Electroconvulsive therapy (ECT) is a procedure in which a brief application of electric stimulus is used to produce a generalized seizure. It is not known how or why ECT works or what the electrically stimulated seizure does to the brain. In the U.S.
What conditions does electroconvulsive therapy treat?
Electroconvulsive therapy may help people who have the following conditions:
- Severe depression with insomnia (trouble sleeping), weight change, feelings of hopelessness or guilt and thoughts of suicide (hurting or killing yourself) or homicide (hurting or killing someone else).
- Severe depression that does not respond to antidepressants (medicines used to treat depression) or counseling.
- Severe depression in patients who can't take antidepressants.
- Severe mania that does not respond to medication. Symptoms of severe mania may include talking too much, insomnia, weight loss or impulsive behavior.
- Schizophrenia that does not respond to medication.
How does ECT work?
Traditionally, it was believed that ECT works by using an electrical shock to cause a seizure (a short period of irregular brain activity) in the brain. This seizure releases many chemicals in the brain. These chemicals, called neurotransmitters, deliver messages from one brain cell to another. The release of these chemicals makes the brain cells work better. A person's mood will improve when his or her brain cells and chemical messengers work better.
Update 03-19-2012: The recent study revealed absolutely different mechanism of ECT action on the brain affected by depression. The clinical depression causes "over-communication" in the brain that may make it difficult for people with depression to think and concentrate, said study researcher Jennifer Perrin, a mental health researcher at the University of Aberdeen in Scotland. The ECT treatment appeared to turn down an overactive connection between brain regions responsible for mood and emotion and those responsible for thinking and concentrating. Perrin likened the mechanism to dialing down a stereo that's too loud.
Update 03-19-2012: The recent study revealed absolutely different mechanism of ECT action on the brain affected by depression. The clinical depression causes "over-communication" in the brain that may make it difficult for people with depression to think and concentrate, said study researcher Jennifer Perrin, a mental health researcher at the University of Aberdeen in Scotland. The ECT treatment appeared to turn down an overactive connection between brain regions responsible for mood and emotion and those responsible for thinking and concentrating. Perrin likened the mechanism to dialing down a stereo that's too loud.
What steps are taken to prepare a person for ECT treatment?
First, a doctor will perform a physical exam to make sure you're physically able to handle the treatment. If you are, you will meet with an anesthesiologist, a doctor who specializes in giving anesthesia. Anesthesia is medicine used to put you in a sleep-like state so that you don't feel any pain or discomfort. The anesthesiologist will examine your heart and lungs to see if it is safe for you to have anesthesia. You may need to have some blood tests and an electrocardiogram (a test showing the rhythm of your heart) before your first ECT treatment.
How is it administered?
ECT treatment is generally administered in the morning, before breakfast. Prior to the actual treatment, the patient is given general anesthesia and a muscle relaxant. Electrodes are then attached to the patients scalp and an electric current is applied which causes a brief convulsion. Minutes later, the patient awakens confused and without memory of events surrounding the treatment. This treatment is usually repeated three times a week for approximately one month. The number of treatments varies from six to twelve. It is often recommended that the patient maintain a regimen of medication, after the ECT treatments, to reduce the chance of relapse.
To maximize the benefits of ECT, it is crucial that the patient’s illness be accurately diagnosed and that the risks and adverse side effects to be weighed against those of alternative treatments. The risks and side effects involved with the use ECT are related to the misuse of equipment, ill-trained staff, incorrect methods of administration, persistent memory loss, and transient post-treatment confusion.
ECT Approaches: RIGHT UNILATERAL TREATMENT versus BILATERAL ECT TREATMENTS
There are primarily two types of electrode placements used for the delivery of ECT. Differences between these two techniques include the area of the brain stimulated, timing of response and potential side effects.
Bilateral ECT treatment involves placing the electrodes on both temples. This treatment may be associated with more acute memory side effects than right unilateral treatments. Bilateral ECT is indicated for severe mental illnesses including depression with psychosis, manic episodes of bipolar disorder, psychosis related to schizophrenia and catatonia.
You and your doctor will work together to determine which treatment option is best for you. Specific recommendations will be made after carefully evaluating your concerns, medical/psychiatric history, and the severity of your symptoms.
What are some side effects of ECT?
Side effects may result from the anesthesia, the ECT treatment or both. Common side effects include temporary short-term memory loss, confusion, nausea, muscle aches and headache. Some people may have longer-lasting problems with memory after ECT.
Sometimes a person's blood pressure or heart rhythm changes. If these changes occur, they are carefully watched during the ECT treatments and are immediately treated.
The mechanism linking ECT to memory is not well understood, but about one third of patients experience a significant loss. The ability to remember should come back after treatment, but specific memories might not. Research suggests that factors contributing the most to cognitive problems are the use of a high electrical dose and the placement of electrodes on both temples, rather than just on the side of the head associated with the patient's non-dominant half of the brain. The difficulty for practitioners—as well as fuel for debate—is that when both temples are used, a patient might not require as high a dose of electricity to achieve the necessary rejiggering of brain circuitry.
How distressing is ECT to Patients?
While there are certainly patients who perceive the treatment as terrifying and shameful, and some patients who report distress about persistent memory loss, many speak positively of the benefits. An article entitled "Are Patients Shocked by ECT?" reported on interviews with 72 consecutive patients treated with ECT. The patients were asked whether they were frightened or angered by the experience, how they looked back at the treatment, & whether they would do it again. Of the patients interviewed, 54% considered a trip to the dentist more distressing, many praised the treatment, & 81% said they would agree to have ECT again. Those are comforting statistics about a treatment that has an ugly name and unfavorable connotations, while sometimes offering amazing and occasionally even life-saving results.
Why is ECT so controversial?
After 60 years of use, ECT is still the most controversial psychiatric treatment. Much of the controversy surrounding ECT revolves around its effectiveness vs. the side effects, the objectivity of ECT experts, and the recent increase in ECT as a quick and easy solution, instead of long-term psychotherapy or hospitalization.
Because of the concern about permanent memory loss and confusion related to ECT treatment, some researchers recommend that the treatment only be used as a last resort. It is also unclear whether or not ECT is effective. In some cases, the numbers are extremely favorable, citing 80 percent improvement in severely depressed patients, after ECT. However, other studies indicate that the relapse is high, even for patients who take medication after ECT. Some researchers insist that no study proves that ECT is effective for more than four weeks.
During the last decade, the “typical” ECT patient has changed from low-income males under 40, to middle-income women over 65. This coincides with changing demographics. The increase in the elderly population and Medicare, and the push by insurance companies to provide fast, “medical” treatment rather than talk therapy. Unfortunately, concerns have been raised concerning inappropriate and even dangerous treatment of elderly patients with heart conditions, and the administration of ECT without proper patient consent.
Is ECT an option?
The patient and physician should discuss all options available before deciding on any treatment. If ECT is recommended, the patient should be given a complete medical examination including a history, physical, neurological examination, EKG and laboratory test. Medications need to be noted and monitored closely, as should cardiac conditions and hypertension. The patient and family should be educated and informed about the procedure via videos, written material, discussion, and any other means available before a written consent is signed.
The procedure should be administered by trained health professionals with experience in ECT administration as well as a specifically trained and certified anesthesiologist to administer the anesthesia. The seizure initiated by the electrical stimulus varies from person to person and should be monitored carefully by the administration team. Monitoring should be done by an EEG or “cuff” technique.
The nature of ECT, its history of abuse, unfavorable medical and media reports, and testimony from former patients all contribute to the debate surrounding its use. Research should continue, and techniques should be refined to maximize the efficacy and minimize the risks and side effects resulting from ECT.
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