Electroconvulsive Therapy (ECT)
A Brief History of ECT
Electro convulsive therapy, commonly called ECT, was developed in 1938. During the period following its introduction, ECT was found effective for treating multiple psychiatric illnesses, especially depression. With the development of psychiatric medications and stigma associated with ECT in the 1960's, the use of ECT treatment declined. The use of ECT has increased since the 1980's because of improved treatment delivery methods, increased safety and comfort measures, and enhanced anesthesia management. ECT is the most effective treatment for severe mental illness and is a safe treatment.
ECT is most commonly used to treat patients with severe depression who fail to respond to medications or who are unable to tolerate the side effects associated with the medications. ECT may also be the treatment of choice for patients who need a more rapid response than medications can provide. This would include those who are severely agitated, delusional, suicidal, not eating or drinking, as well as those who suffer from catatonia (a potentially life threatening trance-like state).
The use of ECT is not limited to the treatment of depression. It may also be used to stabilize bipolar illness during extreme episodes of mania or depression. Additionally, ECT can be used to halt psychotic episodes associated with schizophrenia.
How Does ECT Work?
Mechanisms Of ECT
Electro convulsive therapy involves applying a brief electrical pulse to the scalp while the patient is under anesthesia. This pulse excites the brain cells causing them to fire in unison and produces a seizure.
The specific reason for the positive action of ECT is unknown, but this treatment appears to have many effects. There are multiple theories to explain why ECT is effective. One theory suggests that the seizure activity itself causes an alteration of the chemical messengers in the brain known as neurotransmitters. Another theory proposes that ECT treatments adjust the stress hormone regulation in the brain, which may affect energy, sleep, appetite, and mood.
The Number Of Treatments Needed
Treatments are normally administered two to three times a week. A course of ECT normally ranges from ten to twelve treatments. The number of treatments that you need will be determined by the severity of your symptoms and how rapidly you respond and side effects. It usually takes three to four treatments before major improvements in your symptoms are noted. However, some patients can see the improvement as quickly as after the first treatment itself. These improvements may include feeling happy, not crying, increase in your activity level, improved sleeping patterns, and a mild increase in your appetite. Your psychiatric care providers will monitor your response to the treatments. This information combined with your input will be used to determine how many treatments you will receive.
Right Unilateral Treatment Versus Bilateral ECT Treatments
There are primarily two types of electrode placements used for the delivery of ECT. Differences between these two techniques include the area of the brain stimulated, timing of response and potential side effects.
To generate a seizure with a right unilateral treatment, one electrode is placed on the crown of the head and the other on the right temple. Those receiving the right unilateral treatments may respond somewhat more slowly than those who receive bilateral treatments. This difference is usually no greater than 1 to 2 treatments. Right unilateral treatment is typically associated with less memory side effects. Patients who do not respond to right unilateral treatments may require a switch to bilateral placement.
Bilateral ECT treatment involves placing the electrodes on both temples. This treatment may be associated with more memory side effects than right unilateral treatments. Bilateral ECT is indicated for severe mental illnesses including depression with psychosis, manic episodes of bipolar disorder, psychosis related to schizophrenia and catatonia.
You and your doctor will work together to determine which treatment option is best for you. Specific recommendations will be made after carefully evaluating your concerns, medical/psychiatric history, and the severity of your symptoms.
The Treatment Team And Their Roles
Typically, ECT is performed by a team of medical professionals specifically trained in the delivery of ECT. This team consists of a psychiatrist, anesthesiologist, and nursing staff. The psychiatrist delivers the ECT stimulation. The anesthesia team administers medications and monitors your medical status throughout the procedure. After the treatment, nursing staff will continue to monitor your progress until you return to the inpatient or outpatient unit.
The Treatment
The night before a treatment you will not have anything to eat or drink after midnight. Some people may receive medications in the morning with a sip of water for headache, high blood pressure, stomach reflux, or other significant medical conditions. Shortly after you arrive in the ECT treatment area, an ECT team member will insert a catheter into your vein, often referred to as an IV. The IV will be used to administer medications necessary for both the ECT and your comfort. Pads with monitoring wires will be placed on your head and upper body to monitor your brain waves and your heart during the procedure. Blood pressure cuffs will be placed on both your upper arm and lower right leg. The cuff on your arm will be used to monitor your blood pressure. The cuff on your leg will be used to prevent the muscle relaxant medication from traveling to your foot, allowing the psychiatrist to monitor your motor seizure. You will then be given a medication to make you sleepy. At the same time, a mask will be placed over your nose and mouth. The mask is used to provide you with oxygen. When you are completely asleep, a muscle relaxant will be administered to prevent your muscles from twitching. After your muscles are sufficiently relaxed, two electrodes will be placed on your scalp and a pulse of electricity will be administered. Seizures vary, but are generally in the 25 to 45 second range.
You will be closely monitored during and immediately after this treatment. After you awaken and your vital signs are stable, you will be transferred to the recovery area. The ECT treatment generally lasts only 10 to 20 minutes. In the recovery area, the nurse will closely monitor your blood pressure and level of consciousness for another 20 to 30 minutes. Once the anesthesiologist is satisfied that you are ready, you will return to the inpatient or go home. Upon arrival in the inpatient or outpatient unit, your vital signs and level of consciousness will be checked again. As soon as you are alert, you will be provided with food and beverages and assisted with dressing as needed. At this point, if you are an outpatient, you will be released in the care of the person who accompanied you to the hospital. If you are an inpatient, you will be encouraged to participate in unit activities, or you may continue to rest if you are feeling tired.
Common Side Effects After Treatment
Occasionally, a patient may have a headache, muscle aches, or nausea after the treatment. These side effects can be treated with medications before or after the ECT. If you experience any of these side effects please inform your doctor and nurse. Once the staff is aware of these side effects, measures can be taken to prevent them.
Possible Memory Side Effects
Memory loss is one of the side effects from ECT. Two different kinds of memory loss may occur during the course of ECT treatments. The first is the loss of short-term memory during the period of time that you are having ECT treatments. Some examples of short-term memory loss include forgetting what you had for lunch or not remembering talking to someone earlier in the day. Your ability to remember new information will generally return to your normal level within a few weeks to a few months after the treatments are finished.
The second type of memory loss that may occur involves memory loss for past events. Recent past events (2 to 6 weeks before treatment) are more sensitive to ECT. However, some patients may describe "spotty" memory loss for events that occurred as far back as 6 months before beginning ECT. Although it is rare, some patients have reported a more severe memory loss of events, which dates back, further than the 6 months preceding ECT treatments.
The Safety Of ECT
Any medical procedure-involving anesthesia carries some risks. The potential risks include cardiac or respiratory arrest. The risk of respiratory or cardiac arrest resulting in death during ECT is negligible (less than 1 in 10,000 cases). This risk is typically regarded as being similar to the risks of having an outpatient surgical procedure under anesthesia. ECT treatments are safe and severe medical complications are rare. You will be monitored constantly during the procedure by a team of medical professionals in the event of a complication.
Maintenance ECT
Because depression is often a relapsing illness, patients may experience repeated episodes of depression even if they respond very well to ECT. Patients often have failed numerous medications prior to ECT, and their illness may be significantly resistant medications. When repeated episodes of depression occur, your doctors may recommend a taper of ECT over a course of several weeks to months. Modern clinical practice and recent research have found that Maintenance ECT is often very effective in keeping patients well. A common taper of ECT is treatments once a week for a month, once every 2 weeks for two months, once every 3 weeks for two months, and once every month for two-four months. Although there is a considerable commitment by patients and families to undergo Maintenance ECT, the avoidance of lengthy re-hospitalizations and undergoing more medication trials is often worth any inconveniences.
What To Expect After ECT
ECT is an extremely effective treatment, but ECT treatment is only one component of a complete treatment regimen. After your ECT course, medications will likely be required as maintenance therapy to prevent a return of your illness. ECT also cannot resolve other problems associated with personal relationships or how an individual copes with the stressors of life. Other interventions such as psychotherapy may be recommended. Hopefully, because you are being relieved of the severe symptoms of your illness, you will be able to participate more effectively with other therapies that are recommended.