SHOCKING!!! The role of ECT in the treatment of mental illness

I just have a question for you: what are your views on ECT – mine are completely negative since I have had so many and they did absolutely NOTHING for me but cause long term memory loss.

There is absolutely NOTHING that will scare a patient more than when the doc starts bringing up ECT–electroconvulsive treatment . . . shock treatments, if you didn’t already know.  It brings up all sorts of visions in your head from old pictures of crumbling and dirty state hospitals to Jack Nicholson in “One Flew Over The Cuckoo’s Nest”.  It is frightening from the standpoint of what the experience might be like, but also because of what it means . . . “that I am really, really sick”.  ECT is not a topic I have covered here before so I thought I would wright a brief entry about it.  From a purely historical perspective, shock treatment is not one of psychiatry’s finest moments.  In it’s earliest and crudest form, the patient would receive an infusion of insulin.  That would drive the patient’s blood sugar down to the point where there was a disruption of brain function and the patient would have a seizure.  (Wouldn’t you love to meet the guy that first thought of THAT!).  In an effort to improve on this (HA HA), the world of psychiatry thought that it would be fun to put a jolt of electricity to the temple of a patient strapped to a gurney.  That is the pretty picture immortalized by Jack.  Aside from the behavior modification that this would bring about (after one or two of those, I would NEVER complain again about being depressed), people would have all sorts of complications such as broken teeth and bones, bruises, lacerated tongues, etc, etc.  

It is nothing like that now.

ECT is done now done in highly controlled and medically sound conditions. During my training days, it was done in the surgical recovery room before the day’s surgeries began, but it can be done in less intense environments now as well.  It is done to patients who are psychiatrically hospitalized, but also to patients on an outpatient basis.  Obviously, there is a degree of medical clearance that must take place so that the patient getting it is in reasonable medical shape. It is done in the presence of a supervising psychiatrist who is trained in the application of ECT.  Also present is an anesthesiologist, and at least one nurse.  A patient who is getting the treatment done will lay down on a gurney and have an IV started. Sedation is given to essentially knock you out so that you have no memory of the event.   A blood pressure cuff is blown up slightly over the systolic number to limit blood flow to one arm.  The patient is then given a very short acting neuromuscular blocking agent (similarly given during some surgeries) that prevents you from moving during the ECT treatment.  A bite block is put into place and, because you are paralyzed and unable to breathe on your own, the nurse hooks up a bag to the bite block and breathes for you.  An measured burst of electric current is then applied to your temple and your brain has a seizure that lasts for about one minute.  Because you have been given a neuromuscular blocking agent, you don’t move . . . except for your arm with the blood pressure cuff on it.  Because the cuff restricted the flow of the neuromuscular blocking agent to your arm, there is some slight movement of the forearm and hand.  This is carefully managed by a nurse or aide.  When the seizure is over, the cuff is taken down.  The nurse “bags” your breathing until the neuromuscular agent wears off (only a few minutes).  The sedation wears off over the course of 10-30 minutes and you are able to get up and go home.  It is neither scary to watch or experience.  

ECT is used as a “last resort” intervention.  It is a big deal.  Nobody likes it.  Nobody likes to recommend it.  But, for many people, it is the difference between life and death.  Or life being reasonably happy and life being a depressed hell.  It can be a useful intervention in refractory depression, Bipolar Disorder and psychosis. It is most commonly used to treat refractory depression.  The typical scenario for recommending ECT is when someone has essentially failed multiple trials of medications, combinations of medications, and various augmenting strategies.  It should never be recommended as a first line, second line, or third line intervention.  It is used when nothing else has worked.  It is highly effective in taking people who are very, very depressed and helping them to be to less depressed and, sometimes, happy.  It is used in conjunction with antidepressants and the idea is for the antidepressants to “take over” and maintain the patient’s mood improvement after the ECT jump-starts their recovery.  Because it is a big deal, it is not a process that is easy to initiate.  Where I practice, it requires an evaluation by a doc that specializes in ECT.  It must then be approved through the insurance company (because they know better than anybody about how to keep you healthy . . . more on that another time).  You are then set up for a series of treatments.  Usually this consists of six to twelve treatments that occur at a rate of two or three per week.  So you are talking about multiple weeks of treatments.  Improvement often occurs after just a few treatments, but it might take ten or twelve before you get better.  It is important that the treatments continue even after improvements occur as a way of solidifying the improvements.  This is FAR from an exact science.  The conventional wisdom we always used back in the day was do it till they are better . . . then do two more!  It is clear that if you don’t continue after a certain degree of improvement occurs, there is a higher chance of relapse.  It does not work for everyone, but most have a degree of improvement if not a resolution of their symptoms.

It’s the potential side effects that scare most people.  It it’s worst, it can cause long term memory issues that you don’t recover from.  In the short run, most people experience a degree of amnesia for the events of the time before and after the shock treatments.  This can be a few hours or be a few days of amnesia.  It can result in a period of incontinence following the events.  You can be a walking zombie with little personality and little motivation for a while after the treatments.  Most of the side effects gradually taper off over time.  But for some, there is a residual memory deficit that manifests mostly as short term memory loss.  It can be permanent.  

That is why it is not a first line agent . . . or a second . . . or a third . . . 

There are some that feel that it should be banned and never used.  I think this would be throwing the baby out with the bath water.  It is a life-saver for some people.  I have seen it take people who appear to be doomed to life-long depression and return them to normalcy.  I have told my wife that if I ever get seriously and intractably depressed that I want to be given ECT.  But like all medical procedures, it is not without risks and negative outcomes.  Those risks must be carefully considered by the patient and family of the patient who will receive the treatment.  As with all medical procedures, you MUST be willing to accept the risk of the negative outcome before giving your consent for the procedure.

Medicine . . . and psychiatry in particular . . . is a messy business with a great many potential pitfalls.  Approaching any treatment option needs to be done carefully, systematically and thoughtfully by all involved.  

I know this subject brings up strong feelings . . . send me your comments.  I will pass them along.

–Dan Hartman, MD

6 comments to SHOCKING!!! The role of ECT in the treatment of mental illness

  • I am the one who posed that question, and I thank you for answering it in a way that people can understand it’s procedure. I am very bitter about the whole ECT issue, as I was deemed medication resistant and I suppose they didn’t know what to do with me. I felt I was thrown to the ECT wolves and therefore underwent a total of 77. Looking back, I obviously should have resisted, but just too ill and that all too familiar “maybe the next one will be effective”. As for the docs, you would think when #40, then #55, then #70…..didn’t work they would have come to the conclusion that this was not the perfect method for me.

    That was years ago. I am on the right meds now given by a psych. who knows what the hell he is doing.

  • Too often, doctors get into a line of thinking with a patient and won’t step out and look at what they are doing. I’m not immune to this but I certainly try to be. Your case of repetitive ECT seems a bit over the top. That is why patients should have an advocate come with them to treatment whenever things get bad. That way, someone can speak up for them. Glad you are on the right road now.

    –DH MD

  • D.

    I’m 48, male, (Bipolar depression, Bipolar II, dysthymia, TRD, etc… been on numerous meds from different classes since 95’(SSRI’s, SNRI’s tricyclics, Selegiline, methylphenidate augmentation, anticonvulsants, antipsychotics, alternatives (SAM-E, St. Johns Wort)etc… I’ve also been in behavioral and cognitive therapies since my teens… Nothing, again, nothing has worked, aside from lethargy, and apathy. I live in Philadelphia and have been to U of P and a ton of other psychiatrists. I know one day I will take my own life, there is no question. “Windows” are present every now and then, but there will be more “open-windows” when my family is deceased. TMS was discussed for clinical trials back in the early 2000’s, but no recommendations from Docs. Is there a place where I can go in the Philadelphia area for ECT? Thanks! D

  • D.

    Absolutely!!! Several institutions offer ECT. You do have to have an evaluation at the center to get the treatment but it is readily available and should be strongly considered if you have not gotten results with other treatments. Check out Belmont, Abington Memorial Hospital (Dr. Worthington is the director of ECT there), Princeton House in Princeton. I am sure there are others–you just have to look. Your doc should be able to get you connected to someone.

    Good luck

    DH MD

  • Tammy

    My husband recently underwent this process called E.C.T.
    Please be 100% informed when you decide to undergo this procedure. Don’t let the Dr. tell you that you have to do this because there is nothing else that can be done. And insist that your spouse or another family member is present to observe this film they show you. And have them there also if you have recently been placed on new medications or are suicidal at the time that this procedure is suggested to you. My husband has so many problems from this “Wonderful Treatment Plan” (NOT!!!). He doesn’t even remember our Wedding Day, and we are still Newlyweds how sad is that? I think it us unfair to the family members that are left to sort out a “Professional’s” mistakes. Thank you for allowing me to get this off my chest and hope to keep you updated on my husbands re-education of who he is.

  • Tammy–I’m sorry that you and your husband had such a bad time with the ECT. It can be a lifesaver for some . . . but not for everyone. And the potential for memory and cognitive issues is a real problem. This is not caused by a professional mistake, but by the nature of the treatment. If you did not understand that going into it, then it is an issue of informed consent . . . but not a mistake. I am a fan of ECT, but at this point would NEVER NEVER NEVER NEVER EEEVVVEEERRR recommend it without first recommending TMS (Transcranial Magnetic Stimulation). TMS was not even approved in the USA when this posting was first put up in September, 2008. It is widely available now. Like any treatment for depression, it is not effective for everyone, but it has no cognitive or memory issues associated with it at all so is a better first option for patients with refractory depression. Be patient with your husband. It is likely that a significant portion (if not all) of his past memory will return. It just may take time.
    –DH MD