What is ECT

Introduction to Electroconvulsive Therapy (ECT)

Michelle Magid, MD, Charles H. Kellner, MD, Robert M. Greenberg, MD

What is ECT?

Electroconvulsive therapy (ECT) is a medical procedure used to treat severe psychiatric and neurological illnesses. It is highly effective, with up to a 60-90% success rate in severely depressed patients.^1-3 ECT has a long history which dates back to 1938, though early forms of the treatment bear little resemblance to modern ECT. With advances in both anesthesia and technology, ECT today is very safe; the risk of injury or death is extremely low (mortality less than 1 per 70,000 treatments), far below the risk of childbirth.⁴

ECT is endorsed as a valuable tool in the treatment of certain psychiatric disorders (see below) by the National Institute of Mental Health, the American Psychiatric Association, the American Medical Association, and the U.S. Surgeon General.

Indications

ECT is frequently used to treat:

Severe depression (unipolar or bipolar depression) - as described under “Benefits” below, ECT should be considered a first-line treatment when the depression poses an imminent risk to the life or medical status of a patient.
Treatment-resistant depression - this refers to depression that has not improved after several trials of different types of medications.⁵
Severe mania - which poses a threat to the safety or health of the patient, or is not responding to medication treatment.
Catatonia - a neurological condition in which patients experience extreme immobility or extreme motor excitement, both of which can be life-threatening.

It is also used to treat:

Schizophrenia and other psychotic illnesses.
Parkinson’s disease –for symptoms of depression and psychosis that may complicate the illness, and at times to help improve motor symptoms.
Severe depression during pregnancy and in the post-partum period.

Case reports have suggested possible benefit of ECT in:

Severe obsessive-compulsive disorder (OCD), especially when complicated by depression.
Some forms of chronic pain disorder.
Dementia complicated by severe agitation and aggressive behavior, not responding to other interventions.⁶
Refractory epilepsy.
Severe autism with self-injurious behavior.

Before the First ECT

At some point prior to the procedure, the patient should have an ECT evaluation with an ECT psychiatrist, where the procedure (including risks, potential benefits, side effects, and available alternative treatments) is thoroughly reviewed. If the patient is an appropriate ECT candidate, he/she will receive a medical work-up (including physical exam, laboratory tests, electrocardiogram (a test of heart function), and other necessary diagnostic tests to get the patient “medically optimized” for the treatment.

It is important for the patient to give the physician an accurate list of medications that he/she is taking, as certain medications may make the procedure less effective or cause unwanted side effects. The physician will tell the patient which medications to continue and which medications to hold (stop taking) during the ECT course.

On nights before the treatment, the patient should not have anything to eat or drink from midnight until after the treatment is over. Medications that need to be taken during this time should be taken with a small sip of water.

The ECT Procedure

The entire procedure from start (check-in) to finish (recovery) can last as little as 30 minutes or as long as several hours, depending on the patient’s overall health and the facility’s work-flow.

Check-in:

The patient should come to the procedure wearing comfortable clothes. Some facilities may require the patient to change into a hospital gown. The patient will often get a general assessment of physical health, including measurement of temperature, heart rate, and blood pressure. The patient is often asked to empty the bladder and remove jewelry, eyeglasses, and removable dentures.

Treatment:

The patient will then be brought into the ECT treatment room and asked to lie down on a stretcher. An intravenous line (IV) is started, usually in the arm. The patient is put to sleep using general anesthesia. Common anesthetic agents used include methohexital, propofol, and etomidate. Some facilities may also use sodium thiopental and ketamine(6). Once the patient is asleep, he/she is given a muscle relaxant in order to relax the body’s muscles in preparation for the treatment. The most common muscle relaxant used is succinylcholine. Other medications may be given to reduce oral secretions or to help control heart rate/blood pressure.

Some facilities may inflate a blood pressure cuff around an ankle, to prevent the muscle relaxant from entering the foot. This will allow the doctor to see twitching in the foot during the seizure (otherwise, there are often no physical signs of a seizure). The patient is not intubated (i.e. no tube is put down the airway; this happens during longer procedures). Rather, a team member (usually an anesthesiologist) will breathe for the patient during the procedure, using an oxygen mask.

Right before the treatment, a bite block is put into the mouth to protect the teeth and tongue during the treatment. The ECT device is connected to two small electrodes (either metal discs or adhesive pads), which are then placed on the scalp. A small electrical current is then delivered to the scalp through these paddles, which then causes a short (usually 20-60 seconds), controlled seizure. If the seizure lasts longer than expected, the physician may choose to stop the seizure using medications. The treatment, from the time the patient is asleep to the time the patient wakes up, is usually only about 5-10 minutes.

Recovery:

After the treatment is completed, the patient is then taken to a recovery area to rest/recover. A licensed nurse remains with the patient throughout the entire recovery process. When the patient is awake, alert, and stable, he/she may leave the recovery area. The time in the recovery area varies, with some patients being ready to leave in as little as 10 minutes and other patients needing longer.

The series:

A treatment “series” may begin in the hospital or as an outpatient. ECT treatments are typically given 2 or 3 times a week. A typical series generally consists of 6 to 12 treatments; a longer series can be up to 20 or more treatments, depending on the patient’s specific illness and response to treatment. There is no rationale to prescribe a fixed number of treatments. As long as the patient is improving, treatments should continue until the improvement is maximal.

Facilities vary on the need for supervision and restriction of activities during an ECT series. Some facilities may require that the patient take off from school/work. Many facilities require that the patient be driven to and from the treatment and be monitored closely by a caregiver after the treatment (if the patient is not in the hospital). Patients should not drive after the treatment. Continued restrictions may be recommended for up to two weeks after the last treatment in a series.

Continuation/Maintenance ECT:

"Continuation ECT" refers to ECT treatments that are given for up to 6 months after the initial ECT series. The goal of continuation ECT is to prevent relapse (i.e. becoming depressed again), which can happen, even after a successful ECT series. For some patients with multiple and/or severe depressive episodes, longer term use of ECT beyond 6 months may be recommended. This is known as “maintenance ECT.”

A patient is a candidate for continuation/maintenance ECT if he/she has:

A history of responding to ECT.
A history of relapse despite attempts to optimize medication treatment.
A strong preference to continue ECT over other treatment options.

For continuation/maintenance ECT, the patient must continue to provide informed consent and be able to comply with ECT rules and recommendations. The schedule of continuation/maintenance ECT can vary from one treatment a week to one treatment every 3 months, depending on the patient’s severity of illness and risk for relapse. Continuation ECT usually starts with weekly treatments, since risk of relapse is greatest early on. The treatment interval may be gradually lengthened if the patient remains well. If a patient relapses during continuation/maintenance ECT, another ECT series may be advised. The goal of any ECT service is to provide the fewest treatments necessary to keep the patient well.

Benefits

ECT has the highest rates of response and remission of any form of antidepressant treatment, with 60%–90% of those treated showing major improvement.^1-3 The proportion of patients with depression who respond to ECT is far greater than the proportion who respond to antidepressant medications, and response to ECT is usually significantly faster than with medications. In addition, ECT has been associated with significant improvements in health-related quality of life.⁷

ECT may be particularly beneficial in depressed patients who are:

A high suicide risk.^{8, 9}
Having irrational/psychotic thoughts.¹⁰
Refusing to eat or drink.
Catatonic.

In other words, ECT is extremely beneficial in very ill patients. It should be considered as a first choice treatment whenever a rapid, definitive improvement is clinically urgent (i.e. when the psychiatric illness poses a threat to the patient’s life or health status). ^{5, 8, 11}

Risks and Side Effects

Medical Risks:

ECT is generally considered one of the safest procedures performed under general anesthesia. Serious complications from general anesthesia are rare, but may include heart and lung problems, stroke, infection, and even death. Given the short period of time that the patient is under anesthesia for ECT, serious/life-threatening risks are very rare.

Cognitive Effects:

Most patients experience some degree of temporary cognitive impairment during a course of ECT. The degree of memory loss is variable, and depends both on the type and amount of ECT, as well as on the individual patient. Acute cognitive effects of ECT may involve transient confusion and/or disorientation that resolve within minutes to a few hours after treatment.

Subacute memory effects may involve variable impairment in ability to learn and retain new information for a period of days to weeks following a treatment series. This ability returns to baseline within several weeks to several months. Memory function at this point is often better than it was during the episode of depression.

Spottiness in memory for events that occurred up to several months and rarely several years before ECT may develop, but most of these memories return within several weeks to months following treatment. However, some permanent gaps in memory may remain for events close in time to ECT; rarely, more far-reaching gaps in personal memories may persist.

Patients with pre-existing cognitive deficits may show more pronounced transient effects on memory and have slower recovery times, but there is no evidence of any permanent changes in cognitive function. Advanced age has not been shown to increase the memory side effects of ECT.⁶ Depression itself and some medications used to treat depression can also produce memory impairment.

Overall, ECT today causes far less memory loss than ECT in past decades. For most patients, a small degree of temporary memory difficulty is a reasonable side effect to tolerate, given the likelihood of substantial improvement in depressive and other psychiatric symptoms.

Other Side Effects:

Common side effects include headaches, muscle soreness, and nausea.

Headaches are usually treated with over-the-counter pain medications such as acetaminophen (Tylenol) or ibuprofen (Advil). Many practitioners now offer patients intravenous ketorolac (a non-steroidal analgesic) just before a treatment to prevent headache.

Muscle soreness, mainly a result of the muscle relaxant medication succinylcholine, usually occurs only at the first few treatments, and also responds to simple analgesics.

Temporary nausea commonly occurs after treatment. Carbonated beverages may help relieve nausea. Many practitioners now offer patients intravenous ondansetron (Zofran) before treatment to prevent or decrease nausea in sensitive individuals.

Alternatives:

Other treatments for depression, mainly psychotherapy and antidepressant medications, are much more commonly used than ECT; however, none is equivalent to ECT in efficacy for severe depression. ECT is generally reserved for patients with the most severe forms of depression or other psychiatric illness (see “Indications”).

Newer “neuromodulation” treatments, including transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), transcranial direct current stimulation (TDCS, and deep brain stimulation (DBS) have been demonstrated to have antidepressant effects in some patients, but none of these techniques has both the efficacy and proven clinical track record of ECT.

ECT Technique

Electrode Placement:

The electrode placement is where the electrodes are placed on the patient’s scalp. Most ECT facilities use three main electrode placements—bilateral, right unilateral and bifrontal.^11-14

Right unilateral electrode placement is often associated with fewer cognitive effects. Bilateral electrode placement is often associated with the greatest efficacy and fastest response. Bifrontal electrode placement is often considered a “middle ground,” potentially having slightly more efficacy than right unilateral electrode placement and slightly fewer cognitive effects than bilateral electrode placement. Although different facilities may have different protocols and preferences, it is important to be able to offer patients different options, tailored to their specific needs. Many facilities will start with right unilateral or bifrontal placement, but change to bilateral placement if the patient is not improving. Bilateral placement is often chosen when rapid, definitive improvement is urgent (i.e. – in patients who are actively suicidal, catatonic, or experiencing an acute worsening of their medical status as a result of the psychiatric illness).

Stimulus:

The electrical stimulus used to induce the seizure in ECT today may be referred to as “brief pulse” or “ultrabrief” pulse. Brief pulse is still considered the standard way to perform ECT, but ultrabrief pulse, especially with right unilateral electrode placement, is gaining popularity, because there is accumulating evidence that it may cause less memory impairment.^15-17

Consent:

As with any medical procedure, the patient must give informed consent before starting ECT. Most states require that informed consent for ECT be obtained in writing after a thorough explanation of the procedure, the risks, side effects, potential benefits, and available alternative treatments. The patient may withdraw consent at any time. The patient must demonstrate capacity for the consent process. If a patient who requires ECT is unable to give consent, further legal steps may be necessary, depending on state laws and regulations. Individual states may have specific restrictions and/or additional consent regulations when treating children and adolescents (5).

Additional Resources:

Websites:

International Society for ECT and Neurostimulation

http://www.isen-ect.org/

Kitty Dukakis' Wuebsite on ECT: A Light in the Darkness.

http://www.ecttreatment.org/

Sherwin Nuland: a surgeon speaks about his ECT experience

http://www.ted.com/talks/sherwin_nuland_on_electroshock_therapy.html http://www.youtube.com/watch?v=oEZrAGdZ1i8

Julie K. Hersh's website on ECT and her experience: Struck By Living

http://www.struckbyliving.com/

Mayo Clinic on ECT:

http://www.mayoclinic.com/health/electroconvulsive-therapy/MY00129

Up-to-Date Patient information on ECT

http://www.uptodate.com/contents/electroconvulsive-therapy-ect-beyond-the-basics

Mental Health America ECT Fact Sheet

http://www.nmha.org/go/information/get-info/treatment/electroconvulsive-therapy-ect

Personal Stories and Professional Experiences with ECT

http://psychcentral.com/lib/?cat=54,11896&intersect=1&ect-=1

Medscape Clinical Procedures on ECT

http://emedicine.medscape.com/article/1525957-overview

WebMD on ECT

http://www.webmd.com/depression/guide/electroconvulsive-therapy

National Alliance on Mental Illness (NAMI) on ECT

http://www.nami.org/Template.cfm?Section=About_Treatments_and_Supports&Template=/ContentManagement/ContentDisplay.cfm&ContentID=142939

NY Times Overview on ECT

http://health.nytimes.com/health/guides/test/electroconvulsive-therapy/overview.html

Q & A about ECT with Sarah Hollingsworth Lisanby

http://www.dukehealth.org/health_library/health_articles/electroconvulsive-therapy-ect-q-a-with-sarah-hollingsworth-lisanby-md

ECT is featured on the Dr. Oz Show

http://www.doctoroz.com/videos/treating-depression-electroconvulsive-therapy http://www.doctoroz.com/videos/shock-could-save-your-life-pt-1

An Information Booklet on ECT published by St. Patrick's Hospital in Dublin, Ireland

http://www.stpatricks.ie/sites/default/files/flash/SPUH_ECT_Information_Leaflet.swf

The Royal College of Psychiatrists (UK) information on ECT

http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/ect.aspx Online videos of ECT procedure and indications:

ECT makes a quiet comeback. NBC News. 4 minute video. Patient Bill. Aug. 2008.

http://www.nbcnews.com/id/26044935/#.UvRik_ldUbN

Mayo Clinic (short version) ECT video. 2 minute video. Patient Joanne.

http://www.mayoclinic.org/condition/depression/multimedia/electroconvulsive-therapy/VID-20084705

Insight. 52 minute video on ECT Patients Michael, Natalie, Kylie, Ella, Lisa. Sept. 24th 2013

http://www.sbs.com.au/insight/episode/watchonline/575/Electroshock

“Mary, a case study.” 9 minute video with Max Fink. Patient Mary. Apr. 2007.

http://www.youtube.com/watch?v=1JG9eQsjaZY&feature=youtu.be

Lakeside Behavioral Health. ECT general overview video 6 min. ECT technical video 7 min.

http://lakesidebhs.com/treatment/neuroscience-center/ect/

Current Psychiatry library. 5 minute video. Nagy Youssef, MD discusses indications for ECT. Sept 2013

http://www.currentpsychiatry.com/home/article/using-ect/1881da463930ab14bd0d2096e475f826.html

St George's, University of London & South West London & St George's Mental Health NHS Trust. Short ECT procedure film. Features real healthcare staff and a simulated patient (actor). 6 min. Wed, Oct 12, 2011

http://www.youtube.com/watch?v=9L2-B-aluCE

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2. Gelenberg AJ, Freeman MP, Markowitz JC, Rosenbaum JF, Thase ME, Trivedi MH. Practice guideline for the treatment of patients with major depressive disorder American Psychiatric Association; 2010. http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1667485.

3. Husain MM, Rush AJ, Fink M, Knapp R, Petrides G, Rummans T, et al. Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for Research in ECT (CORE) report. The Journal of clinical psychiatry. 2004;65(4):485-91.

4. Watts BV, Groft A, Bagian JP, Mills PD. An examination of mortality and other adverse events related to electroconvulsive therapy using a national adverse event report system. The journal of ECT. 2011;27(2):105-8.

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8. Fink M, Kellner CH, McCall WV. The role of ECT in suicide prevention. The journal of ECT. 2014;30(1):5-9.

9. Kellner CH, Fink M, Knapp R, Petrides G, Husain M, Rummans T, et al. Relief of expressed suicidal intent by ECT: a consortium for research in ECT study. The American journal of psychiatry. 2005;162(5):977-82.

10. Fink M, Taylor MA. Electroconvulsive therapy: evidence and challenges. JAMA : the journal of the American Medical Association. 2007;298(3):330-2.

11. Lisanby SH. Electroconvulsive therapy for depression. The New England journal of medicine. 2007;357(19):1939-45.

12. Lapidus KA, Kellner CH. When to switch from unilateral to bilateral electroconvulsive therapy. The journal of ECT. 2011;27(3):244-6.

13. Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Archives of general psychiatry. 2000;57(5):425-34.

14. Sackeim HA, Prudic J, Nobler MS, Fitzsimons L, Lisanby SH, Payne N, et al. Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Brain stimulation. 2008;1(2):71-83.

15. Magid M, Truong L, Trevino K, Husain M. Efficacy of right unilateral ultrabrief pulse width ECT: a preliminary report. The journal of ECT. 2013;29(4):258-64.

16. Loo CK, Katalinic N, Martin D, Schweitzer I. A review of ultrabrief pulse width electroconvulsive therapy. Therapeutic advances in chronic disease. 2012;3(2):69-85.

17. Coffey CE. Some brief thoughts on brief and ultra-brief pulse ECT. Brain stimulation. 2008;1(2):86-7.