Electroconvulsive Therapy

Electroconvulsive therapy (ECT), previously known as electroshock, is a well-established, albeit controversial, psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Today, ECT is most often used as a treatment for severe major depression which has not responded to other treatment, and is also used in the treatment of mania (often in bipolar disorder), and catatonia.

Many people opposed to ECT are against it because they feel it is being used to “control” patients. Many years ago when psychiatry was less advanced, ECT was used for a much wider range of mental illnesses and unfortunately sometimes it was used to control troublesome patients. Today, the American Psychiatric Association has very specific guidelines for the administration of ECT. It is to be used only to treat severe, debilitating mental disorders and not to control behavior. In most states, written and informed consent is required. The doctor will explain in detail to the patient and or family the reasons why ECT is being considered along with the potential side effects. ECT is generally used in severely depressed patients for whom psychotherapy and medication are proving ineffective. It may also be considered when there is an imminent risk of suicide because ECT often has much quicker results than antidepressant remedies.

The procedure is usually performed on an inpatient basis although maintenance ECT may be performed once a week or so as an outpatient. The patient is required to fast for 8-12 hours prior to treatment. Involved in the administration of ECT are usually a psychiatrist, anesthesiologist, and other supportive medical personnel. The patient is anesthetized with an intravenous injection of a barbiturate or other anesthetic. The muscles are temporarily paralyzed with the drug succinylcholine which prevents the violent jerking motions that used to break bones. The heart rate and other vital signs are monitored throughout the procedure.

In bilateral ECT, electrodes are placed above each temple. In unilateral ECT, the electrodes are placed above the temple of one side of the brain and in the middle of the forehead. An electrical current is then passed through the brain, inducing a grand mal seizure. Evidence of the seizure may show in twitching toes, an increased heart rate, clenched fists or a chest heave. Clinically effective seizures generally last from about 30 seconds to just over a minute. The patient’s body does not convulse and the patient feels no pain. During the seizure there are a series of changes in brain waves on an electroencephalogram (EEG) and when the EEG tracing levels of this is an indication that the seizure is over. As the patient awakens there may be headache, nausea, and temporary confusion and muscle stiffness.

» Why the Test is performed: ECT is a highly effective treatment for depression, most commonly severe depression. It is also used to treat bipolar disorder, people who are rigid and not responsive (catatonic), and some psychotic disorders. It can be especially helpful for treating depression in patients who:

- Cannot take antidepressant drugs
- Are suicidal
- Are pregnant and severely depressed
- Have certain heart problems
- Are psychotic

» How the Test is performed: Electroconvulsive therapy (ECT) is most often done in a hospital's operating or recovery room while you are asleep and pain-free (general anesthesia).

- You receive medicine to relax you (muscle relaxant) and to prevent you from feeling pain (short-acting anesthetic).
- A small amount of electric current is delivered to the brain to cause seizure activity. It lasts for about 40 seconds. Medicine is given to prevent the seizure from spreading throughout the body.
- ECT is usually given once every 2 - 5 days for a total of 6 - 12 sessions.

» How does ECT work: It is believed that the seizure in the brain caused by ECT works to release 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.

There are varying opinions as to how the memory is affected by ECT. Many patients report loss of memory for events that occurred in the days, weeks or months surrounding the ECT. Many of these memories may return, although not always. Some patients have also reported that their short-term memory continues for months to be affected by ECT although there is the argument that this may be the type of amnesia that is sometimes associated with severe depression.

There is no doubt that properly used; ECT can be an effective procedure in the treatment of severe depression. Surprisingly, experts are still uncertain as to why it works. It is thought that ECT acts by temporarily altering some of the brain’s electrochemical processes. Electroconvulsive therapy is the most controversial treatment in psychiatry. It’s history of abuse, unfavorable media presentation and compelling testimony of former patients all contribute to the controversial context in which ECT is viewed. There are clearly significant side effects, especially acute confusion and persistent memory deficits.