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by Donna Ecklesdafer, R.N.
Electroconvulsive Therapy, or ECT, is a treatment
option available at Pine Rest Christian Mental Services’ ECT Clinic.
ECT is a long-established, safe and effective treatment usually
given to help decrease the symptoms of depression, bipolar, mania, and
some forms of schizophrenia.
While the patient is asleep, a small amount of electrical current is
used to stimulate a brief seizure within the brain. The seizure lasts
about 30-60 seconds and causes biochemical changes in the brain that may
help decrease symptoms or even cause them to stop. The results of ECT
can be seen much more quickly than that of medications. These biochemical
changes are similar to antidepressant medications. Patients who have had
ECT report it helps improve and stabilize their mood, increases energy,
and gives hope. Some of the other improvements include more restful sleep,
increased sexual interest, clearer thinking, and increased pleasure.
The 2001 American Psychiatric Association’s Task Force on ECT states,
“No trial has ever found an antidepressant medication regimen to
be more effective than ECT. Among patients who are receiving ECT as a
first-line treatment (for depression), the response rates continue to
be reported in the range of 80-90%. Among patients who have not responded
to one or more adequate antidepressant trials, the response rate remains
substantial, in the range of 50-60%.” (1)
Medication often is an effective treatment. In some cases, however, medications
have proven ineffective. ECT is another treatment option available for
patients.
Because ECT works quicker than medications, it is used as a first choice
treatment when a rapid response is needed or if there is greater risk
in using medications. Physicians may also prescribe ECT if the patient
has had a good response to treatments in the past. The American Psychiatric
Association has now determined patient preference to be another reason
to give ECT as a first choice treatment.
Electroconvulsive Therapy may benefit some patients with medical disorders.
There is considerable experience with the use of ECT in patients with
Parkinson’s disease. “ECT commonly results in general improvement
in motor function. Patients with the “on-off” phenomenon, in
particular, may show considerable improvement.” The benefits on the
motor symptoms are variable. Because ECT has anticonvulsant properties,
it has been used in patients with intractable seizure disorder. ECT is
also used for patients with Neuroleptic Malignant Syndrome. (2)
Many elderly patients respond successfully to ECT. It is thought that
as people get older, they become more resistant to treatment. Elderly
patients may have an intolerance to antidepressant medications and may
also have medical issues. As long as they are healthy and medically stable,
ECT can be a safer treatment for the elderly population.
The use of ECT in pregnant women has been determined to be low risk and
have a high response rate in all three trimesters of pregnancy. The American
Psychiatric Association practice guidelines endorse the safety and effectiveness
of ECT as a primary treatment for major depression and bipolar disorder
during pregnancy. In addition, patients with severe postpartum depression
or mania also respond favorably to ECT.
History of ECT
In 1934, Hungarian neuropsychiatrist, Ladislas Meduna, believed those
patients who had epilepsy were “protected” against the psychotic
symptoms of schizophrenia. He thought if seizures were induced in schizophrenic
patients, their symptoms would decrease. There were clinical trials that
showed there was a significant decrease in psychotic symptoms in patients
treated with a series of induced seizures. Camphor was injected to induce
seizures. Eventually Metrazol replaced Camphor. Although these medications
were successful in starting seizures, there were a number of side effects.
Insulin coma therapy was also used to induce seizures.
In 1937, Italian neuropsychiatrists, Ugo Cerletti and Lucino Bini, began
using electricity to stimulate seizures. They found it was easier and
safer to induce seizures with electricity. Soon ECT was the treatment
of choice for schizophrenia and mood disorders.
In the mid 1950s, use of ECT decreased due to the discovery of medications:
anti-depressants, anti-psychotics, and anti-manic agents. ECT was also
the subject of highly negative publicity in the media—i.e. One
Flew Over the Cuckoo’s Nest.
Even though there is still a stigma surrounding ECT today, more people
realize it has been proven as an effective and even life saving treatment.
Like surgery, there have been many changes to ECT over the years. Some
of the improvements include the use of medications, oxygen, seizure monitoring,
and type of electrical stimulus used.
The ECT Procedure
When receiving ECT, all patients receive two medications: an anesthetic
and a muscle relaxer. Brevital (Methohexital) is a short acting
anesthetic. The patient is completely asleep during the treatment. The
muscle relaxant, Succinylcholine (Anectine), blocks muscle movement
so usually only the hands and feet move - just enough to see the seizure
activity. An anesthesiologist administers oxygen during the treatment
and the patient’s oxygen saturation is monitored throughout his or
her treatment and recovery. The electricity used is a brief pulse form.
This allows less electricity to be used to stimulate a seizure, which
in turn causes less confusion.
Since ECT produces biochemical changes similar to antidepressant medications,
it is recommended that antidepressant medications be discontinued during
an acute series. Other medications that interfere with ECT treatments
are Benzodiazepines (Xanax, Ativan, Restoril, Valium, Serax) and
anti-seizure medications used as mood stabilizers (Depakote, Topamax,
Klonopin). Lithium and MAOIs are discontinued before ECT treatments
begin. Anti-psychotic medications, however, may be used while receiving
ECT.
As with any type of treatment, there are side effects and risks. Many
people do not experience any side effects from ECT, but those who do commonly
report headaches, nausea, and muscle aches. Medications can be taken to
help decrease or eliminate these side effects.
Other potential side effects are confusion and memory loss. It is common
for people to be confused when they begin to wake up. As they wake up,
they become more alert and less confused. Some patients won’t remember
they just had a treatment. Psychological tests show that memory loss can
occur for events that happen during the weeks surrounding the treatments,
usually right before, during, and after treatments. Even though these
tests do not confirm permanent memory loss, some patients report lasting
trouble remembering some things occurring a few months before and/or after
their treatments.
The risks of ECT are related to the use of general anesthesia and to
the treatment. “The risk of death or serious injury with ECT is about
1 in 50,000 treatments, much smaller than that reported for childbirth.”
(3)
There are different ways ECT can be administered. Unilateral ECT is
given to one side of the brain. It is usually given to the right side,
which causes less confusion. Bilateral ECT is given to both sides of the
head. Although this is a more effective way to give ECT, there is potentially
more confusion associated with bilateral ECT. All patients receiving ECT
treatments at Pine Rest will go through a Pre-ECT workup. (Other treatment
clinics may use a similar process.) The patient’s psychiatrist will
refer him or her to the ECT Clinic. A psychiatrist credentialed in ECT
at Pine Rest will also evaluate him or her to determine if he or she will
benefit from ECT. An internist will complete a history and physical examination,
review laboratory studies and electrocardiogram (EKG), and give medical
clearance. The nursing staff will give the patient and his or her family
information about ECT and answer questions. A written consent form and
other necessary paperwork are then completed.
An acute series consists of 6-12 treatments given over a period of 4-5
weeks. Because ECT has an accumulative effect, it usually takes 4-6 treatments
to see an improvement. Those around the patient will often notice a change
before the patient does. Some of the changes that might be seen are: the
patient is smiling more, he or she looks brighter, he or she wants to
get out a little more, or he or she interacts more.
Even though ECT may decrease or end a depression, it will not prevent
another episode from occurring weeks, months, or even years later. Many
people use medications to prevent this relapse; some people use maintenance
ECT. After an acute series is completed, it is important to follow up
with medications or maintenance ECT.
Today, more patients are receiving maintenance ECT. Maintenance ECT is
used when the patient has a history of good response to an ECT series
but is unable to remain out of depression with medications. Treatments
are given once every week to once every month, depending on the patient
and his or her symptoms.
The patient should be evaluated by his or her psychiatrist weekly while
receiving an acute series and at least every 3 months while receiving
maintenance treatments. Every time the patient receives ECT, a summary
of his or her treatment is faxed to his or her psychiatrist.
ECT treatments can be on either an inpatient and outpatient basis. If
done on an outpatient basis, someone will need to drive the patient to
and from the clinic due to the anesthesia he or she receives. The patient
may feel fine, but his or her judgment is affected by the medications
received before and after treatment.
Summary
Electroconvulsive Therapy is a safe and effective treatment. It is usually
prescribed for patients with depression, bipolar, mania, or some types
of schizophrenia. ECT involves the use of a brief seizure within the brain.
This seizure activity causes biochemical changes that may help to decrease
symptoms or even cause them to stop. The results of ECT can be seen more
quickly than the results of medications. It can provide help and give
hope to many patients and their families. We are pleased to provide this
service to you. If you have any questions, please contact Pine Rest’s
ECT Clinic at (616) 281-6341.
Bibliography
(1) American Psychiatric Association Task Force on Electroconvulsive
Therapy. (2001) The Practice of Electroconvulsive Therapy: Recommendations
for Treatment, Training, and Privileging. Washington, DC: American
Psychiatric Association.
(2) Ibid: APA Task Force on ECT
(3)Abrams, Richard: Electroconvulsive Therapy, 3rd Edition. New
York, Oxford University Press, 1997.
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