Provided By: The Mayo Clinic
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.