Ashley is an experienced mental health nurse and former pharmacist. She blogs about mental health and lives with major depressive disorder.
What Is Electroconvulsive Therapy?
There are few medical treatments with as notorious a reputation as "shock therapy", yet that reputation is based far more in myth than fact. The modern medical term is electroconvulsive therapy (ECT), and it plays an important role in the treatment of depression and other conditions. A Canadian Psychiatric Association position paper defines ECT as " a medical procedure in which a brief electrical stimulus is used to induce a cerebral seizure under controlled conditions."
The idea of inducing seizures to treat mental illness stemmed from observations that patients with psychosis and epilepsy experienced improved psychosis following seizures. Initially drugs such as insulin were used to produce the seizures, but in 1938 electric shocks were first introduced to treat patients with schizophrenia.
It's unclear exactly how the ECT produces its therapeutic effects. One hypothesis is that it leads to an increase in the production of brain-derived neurotrophic factor (BDNF), which promotes healthy brain growth and function.
Who Should Receive ECT?
The most common indication for ECT is severe depression. It may also be used for mania, bipolar mixed states, and psychosis. ECT is often reserved for use as a second or third line therapy, but this has more to do with public misperceptions about the treatment than any concerns about safety or efficacy.
ECT is very effective, even in patients who have not responded to any other treatment. Success rates typically range from 70-90%, which is significantly better than the efficacy of antidepressant medications.
The therapeutic effect of ECT can be seen far more rapidly than with antidepressants. It may begin to take effect in a week, as opposed to four weeks or more with antidepressants. This makes ECT a particularly good choice for patients who are actively suicidal, especially those trying to take their own lives while in hospital, or for people who are catatonic and as a result have limited or no oral intake.
Despite common assumptions to the contrary, ECT is actually considered safer than medications, and may be a better option for people who are pregnant, elderly, or dealing with major physical illness. An anaesthesiology consultation is done prior to treatment to ensure that the patient is medically appropriate for ECT, particularly with respect to any cardiovascular, respiratory, and central nervous system conditions.
The effects of ECT are not permanent, so some form of maintenance therapy is generally required. This should be taken into account early on in treatment planning.
How Is ECT Performed?
ECT may be done on an inpatient or outpatient basis. An acute course of ECT as an inpatient typically involves treatments 2-3 times per week, for around 8-12 treatments. The total number of treatments can vary widely depending on treatment response.
Outpatient ECT is usually done for maintenance purposes, and the frequency of treatments tends to be lower. Because ECT involves general anaesthesia, outpatient treatment programs will typically recommend that the person receiving ECT should not be left alone on the day of treatment.
Because of the anaesthetic, the patient must have nothing by mouth in the hours leading up to the procedure. Morning medications are typically held until after the treatment has been completed, although in some cases certain medications may be ordered pre-procedure, such as antacids to prevent gastric reflux. Medications that affect that seizure threshold may be held the night prior to treatment.
Health care team members involved in administering ECT include a psychiatrist, an anaesthesiologist, and a nurse. ECT is performed under general anaesthesia, and the muscle relaxant succinylcholine is also used to prevent muscle contractions, meaning there is not visible seizure activity.
The two electrodes that deliver the electrical stimulus may be placed unilaterally over the non-dominant hemisphere of the brain or bilaterally, typically over each temple. Unilateral placement has a lower risk of cognitive side effects, but bilateral placement produces better therapeutic effects.
The electric current is applied for 1-2 seconds, leading to a brief generalized seizure that usually lasts under a minute. The seizure activity in the brain is monitored using an electroencephalogram (EEG).
Supplementary oxygen is administered via facial mask both before and after the seizure to ensure that the patient is well oxygenated. A bite block is placed in the mouth prior to the stimulus being delivered to ensure there is no damage to the teeth or tongue during the seizure.
There is a visual representation of the procedure in the TED-Ed video below.
TED-Ed: The Truth About ECT
The Risks of ECT
Common minor side effects include headaches or muscle pain following ECT treatments. The muscle pain is generally a side effect of the muscle relaxant rather than a result of the seizure. These effects are transient and respond well to over-the-counter medication.
Cognitive side effects can be the most concerning. These can include disorientation immediately following ECT, and problems with attention and memory. There may be short-term effects on anterograde memory, which is the ability to form new memories. There may also be effects on retrograde memory, which involves loss of memories that were already stored. Often these memories will come back within six months after treatment, but this isn't always the case.
For most people who do experiencing lasting memory effects, the period of time affected lasts from a few months before the ECT to a few weeks after the treatment is complete. The risk of memory loss is lower now than it was in the past due to refinements in treatment parameters.
While critics of the treatment have expressed concerns about permanent brain damage resulting from ECT, multiple scientific reviews have not found any credible evidence to support this assertion.
There is a very small risk of cardiovascular complications, and the anaesthesiology consultation prior to ECT helps to screen out patients that would be at a higher level of risk.
There is tremendous stigma around ECT, and unfortunately, many of the ideas commonly associated with ECT are not based in the reality of current pracrtice. Modern ECT is not in any way barbaric, and it's not something that's reserved only for extreme circumstances. It's certainly nothing at all like what you see in the film One Flew Over the Cuckoo's Nest.
Of course, people living with mental illness have grown up exposed to the same stigmatized ideas everyone else has, and that can be dangerous if someone is refusing a potentially life-saving treatment due to stigma.
If stigma is standing in the way of people getting effective treatment for serious mental illness, then that's a serious problem, not just for the people being under-treated, but also for their families, friends, employers, and other community connections. Keeping people ill longer because of misconceptions is not an effective way to approach mental health care.
I worked as a nurse for five years on an inpatient acute psychiatry unit, and we had many patients who were receiving ECT. Headache was the most common side effect reported, and this tended to respond well to analgesic medication. By the time patients made it back to the unit from the ECT suite, disorientation was rare. For the most part effects on memory were minor, particularly in relation to the therapeutic benefit achieved.
I also experienced ECT as a patient during three separate hospitalizations for major depressive disorder. Early on in my first hospitalization, I was actively suicidal, making multiple attempts to end my life while on the ward. Waiting around for oral medications to work really wasn't a feasible option if the treatment team was going to keep me alive. I didn't respond well to unilateral treatments, so I was soon switched to bilateral. I got three treatments per week, for a total of around 17 altogether, which is a relatively long course of treatment. Once I began responding, I would notice an improvement with each treatment, and then I would start to dip again just before the next one was due. The ECT didn't get me completely well, but it got me well enough that other treatment strategies could take over.
The ECT procedure itself was very easy. They put an IV in, put on an oxygen mask, pushed the anaesthetic in through the IV line, and out I went. Later I woke up as if nothing had happened. The odd time I had a headache afterwards, but aside from that I had no physical adverse effects.
I did experience memory loss, and more so than most of my patients at work ever had. The anterograde memory loss continued while I was getting the treatments, but didn't persist beyond that. My family noticed it the most, but I wasn't overly bothered by it. I also experienced retrograde amnesia going back several months prior to my hospitalization, which I found more disconcerting. Some of those memories eventually came back, but not all. It made for some strange experiences when I came home from hospital to find items in my closet that I didn't recognize, and I saw pictures of myself doing things I had no memory of ever having done.
The second time I was hospitalized, I presented myself to ER asking specifically to be admitted and given ECT. Despite the memory loss I experienced with the first course, I knew that it was my best treatment option. I received another course of 16 bilateral ECT. It helped, but the effect wasn't as sustained as with my previous course of treatment. I had significantly less retrograde memory loss the second time around, and the anterograde memory effects were about the same.
All in all, I consider any effects on memory to be a minor price to pay for the beneficial effect. ECT worked when medications weren't enough, and that's a valuable weapon to have in my arsenal of treatment options.
According to the Canadian Psychiatric Association's position paper, "When used according to contemporary standards, ECT is a safe and effective treatment that should continue to be readily available as a treatment option for mental disorders."
Modern ECT is entire worlds away from what is depicted in One Flew Over the Cuckoo's Nest. It's time to leave the preconceived notions behind and get on with helping the people who need it the most. ECT is a safe, well-researched option, and people living with mental illness deserve to have as many effective options open to them as possible.
Enns, M.W., Reiss, J.P., & Chan, P. (2010). Canadian Psychiatric Association position paper: Electroconvulsive therapy. The Canadian Journal of Psychiatry, 55(6, insert), 1-12. Retrieved from https://www.cpa-apc.org/wp-content/uploads/ECT-CPA_position_paper_27-revision_1-web-EN.pdf
Harvard Mental Health Letter. (2007). Electroconvulsive therapy.
Ruffalo, M.L. (2018). A brief history of electroconvulsive therapy. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/freud-fluoxetine/201811/brief-history-electroconvulsive-therapy
Uppal, V., & Macfarlane, A. (2010). Anaesthesia for electroconvulsive therapy. Continuing Education in Anaesthesia Critical Care & Pain, 10(6), 192-196. Retrieved from https://academic.oup.com/bjaed/article/10/6/192/299664
This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
© 2019 Ashley Peterson
Lorna Lamon on April 16, 2019:
This is a really interesting article Ashley and one which certainly dispels all those myths. I have know a few people who have used this procedure for severe depression and it has been very successful, especially as medication just did not help. Thank you for sharing.