Electroconvulsive Therapy (ECT): Definition, Types, Techniques, Efficacy

Electroconvulsive therapy (ECT) is a form of psychiatric treatment that involves inducing seizures with the use of electrical stimulation while an individual is under general anesthesia. An estimated 100,000 people in the US have ECT each year.

ECT is most often used for cases of treatment-resistant depression and some other psychiatric conditions, including bipolar disorder and psychosis, although its use still remains somewhat controversial in the general public.

ECT was first introduced in 1938, and by 1941 it was used by nearly half of the mental health institutions in the United States. Stigma as well as the emergence of effective psychiatric medications led to a decline in its use; in fact, it was only approved by the FDA in 2018 for depression and catatonia.

Types of ECT

Generally speaking, there are two types of ECT:

• Bilateral ECT, in which the electrodes are placed on both sides of the head. This is designed to affect the entire brain.
• Unilateral ECT, in which one electrode placed on top of the head and the other on one temple, usually the right. In this case, the current only passes through one side of the brain.

Techniques

ECT can be done while you’re in the hospital or as an outpatient procedure.

On the day of the procedure, you can expect the following:

• You’ll receive a short-acting anesthetic to briefly put you to sleep and prevent you from feeling any pain or discomfort from the procedure. You will also receive a muscle relaxant to prevent muscle contractions that would otherwise accompany the induced seizure.
• Two sets of electrodes are placed on your scalp: one to monitor your brain activity and another to deliver a small and painless electric current.
• When you are asleep, a small amount of electric current delivered to your head will cause seizure activity (for about 40 seconds) in the brain.
• Several minutes after the treatment, you wake up in a recovery area but do not remember the actual treatment.
• You won’t be able to drive the day of the treatment.

What ECT Can Help With

ECT is often used when people are unresponsive to other mainstream treatments, like antidepressant drugs and psychotherapy. ECT has also been found effective in people who require a rapid treatment response due to the severity of their condition or risk for suicide.

ECT is used to treat the following:

• Aggression and agitation in dementia, which can be related to the disease itself or the emotional impact of dementia.
• Catatonia, a psychomotor condition in which a person may appear immobile, rigid, or mute; it often results from psychiatric disorders such as bipolar disorder or schizophrenia.
• Parkinson's disease, particularly Parkinson's related depression as well as "on-off" syndrome, neuroleptic malignant syndrome, and intractable seizure disorders.
• Postpartum psychosis and severe depression in pregnant and nursing people, as ECT may reduce the risks associated with medication exposure to the fetus or breastfeeding infant.
• Schizophrenia, especially when a person is not responding to other available treatments like antipsychotics. ECT can also be used as augmentation for antipsychotics, including clozapine.
• Severe depression, especially when a person also experiences psychosis, suicidal thoughts, or refusal to eat in addition to the usual symptoms of depression.
• Treatment-resistant depression, a type of severe depression that does not respond to medication or psychotherapy treatment, or that returns after brief improvements.

Researchers don't yet know the precise reason why ECT works, but one theory is that it helps to correct imbalances in the brain’s chemical messenger system. Others say that the seizure "resets" the brain. Several treatments may be needed to see a lasting effect.

Benefits of ECT

ECT may offer a number of important benefits, including:

• Fast-acting: ECT usually works very quickly to relieve symptoms of psychiatric conditions. This can be particularly helpful in cases where a person is experiencing severe symptoms.
• Effectiveness: ECT has shown a high level of efficacy in the treatment of some conditions. It can be particularly beneficial to people with severe depression, psychosis, and suicidal thoughts and behaviors.

Another benefit of ECT is that it may work even when other treatments have not. People who have not experienced significant benefits from psychotherapy and medications may show improvements after being treated with ECT.

Effectiveness

While the use of ECT maintains some stigma, many studies and literature reviews suggest that it can be a safe and effective treatment, particularly in the case of depression, catatonia, psychosis, and suicidality.

• Severe depression: One study found that 42.8% of people who had ECT achieved remission of depressive disorder symptoms.
• Psychosis: Yet another study found that ECT gave older patients with psychotic depression the best chance at reducing the risk of relapse.
• Catatonic depression: Research suggests that ECT works for about 80% to 100% of people with catatonia.
• Suicidality: Studies have found that ECT significantly improves suicidal ideation accompanying a variety of mental illnesses.

Things to Consider

People may feel relief from their symptoms fairly quickly, but it often takes several treatments to experience the benefit. They may also experience side effects ranging from minor to more severe, including:

• Confusion
• Headache
• Hypotension (low blood pressure) or hypertension (high blood pressure)
• Increased risk of cardiac issues, particularly in those who have coronary artery disease
• Jaw pain
• Memory loss
• Muscle aches
• Nausea

Memory loss, usually short-term and retrograde (things learned in the recent past), during the acute course of the treatment is one of the most commonly reported side effects of ECT.

A newer ECT technique, right unilateral ultrabrief pulse electroconvulsive therapy, may allow for fewer memory issues with the treatment.

How to Get Started

If you think that ECT might be helpful for you, talk to your doctor. Prior to receiving ECT, you'll need a full health evaluation, including:

• Physical exam
• Psychiatric assessment
• Blood and lab tests (including electrocardiogram to check your heart health)

Having certain medical conditions may rule out ECT as a treatment option. Your doctor will weigh your personal risk level and also discuss the risks of anesthesia, which vary from procedure to procedure and person to person.

The actual procedure itself usually takes just five to 10 minutes to perform, but you will need extra time to prepare and recover.

Your doctor will provide more detailed instructions and information about what you need to do to prepare for and recover from the procedure. In most cases, you can expect a fairly quick return to your normal daily routine after ECT treatment. 

Before undergoing ECT, talk with your doctor to make sure you have explored other options and discussed the risks. It’s also important to keep in mind that ECT is not a cure. People with serious mental health conditions will need to continue maintenance treatment, including psychotherapy, medication, and ongoing ECT treatments.