Introduction 

Electroconvulsive Therapy (ECT) is a treatment used to alleviate severe symptoms of some mental health disorders including depression. It involves delivering an electric current to the brain, which induces a seizure.¹ This is performed under general anaesthetic meaning the patient is not conscious during the process.  

ECT has been a long-standing treatment in psychiatry with the first procedure taking place in Italy in 1938. Since then it has been used in the treatment of severe depression, bipolar disorder, severe mania, and other mental health disorders.² ECT was developed as an alternative to chemical seizure therapy which had undesirable side effects and was hard to dose correctly.³

Nowadays, ECT is used much less frequently. Other treatments such as talking therapy or medications are now more effective than they were in the past. These are used as first-line options with ECT mainly being to treat those with severe depression where other treatments have not proved successful. 

How does ECT work?

The induction of a seizure causes chemical and cellular changes in the whole of the brain. However, ECT’s exact mechanism of action is not fully known.  It is thought that the electro-stimulation affects neurotransmitters. These are chemical messengers that act in the body. Serotonin and dopamine are two key neurotransmitters and a chemical imbalance of these is known to cause depression and other mental health disorders. It is thought that ECT affects these.⁴

When might ECT be used to treat depression?

ECT is used to treat severe depression, particularly those in which other treatments have not worked.⁵ This includes:

• Physiotherapy
  • Talking therapies such as cognitive behavioural therapy (CBT)
  • Counselling
• Medication
  • Selective serotonin reuptake inhibitors (SSRIs). These increase the uptake of serotonin in the brain. Serotonin is a neurotransmitter that is diminished in those with depression.
  • Serotonin and norepinephrine reuptake inhibitors (SNIRs)
  • Monoamine oxidase inhibitors (MAOIs)

Particular cases when ECT is recommended include:

• A severe or long-lasting period of mania
  • This is when a patient has an abnormally high level of energy leading to a lack of sleep and engagement in potentially harmful activities due to increased impulsivity.
  • It can cause some to become irritable or aggressive
  • Patients with Manic Depressive Disorder and Bipolar Disorder with depressive episodes
• Catatonia
  • Here someone will appear awake but not respond to external stimuli
  • They may be frozen in position, make repetitive movements, or be extremely restless for which they can not be consoled. 
• Urgent treatment
  • There is a threat to life, for example,, a patient will not eat or drink

Additionally, some patients may have already received ECT in the past and chose to undergo a treatment course again as it has worked well for them. 

What happens before treatment?

An assessment will be used to determine if ECT is suitable for a patient. Examination of medical history, blood tests, and an ECG test are all involved in this. The ECG test will determine the condition of the patient's heart. Overall, the tests will ensure ECT is safe for the patient, and that no other conditions are underlying the depressive disorder. 

Before the treatment, a patient will be unable to eat or drink anything from midnight onwards or the night before the procedure. Additionally, smoking is prohibited as it may have adverse effects on treatment. The clinician may provide additional instructions and advise on what medication to take or not take beforehand.⁶ 

What happens during an ECT procedure?

Throughout the procedure, a patient is asleep under general anaesthesia meaning they neither are aware of the process nor feel any discomfort. This makes the treatment much more comfortable. Anaesthesia will be administered by IV (needle) in the arm, which is also used to deliver any medication while the patient is undergoing treatment. 

Other preparation for the treatment occurs while the patient is still awake, this includes:

• Electrodes are placed on the head. These sensors measure the electrical activity in the brain via a device called an electroencephalogram (EEG).
• Electrodes are placed on the chest to measure the activity of the heart via an electrocardiogram (ECG).
• A blood pressure cuff is wrapped around the arm to monitor blood pressure. 
• The blood oxygen is monitored to ensure normal breathing. This is done with a pulse oximeter which is a small device that can be clipped to a finger.
• The patient has an oxygen mask fitted which will provide them with oxygen during the duration of the treatment
• The ECT device is fitted which normally consists of two small electrodes placed on either side of the head.
• A mouth guard is used to protect the mouth and teeth 

After this, the administration of a drug such as methohexital or propofol will be given. This will cause the patient to fall asleep, usually within 5 to 10 minutes. When the patient is asleep a muscle relaxant is administered to prevent movement during treatment. This may cause mild soreness upon waking. 

When the patient is asleep the ECT treatment is administered and a seizure is induced. The patient cannot feel any pain or sensation and there is little movement apart from slight twitching. This lasts for less than 2 minutes. Healthcare professionals will be monitoring the state of the patient continuously through the treatment. 

ECT therapy consists of multiple treatments ranging from 4 to 20 when regarding depression. Treatment is often given three times a week until the clinician is confident it has been effective.¹

What are the side effects of ECT?

Upon waking, patients often feel confused about both the medication and the treatment. This often passes within an hour.

Other side effects include:

• Muscle soreness
• Headache
• Nausea 
• Loss of appetite

These usually only last a few hours and painkillers can be used to relieve any discomfort. 

The most significant side effect of ECT is short-term memory loss. This will most likely persist for the duration of the treatments with memory returning within around a fortnight. However, events within, just before or after the treatment duration may not return. Using your brain by reading, watching TV and talking to others will help speed up the return of memory. 

Because of this side effect,, it is best to postpone decision-making for 2 weeks or so after the therapy. Driving is also prohibited while undergoing the treatment course. 

How effective is ECT?

ECT has been reported to be effective for 80-85% of patients. The procedure has been shown to quickly reverse the symptoms of severe depression by elevating suicidal feelings, refusal to eat, catatonia, psychosis, and mania.⁷

The effects of ECT can last for months, and with follow-up treatment of medication and psychotherapy, many patients find ECT very useful. 

What are the risks of ECT?

ECT is a safe practice, although like with all medical intervention, it does come with risks.

• Heart Problems
  • Heart rate and blood pressure increase through the duration of the procedure. In some rare cases, this can lead to complications.
  • This is why extensive health checks are performed before the procedure
• Memory loss
  • Although memory loss from the time surrounding the treatment is expected and often regained, some may experience a larger loss of memory. Occasionally patients lose memory from months or, very rarely, years before treatment.
  • However, with the advances that have been made in the field and tight regulations surrounding it, this is very unlikely.
  • Most people will regain memory within a few weeks

There has been lots of research on the long-term side effects of ECT and no research has concluded ECT causes brain damage and does not increase the risk of epilepsy, stroke, or dementia.⁶

How does consent work for ECT?

If ECT is offered it is because healthcare providers feel that the treatment will be beneficial to the patient. However, in most cases, it is up to the patient whether they wish to undergo the treatment. Giving informed consent involves discussing the benefits, side effects, risks, and alternatives to the treatment as well as gaining an understanding of what ECT involves. This can be a big decision for some and at least 24 hours should be allowed to make this. Discussing this with a loved one or advocate can help in making this choice.

Those detained under the Mental Health Act 1983 must normally provide consent to be given ECT, along with certification from their approved clinician that they could do so.

If consent to ECT is confirmed in a written form and can be withdrawn at any stage of treatment. The clinician should verbally ask for consent at each stage. 

If you cannot consent or emergency treatment is needed, ECT may be given without consent.¹

Why is there a controversy surrounding ECT?

ECT has a controversial past which has led to a negative stigma surrounding it now. In the past, ECT was administered without anaesthesia or relaxants which could often lead to patients harming themselves during treatment. Additionally, high levels of electrical currents were used making the procedure significantly more dangerous. There was also an overall poorer treatment and understanding of those with mental health disorders, especially those who had been hospitalized. Luckily, ECT has advanced a lot since then and has been proven to be safe and effective. Additionally, patients' right to consent is now much more protected and informed consent is an upheld priority.⁸ 

Conclusion

In summary, Electroconvulsive Therapy (ECT) remains a crucial treatment for severe mental health disorders, especially in cases of treatment-resistant depression. Despite a decline in usage due to emerging first-line treatments, ECT serves as a vital option for individuals with persistent symptoms.

Initiated almost a century ago as an alternative to chemical seizure therapy, ECT has advanced in safety and efficacy. Its mechanism of action, though not fully understood, is believed to influence neurotransmitters. The procedure involves a careful pre-treatment assessment, ensuring patient safety. Under general anaesthesia, patients experience minimal discomfort, and thorough monitoring ensures their well-being.

ECT's side effects, including short-term memory loss, are generally transient. It proves effective in rapidly alleviating severe depression symptoms, with lasting benefits achieved through follow-up treatments and a combination of medication and psychotherapy.

Risks associated with ECT, such as potential heart problems and memory loss, are typically confined to the treatment period. Research does not support claims of long-term brain damage or increased risks of epilepsy, stroke, or dementia.

Consent is a critical aspect of ECT, with patients informed about benefits, risks, and alternatives. The historical controversy surrounding ECT has led to a negative stigma, but advancements in the field and enhanced patient rights have improved safety and ethical considerations.

In essence, ECT remains a contentious yet valuable tool in addressing severe and persistent mental health disorders, offering relief to those unresponsive to other interventions.