What Is Electroconvulsive Therapy?

Introduction

Electroconvulsive therapy (ECT) is used for the treatment of severe mental health conditions, where other treatment has been unsuccessful, or emergency treatment is required. This treatment involves a brief electrical current to the brain via one or two electrodes placed on the scalp, which induces a small seizure (a convulsion). A seizure is a brief disruption to the electrical activity in the brain, causing symptoms such as involuntary muscle movements, stiffness, and potential loss of consciousness. This is performed under general anaesthesia and a muscle relaxant is also given. The whole process is supervised by an anaesthetist. In most cases of ECT, the seizure will last for around 40 seconds.¹ 

This technique was first proposed in the 1930s after individuals with schizophrenia appeared to improve following a spontaneous seizure.^2,3 Theories produced at the time regarding mode of action have not been proven and the exact mechanism remains unclear. There are various proposed theories to explain ECT, including a release of chemical messengers in the brain, an increase in blood flow, and the modification of connections in the brain.^3,4

ECT still remains a highly controversial topic and the views of patients and clinicians remain varied. This is due to the potential side effects of memory loss, negative media portrayal, and previous historical misuse.^5,6 Despite this, ECT can be highly successful for the treatment of some mental health conditions, especially where other treatments have failed.⁷ This article aims to help you understand more about ECT, its potential success, and its side effects.

Use of ECT

ECT can be useful for treatment of severe treatment-resistant depression, catatonia, or severe mania. The development of antipsychotics means ECT is no longer used for routine treatment of schizophrenia.^7,8,9 

Catatonia is a condition where a personbecomes unresponsive and does not move, eat, or drink. This can be caused by several conditions including bipolar disorder,depression, and schizophrenia. 

Treatment-resistant depression is where there is no improvement in symptoms after trying 2 or more types of antidepressants.⁴ There are many alternative treatments for these conditions, which should be tried before ECT, unless it is life-threatening.⁷ Alternatives include talking therapies and medication such as different classes of antidepressants and antipsychotics. In some cases, these medications can be combined to work more effectively.

As with any treatment, the benefit will need to be compared to the risk of not having the treatment. This decision should be made jointly by health professionals, patients and carers. ECT is not currently recommended in those under the age of 11 and caution should be taken if the individual is 11-18 years old. Side effects are more common in children and the elderly, and so the risk often outweighs the benefit.^7,8 Additionally, the risks of general anaesthesia need to be considered as those with other physical health conditions may be at increased risk of side effects.

What happens during ECT?

ECT can take place as a hospital inpatient or outpatient and is often performed in an ECT suite. If ECT is being performed as an outpatient, you will require someone to attend with you to ensure you have someone to look after you.

On the day of your ECT treatment, you will need to fast for 6 hours before the treatment, with water allowed up to 2 hours before.¹ Before the procedure, your basic observations will be taken including your blood pressure, heart rate and oxygen saturations. If you are fit for the procedure, a cannula will be inserted into your arm. This is a small tube inserted into your arm that allows medication to be given directly into your veins. A general anaesthetic medication and a muscle relaxant will be given through the cannula. The general anaesthetic will send you to sleep, so you will be unaware of the procedure from this point onwards. The muscle relaxant reduces the amount of muscle movement during the procedure and will therefore reduce any injuries from the seizure itself.⁴

Electrodes are placed on the head, either in a unilateral (one single electrode) or bilateral (two electrodes) position. The bilateral position, where an electrode is placed on both the left and right temple, is said to work more quickly.¹ However, the bilateral position can be associated with a greater level of memory loss than the unilateral position.⁴ Either technique may be used and the technique may switch between sessions depending on your response.⁴

A small electrical current will pass through the system causing a small seizure. This will typically last for around 40 seconds. Following this, you will be moved to the recovery suite where you will be monitored by nurses until the anaesthetic effects wear off. 

ECT sessions will usually occur twice a week. Typically, individuals will have around 10 sessions but can have up to 12 sessions.¹ Your cognitive state and mental health should be re-assessed following each session and ECT should be stopped as soon as symptoms improve.^7,8

How successful is ECT?

ECT has been shown to be successful in many cases of depression, with bilateral ECT being more effective than unilateral ECT.⁷ There is also evidence to show ECT may be beneficial in mania and catatonia. In 2018-2019, 68% of patients treated with ECT improved.^1,7 Those who have severe depression and undergo ECT are likely to stay better for longer and have a reduced risk of suicide.¹

As with all treatments for mental health, ECT does not work for everyone. If there has been no improvement after 6 sessions, then another treatment should be considered. Additionally, talking therapies and antidepressants are useful following ECT to allow for a longer-term benefit.¹

Side effects

In the short term, ECT can cause nausea, headaches, confusion, and memory loss.² In some rare cases, there is an impact on the heart or the seizure lasts too long, these will need to be managed appropriately or even as an emergency.⁴ There is no physical damage to the brain during ECT but the long term effects remain unclear.^1,9

Memory loss can be described as anterograde or retrograde, with around 40% of people experiencing retrograde amnesia.¹ Anterograde refers to the formation new memories, whereas retrograde refers to the loss of old memories. It is difficult to report the exact impact of ECT on memory as depression itself can cause memory problems.⁵ In most cases, memory will improve and return in 2-6 months following treatment.^1,3

Informed consent

ECT requires written consent from a patient who has the capacity to make treatment decisions. Capacity is defined as the ability to understand, retain, weigh up risks and decide on a treatment. Doctors will provide you with information leaflets and allow you time to think about your decision, providing the treatment is not needed urgently. It is important you remember you still have the option of changing your mind at any stage after signing the consent form.

If a patient does not have the capacity to consent to treatment, the decision regarding ECT becomes more complicated. The decision will be discussed as part of a large team and a second independent opinion will be sought.¹⁰ Treatment in this scenario will usually be under the Mental Health Act but can be under the Mental Capacity Act.¹⁰ The Mental Health Act states that individuals can be detained for a period of assessment and treatment, varying depending on the type of section. The Mental Capacity Act states that if an individual lacks capacity, treatment can be given in the ‘best interests’ of the patient. The ‘best interests’, means the risk-benefits will be weighted up, alongside your previous preferences and what your family thinks your preferences were.

It can be useful to think about what care you might want if your health condition were to deteriorate in the future and you were no longer able to communicate your wishes. You can let your doctors, carers, or family members know your wishes. You can also complete an Advanced Decision to Refuse Treatment. This is a form that allows you to state your preferences for treatment in certain scenarios. This will help doctors consider your viewpoints when making treatment decisions in your best interests.

Controversies around ECT

There are still many negative associations with ECT, leading to its controversial nature in modern clinical practice. Lots of this stems from poor media portrayal of ECT, for example, in the films ‘One Flew Over the Cuckoo’s Nest’ and ‘Shine’.^3,5 These films depict ECT as a cruel, old-fashioned method that has limited success in treating mental illness. This inaccurate information can lead to fear, discrimination, stigma and believing ECT is unsafe.^5,6,11 Many patients with lived experiences, have a positive attitude due to the positive impact on their mental health condition.^5,6

The use of ECT across the world is extremely varied with some countries imposing strict regulations on the use of ECT, while others may not even use anaesthesia.^2,3 The ECT Accreditation Standards ensure ECT services in the United Kingdom and Ireland are up to standard.

Summary

Electroconvulsive therapy involves a brief electrical current to the brain while the patient is asleep under general anaesthesia. This treatment is used in severe cases of treatment-resistant depression and mania. ECT has been shown to be effective in many cases, especially in the short-term. However, there are side effects associated with ECT including nausea and memory loss.

There are still many negative perceptions around ECT, especially in the media. It is important that the media portrays ECT in an honest light to educate the public and reduce discrimination against the treatment and those who go trough it. Patients should receive clear information on the risks and benefits involved in ECT and have time to reflect on their preferences.