Electroconvulsive therapy (ECT): Treating severe depression and mental illness

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Electroconvulsive therapy (ECT): Treating severe depression and mental illness

Electroconvulsive therapy — Learn how modern-day ECT works.

For some people, electroconvulsive therapy (ECT) conjures up frightening images. You may envision painful, violent seizures. Or you may simply have a generally negative emotional reaction to electroconvulsive therapy. Indeed, although it's much safer today, the use of electroconvulsive therapy in treating depression and other mental illnesses remains controversial, 70 years after it was first introduced.

In certain cases, though, electroconvulsive therapy may be the best treatment option, sometimes offering fast and significant benefits. In severe depression, for instance, the risk of suicide may be high, requiring treatment that can quickly alleviate symptoms. For some people, antidepressant medications aren't effective. For still others, mental illness may have left them in a state of psychosis, and ECT may be able to help end that episode.

Deciding whether electroconvulsive therapy is a good option for you or a loved one can be extremely difficult. Should electroconvulsive therapy be your first treatment choice? Or should it only be a last resort? Will it cause lasting side effects? It's not a decision to make lightly. But understanding more about the potential benefits and risks of electronconvulsive therapy can help in your decision.

Modern-day ECT a far cry from years past

Today, although electroconvulsive therapy isn't risk-free, it's a far cry from the old methods that helped give electroconvulsive therapy a bad reputation — a reputation that lingers on. Its use began in the early 1930s, when researchers injected chemicals in people with mental illnesses to induce seizures. The chemicals were soon replaced by electrical currents. The success of electroconvulsive therapy propelled it into widespread and sometimes indiscriminate use over the next few decades, before the advent in the 1950s of medications to treat depression.

In those early years, electroconvulsive therapy could be painful and downright dangerous. It was administered with neither anesthetics nor muscle relaxants, and the electrical current was much higher. Powerful seizures racked the body with a force that could break bones. The images of doctors and nurses holding people down as they endured violent seizures were captured in books and films and have become nearly indelible.

Electroconvulsive therapy is different today, although it still does pose a risk of side effects and complications, such as memory loss and confusion. Yet the procedure has become refined, with precisely calculated electrical currents administered in a controlled medical setting to achieve the most benefits with the fewest risks.

Who might benefit from ECT?

Electroconvulsive therapy is a procedure in which electrical currents are passed through the brain to trigger a seizure. Researchers don't fully understand just how ECT works. But it's thought that the seizure causes changes in brain chemistry. Given in a series over several weeks, ECT can help alleviate the symptoms of certain mental illnesses.

ECT is most commonly recommended for people with:

  • Severe depression, accompanied by psychosis, suicidal intent or refusal to eat
  • Mania that hasn't been improved with medications
  • Schizophrenia, when symptoms are severe or medications aren't sufficient

Preparing for ECT

Before having your first electroconvulsive therapy treatment, you need a complete physical examination, in addition to a psychiatric evaluation. You may also have a consultation with an anesthesiologist to assess the risks associated with having anesthesia. These exams help make sure that ECT is safe for you.

A pre-ECT evaluation usually includes:

  • A medical history
  • A physical examination
  • Basic blood tests
  • An electrocardiogram (ECG) to check for certain types of heart disease

You must also sign informed consent documents authorizing the use of electroconvulsive therapy. Consent means that you understand the procedure and its risks and benefits. If you're unable to provide written consent, state or local laws may allow the appointment of a legal guardian who can approve the procedure on your behalf if deemed medically necessary.

What to expect during ECT

The ECT procedure takes about 10 or 15 minutes, with added time for preparation and recovery. Electroconvulsive therapy may be performed while you're hospitalized or as an outpatient procedure. In either case, it's done under brief general anesthesia. Your health care team will tell you how long you must avoid food and drinks before the procedure.

When it's time for the procedure, you may have a brief physical exam to check your heart and lungs. An intravenous (IV) catheter is inserted in your arm or hand through which medications or fluids can be given. During the procedure, monitors constantly check your heart, blood pressure and oxygen use. You may be given oxygen through an oxygen mask.

Doctors place electrode pads, each about the size of a silver dollar, on your head. Electroconvulsive therapy can be unilateral, in which only one side of the brain is subject to electricity, or bilateral, in which both sides of the brain receive electrical currents.

Anesthesia and medications
An anesthetic is injected in the IV to make you unconscious and unaware of the procedure. A muscle relaxant is also injected to help prevent your body from convulsing violently during the seizure. A blood pressure cuff is placed around your forearm or ankle area, preventing the muscle relaxant from paralyzing those particular muscles. When the procedure begins, the doctor can make sure you're actually having a seizure by watching for movement in that one hand or foot.

In addition to the anesthetic and muscle relaxant, you may be given other medications, depending on any health conditions you have or your previous reactions to ECT. You may also be given a mouth guard to help protect your teeth and tongue from injury.

Inducing a seizure
When you're asleep from the anesthetic and your muscles are relaxed, the doctor presses a button on the ECT machine. This causes a small amount of electrical current to pass through the electrodes to your brain, producing a seizure that usually lasts 30 to 60 seconds.

Because of the anesthetic and muscle relaxant, you remain relaxed and unaware of the seizure. The only outward indication that you're experiencing a seizure may be a rhythmic movement of a foot or a hand. But internally, activity in your brain increases dramatically. This is recorded by an electroencephalogram (EEG) in much the same way as an ECG measures your heart's activity. Sudden, increased activity on the EEG signals the beginning of a seizure, followed by a leveling off that shows the seizure is over.

A few minutes later, the effects of the short-acting anesthetic and muscle relaxant begin to wear off. You're taken to a recovery area, where you're monitored for problems. Upon awakening, you may experience a period of confusion lasting from a few minutes to a few hours or more.

Seeing improvements with ECT

Many people begin to notice an improvement in their symptoms after two or three treatments with electroconvulsive therapy. Full improvement may take longer, though. Response to antidepressant medications, in comparison, can take several weeks or more.

No one knows for certain how ECT helps treat severe depression or other mental illnesses. What is known, though, is that many chemical aspects of brain function are altered during and after seizure activity. Researchers theorize that when ECT is administered on a regular basis, these chemical changes build upon one another, somehow reducing symptoms of severe depression or other mental illnesses.

That's why electroconvulsive therapy is most effective with multiple treatments. Most people who receive ECT have treatments three times a week, usually for two to four weeks. ECT is effective in about 80 percent of people who receive the full course.

Even after your symptoms improve, you likely will need ongoing treatment to prevent a recurrence. That ongoing treatment doesn't have to be ECT, but it can be. This ongoing treatment is known as maintenance treatment. It may include antidepressants or other psychiatric medications or psychotherapy.

Understanding the risks of ECT

Although electroconvulsive therapy is generally safe, there are known risks and side effects. These include:

  • Cognitive impairment. Immediately after an ECT treatment, you may experience a period of confusion. You may not know where you are or why you're there. This impairment in your thought process (cognition) generally lasts from a few minutes to several hours. However, the more ECT treatments you have, the longer confusion may last. Occasionally, the confusion may last several days. It typically goes away when the course of treatment is over.
  • Memory loss. ECT can affect memory in several ways. You may have trouble remembering events that occurred before treatment began, a condition known as retrograde amnesia. For most, retrograde amnesia obscures memory of the weeks or months leading up to treatment, although some people do have problems with memories from years previous, as well. You may also have trouble recalling events that occurred during the weeks of your treatment. And some people have trouble with memory of events that occur even after ECT has stopped. These memory problems usually improve within a couple of months. For some, though, memory loss is permanent.
  • Medical complications. As with any type of medical procedure, especially one in which anesthesia is used, there are risks of medical complications. The pre-ECT medical evaluation helps identify medical conditions that may put you at increased risk of complications during ECT, enabling doctors to take special precautions. During ECT, heart rate and blood pressure increase, and in rare cases, that can lead to serious heart problems. ECT also carries a very small risk of death, about the same as with other procedures in which anesthesia is used.
  • Physical issues. On the days you have an ECT treatment, you may experience nausea, vomiting, headache, muscle ache or jaw pain. These are common and generally can be treated effectively with medications.

Deciding if ECT is right for you

Some 100,000 Americans have ECT treatments each year. But how do you know if electroconvulsive therapy is right for you? Talking to your doctors, family members and others who've had ECT can help you make an informed decision.

Here are some issues to consider:

  • You need quick relief of symptoms. Perhaps your symptoms are severe enough that there's a fear you may attempt suicide. In some cases of severe depression, people refuse food and fluids to the point where their physical health is at risk. Occasionally, people with severe depression experience delusions or hallucinations that put them at risk of hurting themselves or others. In these situations, when you may not have time to wait for antidepressants to take effect, ECT may offer faster benefits.
  • Other treatments aren't effective. When you've tried antidepressants, and possibly psychotherapy, to no avail, ECT may be your next best option.
  • You can't take antidepressants. Some people are extremely sensitive to antidepressants and experience significant side effects even with the lowest possible doses. In addition, women who are pregnant may not want to risk exposing their unborn babies to psychiatric medications.
  • You didn't respond well to other treatments in the past. If you've had depression or other mental illnesses in the past and treatment wasn't effective, it may be time to consider ECT for the latest recurrence.
  • You've already done well with ECT. If you were treated with ECT in the past and it worked well, you may decide that it makes sense to stick with a proven treatment if your condition recurs.

Despite its dubious past, electroconvulsive therapy is now a relatively safe and effective procedure. ECT can often work faster than psychiatric medications or psychotherapy can, and it can help when other treatments have failed. The risks are real but usually small.

Last Updated: 07/14/2006
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