Electroconvulsive therapy (ECT)

Definition

Electroconvulsive therapy (ECT) is a procedure in which electric currents are passed through the brain, deliberately triggering a brief seizure. Electroconvulsive therapy seems to cause changes in brain chemistry that can immediately reverse symptoms of certain mental illnesses. It often works when other treatments are unsuccessful.

Much of the stigma attached to electroconvulsive therapy is based on early treatments in which high doses of electricity were administered without anesthesia, leading to memory loss, fractured bones and other serious side effects.

Electroconvulsive therapy is much safer today. Although electroconvulsive therapy still causes some side effects, it now uses electrical currents given in a controlled setting to achieve the most benefit with the fewest possible risks.

Why it's done

Electroconvulsive therapy (ECT) can provide rapid, significant improvements in severe symptoms of a number of mental health conditions. It may be an effective treatment in someone who is suicidal, for instance, or end an episode of severe mania. ECT is used to treat:

• Severe depression, particularly when accompanied by detachment from reality (psychosis), a desire to commit suicide or refusal to eat.
• Treatment-resistant depression, long-term depression that doesn't improve with medications or other treatments.
• Schizophrenia, particularly when accompanied by psychosis, a desire to commit suicide or hurt someone else, or refusal to eat.
• Severe mania, a state of intense euphoria, agitation or hyperactivity that occurs as part of bipolar disorder. Other signs of mania include impaired decision making, impulsive or risky behavior, substance abuse and psychosis.
• Catatonia, characterized by lack of movement, fast or strange movements, lack of speech, and other symptoms. It's associated with schizophrenia and some other psychiatric disorders. In some cases, catatonia is caused by a medical illness.

Electroconvulsive therapy is sometimes used as a last-resort treatment for:

• Treatment-resistant obsessive compulsive disorder, severe obsessive compulsive disorder that doesn't improve with medications or other treatments
• Parkinson's disease, epilepsy, and certain other conditions that cause movement problems or seizures
• Tourette syndrome that doesn't improve with medications or other treatments

ECT may be a good treatment option when medications aren't tolerated or other forms of therapy haven't worked. In some cases ECT is used:

• During pregnancy, when medications can't be taken because they might harm the developing fetus
• In older adults who can't tolerate drug side effects
• In people who prefer ECT treatments over taking medications
• When ECT has been successful in the past

Risks

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

• Confusion. 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 confusion may last from a few minutes to several hours. You may be able to return to work and normal activities right away; or, you may need to rest for several hours after treatment. Rarely, confusion may last several days or longer. Confusion is generally more noticeable in older adults.
• 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. It may be hard to remember things in 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.
• Physical side effects. On the days you have an ECT treatment, you may experience nausea, vomiting, headache, jaw pain, muscle ache or muscle spasms. These are common and generally can be treated with medications.
• Medical complications. As with any type of medical procedure, especially one in which anesthesia is used, there are risks of medical complications. During ECT, heart rate and blood pressure increase, and in rare cases, that can lead to serious heart problems. If you have heart problems, ECT may be more risky.

How you prepare

Before having your first ECT treatment, you need a complete physical examination, in addition to a psychiatric evaluation. You may also see an anesthesiologist to go over 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 your heart health

What you can expect

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

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. ECT 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 also is 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.

Series of treatments
In the United States, ECT treatments are generally given three times weekly for two to four weeks — for a total of six to twelve treatments. The number of treatments you will need depends on the severity of your symptoms and how rapidly they improve.

Results

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 and other mental illnesses. What is known, though, is that many chemical aspects of brain function are changed during and after seizure activity. These chemical changes may build upon one another, somehow reducing symptoms of severe depression or other mental illnesses.

That's why ECT 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 most people who receive the full course.

Even after your symptoms improve, you likely will need ongoing treatment to prevent a recurrence. That ongoing treatment, known as maintenance therapy, doesn't have to be ECT, but it can be. More often, it includes antidepressants or other medications or psychological counseling (psychotherapy).