. Kirk CA. Sylvia Plath: A Biography. Westport,
CT: Greenwood Press; 2004.
5. McDonald A, Walter G. Electroconvulsive therapy
in biographical books and movies. In: Swartz CM,
ed. Electroconvulsive and Neuromodulation
Therapies. Cambridge, United Kingdom:
Cambridge University Press; 2009:180–196.
Electroconvulsive Therapy
in Autoimmune and
Vascular Pathology
To the Editor:
W e report a case of cerebral venous si-
nus thrombosis as the first symptom
of systemic lupus erythematosus (SLE) in a
patient who later on developed catatonic
syndrome. Because of the concurrence of
a vascular and a systemic disease, the patient
required anticoagulation therapy. However,
he was successfully treated with electrocon-
vulsive therapy.
A 19-year-old male with no medical
history of interest, no psychiatric background,
and no active consumption of substances
was admitted in the internal medicine
ward with fever of unknown origin and
polyadenopathic syndrome. Serology tests