The Healing Power of ECT
by Joshua Bess, M.D.
There are myriad words used by patients and providers when discussing electroconvulsive therapy (ECT): “complicated,” “effective,” “drastic,” “antiquated,” “hopeful,” “lifesaving,” and “scary” are just a few. As someone who has studied and practiced ECT for many years, I can attest that there is at least some truth to all of them. ECT has been around for a very long time – much longer than antidepressants, mood stabilizers, and antipsychotics. These medications and several other “brain stimulation” modalities have been developed and refined since ECT was invented. But for an important subset of patients – especially the most severely ill – ECT remains the most effective treatment option available.
For centuries, physicians had wondered about a link between seizures and improvement in the condition of patients suffering from what was then called “lunacy.” Chemically-induced convulsions were administered to patients in the latter 19th and early 20th centuries, but the agents used were quite unpleasant. Scientists in Switzerland worked out how to induce seizures in animals using electrical current, and Italian scientists Cerletti and Bini translated that research to the first human patient in 1938. A young man who was found delusional in a train station received 11 treatments and made a full recovery.
In the 1940s ECT took its place alongside several other “somatic” (i.e. physical, as opposed to psychological) treatments employed by psychiatrists. Through the 1950s and 1960s the first effective medications for psychiatric illness were developed. By the late 1960s and into the 1970s, ECT use was declining, in part due to increase in stigma and negative media portrayals, despite the fact that through that same period modern anesthesia techniques and other advances markedly reduced patient discomfort and increased safety of the procedure. Through the 1980s, recognition of the limited efficacy of medication in some patients as well as a general increase in acceptance of the need to treat mental illness allowed ECT to make a comeback of sorts, again taking a place amongst legitimate, effective treatments for patients who otherwise would suffer severely.
ECT is performed either in the pre-operative/post-anesthesia (PACU) area of the hospital or in a separate ECT suite. The patient is under the care of an anesthesiologist or nurse anesthetist and an attending psychiatrist throughout the entire procedure. Monitors are attached to the patient to assess vital signs and brain function (EEG) during the procedure. Intravenous sedative is administered at a dose that causes the patient to be completely asleep. A muscle relaxant is then administered to prevent the patient from having physical convulsions during the seizure. Once everything is ready, a small electrical current is run through one part of the patient’s brain to another, depending on the specific type of ECT being performed. This current – the “stimulus” – results in a generalized, whole brain seizure. The seizure is monitored via the EEG and usually lasts between 30 and 60 seconds. The whole procedure from administration of anesthetic until the patient begins to awaken takes about 5 minutes.
The most common indication for ECT is “treatment-resistant depression.” Such an episode can be part of bipolar disorder or major depressive disorder. Usually ECT is only recommended after a patient has tried several, even many, medications – hence the term “treatment-resistant.” However, there are situations in which ECT is recommended as a first-line treatment. These are cases in which either medications are potentially more dangerous than ECT (pregnant or elderly patients) or when the symptoms are so severe that the quickest response possible is desired (extreme malnutrition or strong suicidal urges). ECT can also be helpful in patients suffering from the manic phase of bipolar disorder or an acute psychotic episode in schizophrenia.
Against the forces of stigma, less drastic treatment interventions, and regulatory obstacles, ECT continues to offer hope for thousands of patients suffering from mood disorders and their disabling symptoms. The safety and tolerability of the treatment have improved markedly over the years. I hope that the availability of this important treatment modality continues to improve and that more individuals will be able to gain relief from lives of intense suffering. While I also hope for further advances in other therapies, and eventually for treatments that are as effective as ECT without the complexity and historical “baggage,” for now I will continue to encourage my patients and their families to proceed with ECT in cases where all else has failed or where ECT is the safest or most effective treatment regardless of alternatives.