What is ECT?

Electroconvulsive therapy (ECT) is an approved medical procedure that is is endorsed as a safe and effective treatment by the National Mental Health Association, the National Alliance on Mental Illness, the U.S. Surgeon General, the American Psychiatric Association and the National Depressive and Manic Depressive Association. Electroconvulsive therapy is used most often under these circumstances:
  • Patients with drug resistant depression.
  • When drug therapy would adversely affect other existing medical ailments.
  • When a patient is experiencing severe unresponsive mania.
  • Patients with severe catatonia.
  • When a high risk of suicide is present and quick treatment response is needed.
  • When a patient poses an extreme threat to others and quick treatment response is needed.
  • When a patient is pregnant and drug therapy threatens adverse consequences to her unborn child.
  • When an elderly person can not tolerate medication.
ECT has been used in all of the above situations. However, ECT is most commonly used when attempts at other treatments such as drug therapy and psychotherapy have failed. 

The Electroconvulsive Procedure:

The patient is administered a general anesthesia and muscle relaxant just prior to the procedure. Once the patient is asleep 2 electrodes are placed on the head, in the case of a bilateral ECT one to each side of the head, in the case of right unilateral ECT one electrode is placed on the top of the head and the other on the right side of the head. 
Bilateral ECT treatment

By use of these electrodes controlled electric currents are then passed through the brain. This current is applied in order to induce a brief seizure in the patient, and the procedure generally lasts about 1 minute. The patient generally awakens just minutes after often confused and with no recollection of the events. This confusion experienced after the procedure most commonly lasts between several minutes to several hours.

Why ECT is effective has still not been substantially concluded.
One hypothesis is that, by inducing a seizure there is a consequent dampening down of brain circuits afterward. This quieting of the brain, it is thought, may help alleviate symptoms. (Johns Hopkins Medicine) Reports of effectiveness of ECT are very high. The reported likelihood of one having complete resolution of their symptoms after ECT has on average ranged from 70 to 90 percent. 

It is estimated that between 100 and 200 thousand people get ECT treatments each year. The estimate is so broad because in the U.S. there is no federal law mandating the reporting of ECT procedures and most states do not require record keeping. ECT is a procedure that can be done on either an outpatient or inpatient basis. The procedure is usually administered between 6-12 times over a 2-4 week period. ECT is administered with either standard pulse or ultra-brief pulses, the latter reported to produce less memory loss and other cognitive side effects. (NCBI) 

Short documentary film about the current use of ECT in Psychiatry. Features real healthcare staff and a simulated patient. 

After the initial ECT treatment patients are sometimes advised to have follow up maintenance ECT treatments as a preventive measure of symptom returns. The extent of a patients maintenance ECT varies according to each individuals need. Some patients may be advised to have a maintenance session every week, while others may be advised to come in only every few months. Contrary to many peoples beliefs, ECT treatment does not necessarily mean their will be no need of drug therapy. Oftentimes, preventive and maintenance treatment includes taking antidepressants and mood stabilizers.
There are many promising results and reports about ECT. However, ECT is not without its controversies. 

Differing Opinions on its Safety and Effectiveness:

ECT has been endorsed as safe and effective by many leading mental health organizations. Some medical professionals when discussing ECT and its use in treatment have made powerful endorsing statements, such as:

  • "ECT is an important lifesaving treatment that is a standard part of contemporary medical practice. When the clinical and scientific evidence is fairly considered, ECT is shown to be remarkably safe and effective." Pamela Sullivan, M.D. a practicing psychiatrist and an officer of the International Society for ECT and Neurostimulation.
  • "ECT refers to the most effective and rapidly acting treatment that we have today for severe depression and other conditions, and is used throughout the world" "Depression kills; ECT saves lives." Sarah Hollingsworth Lisanby, M.D. a geriatric psychiatrist and professor and chair of the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine.
  • "Seriously depressed patients who have not responded to medication trials benefit from modern ECT therapy, especially geriatric patients." Charles Kellner, M.D. Professor of Psychiatry and Chief of the Division of Geriatric Psychiatry at the Mount Sinai School of Medicine.
  • "ECT is far and away the most effective treatment that currently exists for depression. The recent resurgence of interest in the procedure is therefore not surprising." Irving M. Reti, M.B.B.S. Johns Hopkins.
  • "Recent developments in ECT have confirmed the high remission rate and significantly decreased the side-effect burden, including cognitive side effects, of ECT." William McDonald, M.D., a professor of psychiatry and behavioral sciences and chief of geriatric psychiatry services at Emory University.
  • "ECT continues to restore the health and sometimes save the lives of people with the potentially lethal disorders of severe depression, mania, and acute psychosis. For the patients who suffer most with mood symptoms, nothing better than ECT has been devised." "That is the most important reason for its survival through doubts, fears, and political controversy." Dr. Michael Miller, editor in chief of the Harvard Mental Health Letter
On the other side of the isle there are those who have strongly differing opinions or concerns about ECT treatment. Some of the most mentioned concerns expressed, include:
  • "It is also unclear whether or not ECT is effective. In some cases, the numbers are extremely favorable, citing 80 percent improvement in severely depressed patients, after ECT. However, other studies indicate that the relapse is high, even for patients who take medication after ECT. Some researchers insist that no study proves that ECT is effective for more than four weeks." (MHA)
  • The very short – term benefit gained by a small minority cannot justify the significant risks to which all ECT recipients are exposed. The continued use of ECT therefore represents a failure to introduce the ideals of evidence-based medicine into psychiatry.” John Read, M.D. Professor of Clinical Psychology at the University of Auckland in New Zealand.
  • "We know this is essentially a damaging procedure, a brain damaging procedure. A procedure that wipes out whole skills, huge aspects of memory. Dr. Bonnie Burstow, a psychotherapist and trauma specialist as well as a research specialist and whose expertise includes among other things working with clients harmed by electroshock. She also is a founding member of Healthcare Professionals Against Electroshock whose aim is to abolish the use of ECT.
  • "Shock treatment is simply closed-head injury caused by an overwhelming current of electricity sufficient to cause a grand mal seizure. When the patient becomes apathetic, the doctor writes in the hospital chart, 'No longer complaining.' When the patient displays the euphoria commonly associated brain damage, the doctor writes, 'mood improved.' Meanwhile, the individual’s brain and mind are so drastically injured that he or she is rendered unable to protest.Peter R. Breggin, M.D.  is a Harvard-trained psychiatrist and former full-time consultant at NIMH. 
There are certainly extremely differing views about the use and effectiveness of ECT treatment. However, statistically those in opposition to ECT are clearly currently in a minority position. But it is wise to review all related professional opinions concerning a medical procedure one may be considering. 

Opponents cite studies which concluded that after treatment stops the favorable results obtained by ECT only lasts a short period of time.They question the risk rewards of ECT treatment. Should one risk a potential life altering serious long term memory loss if the improvement is only short lived? The fact that it is still unknown exactly why ECT even works is an issue that has been brought up by opponents. They thus consider the treatment as unscientific and non evidence based. 

On the other hand, the vast majority of medical professionals and mental health organizations are currently in favor of ECT treatment in the situations it is currently being used. Some doctors even believe that it should be considered as a first choice treatment method for depression. Studies are cited which concluded that ECT is both an effective and safe treatment, and that improvements in procedure methods have reduced the risk of memory loss associated with the procedure. 

What are patients who have had ECT treatment saying? There are forums on the internet with countless testimonials of the personal experiences patients have had with electroconvulsive therapy. These testimonies are quite differing, they range from some expressing that ECT has saved their lives, to others exclaiming it ruined their's. These testimonials included such statements as:
  • After three weeks and 9 ECT treatments, I remember being amazed that this was the way people feel without depression. It was a new world, the procedure saved my life. It did leave me with some memory problems, my balance is a little worse, and I will probably need more future treatments. But in my opinion, this was a small price to pay for being able to be alive again.
  • I went into the hospital and after preliminaries I was feeling really nervous as they wheeled me off for the procedure. After being taken home I immediately went straight to bed. About 1:30 am I woke up a completely different person. I do have some memory loss, but all in all I think it has helped me. I feel like I did years ago, I feel really good.
  • About 10 years ago I had a series of 11 ECT's. They were basically painless and I had no problems (such as memory loss that some experience). They brought me out of a deep depression and I did not have serious depression for several years. 
  • I was told I would have no lasting effects but right after I was never the same. I have lost all but a few of my childhood memories. I have forgotten my Grandmother who helped raise me, my sisters wedding, all the stuff I had learned when I went back to school in 2004, and often cannot remember things I talked about the day before. My whole memory is shot!! All ECT did for me was make bad things even worse. 
  • I think it's worth mentioning that ECT is not always successful. I had 14 treatments of ECT this past fall. I had no fear of memory problems, because for anything that could relieve me of depression, the side effects would be well worth it. Anyway, here I am a few months later still suffering from depression and with little hope left of ever recovering
  • I don’t know how to express myself anymore, that’s what ect has done to me. The thoughts don’t flow anymore. I have a hard time having a conversation. I’m afraid to talk to people because I don’t know what to say. I just can’t believe the damage that ect has done. My life is totally destroyed.
Based on internet ECT patient testimonials alone, it is impossible to reach a conclusion about the safety and efficacy of ECT treatment. On one hand they seem to hold out hope and on the other they ring out to be cautious or stay away. You can find both patients in support of ECT and patients against it. Which opinion outnumbers the other is difficult to determine as both have many supporters. 

Most patient testimonials you can find do not reveal which method of ECT treatment they had, or if they participated in follow up maintenance treatment which is often needed. There are too many unknown factors to draw an absolute conclusion from testimonials as to the safety and effectiveness of ECT. But for certain some have greatly benefited from ECT treatment while others have suffered as result of them. Some have had very severe long term side effects while others have had very minimal or short lasting ones.

Most Common Risks and Side Effects:

Just after awaking from anesthesia patients may experience confusion, nausea, muscle aching or headaches.
Loss of memory is the most talked about side effect of ECT treatment. ECT treatment is definitely associated in varying degrees with both retrograde amnesia (loss of past memories) and anterograde amnesia (difficulty remembering new information) such as a conversation that may have just occurred the day before.

For most any short term memory problems they may be experiencing will disappear within a few weeks after the ECT treatments have ended. However, memory of events in the weeks leading up to and surrounding the treatment itself is often permanently loss.

Retrograde amnesia can result in the loss of months to years of ones past memories. These losses generally improve in the weeks and months that follow the completion of treatment. However, in some cases these memory losses last longer, and for some they may not completely resolve. According to available studies this however is not common.

Type of ECT treatment is found to be related to ones overall risks for memory loss. In a larger scale 2007 follow up study of  the cognitive effects of ECT, it was re-concluded that the use of right unilateral ECT in place of bilateral ECT helps reduce the risks of memory loss. (Cognitive effects of ECT HA Sackeim et al) Additionally, the use of ultra brief pulse right unilateral ECT causes less decline in memory than brief pulse right unilateral ECT.

As with any medical procedure there are risks of medical complications. In the case of ECT those risks include the following (all of which are rare):

  • Cardiovascular complications like arrhythmia s and/or ischemia.
  • Adverse reactions to anesthesia.
  • Prolonged seizures
  • Pulmonary complications such as aspiration or prolonged apnea.
  • Stroke
  • Death

Prior to an ECT procedure thorough discussion of medical history, appropriate tests, and medical assessments are completed to reduce the risk of medical complications. Additionally patients are monitored during the procedure in a controlled environment. 

As aforementioned, very few U.S. states require ECT record keeping of the facilities that perform them. However, Texas State laws do require that Texas hospitals administering ECT provide information on a quarterly basis to the department on the number of patients receiving treatments, and the type of equipment used. In addition they have recorded the levels of memory impairment in patients before ECT and 2-4 weeks after. You can use the link below for a full view of that report. Here is a small sample of that data:
State of Texas ECT Summary-All Facilities for Treatments Given September 1, 2010 to August 31, 2011 
Physicians Assessment: 
Level of Memory Impairment Before ECT 
   None                        Q1- 265   Q2- 263   Q3- 212   Q4- 308   Total- 1,048 
   Mild                                211         158          223         139               731 
   Moderate                          37           37            25           30               129 
   Severe                               7            51           72            60               190 
   Extreme                             4             0              1             1                  6 
   Unable to be determine      6           10             5             1                 22 
   Ongoing series N/A N/A N/A N/A 0 
   Reports Reflected *2,126 

Level of Memory Impairment 2-4 Weeks After ECT 
   None                             Q1- 170   Q2- 169   Q3- 183   Q4- 252   Total- 774 
   Mild                                     277          296         304          210          1,087 
   Moderate                               72            42           34            72             220 
   Severe                                     1             2            11             4              18 
   Extreme                                   1              0             0             0               1 
   Unable to be determine            0             0             1             0               1  
   Ongoing series                          9            10            5              1              25 
   Reports Reflected *2,126 

Level of Symptom Severity Before ECT 
   None                              Q1- 3   Q2- 2   Q3- 9   Q4- 3   Total- 17 
   Mild                                     23       13        30       19             85 
   Moderate                              54       70      135      187          446 
   Severe                                354     338      281      265       1,238 
   Extreme                                90       86        78       64           318 
   Unable to be determine          6        10         5         1             22 
   Ongoing series N/A N/A N/A N/A 0 
   Reports Reflected *2,126 

Level of Symptom Severity 2-4 Weeks After ECT 
   None                           Q1- 97   Q2- 86   Q3- 81   Q4-96   Total- 360 
   Mild                                  300        305       311      343          1,259 
   Moderate                            99        111       124        84             418 
   Severe                               19            6         15         15              55 
   Extreme                               1            1           1           0               3 
   Unable to be determine        4            0           1          0               5 
   Ongoing series                    10          10            5          1              26 
   Reports Reflected *2,126 
Access full summary report here.
*This number may reflect patients who have received ECT in more than one quarter this year. 
Such public state statistics are helpful to people considering ECT treatment. In addition to the all state report there is also an individual facility report available on the same linked page. Such information like this should really be made available by all states, not just a few. Texas's ECT report was the only one I could easily find online. With a procedure like ECT that has so much controversy as to safety and efficacy, this makes no sense and needs to change. Record keeping and open disclosure needs to be enacted by all states. 

If you are considering ECT as a treatment option you should consult with your doctor about all additional options of treatment that are available. You should try and get all the educational material you can on the treatment. After discussing all the options and the risk/rewards of this treatment in your case, if the conclusion is to proceed, seek out ECT practitioners that are well renowned in the field, and make sure they are using the currently regarded safest methods of ECT.

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