Shedding light on electroconvulsive therapy (ECT)

What is ECT?

Electroconvulsive therapy (ECT) is stimulation of the brain under anesthesia using a brief, tiny, highly controlled electrical current. At most it is one-third to one-quarter of the electrical energy and charge of the defibrillator machine used on the heart. It is delivered in a series of treatments over several weeks as a course of ECT. Despite some concerns with the descriptive name for the treatment, it is the best treatment for major depressive disorder and has far better results than current medications and psychotherapies for the right patients. It is a safe, brief (six- to eight-minute), minor procedure that is routinely and safely given to outpatients.

Why use ECT?

ECT is the best treatment for major depressive disorder and some other conditions. Like many medical treatments, it requires several treatments to obtain its effect and for the benefits to "stick." (Think of how one dose of an antibiotic usually is not enough to clear up an infection.) Like many medical treatments such as dialysis, insulin, even eyeglasses, in some cases once the benefit is obtained, it may need to be repeated at some interval, such as once a week to every eight or more weeks for an indefinite period of time as maintenance ECT.

Why does ECT work?

The brain uses electricity naturally. Nerve cells are tiny electrochemical units. Modern ECT controls electrical parameters to more closely match those of the brain and deliver appropriate, corrective electrical treatments.

The entire answer for why ECT works is not known. This continues to be actively researched and investigated. There are many theories; essentially, the brain is thought to "reset" itself. The fact that science cannot fully explain all of the mechanisms of action is not very concerning in medicine, and the situation is the same for many other treatments.

What we do have with ECT is a treatment that has had more than seven decades of investigation, revision and refinement. When it was first developed, some people went home from mental hospitals in an era when that almost never happened. Today, for some it is like a miraculous cure; for others, it may hold them from suicide until a better treatment can emerge. Unfortunately, for some it does not work or seems related to severe side-effects or worse. We are always concerned first about side-effects and second about benefits with any treatment including ECT, but ECT is not controversial among most psychiatrists. ECT helps far more than it hinders, and many other treatments in medicine are far more toxic and filled with far greater risks.

When is ECT used?

ECT is the gold standard life-saving treatment for people with a condition called catatonia (and related or similar conditions). People with major depression may be candidates for treatment, especially if they are experiencing hallucinations or delusions, or if they are actively suicidal.

ECT can also be used:

• for treatment refractory major depressive disorder, bipolar affective disorder and schizophrenia
• for people who prefer ECT or for whom ECT has been beneficial
• for some types of Parkinson’s disease and some other conditions

What happens during an ECT procedure?

First the person is checked in by the nurses and indicates whether there have been any changes in their health status or treatments, including their medications. The person typically has had nothing to eat or drink after midnight, including no medications. They bring their medications and food with them to take after they safely recover from the treatment.

They are brought into the ECT suite by a nurse where their identity, allergies and so on are reconfirmed and they speak to and update the anesthesiologist, psychiatrist and two nurses in the room. During the procedure, an intravenous line is started, and the patient is hooked up to a heart monitor, oxygen saturation monitor, brainwave monitor, blood pressure machine and oxygen mask. When all is ready they are given medicines to sleep and to relax their muscles. The psychiatrist checks their brainwaves and prints off a baseline strip for reference later, sets the dosing for the ECT and, once the person is safely asleep and muscles properly relaxed, delivers the ECT. The stimulus lasts at most eight seconds. The person is constantly monitored and their brain is monitored for a proper response, a generalized seizure. Once the seizure ends, the monitors and oxygen are disconnected so the anesthesiologist and a nurse can transfer them to the recovery room, which is immediately off the ECT suite. Once the person is awake and can safely get up, they are transferred to a wheelchair if they are an outpatient and taken to the secondary recovery room where there are comfortable reclining chairs. Patients having ECT wait until they can safely go home with a responsible adult person who should remain with them for 24 hours.

How long is an ECT procedure?

ECT is a minor procedure and usually can be safely done for outpatients. It is a series of treatments, and there is no magic number; it depends on the person, their condition, the type of ECT used and other factors. Typically it is two to three times a week for 12 to 18 treatments. Each treatment is short—six to eight minutes on average in the ECT suite at an efficient centre.

What are the side-effects of ECT?

There is a risk of death, usually quoted at its worst as 1 in 10,000. Some recent studies have put the risk at 1 in 50,000 to 100,000; contrast that with the risk of suicide in untreated major depression at 1 in 10. More commonly, some people experience headaches and muscle pains. Other risks include delirium; confusion; agitation; switching to manic, hypomanic or mixed states and rapid cycling; lack of, limited or loss of benefit; and nausea. There may be unknown, unpredicted or unpredictable risks. The field well recognizes that some patients have reported both global and permanent memory impairments, both anterograde (making new memories) and retrograde (remembering old memories). All potential side-effects can and should be reported and managed as best as possible.

How can families help patients who will be receiving ECT?

First recognize that there is always hope, that recovery is supported in the medical literature and that some patients will need lifelong maintenance ECT, just like some need blood pressure medications, insulin or dialysis for the rest of their lives.

Family members are encouraged to remember to monitor and report any concerns. Although ECT is a minor procedure, it is a repeated procedure that the person receiving ECT will probably be anxious about before each treatment, may have some insomnia the night before, and may need help in the future with remembering what they were suffering with before the treatment and what was going on during the weeks of the treatment. Because ECT is a series of treatments, loved ones need to know that it will often take three or four (or more) treatments before they notice a difference and a few more for the person themselves to notice that the ECT is working. However, some patients have a more rapid response. Some types of ECT result in a more rapid response than other types (which may have a better side-effect risk profile). I like to think of the analogy of building a pyramid: it takes awhile to build the base layers, but eventually a day's work results in more rapid reaching for the sky.