Electroconvulsive Therapy (ECT) is a procedure in which a small electric current is passed through the brain, intentionally triggering a brief seizure. Older theories of ECT's effect involve changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses. However, there has been an explosion in research about how ECT and other Interventional treatments work. These theories involve the effect of ECT on brain circuitry, activating circuits that are inactive, and damping down circuits that are overactive. These changes are referred to as NEUROMODULATION. Neuromodulatory therapies like ECT often work when other treatments are unsuccessful.
Much of the stigma attached to ECT 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.
ECT is much safer today and is given to people while they're under general anesthesia. Although ECT 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 is ECT 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, even when accompanied by detachment from reality (psychosis), a desire to commit suicide or refusal to eat.
- Treatment-resistant depression, a severe depression that doesn't improve with medications or other treatments.
- 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. Catatonia can occur in both schizophrenia and some other psychiatric disorders including severe depression. In some cases, catatonia is caused by a medical illness.
- Agitation and aggression in people with dementia, which can be difficult to treat and negatively affect quality of life.
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
ECT may be a good treatment option when medications aren't tolerated or other forms of therapy haven't worked. The graph below demonstrates how effective ECT can be in patients who have failed three or more medication trials (the bars on the right of the graph). As you can see, ECT is more effective than TMS, and far more effective than yet another trial of medication (the bars on the left of the graph).
What are the risks and side effects of ECT?
Although ECT is generally safe, risks and side effects may include:
- Confusion. Immediately after an ECT treatment, you may experience a brief period of confusion that can last a few minutes or rarely longer. You may not know where you are or why you're there. You may be able to return to normal activities right away, or you may need to rest for several hours after treatment. Rarely, some confusion may last several days. 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 previous years, as well. We will monitor your memory function carefully during treatment to try to avoid any loss of older memories. 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 generally can be treated with medications to prevent their occurrence with future treatments.
- Medical complications. As with any type of medical procedure, especially one that involves anesthesia, there are risks of medical complications. During ECT, heart rate and blood pressure increase, and in rare cases, that can lead to brief abnormalities in heart rhythm. If you have heart problems, ECT may pose a greater risk.
How do I prepare for ECT?
Before having your first ECT treatment, you'll need a full evaluation, which usually includes:
- A medical history
- A complete physical exam
- A psychiatric assessment
- Basic blood tests
- An electrocardiogram (ECG) to check your heart health
These exams help make sure that ECT is safe for you. You may also see an anesthesiologist to go over the risks of anesthesia.
What can I expect when I have ECT?
The ECT procedure takes about five to 10 minutes, with added time for preparation and recovery. ECT can be done while you're hospitalized or as an outpatient procedure. Usually, we admit patients to the hospital to begin ECT, but after the first treatment, you can go home and continue your treatments as an outpatient.
Before the procedure
To get ready for the ECT procedure:
- Since you will have general anesthesia, you will be instructed to not eat after midnight before the treatment. You may drink clear liquids (liquids you can see through) up to 2 hours before your ECT treatment. You should take your morning medications with a sip of water on the morning of your treatments.
- The anesthesiologist will do a brief physical exam to check your heart and lungs.
- You will have an intravenous (IV) line inserted. Your nurse or another health care team member inserts an IV tube into your arm or hand through which medications or fluids can be given.
- The ECT nurse places electrode pads on your head. Each pad is about the size of a silver dollar. ECT can be unilateral, in which electrical currents focus on only one side of the brain, or bilateral, in which both sides of the brain receive focused electrical currents.
Anesthesia and medications
At the start of the procedure, you'll receive these medications through your IV:
- An anesthetic to make you unconscious and unaware of the procedure
- A muscle relaxant to help minimize the seizure and prevent injury
You also may receive other medications, depending on any health conditions you have or your previous reactions to ECT.
A blood pressure cuff placed around your ankle stops the muscle relaxant medication from entering the foot and affecting the muscles there. When the procedure begins, your doctor can monitor seizure activity by watching for movement in that foot. During the procedure, monitors constantly check your heart, blood pressure and oxygen use. You may be given oxygen through an oxygen mask. You will 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 less than 60 seconds.
Because of the anesthetic and muscle relaxant, you remain relaxed and unaware of the seizure. The only outward indication that you're having a seizure may be a rhythmic movement of your foot if there's a blood pressure cuff around your ankle. But internally, activity in your brain increases dramatically. A test called an electroencephalogram (EEG) records the electrical activity in your brain. 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 will be taken to a recovery area, where you will be monitored for a few minutes. When you wake up, you may experience a period of confusion. If that occurs, you will be discharged from the treatment area once you are thinking clearly.
Series of treatments
In the United States, ECT treatments are generally given two to three times weekly for three to four weeks. Most people require six to 12 treatments, although up to 20 or more treatments are needed in some cases. The number of treatments you will need depends on the severity of your symptoms and how rapidly they improve. After the initial series of treatments, additional treatments are usually given on a less frequent basis to prevent the return of depression or other symptoms. These treatments are progressively spread out over time to help test new medication you will be given to insure it is protecting you as ECT becomes less frequent.
Why should I receive ECT from the physicians at Psychiatric Intervention Associates?
The physicians at Psychiatric Intervention Medical Associates are highly experienced brain stimulation psychiatrists, performing by far the most ECT in Central and Northern California. Dr. Goodman has been treating patients with ECT since 1985 and has performed many thousands of treatments during this time. Dr. Blanco has been treating patients with ECT for many years as well. The Psychiatric Intervention doctors understand that the decision to have ECT is an important step for patients, and make every effort to educate patients and their families about ECT before, during and after this decision is reached. They also are dedicated to remaining current with new advances in the field. As a result, their treatment methods are always up to date and state of the art. Furthermore, by working together as a team, the Psychiatric Intervention doctors constantly review their patients' progress and make any necessary modifications to the treatment plan. Most importantly, the Psychiatric Intervention psychiatrists have deep concern for their patients and are committed to providing the highest quality of care possible.