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Electroconvulsive Therapy: Beneficial or Barbaric?

By far the most controversial modality in the treatment of depression is electroconvulsive therapy (ECT), also known as electric shock therapy. Much of the public's concerns about ECT arise from the gruesome way in which the treatment has been portrayed by the popular media. Many people still cringe when they recall the memory of Jack Nicholson being punished with ECT treatments in the film "One Flew Over the Cuckoo's Nest." The idea of having electrical currents forced through one's brain inspires fear and terror while conjuring images of Frankenstein, mad scientists and electrocution. Can such a seemingly barbaric practice be effective in treating severe depression? In this page, we will explore the pros and cons of ECT.

What is ECT?

Electroconvulsive therapy is a treatment for severe mental illness in which the brain is stimulated with a strong electrical current which induces a seizure, similar to those of epilepsy. In a manner that is not understood, this seizure rearranges the brain's neurochemistry, resulting in an elevation of mood. Although ECT is by necessity an invasive procedure, in recent years safer and less traumatic ways of administering ECT have evolved, the treatment has made a comeback.

How effective is ECT in treating mental disorders?

The efficacy of ECT has been established most convincingly in the treatment of delusional and severe clinical depressions (the latter is what I experienced), which make up a clinically important minority of depressive disorders. Some studies find ECT to be as effective as antidepressants, while others find ECT to be superior to medication. The literature also indicates that ECT, when compared with antidepressants, has a more rapid onset of action.

A nurse at one hospital reported, "I have seen severely depressed people who were unable to dress or feed themselves; I had to change their diapers because they were so regressed and withdrawn. By the end of their ECT treatments they were smiling, eating and drinking on their own. It's as if they were brought back from the dead." ECT has also been shown to be a safe and effective treatment for mania.

Before the discovery of lithium, ECT was the mainstay treatment for mania as well as for severe depression. It is still often effective for mania when lithium and antipsychotic drugs fail. For example, in one study ECT was given for eight weeks to seventeen patients who had failed to respond to lithium. All of them recovered. Although ECT can jolt people out of severe depression and mania, recovery is not necessarily permanent. Relapse rates in the year following ECT are likely to be high unless maintenance antidepressant medications are subsequently prescribed. In other instances, "maintenance doses" of ECT are given two to six times a year to prevent relapse. ECT is also useful in certain types of schizophrenia, although antipsychotic drugs remain the first line of treatment.

How is ECT administered?

Once the patient (or his or her guardians) and the physician have decided that ECT may be indicated, the patient undergoes a pre-treatment medical workup that includes a history, physical, neurologic examination, electrocardiogram (EKG), and laboratory tests. Typically, ECT is administered in the early morning after an eight-to twelve-hour period of fasting, although mid-afternoon treatments are also used. A number of medications and muscle relaxants are given to the patient, and stimulus electrodes are placed on the head, either on one or both temporal lobes (for unilateral or bilateral ECT, respectively). After the muscle relaxant has taken effect, the brain is stimulated with an electrical pulse lasting from a quarter of a second to two seconds. The pulse induces a seizure which usually lasts from 30 seconds to two minutes, during which time the patient is closely monitored. After the treatment, the patient is brought to a recovery room where he or she remains until waking. The number of ECT treatments in a course of therapy varies between six and twelve. Treatments are given three times a week, for two to four weeks. Following ECT, most depressed patients are continued on antidepressant medication or lithium to reduce the risk of relapse. Sometimes, physicians give maintenance doses of ECT to their patients on an outpatient basis.

What are the risks and adverse effects of ECT?

ECT is clearly less dangerous than it once was. Over the years, safer methods of administration have been developed, including the use of short-acting anesthetics, muscle relaxants, and adequate oxygenation, which have reduced the risk of physical injury and mortality. Yet even under optimal conditions of administration, the ECT seizure produces two main reactions-transient post-treatment confusion, and spotty but persistent memory loss.

Immediately after awakening from the treatment, the patient experiences confusion, temporary memory loss, and headache. Some people compare their experience to having a bad hangover. The time it takes to recover clear consciousness may vary from minutes to several hours, the exact length depending on the type of ECT administered (stimulating both hemispheres produces more confusion than unilateral ECT), as well as individual differences in the patients' response patterns.

The second side effect of ECT is memory loss which persists after the termination of a normal course of treatment. This amnesia seems to surround events that occurred around the time of the treatment, either several weeks before or after. For example, the patient may not remember who took him to the hospital or what gifts he gave a month before the treatment. The ability to learn and retain new information does not seem to be adversely affected, although learning difficulties may exist during the first few weeks after the treatment.

Because there is also a wide difference in individual perception of the memory deficit, the subjective loss can be extremely distressing to some and of little concern to others. For example, many patients who complain about autobiographical memory loss say that being free of depression is well worth whatever memory disruption they experience. Others insist, however, that they have suffered a terrible disruption to their memory and to their lives. Although the second group is in the minority (80 percent of people who have had ECT report that the procedure was no more frightening than going to the dentist), accounts of the suffering of those who perceive they have been harmed may add to the apprehension of many patients who consider ECT treatment.

Conclusion

ECT remains controversial despite its documented benefits. This controversy is perpetuated by the following factors: the nature of the treatment itself, its history of abuse, unfavorable media presentations, compelling testimony of former patients, special attention by the legal system, and uneven distribution of ECT use among practitioners and facilities.

Nonetheless, ECT is demonstrably effective for a narrow range of severe psychiatric disorders-delusional and severe endogenous depression, manic episodes, and certain schizophrenic syndromes. There are, however, significant side effects, especially confused states and persistent memory deficits for events during the weeks surrounding the ECT treatment. Proper administration of ECT can reduce potential side effects while still providing for adequate therapeutic effects.

Much additional research is needed into the basic mechanisms by which ECT exerts its therapeutic effects. Studies are also needed to better identify groups for whom the treatment is particularly beneficial (or toxic) and to refine techniques that will maximize the treatment's effectiveness and reduce side effects. A national survey should be conducted on how ECT is being used in the United States. To prevent misapplication and abuse, it is essential that appropriate mechanisms be established to ensure proper standards and monitoring of ECT. Moreover, rigorous double blind studies must be implemented to determine if ECT really is effective, to carefully document side effects, and to identify potential patients at risk. In this manner, ECT can be administered in the right way, at the right time, for the right patients.