Electroconvulsive therapy (ECT). What is it? Does it work? Who is a candidate?
The number one question I’ve been asked by those unable to get relief from depressive symptoms through medications, psychotherapy, or other methods. “Dr. Hill, Is ECT safe?” My answer, a qualified, Yes, because ECT itself is a safe and tested procedure for depressive symptom relief; much safer, in fact, than the ordeal of the ECT procedure. ECT is conducted in a hospital under general anesthesia. I say this because there is probably more risk to the anesthesia than the ECT itself.
Still, ECT is a useful and appropriate treatment for those with chronic and persistent depressive symptoms even though it has been maligned by the media. Some people who have received it feel stigmatized by the mystery behind how and why it works. Labels of a person as having an terrible, incurable disease where heroic measures are needed persist. But, ECT has been around for a long time and many people have been helped by it.
Mary’s Experience with ECT
Mary, a client I saw several years ago, was suffering from what is commonly known as treatment resistant depression (TRD). The research literature of 12-month prevalence rates of TRD is 3% in the U.S. population for Stage 1 type, (failure to respond to 1 adequate trial of an antidepressant) and 2% in the U.S. population for Stage 2 type (failure to respond to 2 adequate trials of an antidepressant). TRD is not easily treatable with psychotherapy and medication. It is from this group of persons that most ECT candidates come.
After years of attempts to find a treatment with lasting positive effects, Mary felt frustrated and demoralized by her symptoms of lethargy, self-loathing, and profound hopelessness that anything she might do to feel better would fail. She felt helpless to do anything about her symptoms, and she felt worthless because she was surrounded by a supportive network of friends and family. This irony, in her mind, contributed to a persistent feeling of personal worthlessness. She thought, “I’d rather be dead than drag all these people I love through the constant struggle I’m having.“ Still, she was trying her best and looking for novel solutions to get relief. It was from this background that her psychiatrist suggested ECT.
At first, Mary rejected the idea. She had seen television programs and had looked up ECT on the internet with a bias of finding all the things that were negative about it. That information is available if you look for it.
However, more contemporary research with ECT including new technologies to administer it and better procedures for conducting it, indicate that it has a number of advantages over tradition approaches. For one, the actual side effects are much less than those associated with pharmacology agents.
Mary eventually convinced herself to make an appointment with an ECT clinic in her local hospital and explore the issue further.
What is ECT
ECT is delivered with electrified paddles (similar to what might be used in a cardiac defibrillation machine). These paddles generate a mild electric current that is passed through the brain. The electric current intentionally triggers a brief seizure similar to an epileptic seizure. That’s why the patient is routinely anesthetized. Seizure-generated brain electrification seems to cause subtle changes in brain chemistry that can quickly (sometimes immediately) reverse symptoms of depression.
Much of the stigma attached to ECT is from the 1960’s (One Flew Over the Cukoo’s Nest) when very high doses of electricity were used (without anesthesia), to control unwanted behavior or acting out on, say, a psychiatric ward. At such intensity it was almost guaranteed that ECT would produce recent memory loss, and the person receiving the procedure, due to violent seizure spasms, would occasionally fracture bones, swallow the tongue, experience gross disorientation, or experience a variety of unwanted consequences.
Today, many people, at the low doses it is administered, don’t experience any loss of memory even though recent treatment protocols usually involve receiving ECT (under anesthesia three to five times per week for a month in duration). The biggest issue is the re-occurring anesthesia and the sizeable medical bills for the procedure that usually require multiple hospital personnel.
Below is a typical protocol for a first ECT procedure. I’ve abstracted this from several sources. I’ve also witnessed ECT first-hand while I was a psychologist working at an inpatient facility at Stanford University.
ECT Protocol
Before you receive the treatment, a doctor or nurse will place a needle into a vein in your arm (IV). That way, the medical team can easily give you the medications you need before and during the procedure.
Although you will be asleep during the treatment, the medical team will need to start preparing you for the treatment while you are still awake. The team will:
Place sensors called electrodes on your head, so that they can measure the electrical activity in your brain. To do this, they will use a device called an EEG, or "electroencephalogram."
Place electrodes on your chest, so that they can measure the electrical activity in your heart. To do this, they will use a device called an ECG, or "electrocardiogram."
Wrap a blood pressure cuff around your arm, so that they can monitor your blood pressure during the procedure.
Put a small sensor on one of your fingers called a "pulse oximeter," which will allow them to measure the amount of oxygen in your blood. This will tell them if you are breathing normally.
Give you oxygen through a mask or a tube that rests below your nose. You will get oxygen throughout the whole procedure, until you wake up.
When everything is connected, the medical team will set the ECT device for your treatment. You will then be injected with a medication (such as methohexital or propofol) that will make you go to sleep for 5 to 10 minutes. When you are asleep, you will get another injection, of a muscle relaxant (succinylcholine). This will keep you from moving during the treatment. The muscle relaxant may cause mild muscle soreness after the treatment, but this soreness will pass.
Once you are deeply asleep and your muscles are completely relaxed, the team will administer the ECT treatment. Because you will be asleep, you will experience no pain during the treatment and will not feel the current or the seizure. If you were watching the treatment instead of receiving it, you would see your toes wiggling or other parts of your body moving a little — but not much else.
If you are interested in more detail about ECT procedures here is webpage that provides a deeper dive into the steps and protocol of an ECT intervention.
https://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/about/pac-20393894
Two ECT Success Stories
I’ve abstracted two stories that offer personal viewpoints of the ECT experience and outcome: 1. Carrie Fisher’s (now deceased) experience with ECT and 2. A reader’s shared experience that was published in the Atlantic, January 11, 2017, from the Article: Coming out of Electroshock therapy. The reader’s viewpoint is instructive. It also provides perspective of how ECT is frequently viewed by the general public.
CARRIE FISHER’S EXPERIENCE
…In 2012, an overwhelming mixed episode had me fighting for my mind and my life, and I begged my psychiatrist for help. He admitted me to the psych ward. After I settled in, we discussed changing my medication. We’d been conducting this chemistry experiment for 15 years, but it wasn’t enough. I had run out of options. He recommended ECT. It was my best shot at taking back control of my bipolar brain.
Before I agreed, I did some research. I learned that ECT was still the recommended second line of treatment in the standard medical guide to mental illness (the first being the drugs that had failed me). I considered the list of side effects, including memory loss, impaired thinking, and headaches. When the other option was waiting until I finally snapped and took my own life, these seemed like minor inconveniences.
So, I signed up for voluntary brain electrocution. For those unfamiliar with ECT, it goes something like this:
You are given general anesthesia and taken into the treatment room. You are given a drug that paralyzes your body. The doctor then sends electricity into your brain to disrupt its signals. In simple terms, you experience a seizure-like interruption of the electrical current inside your head and, over the course of treatment, the mind over which you’d lost control is supposed to return to its old self. The procedure itself is thankfully quite brief, and you wake up in recovery with no memory of what happened.
Despite the memory loss that followed my first treatment, that day stands out with startling clarity. The hospital had already been scheduled for demolition, and the interior was aged and neglected. As I rode the rickety elevator to the fourth floor, I struggled to squelch my growing terror. My mind is my primary marketable feature—the sudden reality of what I was about to do turned my stomach when I realized that my choice of treatment might leave me with permanent impairment. And might not work at all.
There were eight of us scheduled for ECT that morning. The nurses lined up our stretchers in the pink tile-lined hallway and systematically administered our sedatives. It was an assembly line of last resort. The fluorescent lights came in and out of focus as I slipped into the drug-induced slumber. My next memory is of being thrust back to awareness by the force with which I vomited on the recovery-room nurse.
I had felt nothing during the procedure and was shipped back to the main hospital while I was still numb. The memories from before, during, and after the treatments are either completely blurred or simply missing. Trying to recall specifics from the rest of my hospital stay is like searching in vain for a simple word that rests on the tip of your tongue but refuses to be said. I don’t remember that Christmas with my family or spending time with my parents in Florida. The photos I took while I was there look foreign and staged.
I did three sessions a week for six weeks. On treatment days, I was ferried to the regional mental health centre in a taxi before sunrise. Nothing quite cements the idea that you’re crazy like daydreaming of Nurse Ratched…
ATLANTIC READER’S EXPERIENCE
The first stay in the psych ward was for a month. I remember thinking at a certain point that they were never going to let me out, because I was never going to get better, and that I was going to have to either 1) make a break for it, or 2) kill myself on the unit. I remember actually planning it.
Every day they would ask me if I have any intent of harming myself on the unit, and I would lie—even though I told them in the emergency room it was my intent to kill myself, so that at least my partner would feel he did everything he could. I remember feeling awful about that, as the nurses were (in hindsight) generally kind and well-intentioned people. But I remember feeling like they were my captors, and not really feeling like my well-being was their concern so much as my safety in the most basic physical sense.
One of the early nights I was there, another patient howled through most of the night. I mean, really scream. My roommate had PTSD, so she would sort of start howling too. Another woman I met told me she really believed that she was being watched by the government. She knew how it sounded. Another had actually tried to kill herself; she’d jumped in front of a train. They’d had to amputate a leg and arm, and she was in a wheelchair. She is the hardest person to think about.
They threw the book at me in terms of medications: Klonopin, Effexor, Remeron, Zoloft, Lithium, Seroquel, and Zyprexa—serious drugs with awful side effects. After one dose of Seroquel, my tongue started making weird circles in my mouth and I start smacking my lips—it’s called tardive dyskinesia, or TD—and one of the doctors told me it was possibly permanent. I remember that I didn’t even care. At that point I had so thoroughly lost my mind—myself—that if this drug could bring that back, it would be a small price to pay.
***
Eventually, the psychiatrist recommended ECT. ECT! It was something that would have struck terror in my heart in my former life: the general anesthesia, the possibility of memory loss, the tinkering with your brain. And all I remember thinking was “Well, maybe I’ll just die on the table.”
Believe it or not, I am actually well now. The ECT helped, eventually. (20 rounds! I kid you not.) I can no longer really access that person I was; her thoughts, her feelings, are hermetically sealed, and mercifully alien to me. It’s almost as if it happened to someone else. I guess that form of magical thinking is part of mental health.
But the psych ward kept me safe so I could outlive my worst thoughts, and for that I am grateful. Like anyone who survives suicidal depression, I hope that maybe someone else out there somewhere will read this and think “Hey, if she could get through that, maybe I can get through this, too.” Because the adage really is true: This, too, shall pass.
SUMMARY
What should we conclude about ECT? For some people, clearly, it has been a lifesaver. For others, it has had mixed success. In some ways, ECT offers the same story for treating depression that other strategies have offered: A percentage of people benefit from ECT (some markedly so), a percentage of people get no benefits, but also no harm from ECT, a percentage of people are likely worse off after having engaged in ECT.
It does seem, however, that the percentage who benefit from ECT is higher than those who are worse off, so, for myself, I would consider it if I was struggling with chronic debilitating and painful symptoms of depression especially if I had tried drug therapy and psychotherapy and neither of these made much of a difference.
As a final note, in this entry which has focused more on personal experiences than on facts and figures, I recently read a case study by a psychiatrist who tried ECT herself. My thinking here is that a story from an individual in the profession that administers ECT is a perspective worth paying attention to.
“MY BENEFITS FROM ELECTROCONVULSIVE THERAPY-WHAT A PSYCHATRIST LEARNED BY BEING A PATIENT.” AUTHOR: Rebecca E. Barchas, MD, Psychiatric Services, 10 Novemember 2020.
I always thought of myself as a good psychiatrist, actually a very good psychiatrist. I saw much improvement in almost all of my patients and could control each person’s symptoms with psychopharmacological medications and with psychotherapy, which I loved to do. I never had to refer more than about 1% of my large patient population to hospitals, even though some of my patients were very ill. I could maintain treatment on an outpatient basis, and, in my 34 years of private practice, I never had a patient commit suicide. Now I am 71 years old and have been retired 8 years. Yet I realize now that despite having been a board-certified psychiatrist and a Life Fellow of the American Psychiatric Association, I was ignorant about something very important—the full range of patients who could receive the broad spectrum of benefits from electroconvulsive therapy (ECT). I rarely referred patients for ECT and always thought of it as a last resort. I was not sufficiently knowledgeable of the benefits of ECT until I myself was the beneficiary.
My husband died in the fall of 2019 after struggling for 9 years with progressive mental and physical decline from Parkinson’s disease. During those last 2–3 years, I developed symptoms of clinical depression, which became quite severe and were disturbing to both of us. I never felt suicidal, but I became extremely indecisive and lost my joie de vivre, my ability to experience pleasure, and my motivation; most important, I lost my resilience. Everything took such effort. I tried three antidepressants, but I could not tolerate their adverse effects and quit them before they could have conferred any benefit. I felt very discouraged and disheartened, especially when my primary care physician told me that my psychiatric symptoms were above and beyond his level of knowledge or training and that he did not have a clue how to help me. It made me feel that something was terribly wrong with me. Despite good insights from psychotherapy, I knew deep inside that my depression was not really getting better, but finally it improved for a few months. Nonetheless, my symptoms returned and got progressively worse during the last few months of my husband’s life. This time, no matter how good the insights were from psychotherapy, my depression only went downhill, especially after my husband’s death, and my cognition became so adversely affected that I developed irrational thoughts.
My family was very worried about me, and I received daily phone calls from concerned siblings, as well as two cross-country visits from one of my sisters. I was too embarrassed to fully seek the medical help I needed. I was certainly not going to go to any local psychiatric hospital because I did not want people who had been my colleagues to see my level of debilitation after my husband’s death. Yet I was unable to accomplish much of anything as I just stared into space, feeling very overwhelmed by everything I needed to do. I was repeatedly urged by my brothers and sisters to agree to hospitalization, and they even sought out places for me that would respect my privacy. One of my sisters-in-law did some research and finally learned that Sheppard Pratt Hospital in Baltimore had one of the finest psychiatric units in the country. When she and my brother flew across the country to drive me to Baltimore to be admitted, I offered no resistance.
I was assigned to a wonderful psychiatrist who, after a thorough initial evaluation, recommended I get ECT. I was indignant at his suggestion because none of the five doctors I had previously consulted who knew that I was depressed had ever suggested I needed ECT. And I certainly was too impaired myself to recognize that I needed ECT. I was scared by the suggestion because I knew very little about the treatment, despite my training and despite my many continuing medical education courses in which ECT would inevitably be mentioned but never emphasized. I had thought it should be reserved just for the absolute sickest of the sick—which I did not consider myself to be. But my psychiatrist said in a very reassuring voice that it would certainly turn my symptoms around faster than anything else and that I needed to trust him because he would not have recommended it if he did not genuinely believe it would help me. Finally, after many days of resistance, I signed the consent form to undergo ECT.
It took only three ECT treatments to totally turn around my depression and to stop whatever irrational thoughts had developed. I was more sensitive to the ECT treatment, resulting in seizures induced by the treatment that were longer than the seizure lengths typically achieved with ECT. This greater sensitivity had the advantage of making each treatment maximally effective in improving my mood but had the disadvantage of causing more post-ECT disorientation (i.e., when asked where I was, I would say “Tucson” instead of Baltimore). But my orientation improved each day, and the confusion finally disappeared completely. I have no memory of the actual ECT treatment because a general anesthetic and a short-acting benzodiazepine had suppressed any memories during the treatment. I never felt the seizure and had no later discomfort from it. On awakening from the general anesthetic, I was wheeled back to the psychiatric unit, whereupon I could eat a meal that had been delayed until after the treatment because of the general anesthesia.
Once my symptoms of clinical depression disappeared, which they did very rapidly, I could take pleasure in life, regaining my joie de vivre, my high level of motivation, and my ability to make decisions, and I once again had my resilience back. I no longer felt overwhelmed and could accomplish whatever I needed to do. What a difference a change in brain chemistry made!
The positive experience made me think that maybe I could do some good by writing this article and by recognizing that perhaps ECT is underutilized and should be considered more frequently as a treatment option than it usually is. After all, I now reap only the benefits of ECT and have no adverse effects at all. And for that I am very fortunate, because I had the best possible outcome. I realize that for too many people—for both patients who might be candidates for ECT and the doctors treating them—ignorance about the benefits of ECT and a persistent stigma may cause them to oppose the treatment. Even doctors who do not themselves “do ECT” or are not psychiatrists should have at least some basic understanding of the procedure and the types of patients who could benefit. When such a patient presents in their practice, they would then know to refer him or her to a more qualified specialist for evaluation for ECT. The patient will need a thorough discussion with the specialist so that the patient can gain a genuine understanding of both the benefits and risks of ECT and can be a partner with the physician in a shared decision-making process to decide on what might be the optimal treatment. Whenever a procedure is less mysterious, it is more acceptable. Mostly, stigma about any disease or any treatment occurs out of ignorance. For any of us, accurate knowledge and dialogue are essential in replacing the obstacles of fear and stigma. Even I, a doctor, desperately needed that thorough dialogue when I was in the role of being the patient. It enabled me, after several days of deliberation, to finally be willing to consent to ECT, a procedure that truly gave me my life back!
I would like to add that even when a doctor might feel a wall of resistance in discussions with a patient highly ambivalent about any treatment option, including ECT, the patient might become more understanding and accepting over time. With each day of more discussion, of more information being absorbed, and of more seeds being planted in the patient’s mind, arguments that might have been flatly rejected initially might become more understandable and acceptable to the patient several days later. I was given supplemental articles that were helpful for me to read and reach a decision. Some excellent websites educate patients about ECT, including
From the Mayo Clinic: https://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/about/pac-20393894
https://www.brylin.com/programs-services/electroconvulsive-therapy/
Because everything we learn helps to refine questions we can ask our treating physicians, we as patients become more empowered by this learning process to make the right decisions for ourselves.
If reading these thoughts can help even one more patient who needs ECT accept it or help one more physician to consider recommending it when appropriate, I will have accomplished my goal of helping to destigmatize ECT. It may not help everybody who has severe depressive symptoms, but in the hands of competent physicians, it can be a remarkably fast-acting, effective, and safe treatment option for clinical depression. As I mentioned at the start, as a practicing psychiatrist, I only rarely referred patients for ECT. But on the basis of my own experience, I now can see that for some patients ECT should be considered sooner and not just as a last resort. I wish I had gained that realization before I retired. I still think I was a good psychiatrist, but I would have been an even better one if, at the time, I had more fully recognized and appreciated the full range of patients who could benefit from ECT.