When my attending suggested that I go check out Electroconvulsive Therapy (ECT), I wasn’t quite sure what to expect. The first thing that came to my head was the disturbing scene in One Flew Over the Cuckoo’s nest in which Jack Nicholson was restrained by a group of nurses and doctors and while consciously talking, and obviously unaware of what was going to happen, had prongs fitted on his head. Without warning, he was immediately given an electric shock to the head. He screamed in pain and immediately went into convulsions. For a long time, movies like One Flew Over the Cuckoo’s Nest instilled in me a perception that ECT is barbaric, inhumane, and against the patient’s wishes, but after seeing ECT done on the real ward, I found that ECT is quite the opposite of what movies often portray them to be. It is actually a quite humane procedure and one of the most effective ones as well, in which the patient sleeps through the entire procedure, and wakes up becoming a much improved person.
That morning, we had two patients lined up to do ECT. Our first patient walked in for his monthly ECT appointment. He spoke normally, was well kempt, and seemed like any other person you’d meet. With the help of an anesthesiologist (or anaesthetist, as they call here in Britain), he was first given propofol (a short-lasting general anaesthetic, although thiopental is generally used more since propofol may decrease ECT activity) and suxamethonium (a muscle relaxant). The patient immediately fell asleep and became completely relaxed. As the diaphragm muscle was also relaxed, the patient was given artificial ventilation to help him breathe. A mouth guard was put in place to prevent the patient from biting the tongue. EEGs were attached to his forehead to monitor his brain waves. It was then that the junior doctor put two electrodes on the temporal sides of the patient’s head, along with a lubricant that eased the conduction. With the dosage set on the machine, the nurse activated the ECT, and suddenly an electric shock flowed through the patient’s head for a few seconds. The patient’s entire body immediately tensed at the activation of the electrodes, and for the next few seconds, convulsed, then relaxed. Not long after, the EEG printed out to show the duration of the convulsion. While visually we only saw the convulsion for less than 10 seconds, the brain scan shows it actually lasted around 40 seconds in the brain… “that was a good seizure” proclaimed the senior doctor. “Ideally you’d want at least 25 seconds.” The procedure was over.
The patient, now completely relaxed and still asleep, was wheeled into the recovery room by the nursing staff. A few minutes later, the patient opened his eyes. He felt a bit drowsy but was in no pain. As protocols, the nurse asked him a few questions to test his memory and cognitive performance. “Do you know where you are?” asked the nurse. For a brief moment, confused, the patient had no recollection as to what had happened. “You just had a session of ECT.” The patient eventually started remembering, and within 15 minutes, his mind was back to normal, and up on his feet. The nurse offered him some tea with milk, as is customary in Britain. He graciously accepted. I asked him how he was feeling and he told me he was feeling better. The patient then told the medical team that he was very satisfied by the improvements in his well-being from the treatment and wishes to continue treatment.
Seeing this patient today and how normal and well of a life he leads today, it’s hard to imagine that at one point in his life, this patient was once extremely depressed, with multiple suicide attempts, hallucinations, and delusions that severely handicapped his ability to function in society. Antidepressants were not working well enough for him, and he could not afford to wait longer for the drugs to kick in, which often takes several weeks if not months to see effects. Each day that passes was a risk of death by suicide for him. He was a good candidate for ECT. Unlike antipsychotic drugs, you can see much faster and more immediate results with ECT, and studies have shown that ECT often works just as well, if not better, than medications. Within just the first few doses, it was already clear that this patient was improving. Today he is living a more or less normal life with his wife and family and only comes in once a month for a maintenance dose. For him, the ECT treatment was routine, and it was what kept him alive to this day, functioning, and well.
So despite the bad image that ECT often gets in public, I realized during my time on the ECT unit that ECT today is actually a life-saving procedure that is very effective, and its adverse effects of short-term memory loss and disorientation are really just temporary, and are easily recovered. The procedure is short and quite humane, with the patient not being aware during the procedure. Treatment planning in psychiatry is all about risk assessment and what’s best for the patient’s given situation, and often times ECT may be the last hope to improving a patient’s mental well-being.
A Little History of ECT
ECT originally started in the 1930s when doctors at the time noticed that people who have a history of epilepsy seem to be less likely to have psychosis (although this was later discovered to not be entirely true either). Applying this observation, a neurologist by the name of Dr. Ugo Cerletti in 1938 decided to artificially induce a seizure in a patient with severe psychosis, by using electricity. After a few sessions of shock, Cerletti was able to bring the patient back to a functional state of mind. ECT was born.
Why is ECT used?
Studies have shown that ECT is just as effective, if not more effective, than pharmacological interventions in the treatment of depressed patients. So why would you use ECT over drugs? Well, drugs for depression often take many weeks to kick in, whereas the patients who undergo ECT often see results as early as the first dose, and even better results after second and third. Because of this, ECT is mainly reserved for people who either do not respond well to drugs, or who are severely depressed and psychotic who need to get better immediately. These patients are often the ones who are on the brink of suicide, neglect, or danger, and cannot afford to wait 5-6 weeks for drugs to kick in.
How does ECT work?
From what I understand, no one really knows for sure yet. They like to say it “reboots” the brain, but exactly what does this mean?
How is ECT administered?
Often patients are given a course of ECT anywhere from 6-12 sessions, twice a week in the UK (or 3 times a week in the US). The doctor may start the patient off with perhaps a 5% or 10% dose, and work up as needed. 200% is the highest dose one can get. ECT can be given unilaterally or bilaterally. If you are doing unilateral ECT, you need to increase the dose by 4 times.
Giving ECT unilateral on the non-dominant side of the brain has less side effects on memory loss than on giving ECT bilaterally. Therefore unilateral is often used more with older patients, who cannot suffer from any more memory loss. Since the maximum dose for ECT is 200, however, and unilateral is equivalent to 4 times bilateral dosage, the maximum dosage for unilateral ECT is only 50, which may not be enough for some patients.
What are the side effects?
The biggest side effect is temporary short-term memory loss. When the patient first gets finished with ECT, he/she may be disoriented to time and place, but they usually become oriented again after 15 minutes or so. There is also retrograde amnesia, in which the patient may forget the events leading up to the ECT. Sometimes, there may also be anterograde amnesia in which they do not remember the events after ECT later on. Despite these memory problems, there hasn’t been any sufficient evidence of permanent hindering of learning, cognitive, or memory ability, and nor is there evidence of ECT changing brain structure. Nevertheless, further research and analysis should be done to continue to improve its use. ECT has come a long way since it was developed in the 1930s, and certainly much more humane today than how it was practiced before the development of anesthesia. ECT as it is practiced today is generally considered safe and effective by the medical community, and has made a come back in recent years despite a negative image in the media.