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