The Modern Use of Electroconvulsive Therapy

by Randall M.Christenson, M.D., and Roger C. Sider, M.D.

Electroconvulsive Therapy (ECT) is one of the most effective yet controversial treatments in modern psychiatry. Almost everyone has an opinion about it. Often, however, people base their opinion on hearsay or outdated facts. We hope to provide you with an understanding of how modern psychiatrists use ECT. We'll also share what our experience has been with this treatment at Pine Rest.

Let's begin with a description. ECT is a psychiatric treatment given by a team of two specialist physicians. One is an anesthesiologist and the other a psychiatrist. A specially trained nurse assists them.

The anesthesiologist's task is to induce a state of complete muscular relaxation and brief anesthesia by using a short-acting intravenous medication. At the same time, he or she closely monitors the patient's vital signs. During the approximately five minutes of anesthesia, the psychiatrist gives the ECT treatment.

The psychiatrist applies two electrodes to one side of the patient's head and administers an electrical current for one to two seconds. This induces an electrical discharge in the brain similar to that which 1aturally occurs during a seizure.

But, since the patient is anesthetized and in a state of complete muscular relaxation, there is little visible evidence of the seizure. An observer might notice the toes or fingers moving slightly. The seizure usually lasts about one minute. The patient regains consciousness within a few minutes. Patients usually receive treatments three times a week for two-to-four weeks.

ECT has been around for more than 60 years. It originated in Europe in the 1930s. At that time, professionals were trying a variety of new methods to help patients who suffered from serious mental disorders. Until that time there had been little hope for such people. Consequently, many patients spent their entire lives in asylums for the insane.

Convulsive therapy was first tried because physicians erroneously believed that patients with epilepsy seemed to be protected from schizophrenia, one of the most serious mental disorders. Accordingly, they thought if they could induce an epileptic seizure in psychiatric patients, perhaps their serious mental disorders would improve. A Hungarian psychiatrist and later two Italian psychiatrists developed methods for inducing seizures for the treatment of the severely mentally ill.

By the 1940s, ECT had become popular in the United States and was being used around the world as well. Science had not yet discovered any effective medications for the treatment of the severely mentally ill. Other than custodial care, at that time the only treatments available were insulin coma, pre-frontal lobotomy, and ECT. ECT was the safest and most effective of these treatments.

But by the 1950s, ECT's popularity began to decline. Authorities were concerned that it was being used indiscriminately. They felt it was sometimes used more to control the disruptive behavior of difficult patients rather than to treat their mental illness. Additionally, complications which could occur made ECT a risky treatment. Also during that decade, the first effective medications became available for treating severe mental disorders. Many psychiatrists hoped these new medicines would make ECT unnecessary.

In the 1960s and 1970s, ECT came under further attack because of concerns about the civil rights of the mentally ill. Patients and their families were not routinely granted the right to give or refuse consent for the use of ECT. Accordingly, several states passed protective legislation to guarantee patients' rights to informed consent for treatment with ECT. California passed the most restrictive ECT law in 1974. The law guaranteed the right of both voluntary and committed patients to refuse ECT.

All of these developments--together with the unfavorable publicity from films such as One Flew Over the Cuckoo's Nest--resulted in a dramatic decline in the use of ECT in the United States. Between 1974 and 1984, Pine Rest did not perform ECT at all.

Ironically, it was during this same period that technical advances in anesthesia, equipment, and technique made ECT a far safer procedure. Moreover, in spite of the many new drugs available for the treatment of mental disorders, ECT remained the most effective treatment available for certain types of severe depression. For some elderly patients, it was actually safer than medications.

It should be noted that ECT is an adults-only treatment. ECT is most commonly used to treat severe depression. It is also effective for treating mania. Psychiatrists usually recommend ECT for patients whose emotional disorder has not improved with medication and psycho-therapy, or for those who cannot safely take medication. Because it often works faster than medications, it is sometimes recommended immediately for patients whose emotional disorders threaten their lives.

The alternatives to ECT include using medication and psychotherapy. Generally, when psychiatrists recommend ECT to patients, it is because the alternative treatments have not been effective or because the patient's life or health is in danger. Another alternative is no treatment. Without treatment, however, patients not only risk continuation of the intense suffering that accompanies severe emotional disorders, but also risk a decline in their health, greater disability, and even death.

Just as we don't fully understand how aspirin works to relieve pain, scientists have not yet learned exactly how ECT works in the brain to improve depression. We now know, however, that mood states are controlled by a part of the brain called the limbic system. ECT changes the balance of certain chemicals, called neurotransmitters, in this area of the brain.

Whatever the exact mechanism of action may be, we know that ECT works to improve the patient's severely depressed mood. ECT also stabilizes sleep patterns and appetite. It improves energy and reduces the agitation and tension that may accompany the depression. ECT helps reduce negative, worrisome, and troublesome thoughts and fears that are often part of the depressive disorder. Studies have consistently shown that ECT works better than any other treatment available for severe depression. It is especially effective when troublesome or delusional thoughts are part of the depressive disorder.

As with any medical treatment or illness, there are risks involved. The risks of ECT are related to the use of general anesthesia and to the treatment itself. Today it is a safe treatment procedure. Overall, the risk is not different from that associated with using short-acting anesthetic agents. The least favorable studies show that the present mortality rate is less than 0.03 percent. In the early days of ECT, mortality was a significant problem. As many as l out of a 1000 patients died from the procedure. In the past, up to 40 percent of patients receiving ECT suffered from other significant complications. Today the serious complication rate is well under one percent.

Many patients, though, do experience less serious side effects from the ECT treatments. These side effects, while not dangerous, can sometimes cause distress. Confusion, temporary memory loss, and headache are the most common. Memory loss most frequently involves events that happen in the few weeks surrounding the treatments. While most patients do not experience permanent memory changes, some report trouble remembering some events occurring a few months before or after their treatments.

The ECT most commonly used at Pine Rest administers the electrical stimulus to one side of the head only (unilateral treatment). This usually causes significantly fewer problems with confusion and memory loss than applying the stimulus to both sides of the head (bilateral treatment).

Occasionally some temporary irregular heartbeats may result from ECT. The anesthesiologist carefully monitors these during the treatment and recovery period. These rarely cause significant problems and are usually controlled with medications.

The most common side effects from the anesthetic agents are nausea, headaches, and muscle aches. The treatment may cause some brief changes in blood pressure and pulse during the procedure.

In considering the risks of ECT and anesthesia, it is important to remember that depression is a serious illness. Untreated severe depression can result in disability, deterioration of health, and death--often by suicide. The rate of death is two to three times higher in depressed patients than in the general population.

When a psychiatrist suggests ECT to a patient, he or she explains to the patient the rationale for recommending the treatment. Next the doctor describes what will happen during the treatments. Together the doctor and patient discuss the benefits and risks of the treatments and review alternative treatments. Usually the psychiatrist provides similar information to the patient's family. Both patient and family can ask questions about the treatment. The patient then decides whether or not to undergo the treatment. To receive ECT, a person must give written informed consent. This is similar to the process when a person agrees to have surgery.

If the patient is not competent, that is, not mentally capable to decide, the family may obtain a guardianship specifically for ECT through Probate Court. If the judge determines that the patient is incompetent and ECT seems reasonable, he or she grants a guardianship to one person, usually a family member. This person then has responsibility to decide about ECT treatment for the patient. Even if the patient already has a legal guardian, this procedure must be followed for ECT. Thus, no one can receive ECT without the written informed consent of the patient or of the guardian appointed by the court for the specific purpose of deciding about ECT.

Additionally, when a psychiatrist recommends ECT, she or he will get a second opinion. This is to assure that at least two psychiatrists agree that ECT is an appropriate treatment for the patient. The individual will undergo a complete history and physical examination and routine laboratory studies, including an EKG or heart tracing. This is to determine whether ECT is medically safe for the patient. When all this has been accomplished, the patient is ready to begin ECT.

While ECT is effective in reversing a deep depression, it may not result in a permanent cure. Most patients need to continue to take antidepressant medication to help them maintain the gains they have made. Without medication, the depression may return. But if patients stay on antidepressant medications, the chances of this occurring are much less.

ECT does not change one's personality or life situation. Patients whose life situations or patterns of living or thinking contributed to their becoming depressed will need further treatment. Once the depression has been improved by ECT, patients are better able to utilize psychotherapy or counseling to deal with the problems they face. Thus, ECT is often just one component of a comprehensive treatment plan designed to help people with severe depressive disorders.