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All About ECT
Electroconvulsive Therapy

You may be surprised to learn that electroconvulsive therapy (ECT) is still being practiced in most, if not all, psychiatric units in general hospitals and mental institutions.

The original use of electricity as a cure for “insanity” dates back to the beginning of the 16th century when electric fish were used to treat headaches. ECT originates from research in the 1930’s into the effects of camphor-induced seizures in people with schizophrenia. In 1938, two Italian researchers, Ugo Cerletti and Lucio Bini, were the first to use an electric current to induce a seizure in a delusional, hallucinating, schizophrenic man. The man fully recovered after 11 treatments which led to a rapid spread of the use of ECT as a way to induce therapeutic convulsions in the mentally ill.

When we think of ECT many of us recall the terrifying image of Jack Nicholson in “One Flew Over the Cuckoo’s Nest”. This is not an accurate portrayal of the present day application of ECT. Certainly, before the development of effective muscle relaxants, it was not unusual for patients to suffer broken bones as a result of these electrically induced seizures.

Many people opposed to ECT are against it because they feel it is being used to “control” patients. Many years ago when psychiatry was less advanced, ECT was used for a much wider range of mental illnesses and sometimes, unfortunately, it was used to control troublesome patients.

Today, the American Psychiatric Association has very specific guidelines for the administration of ECT. It is to be used only to treat severe, debilitating mental disorders and not to control behavior. In most states, written and informed consent is required. The doctor will explain in detail to the patient and or family the reasons why ECT is being considered along with the potential side effects.

ECT is generally used in severely depressed patients for whom psychotherapy and medication are proving ineffective. It may also be considered when there is an imminent risk of suicide because ECT often has much quicker results than antidepressant remedies.

The procedure is usually performed on an inpatient basis, although maintenance ECT may be performed once a week or so as an outpatient. The patient is required to fast for 8-12 hours prior to treatment. Involved in the administration of ECT are usually a psychiatrist, anesthesiologist, and other supportive medical personnel. The patient is anesthetized with an intravenous injection of a barbiturate or other anesthetic. The muscles are temporarily paralyzed with the drug succinylcholine which prevents the violent jerking motions that used to break bones. The heart rate and other vital signs are monitored throughout the procedure. In bilateral ECT, electrodes are placed above each temple or above the temple of one side of the brain and in the middle of the forehead (unilateral ECT). An electrical current is then passed through the brain, inducing a grand mal seizure. Evidence of the seizure may show in twitching toes, an increased heart rate, clenched fists or a chest heave.

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Clinically effective seizures generally last from about 30 seconds to just over a minute. The patient’s body does not convulse and the patient feels no pain. During the seizure there are a series of changes in brain waves on an electroencephalogram (EEG) and when the EEG tracing levels off this is an indication that the seizure is over. As the patient awakens there may be headache, nausea, temporary confusion and muscle stiffness.

There are varying opinions as to how the memory is affected by ECT. Many patients report loss of memory for events that occurred in the days, weeks or months surrounding the ECT. Many of these memories may return, although not always. Some patients have also reported that their short-term memory continues for months to be affected by ECT, although there is the argument that this may be the type of amnesia that is sometimes associated with severe depression.

In the first few decades of ECT’s use, death occurred in 1 in 1,000 patients. Current studies report a very low mortality rate of 2.9 deaths per 10,000 patients or, in another study, 4.5 deaths per 100,000 treatments. Much of this risk is due to the anesthetic although the risk is no greater than the use of anesthetic for any minor surgical procedure.

There is no doubt that, properly used, ECT can be an effective procedure in the treatment of severe depression. Surprisingly, experts are still uncertain as to why it works. It is thought that ECT acts by temporarily altering some of the brain’s electrochemical processes.

Electroconvulsive therapy is the most controversial treatment in psychiatry. It’s history of abuse, unfavorable media presentation and compelling testimony of former patients all contribute to the controversial context in which ECT is viewed. There are clearly significant side effects, especially acute confusion and persistent memory deficits.

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