Introduction 

Electroconvulsive therapy (ECT) is a therapeutic approach used for conditions such as depression, bipolar disorder and psychosis. Although ECT has been deemed safe and effective, it has been subject to public controversy. This is due to public misconception and a lack of understanding of ECT in regard to its safety. This has resulted in fear and apprehension in the decision-making of ECT as a potential treatment. Over time, this misconception of ECT has accumulated, resulting in stigma. So is ECT risky after all? Read on to find out.

Understanding ECT

In electroconvulsive therapy (ECT), brief pulse stimulations are applied to the brain under anaesthesia and a muscle relaxant. A small amount of electrical current is used to stimulate the brain which leads to a spike of electrical activity, also known as a seizure. The areas of the brain stimulated are those that control mood, appetite and sleep. It ultimately leads to changes in the brain chemistry that are known to reverse the symptoms of mental health conditions.^1,2,3

The seizure occurs in a controlled environment and lasts less than a minute. Since the individual undergoing the treatment is asleep, the seizure will not be felt. ECT regulates this process of neurotransmission and influences the expression of neurochemicals in the brain such as hormones and neurotransmitters.³

Origins

The origin of ECT dates back to the 1930s when it was institutionalised as one of the four main interventional techniques for psychiatric inpatients. Prior to the 1930s, there were limited approaches performed for inpatient psychiatric patients and hence, ECT remains the only effective tool still in use today. 

With the initial purpose of attaining the safety of electroshock therapy, Ugo Cerletti and Lucio Bini began the first electroshock in April 1938 and gradually developed the treatment over the decade. However, a half-century later, ECT has become a controversial issue whose history remains an exciting chapter in the treatment of mental illness.² Having said that, it is crucial that we destigmatise this approach and instead, applaud its discovery as it continuously paves breakthroughs in the treatment modality of mental disorders. 

When is it used?

ECT can be used for a variety of conditions, including:^1,4

• Depression which has not responded to multiple treatments, termed treatment-resistant depression
• Severe or prolonged mania
• Severe depression 
• Schizophrenia
• Bipolar disorder
• Somatic disorders 

Severe depression

ECT is recommended for mental health disorders such as melancholic, catatonic or psychotic depression, where the individual’s movements are inhibited. Since ECT has proven to relieve the symptoms effectively, it can eventually help to get an individual's life back, as they will be able to move and speak again.

In cases where the individual’s life is at risk, for example when experiencing psychotic symptoms or having a high suicide risk, ECT may also be used.^1,2,3

Mania

Mania (severe excitement) is a component of bipolar disorder. Sometimes, however, it can become out of control or last for a long time. Mania classed as delirious mania, malignant catatonia, and neuroleptic malignant syndrome may require ECT.^1,2,3

Consent

Although it is a standard procedure to obtain informed consent from the patient or the responsible legal guardian, some life-threatening cases may pose challenges in obtaining informed consent. In such cases, ECT is administered after legal authorisation and the informed consent of the patient’s legal representatives. These life-threatening cases may range from patients being in manic excitement, and catatonic mutism, to acute states of paranoia. Physicians often consider ECT as a primary indication in those diagnosed as severely ill.¹ 

The historical context of ECT stigma

The stigma over ECT was further ingrained in individuals through negative portrayal in the media. In movies, the perception of ECT was reflected as comical or condescending, with inaccurate information about the treatment. Importantly, it also attributed ECT to punishment, social control or medical benefit in order to justify its approach. In short, it was often fictional, exaggerated and scientifically inaccurate. This misinformation became normalised among the general public and medical professionals which further limits the awareness to bring ECT as a probable therapeutic regimen for patients.^4,5,6 

Impact of stigma on mental health treatment

In today’s society, there is an internalised stigma that has affected the social and occupational relationships of patients with mental disorders. These range from isolating themselves, abandoning their jobs due to having negative emotions such as shame and worthlessness or losing the opportunity of independent living due to self-discriminatory judgements. Therefore, healthcare professionals have strongly advised on psychoeducation which is known to be promising among the implemented interventions. It is recognised as an effective approach to changing the lifestyle of patients through social skill training, cognitive behavioural therapy, goal achievement programs, peer education and narrative therapy.^7,8

Addressing misconceptions

The most common myth is how ECT is perceived as a shock therapy as reflected in mainstream media. Although it was once referred to as ‘shock therapy’, today’s modern technology is safe, advanced, and accurate. The treatment lasts 30 seconds and is pain-free which challenges the ‘shock therapy’ myth. 

Another common myth is the effectiveness of ECT, but it has been proven that about half of patients receiving ECT demonstrate relieving symptoms of depression. In addition, there are other myths such as ECT leading to long-term memory loss which has also been proven wrong as only a small percentage of patients experience temporary loss of recent memories.⁹ 

Due to these myths being perpetuated by the media, it is important to provide accurate information on the safety and efficacy of ECT. Having said that, there have been studies showing¹⁰: 

• Positive changes in brain volume
• Lower depression recurrence rates when treated with ECT compared to medication 
• Improved patient outcomes, reflected in reductions in depression scores
• Improvement in symptoms is seen just after six sessions
• Formation of new neurons
• No evidence thus far shows that ECT causes epilepsy
  • For example, no spontaneous seizures were observed in a study with 619 individuals receiving ECT

Ethical considerations in ECT

Since ECT is controversial among individuals, the ethical implications of the treatment should not be ignored. In short, informed refusal by a competent patient should be respected and likewise, irrational refusal by patients who are incompetent due to disordered cognitive functions should also be not taken into consideration as they are deemed as beneficence or nonmaleficence. Autonomy of the patients is the main priority in patients undergoing ECT. Hence, it is necessary to guide the patients on the potential benefits and risks of the treatment before they provide their consent.¹¹

Other barriers to ETC implementation

Several barriers have restricted the use of ECT. These include:

• Geographical proximity to a clinic
• Lack of funding for modern equipment 
• Lack of anesthesiology support 
• Space limitations limiting the number of patients treated 
• Logistical difficulties in delivering the treatment to outpatients⁷ 

Advocacy and education

Since the stigma is heavily internalised, it is important to combat it by educating patients on the importance of mental health. Primarily, it is important to guide patients and their loved ones who were not well-informed on the aspect of mental health so that they remain optimistic during the course of treatment. This is an important duty for healthcare professionals as they are the direct point of support for the patients. Furthermore, organisations should also raise awareness of the prevalence of mental health disorders and the various treatment approaches that have been developed over the years in order to educate the public and ultimately reduce the stigma on ECT.¹²

Future directions in ECT stigma reduction

As aforementioned, the barriers are the limiting factors that strongly influence the stigma associated with ECT. Taking that into consideration, research has taken new directions in training colleagues and ECT practitioners to fully comprehend the mechanism and effectiveness of ECT so that they are not misinformed. Moreover, resources have been invested to increase physical space and collaborations with institutions to further equip medical professionals with the necessary technology. This helps attain the treatment throughout the world without being dependent on pharmacological approaches. 

Recent trials have shown promising and efficacious results in schizophrenic individuals who were resistant to clozapine and individuals with treatment-resistant bipolar disorder. These have also led to lower rates of re-hospitalisation and suicidal tendencies. Overall, ECT reduces the costs of treatment, especially after the failure of one or two antidepressants.¹²

Summary

In summary, ECT is a valued form of treatment for mental health disorders such as depression and psychosis. However, there has been stigma associated with it which has prevented people from attaining this treatment. Nevertheless, it is the responsibility of healthcare professionals and supporting organisations to educate the public on the importance of ECT and how it could relieve the symptoms of mental health issues. There is hope to see some change in the scrutinised stigma of ECT in the near future.