ELECTROCONVULSIVE THERAPY (ECT)
A Brief History of ECT
Electroconvulsive therapy, commonly called ECT, was developed
in 1938. During the period following its introduction, ECT
was found effective for treating multiple psychiatric illnesses,
especially depression. With the development of psychiatric
medications and stigma associated with ECT in the 1960's,
the use of ECT treatment declined. The use of ECT has increased
since the 1970's because of improved treatment delivery methods,
increased safety and comfort measures, and enhanced anesthesia
management. ECT is the most effective treatment for severe
mental illness and is an extremely safe treatment.
ECT is most commonly used to treat patients
with severe depression who fail to respond
to medications or who are unable to tolerate
the side effects associated with the medications.
ECT may also be the treatment of choice
for patients who need a more rapid response
than medications can provide. This would
include those who are severely agitated,
delusional, suicidal, not eating or drinking,
as well as those who suffer from catatonia
(a potentially life threatening trance-like
state).
The use of ECT is not limited to the treatment
of depression. It may also be used to stabilize
bipolar illness during extreme episodes
of mania or depression. Additionally, ECT
can be used to halt psychotic episodes associated
with schizophrenia. Once these individuals
are stabilized, medications are started
or resumed.
How Does ECT Work?
MECHANISMS OF ECT
Electroconvulsive therapy involves applying
a brief electrical pulse to the scalp while
the patient is under anesthesia. This pulse
excites the brain cells causing them to
fire in unison and produces a seizure.
The specific reason for the positive action
of ECT is unknown, but this treatment appears
to have many effects. There are multiple
theories to explain why ECT is effective.
One theory suggests that the seizure activity
itself causes an alteration of the chemical
messengers in the brain known as neurotransmitters.
Another theory proposes that ECT treatments
adjust the stress hormone regulation in
the brain, which may affect energy, sleep,
appetite, and mood.
THE NUMBER OF TREATMENTS NEEDED
Treatments are normally administered three
times a week on Monday, Wednesday, and Friday.
A course of ECT normally ranges from six
to twelve treatments. The average number
of treatments is nine. The number of treatments
that you need will be determined by the
severity of your symptoms and how rapidly
you respond.
It usually takes six treatments before
major improvements in your symptoms are
noted. However, family members, friends,
and caregivers may begin to see mild improvements
following the first 3 to 6 treatments. These
improvements may include an increase in
your activity level, improved sleeping patterns,
and a mild increase in your appetite.
Your psychiatric care providers will monitor
your response to the treatments. This information
combined with your input will be used to
determine how many treatments you will receive.
RIGHT UNILATERAL TREATMENT versus BILATERAL
ECT TREATMENTS
There are primarily two types of electrode
placements used for the delivery
of ECT. Differences between these two techniques
include the area of the brain stimulated,
timing of response and potential side effects.
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Right Unilateral
Placement
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To generate a seizure with a right
unilateral treatment, one electrode
is placed on the crown of the head and the
other on the right temple. Those receiving
the right unilateral treatments may respond
somewhat more slowly than those who receive
bilateral treatments. This difference is
usually no greater than 1 to 2 treatments.
Right unilateral treatment is typically
associated with less memory side effects.
Patients who do not respond to right unilateral
treatments may require a switch to bilateral
placement.
Bilateral ECT treatment
involves placing the electrodes on both
temples. This treatment may
be associated with more acute memory side
effects than right unilateral treatments.
Bilateral ECT is indicated for severe mental
illnesses including depression with psychosis,
manic episodes of bipolar disorder, psychosis
related to schizophrenia and catatonia.
You and your doctor will work together
to determine which treatment option is best
for you. Specific recommendations will be
made after carefully evaluating your concerns,
medical/psychiatric history, and the severity
of your symptoms.
ECT Treatment
THE TREATMENT TEAM AND THEIR ROLES
Typically, ECT is performed by a team of
medical professionals specifically trained
in the delivery of ECT. This team consists
of a psychiatrist, anesthesiologist, and
nursing staff. The psychiatrist commonly
delivers the ECT stimulation. The anesthesia
team administers medications and monitors
your medical status throughout the procedure.
After the treatment, nursing staff will
continue to monitor your progress until
you return to the inpatient or outpatient
unit.
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Anesthesia Monitoring Equipment
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THE TREATMENT
The night before a treatment you will not
have anything to eat or drink after midnight.
Some people may receive medications in the
morning with a sip of water for headache,
high blood pressure, stomach reflux, or
other significant medical conditions.
Shortly after you arrive in the ECT treatment
area, an ECT team member will insert a catheter
into your vein, often referred to as an
IV. The IV will be used to administer medications
necessary for both the ECT and your comfort.
Pads with monitoring wires will be placed
on your head and upper body to monitor your
brain waves and your heart during the procedure.
Blood pressure cuffs will be placed on both
your upper arm and lower right leg. The
cuff on your arm will be used to monitor
your blood pressure. The cuff on your leg
will be used to prevent the muscle relaxant
medication from traveling to your foot,
allowing the psychiatrist to monitor your
motor seizure.
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Treatment Preparation
and Medication Administration
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You will then be given a medication to
make you sleepy. At the same time, a mask
will be placed over your nose and mouth.
The mask is used to provide you with oxygen.
When you are completely asleep, a muscle
relaxant will be administered to prevent
your muscles from twitching. After your
muscles are sufficiently relaxed, two electrodes
will be placed on your scalp and a pulse
of electricity will be administered. Seizures
vary, but are generally in the 25 to 45
second range.
You will be closely monitored during and
immediately after this treatment. After
you awaken and your vital signs are stable,
you will be transferred to the recovery
area. The ECT treatment generally lasts
only 10 to 20 minutes.
In the recovery area, the nurse will closely
monitor your blood pressure and level of
consciousness for another 20 to 30 minutes.
Once the anesthesiologist is satisfied that
you are ready, you will return to the inpatient
or outpatient unit.
Upon arrival in the inpatient or outpatient
unit, your vital signs and level of consciousness
will be checked again. As soon as you are
alert, you will be provided with food and
beverages and assisted with dressing as
needed. At this point, if you are an outpatient,
you will be released in the care of the
person who accompanied you to the hospital.
If you are an inpatient, you will be encouraged
to participate in unit activities, or you
may continue to rest if you are feeling
tired.
Common Side Effects
COMMON SIDE EFFECTS AFTER TREATMENT
Occasionally, a patient may have a headache,
muscle aches, or nausea after the treatment.
These side effects can be treated with medications
before or after the ECT. If you experience
any of these side effects please inform
your doctor and nurse. Once the staff is
aware of these side effects, measures can
be taken to prevent them.
Additionally, some people may exhibit mental
confusion resulting from the combination
of anesthesia and/or ECT treatment. Acute
confusion, if it occurs, typically lasts
for 30 minutes to 1 hour. You are closely
observed by nursing staff and doctors during
this time for your safety.
POSSIBLE MEMORY SIDE EFFECTS
Memory loss is one of the greatest concerns
of people who receive ECT. Two different
kinds of memory loss may occur during the
course of ECT treatments. The first is the
loss of short-term memory during the period
of time that you are having ECT treatments.
Some examples of short-term memory loss
include forgetting what you had for lunch
or not remembering talking to someone earlier
in the day. Your ability to remember new
information will generally return to your
normal level within a few weeks to a few
months after the treatments are finished.
The second type of memory loss that may
occur involves memory loss for past events.
Recent past events (2 to 6 weeks before
treatment) are more sensitive to ECT. However,
some patients may describe "spotty"
memory loss for events that occurred as
far back as 6 months before beginning ECT.
This memory impairment is potentially permanent.
Although it is rare, some patients have
reported a more severe memory loss of events
which date back further than the 6 months
preceding ECT treatments.
Safety and Other Issues
THE SAFETY OF ECT
Any medical procedure involving anesthesia
carries some risks. The potential risks
include cardiac or respiratory arrest. The
risk of respiratory or cardiac arrest resulting
in death during ECT is negligible (less
than 1 in 10,000 cases). This risk is typically
regarded as being similar to the risks of
having an outpatient surgical procedure
under anesthesia. ECT treatments are extremely
safe and severe medical complications are
rare. You will be monitored constantly during
the procedure by a team of medical professionals
in the event of a complication.
MAINTENANCE ECT
 Because
depression is often a relapsing illness,
patients may experience repeated episodes
of depression even if they respond very
well to ECT. Patients often have failed
numerous medications prior to ECT, and their
illness may be significantly resistant medications.
When repeated episodes of depression occur,
your doctors may recommend a taper of ECT
over a course of several weeks to months.
Modern clinical practice and recent research
have found that Maintenance ECT is often
very effective in keeping patients well.
A common taper of ECT is treatments once
a week for a month, once every 2 weeks for
two months, once every 3 weeks for two months,
and once every month for two-four months.
Although there is a considerable commitment
by patients and families to undergo Maintenance
ECT, the avoidance of lengthy re-hospitalizations
and undergoing more medication trials is
often worth any inconveniences.
WHAT TO EXPECT AFTER ECT
ECT is an extremely effective treatment,
but ECT treatment is only one component
of a complete treatment regimen. After your
ECT course, medications will likely be required
as maintenance therapy to prevent a return
of your illness. ECT also can not resolve
other problems associated with personal
relationships or how an individual copes
with the stressors of life. Other interventions
such as psychotherapy may be recommended.
Hopefully, because you are being relieved
of the severe symptoms of your illness,
you will be able to participate more effectively
with other therapies that are recommended.
Is ECT for You?
The decision to undergo ECT requires understanding
of the treatment by you and your loved ones.
If ECT is offered to you as a treatment
for your illness, it is because your physician
believes you will benefit. Hopefully, after
reviewing this material and talking with
professional staff, you will be more comfortable
in weighing the risks and benefits of ECT
so you can make a decision that is right
for you.
Last updated on:
Thursday, 02-Feb-2006 09:45:40 EST
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