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ECT Electroconvulsive Therapy: What You Need to Know

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 and this produces 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 65 years. In the United States, more than 40,000 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 difficult to tolerate, when patients have responded well to ECT in the past, or when psychiatric or medical considerations indicate that it is particularly important that patients recover quickly and fully.

Why Hasn’t ECT been Replaced by Medications or Psychotherapy?

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 can be of much benefit. 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 faster relief than medications. Overall, about 70 to 90% of the depressed patients treated with ECT show substantial improvement. This makes ECT the most effective of the antidepressant treatments.

Who Administers ECT?

ECT is given by a treatment team. At Westchester Medical Center’s Behavioral Health Center, the team consists of a senior attending psychiatrist, an anesthesiologist and specially trained nurses. The psychiatrists responsible for administering ECT are highly experienced specialists who have made many of the advances that have improved this treatment. Each of the anesthesiologists is also highly experienced and is a member of the Department of Anesthesia of Westchester Medical Center. ECT is administered in a dedicated suite at the Behavioral Health Center. The suite contains a waiting area, a treatment room and a recovery room. The facilities for administering ECT are state-of-the-art.

How is ECT Given?

Before ECT is administered, the patient’s medical condition is carefully assessed. This includes a complete medical history, physical examination, blood and urine tests, electrocardiogram (EKG), chest X-ray and other tests as indicated. The treatments are usually given three times per week – Monday, Wednesday and Friday mornings. Before each treatment, the patient should not eat or drink anything after midnight prior to the scheduled treatments. Patients should also try to refrain from smoking during the morning prior to the treatment.

When a patient comes to the ECT treatment room, an intravenous line is started. Sensors for recording EEG (electrical 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, a sleeping medication (methohexital) is injected through the intravenous line that will cause the patient to sleep for five to ten minutes. Once the patient falls asleep, a muscle relaxant (succinylcholine or propofol) is injected.

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 a seizure that lasts for about a minute. Throughout the procedure, the patient receives oxy gen 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 the recovery room for monitoring by trained staff. Usually within 30 to 60 minutes, the patient can leave the recovery area.

How Many Treatments are Needed?

ECT is given as a course 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 and some may require more treatments.

Is ECT Curative?

ECT is exceptionally effective in providing relief from psychiatric symptoms. However, permanent cures for psychiatric illnesses 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, less than that with childbirth or common medical procedures. ECT appears to have less risk of death or serious medical complications than a number of medications used to treat psychiatric conditions.

Because of the strong safety record, ECT is often recommended for patients with serious medical conditions. With modern 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. With the ECT techniques used at Westchester Medical Center’s Behavioral Health Center, 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 in 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 to months surrounding 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. It is known that the effects on memory are not necessary to obtain the benefits of ECT. Psychiatrists at the Behavioral Health Center have developed specialized techniques to minimize the effects on memory, while ensuring effective treatment. In contrast, shortly following ECT, most patients show improved scores on tests of intelligence, attention and learning. 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.

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 raises brain temperature far less than 1/10 of a degree and can not cause electrical injury.

How does ECT Work?

Like many other treatments in psychiatry, 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. This indicates that biological changes that result from 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 modern 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.

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. You may also wish to read one of the following books. Both books were written by psychologists who were against people having ECT – until they had a severe depression and needed the treatment. Drs. Endler and Manning describe their illness, their experience in treatment with medication and psychotherapy and their experience with ECT.

Recommended Reading:

Holiday of Darkness
By Norman S. Elder
Wiley-Interscience, New York 1982

Undercurrents: A Therapist’s Reckoning with Depression
By Martha Manning
Harper, San Francisco 1995

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