Introduction

Electro Convulsive Therapy (ECT) is a treatment used for severe depression and bipolar disorder. It was developed in the 1930s and is mainly for those not responding to medications. ECT can stabilize extreme bipolar episodes, providing a potent and long-lasting solution, especially when other treatments fail.

It may be recommended if someone is suicidal, if medications aren't effective, or if their medical condition prevents medication use. Elderly patients on multiple medications may also opt for ECT.

During ECT, a controlled electrical impulse is sent through the brain after administering muscle relaxants and inducing sleep. The procedure is monitored for safety, checking heart rate, blood pressure, and brain waves. The patient typically undergoes 6 to 12 sessions, sometimes monthly. Other treatments like medications or therapy may follow.¹

ECT can be a swift and effective option, especially when immediate relief is crucial. Discussing its suitability with a doctor and reporting any side effects for adjustments is essential. Although risks exist, ECT is often considered for patients with significant needs or those not responding to other treatments, especially those at risk of suicide.²

Understanding bipolar disorder

Bipolar disorder is a chronic condition marked by mood and energy fluctuations. It includes bipolar I (with manic episodes) and bipolar II (with hypomanic and major depressive episodes).

The diagnosis relies on recognising mania, opposite to depression symptoms. Manic and hypomanic episodes show distinct mood and behaviour changes.

Bipolar disorder has different forms based on mood elevation severity. Bipolar I involves intense manic episodes causing significant impairment, featuring traits like high self-esteem, reduced sleep needs, rapid speech, racing thoughts, distractibility, agitation, and risky behaviour. Bipolar II has less severe hypomanic periods, not causing significant impairment, hospitalisation, or psychosis. Both types experience depressive episodes.³

Accurate diagnosis and proper management are crucial, as highlighted by mental health organizations like The Royal Australian and New Zealand College of Psychiatrists, the Canadian Network for Mood and Anxiety Treatments, and the International Society for Bipolar Disorders.

Electroconvulsive therapy

Electroconvulsive therapy (ECT) is a medical treatment mainly used for severe major depression or bipolar disorder when other treatments haven't worked. It involves a brief electrical brain stimulation during anaesthesia, intentionally causing a short seizure. ECT can quickly change brain chemistry, reversing symptoms of certain mental health conditions.^1,2

Patients typically undergo ECT two to three times a week for six to twelve sessions, depending on symptom severity and response. It's considered highly effective for severe depression, especially when other treatments fail. ECT is also used in conditions like schizophrenia, particularly when rapid symptom reduction is crucial, such as in cases of catatonia, mania, or severe suicidal thoughts.³

To ensure safety and effectiveness, ECT follows strict guidelines, including pre-treatment evaluation, anaesthesia, and muscle relaxation to minimize the physical effects of the induced seizure, along with post-treatment monitoring. The Indian Psychiatric Society has established specific guidelines for ECT practice, but safe and effective ECT principles are universally applicable.

Treatment options for bipolar disorder

Bipolar disorder treatment involves various approaches like medications, therapy, and, in some cases, neuromodulation techniques. According to guidelines from CANMAT and ISBD, first-line medications for bipolar depression are lithium, quetiapine, and lurasidone, with lamotrigine as an adjunct.

For acute mania, first-line options include lithium, valproate, and certain antipsychotics like olanzapine, risperidone, and aripiprazole. To prevent relapse, maintenance treatment includes lithium, valproate, and antipsychotics such as olanzapine and lamotrigine.

Psychoeducation and psychosocial interventions play a vital role, aiming to enhance medication adherence, reduce symptoms, and support recovery. Specific therapies like cognitive-behavioural therapy (CBT), family-focused therapy (FFT), and interpersonal and social rhythm therapy (IPSRT) complement medication.³

When standard treatments fall short or a rapid response is needed, electroconvulsive therapy (ECT) is a proven option for managing mania, bipolar depression, and mixed states.

Choosing the right treatment is personalised based on the patient's presentation, treatment history, side effects, and personal preferences. Monitoring for potential side effects is crucial, allowing adjustments to maintain a balance between benefits and risks.

Side effects of ECT

Electroconvulsive therapy (ECT) can have both short-term and long-term side effects. Short-term effects like headaches, nausea, muscle pain, and confusion are usually temporary and treated symptomatically. Rare but more serious effects involving the heart, lungs, and brain can be minimized with pre-treatment screening, monitoring during the procedure, and appropriate management.²

Cognitive side effects are linked to ECT, often short-lived. However, some people may face lasting retrograde amnesia, affecting memories around the treatment time and extending back several months. Difficulty learning new information may persist for a couple of months post-treatment. Guidelines from the American Academy of Child and Adolescent Psychiatry emphasize the risks of memory impairment in adolescents undergoing ECT.³

Despite these potential side effects, ECT remains highly effective for certain psychiatric disorders when other treatments fail. The benefits usually outweigh the risks. A thorough evaluation before ECT and a comprehensive team approach are crucial for minimizing and managing these side effects.

Contraindications of ECT

While there are no absolute reasons to avoid electroconvulsive therapy (ECT) in adults with conditions like bipolar disorder, some factors increase the risk of complications and should be carefully considered. These include recent heart attacks, unstable cardiovascular issues, severe lung conditions, high intracranial pressure (pressure on the brain), recent brain haemorrhage, and certain brain lesions. For adolescents, the American Academy of Child and Adolescent Psychiatry suggests potential concerns with conditions like elevated cerebrospinal fluid pressure due to central nervous system tumours, active chest infections, and recent heart attacks.^2,3

A thorough evaluation before ECT is crucial to weigh the risks and benefits based on the patient's specific medical condition. Decisions about ECT should be made case by case, considering potential benefits against associated risks. It's important to have a comprehensive team approach to manage any complications that might arise during ECT treatment.³

Summary

• ECT treats severe depression and bipolar disorder when medications fail, stabilizing extreme episodes
• Controlled electrical impulses induce a brief seizure under anaesthesia, offering swift relief in 6-12 sessions
• Treatment involves meds, therapy, and neuromodulation. Lithium, quetiapine, and lurasidone are first-line for bipolar depression
• Short-term effects include headaches and nausea, with potentially serious impacts minimised through screening and monitoring
• While generally safe, considerations include recent heart issues, unstable conditions, and brain lesions. Decisions are case-specific with a comprehensive team approach