Overview

Electroconvulsive therapy (ECT), also referred to as shock therapy, involves the passing of a low-dose electric current through the brain to produce a therapeutic effect in certain mental disorders such as depression.

With these low-dose electric currents, generalized and controlled seizures are induced in the anesthetized patient to produce the therapeutic effect.

It is widely used in the United States and the rest of the world being endorsed by the American Psychiatric Association (APA) and Professional Associations in Austria, Canada, Australia, Denmark, Netherlands, Germany, and India.

Here we discuss

  • How ECT works
  • Uses
  • ECT procedure
  • Dosage, variations, and results
  • Effects and complications
  • Maintenance therapy with ECT

Formerly, ECT was called electric shock treatment or electric shock therapy, or electroshock therapy and had a stigma attached to it because the high voltage electric currents that were used, produced serious side effects such as loss of memory and fractured bones.

Today it is safe because the currents used, have been optimized to be low and controlled, and side effects thereby are minimal. ECT today is quite safe, fast, and very effective.

For patients with severe depression, bipolar disorder, or psychosis, electroconvulsive therapy can successfully change the life of a person.

How does ECT work?

Although ECT therapy was first introduced in 1938, how it works is still a mystery.

It produces a large release of neurotransmitters, serotonin, norepinephrine, and dopamine, in the brain caused by a controlled seizure.

These neurotransmitters are responsible for mood sentiment and are used by the brain cells to communicate signals.

Another school of thought proposes that the seizures, caused by the shock therapy treatment, adjust the stress hormone levels in the brain, which affect mood, energy, sleep, and appetite.

Uses of ECT and Why it is Done

ECT has proved to be an effective and safe treatment for many psychiatric disorders. Its uses are listed below:

In mental disorders

Electroconvulsive therapy can give rapid and significant relief in even severe symptoms of certain mental health disorders.

It is generally indicated when other forms of treatments such as medications and psychotherapy, have failed and in a life-threatening situation when the risk of a suicide attempt is high.

ECT gives dramatic relief in about 8 out of 10 patients. Today it is given to about 100,000 people a year in the US.

It is effectively used in the treatment of the following mental conditions:-

  • Severe depression, which has not responded to other treatments or when it is accompanied by psychosis (loss of reality) and suicidal tendencies. ECT is the fastest way to give relief. Significant improvement is seen within one to two weeks.
  • Catatonia is loss of motor mobility, lack of speech, and atypical behavior. It is associated with other psychiatric conditions such as schizophrenia, bipolar and severe depression. It is also seen as caused by some medical illnesses such as autoimmune disorders.
  • Schizophrenia is a mental disorder where the thought process and emotional response are disintegrated. ECT becomes the treatment of choice especially when schizophrenia is accompanied by psychosis, suicidal tendency, or a desire to hurt others.
  • Mania is part of bipolar disorder characterized by intense euphoria, agitation, hyperactivity, impulsive behavior, psychosis, and substance abuse.
  • Parkinson’s disease or epilepsy
  • Severe obsessive-compulsive disorder not responding to other treatments

Other general indications

  • During pregnancy when taking medications can prove harmful to the fetus and rapid response is necessary.
  • In older people who cannot tolerate the side effects of medicines.
  • In people who voluntarily prefer ECT instead of taking medicines.
  • Patients who have been previously successfully treated with ECT.

Medical evaluation before ECT

Before ECT, a medical and psychiatric evaluation is necessary to determine your fitness. The anesthetist is also consulted to rule out the possibility of any anesthesia risks. The following examinations help to confirm the safety of ECT in the patient.

  • Medical history for the presence of any existing health conditions such as high blood pressure, diabetes, any heart condition, etc.
  • Physical examination includes checking the pulse and blood pressure, breathing sounds, heart sounds, etc.
  • Certain blood tests may be asked for such as a complete blood cell count and a comprehensive metabolic panel.
  • Chest X-ray is taken.
  • ECG is done to rule out a heart condition.

How is ECT done? Procedure

ECT is administered by a team of trained medical professionals and includes a psychiatrist, an anesthesiologist, and a physician with a nurse standing by.

Before the procedure

It is necessary that the patient comes with an empty stomach for ECT because general anesthesia is used.

The patient should not eat or drink anything at least 6 hours before the procedure. Before the treatment, informed consent is taken.

The patient is given a muscle relaxant and a short-acting anesthetic so that he does not feel pain. He may be administered oxygen.

The doctor may give you a mouth guard to help protect your teeth and tongue from injury during the seizure.

During ECT procedure

Electrodes are placed on the scalp and a fine and controlled current is passed for one second or less. Depending on the requirement, one or both electrodes may be placed. Accordingly, it is called unilateral or bilateral ECT.

In bilateral ECT, electrodes are placed, one on each temple. In unilateral ECT, one electrode is placed on the temple of the nondominant side of the brain (usually the right side) and the other electrode is placed on the center of the forehead.

Unilateral ECT results in delivering the stimulus on the right side of the brain and away from the primary learning and memory centers, which helps to reduce the cognitive complication of ECT.

However, unilateral ECT is less effective than bilateral procedure. In the USA and UK, most patients receive bilateral ECT.

ECT stimulates the brain cells causing them to fire in unison to cause a brief seizure in the brain which lasts for 20 to 90 seconds. Because of the muscle relaxant, the only visible signs are slight movements of the hands and feet.

The patient is carefully monitored during this procedure. The patient wakes up in 5 to 10 minutes. He does not remember the procedure events (short-term memory loss) and is confused. This typically lasts for a short period.

During the procedure, an electroencephalogram (EEG) monitors the activity of the brain during the seizure and an electrocardiogram (ECG) monitors the rhythm of the heart.

After ECT treatment

Generally, the doctor allows you to return to normal activities a few hours after the procedure.

However, the doctor may advise the patient not to return to work immediately, not to take important decisions, or not to drive for one to two weeks after the last ECT in a series or for at least 24 hours after a single treatment session during maintenance therapy.

Usually, after an ECT session, it is important that you postpone any major decisions until a week or two after the completion of your ECT course. It is also important that you do not drive during your course of ECT sessions.

Resuming normal activities depends on how soon the patient recovers from memory loss and confusion.

Dosage

ECT is usually given up to three times a week for 2 to 4 weeks. The average number of treatments is nine but it can vary from six to twelve depending on the severity and the response time.

Variations in procedure guidelines

The application of electroconvulsive therapy can differ in three ways.

  • Electrode placement
  • Frequency of treatments
  • The electric waveform of the stimulus

These variations have their indications and their adverse effects vary. After the ECT, the psychiatrist may put the patient on maintenance therapy with drugs or a maintenance dose of ECT.

Results of ECT

Successful results with this shock therapy may not be seen in everyone. However, it has a success rate of 70 to 90 percent, while antidepressant medications succeed in 50 to 60 percent of patients. Additionally,  ECT produces results faster.

Medications typically take up to eight weeks to show improvement. With ECT, the patient starts feeling better in two weeks or less.

Electroconvulsive therapy can also be very effective in patients in whom multiple medications have failed. In patients with suicidal tendencies, effective treatment can mean the difference between life and death.

Usually, significant improvement in symptoms with ECT is seen after six treatment sessions but mild improvements can be noticed after 3 treatments.

These improvements could show as an increase in activity levels, an increase in appetite, and improved sleep patterns.

Side effects

Electroconvulsive therapy is, generally speaking quite safe. Different people react differently. Side effects that are known to occur can be short-term and long-term. The death rate is around 4 in 100,000 procedures.

It should be used with caution in pregnant women and older people because of the higher risk of these complications.

Short-Term side effects

  • Many people complain of headaches, nausea, vomiting, muscle aches, soreness (due to the muscle relaxant), and a feeling of sickness. They also feel frightened after ECT and during recovery. Most of the time, these effects go away within a few hours with the help of an analgesic and refreshments and a talk from the medical or paramedical talk.
  • There is a temporary loss of memory for the time just before and after the ECT. This can last for a few minutes or a few hours. Taking rest for a few hours after treatment is necessary.
  • Older people become confused and this confusion can last for a couple of hours. Giving unilateral ECT to such patients helps to reduce this problem.
  • Medical risks associated with general anesthesia, such as physical injury, rise in heart rate and blood pressure, heart problems, or even death, can occur. The incidence of such effects due to general anesthesia is 2 in 100,000 treatments.
  • ECT is risky in people who suffer from heart problems as it can cause tachycardia (increased heart rate), hypertension (increased blood pressure), and arrhythmias (irregular heartbeat). In such patients, beta-blockers are given prophylactically and strict monitoring is done.

Long-Term side effects

  • In most people, memory returns within a few weeks after completion of the ECT course. Some people complain of losing their memory permanently. However, it is not clear whether this is due to ECT or mental illness. What is generally agreed is that the risk of memory loss increases with more shock treatment sessions.
  • Some people feel that their personality has permanently changed. Some even complain of having lost their skills and some feel that they are no longer the person they were before treatment.

Maintenance with ECT

Out of the people with depression who respond successfully to ECT treatment, 20% to 50%  suffer from a relapse. The maintenance of depression therapy is, therefore, necessary. This can be with either antidepressants or lithium or ECT. Shocks are given at monthly or 6 weekly intervals for maintenance therapy.

Though ECT may seem to heal mental illness, it is not a cure. There are no cures for depression or mental illness in medicine.

But, there are effective treatments that can get someone over an episode of depression. Patients treated with ECT still need to be on medication to prevent future mental episodes.

Some patients will need to undergo ECT also as maintenance if medication fails to prevent future episodes.