Article by Asif R. Malik, MD (psychiatrist, psychopharmacologist)
ECT is a form of brain stimulation used to help in recovery in severe depression, bipolar disorder and schizophrenia. Transcranial magnetic stimulation (TMS), Vagus nerve stimulation (VNS) are other forms of commonly utilized modalities for brain stimulation. These have their own sets of Pros and cons.
This narrative is not a scientific treatise but an attempt to answer the common questions that arise when patients are referred to ECT. This can also help providers decide when to refer to a patient for ECT.
Electro-convulsive therapy, or ECT is sometimes commonly referred to as “Shock therapy”. Despite the negative depiction in the cinema, this treatment has been used in the current form since the 1960s with a slow evolution greatly decreasing the incident of side effects and improving patient outcomes.
Disclaimer: I am a licensed Physician in the US state of Washington. However, I am not your doctor. I am not putting this out to treat you. Doctors use their decades of training and experience to diagnose and treat medical conditions. This is NOT medical advice, and should not replace a visit to a doctor. If you use this as medical advice, I am not responsible for the outcomes.
You doctor will explain the process to you and ask for your permission. Without this, he or she will not proceed.
- Medical clearance
You will be referred to your primary provider or a family doctor for medical clearance. If you are in the hospital, one of the hospital providers might do this. If you have a complex medical history, they might confer with your sub-specialist such as cardiologist, pulmonologist, surgeon or oncologist. You might be required to take blood draws, and might need to provide a urine sample as well. Imaging including chest Xray and CT scans are sometimes indicated as well. Generally, this should be completed in a day or so in a hospital setting and a little longer in the outpatient clinic.
- The Night before
You will be asked to not take anything by mouth after midnight before the procedure. This includes gum and coffee. Its better to not brush your teeth as well. Your provider will guide before-hand on how to take your medications and insulin on the day of treatment.
Generally, psychiatric medications may be continued with a few exceptions.
A: Lithium: Lithium is generally not used in the course of the treatments as it can lead to confusion. Your psychiatrist will advise you on how to proceed with this.
B: Benzodiazepines: Medications like alprazolam, lorazepam, clonazepam and similar compounds can increase seizure threshold and make ECT less effective. If you have been using them on a regular basis, legally or illegally, please share with your psychiatrist as suddenly stopping the medication can be very harmful and lead to adverse outcomes.
C: Anti-seizure medications and mood stabilizers like valproic acid, lamotrigine, carbamazepine are assessed on an individual basis. Your psychiatrist will advise you on this.
Please refrain from adjusting medications yourself and follow what your provider’s directions.
Anxiety prior to the procedure is normal. If you accidentally took a few sips or water or coffee, please let your provider know. Aspiration of stomach contents into the lungs, however small, can cause severe consequences.
Once you enter the ECT area, you will be checked in, your vitals will be checked and the nurse will start an IV. After asking for your permission to proceed, the psychiatrist will give the anesthetist a green flag to proceed. If you have changed your mind and you do not want to proceed, you can decline further interventions and leave.
Once the anesthetist starts, he will give you a general anesthetic to make you unconscious. Etomidate and methohexital are two commonly used agents. The anesthetist would then inject the muscle relaxing agent such as succinylcholine so your body does not move when the treatment is done. You will be getting oxygen through a mask at this point. Sometimes, it is necessary to intubate a patient if airway management is hard, and a tube is passed through the throat. However, this is required infrequently.
Muscle relaxants are generally short-lived so your psychiatrist will deliver the stimulus about two minutes of the injection. The anesthetist will continue to monitor your body functions including heart rate, oxygen saturation and airway and administer drugs to maintain your cardiovascular stability.
After the delivery of the stimulus, your electrical activity in the brain is monitored to study the seizure. Once the seizure is over, the anesthetist monitors the anesthesia and you will be moved to the recovery room. The recovery area will house you for about 30-45 minutes until you are alert and awake and ready to go home. Remember that you should not drive after treatment and if you are going home, you should be monitored by someone.
ECT suite generally includes anesthetic equipment needed to monitor your status during the treatment and the equipment for seizures itself.
ECT machines are FDA regulated and are designed to have parameters within the FDA guidelines. Two main manufacturers of the equipment include MECTA corporation and Thymatron. The machines are generally similar and are different in their interfaces.
Pulse width (PW) can range from 0.3ms to 1ms. Lower PW generally causes less cognitive side effects.
The number of wave cycles per second ; this perimeter is used for determining total charge delivered.
Current measured in mA which will be delivered through the electrodes. Generally, it is a low number.
It can vary from a fraction of second to 8 seconds, depending on the settings. The total charge set by the machine cannot be exceeded.
568.3-576 mC is the total charge delivered depending on the settings.
Current (in Amperes) X Pulse width X Frequency X 2 (Since the pulses are bi-directional) = Total charge in mC
Since the total charge delivered is dependent on several variables, increase in one variable would require a decrease in another variable at a constant charge.
A common starting setting is 120mC. Some studies show that despite a therapeutic seizure duration, charge of more than 350mC results in better clinical outcome.
Post ECT recovery
Generally speaking, the recovery is mostly uneventful. You might experience a headache, which you will be treated for. Patients can experience confusion, which is somewhat common. You should expect to be in recovery for 45 minutes to an hour. Some times, a longer period is necessary. You will be monitored by nurses and trained staff in this time. Once you are deemed stable, you will be discharged from the ECT with directions and instructions for followup.
Commonly asked questions:
When does ECT work best:
Acute episodes of psychosis, mania or depression.
When depression is accompanied by a biological shift with disturbance in sleep and appetite
Catatonia (Preferred treatment)
Neuroleptic malignant syndrome
When does it work quite well:
Acute exacerbation of a chronic psychotic illness. Patients will improve functionally but may not enter remission
Severe obsessive compulsive disorder
When its better to avoid:
Personality disorders, unless the above mentioned conditions are present and are independent of the personality pathology
Primary anxiety disorders
Primary diagnosis of PTSD unless above conditions are present
Evolving brain injury
There are no absolute contraindications of ECT. Relative contraindications include recent myocardial infection (heart attack) or GI bleed (blood in stools or dark stools). Medical clearance is generally done by the patient’s primary provider or the internist treating the patient on the medical unit. Generally, ECT is considered to be a very safe and life saving treatment which has been used in patients with brain implants (Deep brain stimulator electrodes) , cardiac transplant patients, as well as women in various stages of pregnancy.
Should I get ECT/ Should I refer my patient for ECT?
This is a list of common reasons for recommending ECT.
1. Treatment failure
Treatment failure is the most common reason for recommendation of ECT. ECT has been shown to be effective in 60-80% of patients who have failed conventional treatments. With careful selection of patients, response and remission rates are very high in patients who have failed prior treatments. Conventional treatments include pharmacological interventions with medications including anti-depressants of the SSRI (Fluoxetine, sertraline, paroxetine etc) and non-SSRI (Bupropion, mirtazapine , duloxetine and some more) classes. Many patients are also tried with antipsychotic medications (olanzapine, quetiapine, aripiprazole) , mood stabilizers such as (valproic acid and lithium).
As a generally accepted standard, the anti-depressant medications need to be used for several weeks at a therapeutic dose prior to a switch and calling it a treatment failure unless the patient is not able to tolerate the intervention. Antipsychotic medication augmentation as well as introduction of mood stabilizers are also used in the later stages of treatment if mono-therapy is not effective.
2. Severity of illness
Another factor in considering treatment with ECT is the severity of illness. It is not uncommon to treat patients with ECT early on in their illness or using it as a first line treatment if they are severely ill at the time of presentation. Weight loss, imminent suicide risk, failure to thrive, inability or refusal to eat and a severe ongoing medical illness which makes waiting non-feasible are all indicators that ECT would be a helpful treatment modality.
3. Depression and affective disorders
Severe major depressive episode, and mood episodes with predominant depressive pathology are some of the common reasons behind referrals. Generally, if depressive symptoms are accompanied by a “biological shift” indicated by cachexia and weight loss and insomnia or hypersomnia, patients will tend to respond well to the treatment.
Catatonic patients tend to respond well to ECT treatments. Care needs to be exercised to rule out behavioral difficulties, somatoform and factitious illnesses.
5. Acute mania
Acute mania tends to respond well to ECT and the time to remission might be reduced in many instances. There are times when prolonged hospitalizations and treatment trials could be avoided by utilizing ECT as a first line treatment option.
6. Acute psychosis
Acute psychosis can respond quite rapidly to Electro-convulsive therapy.
1: Will it erase my memory?
No. ECT causes short term memory impairment. Common causes of longer term memory impairments are delirium, cognitive decline related to dementia or age and pseudo-dementia from the incomplete remission of the underlying condition.
You can expect the memory to be quite poor starting the middle of the series till the end. You may not recall conversations with your family and your health care providers completely.
2: Will I get pain killers for my headache?
Generally not but every patient situation is determined by the treating provider.
3: Will I be “hooked” ? Will I continue needing the treatments?
Maintenance treatments every 4-6 weeks or so are sometimes recommended if you have a relapse which does not improve with medications. Generally, this is voluntary.
4: Do I need to stay in the hospital?
If you are otherwise healthy and stable (no medical or psychiatric indications for hospitalization), you can stay at home. You will not be allowed to drive back home, and should arrange for this accordingly.
5: How many treatments do I need?
Generally, eight treatments are considered a series. Treatments are generally done every other day, no more than three a week. Multiple treatments in one day are no longer done as they are no more effective. While eight treatments are an initial goal, some patients show improvement in as few as 3-4 treatments and some patients need more than 15. Each patient’s goal is determined individually.
6: I do not want ECT. Can you force me to get one?
No. Generally, this is a voluntary treatment. In some situations where the patient is not considered “capacitated” or lacks the decision making capacity due to psychiatric or medical impairment, courts can order ECT. This is done is two psychiatrists concur that this is the best course of action and the family and loved ones are on board.
7: Is it painful?
No. Muscle soreness and headaches are sometimes reported post ECT and are treated with over-the counter anti inflammatory medications. Opiate pain medications are rare required. Patients prone to headaches can be pre-treated with anti-inflammatory medications and this helps quite a bit.
8: Does it work/How does it work?
Yes, it works rather effectively. Electricity in ECT induces seizures. The brain’s seizure -stopping mechanism then kicks in and releases neurotropic factors which stop the seizure and provide improvement in psychiatric condition. The exact mechanism of ECT’s action is not known.
9: How long is the seizure/What is it does not stop?
Seizures range from a few seconds to two minutes and longer. Conventional wisdom suggests seizures should be longer than 30 seconds to be effective. There are other variables now which are considered for predicting the effectiveness of the treatment.
If the seizure does not stop between 90-120 seconds, the anesthetist might inject a seizure stopping medication which works quite quickly.
10: Can I drive/return to work tomorrow?
Depending on the total number of treatments, your overall health and cognitive state, you might need 2-5 days prior to being able to drive. If you have early dementia, your doctor might advise you to not drive for longer.
Returning to your job would depend on your age, overall level of functioning prior to the treatments and number of treatments. Many people are able to work in-between the maintenance treatments.
11: Will I get one sided or two sided treatment?
Unilateral and bilateral refers to electrode placement. While unilateral electrode placement causes less memory difficulties, a higher setting is required to induce seizures. Given that the treatments are generally for a brief amount of time, bilateral treatments are preferred by many psychiatrists given the higher effectiveness.