What is Electroconvulsive Therapy?
Electroconvulsive therapy (ECT or shock treatment) is an extremely safe and effective medical treatment for certain psychiatric disorders. With this treatment, a small amount of electricity is applied to the scalp, producing a seizure in the brain. The procedure is painless because the patient is asleep, under general anesthesia.
Who is treated with ECT?
ECT has been used for over 60 years. In the United States, about 100,000 individuals are estimated to receive ECT each year. ECT is most commonly given when patients have severe depressive illness, mania, or some forms of schizophrenia. Frequently, ECT is given when patients have not responded to other treatments, when other treatments appear to be less safe or too difficult to tolerate, when patients have responded well to ECT in the past, or when psychiatric or medical considerations make it particularly important that patients recover quickly and fully.
Not all patients improve when treated with medications or psychotherapy (talk therapy). Indeed, when illnesses such as depression become particularly severe, it is doubtful that psychotherapy alone will be sufficient. For some patients, the medical risks of medications are greater than the medical risks of ECT. Typically, these are people with serious medical problems, such as some types of heart disease. When patients have life-threatening psychiatric problems, such as suicidal tendencies, ECT is also often recommended because it usually provides more immediate relief than medications. Overall, about 70 to 90 percent of depressed patients treated with ECT show substantial improvement. This makes ECT the most effective of the antidepressant treatments.
Who administers ECT?
A treatment team provides ECT. The team consists of a psychiatrist, an anesthesiologist, and nurses. The physicians responsible for administering ECT are experienced specialists.
How is ECT given?
Before ECT is administered, the patient's medical condition is carefully assessed. This includes a complete medical history, physical examination, and medical tests, as needed. The treatments are usually given three times per week in the morning on Monday, Wednesday and Friday. Before each treatment, the patient should fast, not eating or drinking anything after midnight the night before the procedure. Patients should also try to refrain from smoking during the morning prior to the treatment.
When the patient comes to the ECT treatment room, an intravenous line is started. Sensors for recording, EEG (electroencephalogram, a measure of brain activity) are placed on the head. Other sensors are placed on the chest for monitoring EKG (electrocardiogram). A cuff is wrapped around an arm for monitoring blood pressure. When everything is connected and in order, an anesthetic medication is injected through the intravenous line that will cause the patient to sleep for 5 to 10 minutes. Once the patient falls asleep, a muscle relaxant is injected. This prevents movement, and during the seizure there are only minimal contractions of the muscles.
When the patient is completely asleep and the muscles are well relaxed, the treatment is given. A brief electrical charge is applied to electrodes on the scalp. This stimulates the brain and produces the seizure that lasts for about a minute. Throughout the procedure, the patient receives oxygen through a mask. This continues until the patient resumes breathing on his or her own. When the treatment is completed, the patient is taken to a recovery area for monitoring by trained staff. Typically, within 30 to 60 minutes, the patient can leave the recovery area.
How many treatments are needed?
ECT is given in a series of treatments. The total number needed to successfully treat psychiatric disturbance varies from patient to patient. For depression, the typical range is from 6 to 12 treatments, but some patients may require fewer while some patients may require more treatments.
Is ECT effective?
ECT is extremely effective in providing relief from symptoms associated with psychiatric conditions. However, permanent cures for psychiatric illness are rare, regardless of the treatment given. To prevent relapse following ECT, most patients require further treatment with medications or with ECT. If ECT is used to protect against relapse, it is usually administered to outpatients on a weekly to monthly basis.
How safe is ECT?
It is estimated that death associated with ECT occurs in one of 10,000 patients. This rate may be higher in patients with severe medical conditions. ECT appears to have less risk of death or serious medical complications than a number of the medications used to treat psychiatric conditions. Because of this strong safety record, ECT is often recommended for patients with serious medical conditions. With modem anesthesia, fractures and dental complications are very rare.
What are the common side effects of ECT?
The patient will experience some confusion on awakening, following the treatment. This is partly due to the anesthesia and partly due to the treatment. The confusion typically clears within an hour. Some patients have headaches following the treatment. This is usually relieved by Tylenol or aspirin. Other side effects, such as nausea, last for a few hours at most and are relatively uncommon. In patients with heart disease, there is an increased risk of cardiac complications. Cardiac monitoring and other precautions, including the use of additional medications, if required, help to ensure a safe treatment.
The side effect of ECT that has received the most attention is memory loss. ECT results in two types of memory loss. The first involves rapid forgetting of new information. For example, shortly following the treatment, patients may have difficulty remembering conversations or things they have recently read. This type of memory loss is short-lived and has not been shown to persist for more than a few weeks following the completion of ECT. The second type of memory loss concerns events from the past. Some patients will have gaps in their memory for events that occurred in the weeks or months and, less commonly, years prior to the treatment course. This memory loss also reverses following the completion of ECT. However, in some patients there may be permanent gaps in memory for events that occurred close in time to the treatment. However, like with any treatment, patients differ in the extent to which they experience side effects, and more extensive memory loss has been reported by a minority of individuals. It is known that the effects on memory are not necessary to obtain the benefits of ECT.
Many psychiatric illnesses result in impairments of attention and concentration. Consequently, when the psychiatric disturbance improves following ECT, there is often improvement in these aspects of thinking. Shortly following, ECT, most patients show improved scores on tests of intelligence, attention, and learning.
Does ECT cause brain damage?
The scientific evidence strongly speaks against this possibility. Careful studies in animals have shown no evidence of brain damage from brief seizures, like those given with ECT. In the adult, seizures must be sustained for hours before brain damage can occur, yet the ECT seizure lasts only for about a minute. Brain imaging studies following ECT have shown no changes in the structure or composition of the brain. The amount of electricity used in ECT is so small that it cannot cause electrical injury.
How does ECT work?
Like many other treatments in medicine, the exact process that underlies the effectiveness of ECT is uncertain. It is known that the benefits of ECT depend on producing a seizure in the brain and on technical factors in how the seizure is produced. Biological changes that result from the seizure are critical to effectiveness. Most investigators believe that specific changes in brain chemistry produced by ECT are the key to restoring normal function.
Considerable research is being conducted to isolate the critical biochemical processes.
Is ECT frightening?
ECT has often been portrayed in the movies and TV as a painful procedure, used to control or punish patients. These portrayals have no resemblance to modem ECT. One survey found that following ECT most patients reported that it was no worse than going to the dentist, and many found ECT less stressful. Other research has shown that the vast majority of patients report that their memory is improved following ECT and that if needed, they would receive ECT again.
Some people who advocate legislative bans against ECT are former psychiatric patients who have undergone the procedure and believe they have been harmed by it and that the treatment is used to punish patients’ misbehavior and make them more docile. This is untrue.
It is true that many years ago, when psychiatric knowledge was less advanced, ECT was used for a wide range of psychiatric problems, sometimes even to control troublesome patients. The procedure was frightening for patients because it was then administered without anesthesia or muscle relaxants, and the uncontrolled seizures sometimes broke bones. Today, the American Psychiatric Association (APA) has very strict guidelines for ECT administration. This organization supports use of ECT only to treat severe, disabling mental disorders; never to control behavior.
ECT is an extremely effective form of treatment. It is often safer and more effective than medications or no treatment at all. If you have any questions about ECT, please discuss them with your physician.