Electroconvulsive therapy (ECT) is most often prescribed for severe depression and it dramatically helps many patients. It is one of several kinds of treatment that involve brain stimulation. Findings from recent research studies are helping doctors administer ECT in ways that minimize side effects.
Severe depression, called “major depression,” is a common and debilitating illness. Episodes of symptoms can last for months; they can occur only once in a person’s life, but they often happen more than once. Although talking treatment or psychotherapy can help some patients, medication treatment or pharmacotherapy is required for moderate to severe symptoms. Unfortunately, medication is not helpful for some patients and some patients have difficulty with medication side effects. Since major depressive episodes can interfere with work, can lead to life threatening physical health changes, and can lead to death from suicide, it is important to have alternatives such as ECT available.
ECT is sometimes called “shock therapy” and many people have a frightening and incorrect impression that it is a painful and harmful form of treatment. ECT has been described in a disturbing way in popular books and movies, like “One Flew over the Cuckoo’s Nest.” Some of these depictions are loosely based on how ECT was done when it was first used 80 years ago. A lot has changed.
In ECT, doctors cause a controlled seizure, which is a brief period of excess brain activity. This seizure is started by electrical stimulation through the scalp for a few seconds. ECT is usually prescribed three times per week. The number of treatments needed to produce the most improvement in depression symptoms is different from person to person, but the average is 8-10. The reason that these ECT seizures help depression is not known; one idea is that seizures correct overactivity in brain electrical signaling, which might be part of depression.
There are many misconceptions about ECT. For example, patients are not awake; they are asleep before and during the seizure because brief-acting sleeping medication is given before the treatment. Also, the seizure does not involve strong movements: there is actually not much to see because patients are also given a muscle relaxant prior to ECT, which prevents the movement of arms and legs during the seizure and prevents stress to the body. These medications are given by an anesthesiologist who also supports breathing with a face mask and provides extra oxygen. Patients wake up within a couple of minutes and are monitored until they are no longer drowsy and they are oriented.
Temporary memory problems related to ECT have been a significant concern for patients and doctors. It is important to note, however, that memory problems caused by depression can be expected to improve with successful treatment of depression. To avoid or reduce memory impairment related to ECT, there have been several research-based changes in how ECT is done. First, exactly where the electrodes are applied on a person’s scalp can affect the results of the treatment. Locating on the right side (unilateral), rather than on both sides of the brain (bilateral), as was always used historically, can significantly reduce temporary memory problems. Another way of reducing “cognitive” side effects of ECT is to use special forms of electrical current. Also, at the first treatment, doctors test for the minimum amount of electrical stimulus that is required for each patient, using a “titration” procedure that was not part of routine ECT practice originally. Taken together, these changes and improvements in ECT mean that depressed patients will be more comfortable and experience fewer side effects from the treatment.
Researchers are now looking into developing ways to further increase benefit and speed of response from ECT. For example, while ECT alone can help many depressed patients, other recent studies have shown that prescribing certain antidepressant medications at the same time can improve response to ECT.
Keeping patients well after they have responded to ECT is another important challenge. Combining antidepressants with lithium is a medication strategy that is supported by recent studies.
After it has lifted someone’s depression, can adding “booster” ECT treatments as needed, rather than stopping the ECT, help avoid “relapse”? Ongoing research funded by the National Institutes of Mental Health aims to test that idea.
One individual said: “When my doctor suggested that I try ECT, I was hesitant. I preferred to stay on medication, but we could not find one that helped me. When I was depressed, I couldn’t bear the thought of even getting out of bed. I finally decided to go ahead with ECT. My family is amazed by my progress. I am back at work and I feel like my old self. I am looking forward to the future again.”
Clinicians, patients, and families should be aware of changes in ECT practice. When discussing the possible benefits and risks of ECT in an individual with challenging depressive illness, having an up-to-date perspective is essential to the decision-making process.
