ECT, electroconvulsive therapy, is one of the more controversial treatments in all of medicine. Clinicians, administrators, psychiatrists, proponents, detractors, and Hollywood producers all have opinions that range from dogmatic endorsement to total abhorrence. ECT is one of the most misunderstood and misrepresented procedures physicians prescribe and patients experience. Those who see ECT as barbaric present it in a completely different light than those who see it as an effective treatment for mental illness. I have to agree, the idea of sending electricity into the brain of a depressed patient to make them have a seizure seems crazy. How on earth could that help anybody? Well, it does.
Amazingly, it works, and for nearly a century, it has been an accepted, safe, and effective method of treating serious mental illness. “It works faster and better than conventional pharmacological interventions, [but] those benefits come with a burden of side effects, most notably memory loss.” The dangers and fears of detractors are eliminated by current methods by which it is administered. Electroconvulsive therapy is done under general anesthesia, so the patient is asleep and unaware of the proceedings. The “seizure” generated by electrical stimulation of the brain, occurs only as an electrical phenomenon within the brain, and does not cause the jerking movements associated with “epileptic seizures.” The seizures are brief lasting a minute or less. The electrical impulses are directed toward areas of the brain specific to the problem being treated. This new technique of “focused” therapy has “already yielded improvements in cognitive outcomes without sacrificing efficacy.” ECT has thus treated the mental illness without causing the temporary memory problems so commonly seen.
ECT is indicated for the treatment of patients with the following disorders:
Severe depression:
Suicidal patients
Psychotic depression—have hallucinations, delusions, agitation, disconnect from reality
Patients who are failing to thrive—won’t eat, losing weight, withdrawn
Treatment Resistant Depression (TRD)—have failed to improve on drug therapy
Manic phase of bipolar disorder
Schizophrenic patients in a catatonic state
Agitated dementia patients
When the patient cannot take oral meds—during pregnancy, patient has drug side effects
Parkinson’s disease, delirium, autism
“There are no absolute contraindications,” but it is “high risk….for patients with recent myocardial infarction, cerebral hemorrhage, stroke, vascular aneurysm, retinal detachment, and pheochromocytoma (adrenal gland tumor). Mortality rate is very low…modified ECT is currently considered as an effective and safe form of treatment…..in geriatric, adolescent, and pregnant patients.”
ECT is done as a “course of therapy.” In other words, it is done 2 or 3 times a week for 3-4 weeks until a total of 6-12 treatments have been done. “It takes at least 6 treatments to see any significant effect.” Patients still need to continue drug therapy as well because if it is not given, “the relapse rate after a successful course of ECT is extremely high. Pharmacotherapy or continuation of maintenance ECT reduces the relapse rate by up to 40%….Gradual tapering off acute ECT treatments and…..maintenance ECT treatments based on the needs of each patient seems the optimum clinical practice.”
New techniques of ECT are achieving better results with fewer side effects, but memory loss, retrograde amnesia, and cognitive confusion still occur. They can’t last for hours, days, or even months, but with the new methods, these problems are less a concern. Headache, nausea, and muscle aches are common as well.
What actually happens in the brain during ECT? I don’t really know. I could not find a specific answer to that question, but I do know that science has identified areas of the brain that cause particular problems, and these areas are targeted by electrical impulses. Bombarding those areas disrupts, or alters, the existing brain chemistry. This targeted alteration is enough to correct the existing problem leading to improvement in the patient’s mood and behavior, and fewer post-ECT side effects. ECT is effective for treatment resistant depression in 80% of patients.
I can remember only two patients, both women in their 70’s, who had ECT. One of them, a woman with chronic depression, had had ECT numerous times over several years. She was helped by it every time, and got to the point where she knew it was time to have it again. Over the years, she became more tolerant of ECT and had fewer and shorter episodes of post-ECT confusion and memory loss. Her chronic depression was well-controlled by treatments.
The other woman became depressed late in life due to her failing health and that of her husband. She was hospitalized but failed to improve on multiple meds. ECT was prescribed, and did help her enough that she was able to go home. Her husband died not long after, and she was never the same. She died a few months later.
In preparing for this blog post, I actually changed my mind about electroconvulsive therapy. The negative aspects of confusion and memory loss are emphasized and presented far more often than the beneficial effects. That portrayal of ECT frightens patients and medical professionals and as such, so out of ignorance, it probably is under utilized. It certainly works faster than oral drug therapy which can take 3-4 weeks, or more, to take full effect. ECT is still reserved for more severely depressed or psychotic patients, and psychiatrists are trained to know who does and does not need it and prescribe it judiciously. Any previous concerns I had have been replaced by a far better understanding.
References: Kaliora SC, Zervas IM, Papadimitriou GN. Electroconvulsive therapy: 80 years of use in psychiatry. Psychiatriki 2018 Oct-Dec;29(4):291-302.
Deng Z-D, et al. How Electroconvulsive therapy works in the treatment of depression: is it the seizure, the electricity, or both? Neuropsychopharmacology 2024 Jan;49(1):150-162.
Spaans H-P, et al. Efficacy and cognitive side effects after brief pulse and ultra brief pulse right unilateral Electroconvulsive therapy for major depression: a randomized, double-blind, controlled study. J Clin Psychiatry 2013 Nov;74(11):1029-1036.
Brauser D. Electroconvulsive Therapy works, Now Scientists believe they know How. Medscape Medical News 2024 August 7.
