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Electroconvulsive Therapy (ECT)

Electroconvulsive Therapy (ECT)

A short history

ECT works by the electrical induction of a controlled seizure. The concept of the use of intentionally-induced convulsions to treat psychiatric illnesses dates back to the 19th century. In the early 1900’s, Ladislas Joseph von Meduna began to study the therapeutic effects of chemically-induced seizures on patients with psychosis and catatonia. These studies later lead the became the basis of Italian researchers Ugo Cerletti and Lucio Bini’s work who, in 1938, applied electricity to induce convulsions. Later studies established ECT’s effectiveness in treating major depressive disorder and other major psychiatric illnesses.

ECT was extensively used during the 1940’s and 1950’s to treat depression and psychotic illnesses. Despite continuing advances, the use of ECT waned in the 60’s and 70’s. This decline in use primarily resulted from social stigma, the advent of antidepressant and antipsychotic drugs, and a better understanding of some of the causes of psychiatric illnesses.

With significant improvements in safety and tolerability, ECT underwent a significant revival in the 1970’s. Over the past 40 years, there has been extensive refinement of the methods for electrical stimulation and ways to optimize the antidepressant effects of ECT. Additionally, with the use of modern anesthesia, muscle relaxants, and lower charge delivery, ECT has become a mainstay of the treatment of individuals with severe, medication-refractory mood disorders and psychosis. Today, ECT is considered among the most efficacious treatment for severe mental illnesses.

Approximately 150,000 people get ECT every year in the US.

Uses of ECT

  • ECT is considered the treatment of choice for patients suffering from severe major depressive disorder that have either not responded to medications or have failed to tolerate medications as a result of various side effects. ECT is also used in patients where response is needed quickly (for instance acutely suicidal patients, patients who are not eating or drinking, and patients with catatonia).

  • ECT is also employed in the treatment of individuals suffering from medication-resistant bipolar illness (both mania and depression). It is also used in treating psychotic exacerbations or medication-resistant psychosis in schizophrenia.

  • ECT has been used in treating neuroleptic malignant syndrome and refractory Parkinson’s disease.

  • ECT is considered a safe treatment modality in pregnant women in whom a number of medications may be associated with risk to the fetus.

How does ECT work?

ECT involves the administration of electric current to the brain to induce a controlled seizure while the patient is under the influence of general anesthesia and muscle relaxants.

The exact mechanism of how ECT works is still unknown. There are multiple theories that have been put forward and research on this topic is ongoing.

  • The “neurotransmitter theory” suggests that ECT causes an alteration in the levels of various brain chemicals (called neurotransmitters) such as serotonin, norepiphrine, dopamine, and acetylcholine among others.

  • The “anticonvulsant theory” links clinical improvement to increase in the seizure threshold (amount of electricity needed to induce seizure) over time with ECT.

  • The “neuroendocrine theory” proposes that ECT causes the release of certain hormones from the hypothalamus which results in alleviation of symptoms.

How is ECT given?

ECT at Washington University

  • Prior to getting ECT – You will meet with a consulting psychiatrist who will review your previous treatment history. Additionally, the ECT consultant will discuss with you, at length, the risks, benefits and alternatives to ECT and address any concerns you have. An informed consent for the procedure will be taken. A recent set of blood tests and an electrocardiogram (ECG) will be required as part of the pre-treatment workup. You will also be advised whether any of your medications will need to be withheld before ECT. In some instances, additional radiographic tests (x-rays, CT scan of brain) may be required.

  • The night before – You will be asked to consume no food or drink past midnight on the night before an ECT treatment. Please discuss with your treating physician whether you should take medications for high blood pressure, heart conditions, reflux, and other conditions on the morning prior to the treatments (these can usually be taken with sip of water).

  • Getting there – To ensure your safety, our policy mandates that someone accompany you to ECT and stay for the duration of the treatment. You will not be allowed to transport yourself home on the day of ECT, so it is imperative that you have transportation arranged.

  • Schedule – ECT is administered at our center on Monday, Wednesday, Thursday, and Friday. The treatments usually start early (7am) and you will be notified of your appointment in advance. Please try to reach the treatment area approximately half an hour prior to your treatment.

  • The ECT team – Once you arrive at the treatment area, you will meet the members of the ECT team. The team typically consists of an attending psychiatrist, a psychiatry resident, an anesthesiologist, and nursing staff.

  • Step by Step –

    • The nursing staff will meet with you upon arrival and help you change into a hospital gown. They will also perform an initial assessment about your current condition (symptoms, side-effects and vital signs).

    • The psychiatrist will perform a brief physical and mental status exam. This will usually take place in a pre-treatment waiting area.

    • Another member of the team will insert an intravenous (IV) catheter which will allow administration of medications and anesthetic agents necessary to perform the procedure.

    • You will then be taken into the treatment room where you will be attached (via pads and wires) to various equipment monitoring your blood pressure, heart rate, blood oxygen level, and brain waves.

    • The anesthetic agent will be administered to put you to sleep for a short time. Simultaneously a mask to provide oxygen will be placed on your nose and mouth.

    • Once you are under the influence of the anesthetic, a muscle relaxant will be administered. This is done to prevent your muscles from contracting during the seizure. This is a safety measure and prevents the body from inadvertent injuries.

    • Two electrodes will be placed your scalp and brief pulses of electricity will be given over a few seconds to induce the seizure. Seizure duration varies but typically seizure lasts well under a minute. You will be unconscious during the electrical stimulation and seizure. Seizures typically last about 60 sec or less.

    • Your vital signs and brain wave activity will be monitored closely during the procedure. The entire procedure from the time of administration of anesthesia to you beginning to wake up will last around 15 minutes. Once you begin to wake up, you will be transferred to the recovery room. Typically, when patients awaken from the treatment they are momentarily confused. This confusion usually resolves within 30 minutes of awakening.

    • In the recovery room, your vital signs will continue to be monitored and the nursing staff will frequently check your level of consciousness. Once you have regained full consciousness and your vital signs are stable you will be allowed to leave the recovery area. You can expect to spend approximately half an hour recovering from the procedure.

  • How many treatments will I need? – Studies have demonstrated that most patients require a series of treatments in order for ECT to be effective. Most ECT courses necessitate 10 - 12 treatments at a frequency of three times a week (referred to as the “index course” of treatments). Studies also demonstrate that some patients receiving ECT for depression do best when they then receive a slow taper of treatments following this “index course” (initially weekly, then biweekly) over the course of the next 6-8 weeks (these followup treatments are referred to as “maintenance treatments”).

  • Most people receiving ECT do not notice an improvement in their condition until the 5th or 6th treatment (often your family members and friends notice the difference before you do). Clinical response to ECT will be monitored by the treatment team and your primary psychiatrist. Your clinical improvement will play a part in the determining the total number of ECT treatments that you would require.

Side Effects

Every treatment has side effects and so does ECT.

  • Headaches, muscle soreness and nausea are the most common side effects associated with ECT. These are usually minor, may last a few hours and easily managed with medications given either during the procedure or while in recovery.

  • Cardiovascular complications – ECT may cause transient heart rhythm abnormalities or transient elevations in heart rate or blood pressure. With careful screening of patients, close monitoring during the procedure, and timely administration of medications, complications can be minimized.

  • Confusion – Some patients may experience confusion after the procedure which lasts more than a few minutes. Usually this confusion is self-limited and corrects itself within a few hours. Reassurance, frequent reorientation and monitoring are all that is needed for management of confusion.

  • Memory Impairment – Memory loss is probably the biggest concern that people have with ECT. ECT may cause problems with loss of memory for events surrounding or preceding the procedure. This problem typically resolves within days to weeks of cessation of treatments. In a minority of patients, memory of remote events may be affected. However extensive research has proven that ECT does not cause permanent brain damage.

  • Mortality Risk – The risk of mortality with ECT is the same as any minor surgical procedure and corresponds with the risk of anesthesia. The risk of death from a complication is 1 in 10,000 (0.01%). Certain risk factors are associated with a higher risk of anesthesia and thus higher mortality. These factors are discussed with the patient during their consent to treatment.

Contraindications to ECT

According to the American Psychiatric Association (APA) there are no absolute contraindications to ECT. Certain conditions however put a patient at a higher risk for complications. Some of these conditions are

  • Brain tumors or any condition which elevates the normal fluid pressure of the brain.

  • Recent heart attack.

  • Recent episode of bleeding into the brain.

  • Unstable brain blood vessel abnormality predisposed to bleeding.

ECT and other treatment modalities

ECT works best in conjunction with other modes of treatment namely medications and psychotherapy. ECT is the most effective treatment available for depression and other severe mental illnesses; however, in order to remain illness-free it is imperative to continue taking medications.

Misconceptions of ECT

  • ECT does not work — ECT is the most effective treatment for severe major depression & other severe mental illnesses with response rates exceeding medication management or psychotherapy (85% and above).

  • ECT causes brain damage — Extensive research has demonstrated no evidence to support the notion that ECT leads to brain damage over the short or the long term. Some individuals have received over 200 treatments with no evidence of any lasting harm.

  • ECT is a dangerous procedure — The risk of mortality is 1 in 10,000 which is equivalent to minor surgical procedures under general anesthesia. ECT is routinely done as an outpatient and patients go home after spending a few hours recovering from anesthesia.

  • ECT takes a long time to work — ECT is the most rapid treatment available for depression and bipolar disorder.

  • ECT causes fractures — The administration of muscle relaxants prevents injuries and fractures.

  • ECT is usually given against the patient’s wishes — The vast majority of ECT treatments are given voluntarily after obtaining informed consent. The patient undergoes a thorough screening to be determined appropriate for ECT.

  • ECT has not changed since the 60’s — Significant improvements in the techniques (including muscle relaxants, short acting anesthetic agents, use of oxygen, close monitoring, better devices) have made ECT a much safer and more reliable treatment option.