Have you ever heard a medical war story?
I died on the table, and they brought me back twice. Broke two of my left ribs. The doc said it was a miracle.
You probably have. How about a psychiatric war story?
I was so depressed I wanted to kill myself; they gave me shock treatments and I got all better. Look at me now.
You probably haven’t. The reason is not that stories about ECT, electro-convulsive therapy, don’t exist*; it is because there is still a huge amount of stigma about mental illness in general and about ECT in particular. It is not something you talk about when you run into an old friend at the grocery store.
We’re all familiar with the horror stories, though, the images burned into our minds from years of TV and cinema. A feisty, likeable young man strapped down on the gurney, shocked with naked wires till his hair singes, turned into a zombie staring into space. Our hearts turn with indignation. How dare they?
I ran into some of that recently, on Twitter. A simple comment about the effectiveness of ECT brought on the wrath of the antipsychiatry folks.
You’re mixing electricity with water!
Doctors just love to strap people down and shock them don’t they?
Have you had ECT yourself? You seem to have very strong feelings about it.
The wrath has persisted – even when I and two other psychiatrists clearly stated that yes, if severely depressed, we would choose ECT as a treatment for ourselves. It’s no surprise; there is little knowledge and plenty of misinformation about ECT amongst both patients and doctors.
Let’s talk about ECT, then.
What is ECT?
During ECT, a small electric current, smaller than a Taser or a cardiac defibrillator, is applied to the person’s temple to induce a generalized seizure, lasting 15-45 seconds.
How does it work?
*Edited. There is no definitive answer to exactly how ECT works, but there are several well documented changes in the brain. The small seizure releases several neuro-chemicals in the brain. It also modulates the activity of several brain centers, such as the frontal cortex, prefrontal cortex, and cingulate cortex.
What is it used for?
The main use of ECT is in people who are severely depressed, often with strong suicidal thoughts, psychosis, catatonia, or severe malnutrition due to refusal of food.
ECT is not a first line treatment. It is usually considered in patients who have failed multiple treatments with several different medications and psychotherapies.
Is it better than other therapies?
Meta-analyses (collecting and analyzing multiple studies done over years) show that ECT is more effective than any other treatment used for severe major depression**. Significant improvement occurs in 70 to 90 percent of patients who receive ECT, compared with approximately 30 percent for medication.
In 2011, the FDA conducted its own systematic review and meta-analyses** with the following findings:
- An analysis of 5 randomized trials estimated that improvement on the depression rating scale was about 7.1 points greater in patients who received ECT compared with sham ECT.
- A review of 3 randomized trials found that ECT was more effective than placebo.
- An analysis of 8 randomized trials estimated that improvement on the depression rating scale was about 5.0 points greater in patients who received ECT compared with antidepressant medication.
Is it painful?
No. ECT is performed under anesthesia. Along with anesthetic, a muscle relaxant is usually administered so that the body does not shake, unlike a regular generalized seizure. This prevents accidental injuries during the convulsion.
There are two movements commonly seen during ECT- the initial facial grimace, which happens because electrodes directly placed on the temples cause the facial muscles to contract- it is often scary to students watching the procedure, but the patient does not feel a thing.
Second, a blood pressure cuff is placed on one ankle to prevent the muscle relaxant from reaching one foot. This allows the doctors to observe the seizure in the toes of one foot, to corroborate with the EEG.
An EEG- brain wave monitoring – is done during ECT. This allows the doctors to ensure an adequate seizure time, 15-45 seconds. This also allows them to use medication to terminate the seizure if it goes on longer than intended. An EKG-cardiac monitoring- is also commonly done.
What are the side effects? Can it kill the patient?
The death rate of ECT is 2 to 4 deaths per 100,000 treatments, making it one of the safest procedures performed under anesthesia. Death is mostly related to heart-related side effects. All patients must undergo a medical evaluation for clearance prior to receiving ECT, and a cardiac consultation is indicated for those with heart problems. Other side effects include aspiration pneumonia, fractures, injuries to the tongue or teeth, headache, and nausea.
What about the brain damage?
ECT causes three types of brain side effects:
- Acute confusion- this is a result of the seizure and anesthesia. It resolves in half an hour.
- Anterograde amnesia- decreased ability to retain new information. This usually resolves in 1-2 weeks after treatment.
- Retrograde amnesia- forgetting recent memories, for events that occur during the course of ECT and a few weeks- months prior to that. The deficits are greatest for knowledge about public events, rather than personal information. Some of the lost memories may return, while others may not. In one systematic review, 30-55% of patients reported persistent memory loss.***
The typical ECT patient is severely depressed and accepts some degree of memory loss as a reasonable tradeoff for improvement in depression.
Can someone be given ECT against their will?
ECT should be done with informed consent- a discussion of risks and benefits with the patient. It often involves patients watching videos of the procedure to assuage their anxiety, and they are given plenty of time to ask questions and decide if they want to proceed with treatment. Under rare circumstances, if a patient is too sick to give an adequate informed consent, the doctor may petition the court for a treatment order. ****
The trope of a poor, mentally ill person being given ECT against their will is just that, a trope. The typical ECT patient today is relatively affluent and receives ECT in a private center. State hospitals rarely offer the treatment.
For further information, please visit:
The National Institute of Mental Health. http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml
UpToDate basics. http://www.uptodate.com/contents/electroconvulsive-therapy-ect-the-basics?source=see_link
UpToDate beyond the basics. http://www.uptodate.com/contents/electroconvulsive-therapy-ect-beyond-the-basics?source=see_link
* Surgeon/writer Sherwin Nuland gave this wonderful TED talk about the history of ECT and his own experience as an ECT patient. Please watch this video for a patient perspective. http://www.youtube.com/watch?v=oEZrAGdZ1i8
** FDA Executive Summary: Prepared for the January 27-28, 2011 meeting of the Neurological Devices Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices (ECT). http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/NeurologicalDevicesPanel/UCM240933.pdf
**UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361:799.
*** Rose D, Fleischmann P, Wykes T, et al. Patients’ perspectives on electroconvulsive therapy: systematic review. BMJ 2003; 326:1363.
****The only time I saw a court ordered ECT in 6 years of training was an elderly patient, depressed to the point of zero communication. He was completely immobile, could not eat, could not use the restroom. He stayed so still for such a long time that contractures developed in all 4 limbs. Since he could not communicate his wishes, the doctors petitioned the court. After 6 ECT treatments, he started communicating enough to be able to work with physical therapy, and eventually became mobile enough to walk short distances with a walker. I will never forget the first day he smiled at me.