Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) was introduced to treat depression in 1938. There is still a stigma attached to ECT and although it is an effective treatment for depression – it is underused. The stigma attached is based on early ECT treatments when the patients were awake when relatively high doses of electricity were administered. They experienced pain and sometimes bone fractures during the seizure that was induced. It remains a controversial treatment- although now-a-days it is a much safer treatment performed under general anaesthesia with a muscle relaxant to prevent severe seizures occurring. Doctors monitor the heart rate, blood pressure and breathing. It is safe and effective.

Electrodes are positioned on the patient’s head and an electric current crosses the brain tissue causing a seizure. The patient is under general anaesthetic and given a muscle relaxant. The patient must not eat or drink for at least 6 hours before the treatment, though can have clear fluids up to 2 hours before hand. If an outpatient- the patient must be with a responsible adult for 24 hours after the treatment. You must not drive following the procedure and should not wear jewellery during ECT.

Electrodes can be unilateral or bilateral as seen in diagram below. The seizure typically lasts 90 seconds.

As the patient is asleep and muscles are relaxed, there is very little movement. A course of ECT is typically 2-3 x a week for 6-12 treatments with the average number of treatments being 8 although some patients need 20+. ECT can only be given if you give consent for this to happen after it has been fully explained to you. There is a waiting room, a treatment room, and a recovery room in a hospital environment.

ECT has a rapid onset of action- faster than antidepressant medication [1]. It is useful in suicidal patients, in a patient who is not eating or drinking as a result of their depression, patients who are not moving or speaking (catatonic) and in patients with ‘psychotic’ symptoms (‘hallucinations’ – e.g., hearing or seeing things that are not there or ‘delusions’ – fixed firmly held beliefs that are not supported by facts). It can also be used for patients whose depression has not responded to several other treatments. 70-90% of patients’ depression respond to ECT [2, 3] – this is a higher rate than any other current treatment for depression. The relapse rate, however, is high with over 50% of patients relapsing in the months after a course, if maintenance treatment with ECT or antidepressants and/or therapy is not carried out [4]. Continuation treatment, after the depression has gone, may be say 4 treatments spaced a week and then a fortnight apart. This can help to reduce the risk of future relapse-probably by taking patients from much better to being fully well [5]. Maintenance ECT is when the treatment continues to be given every 1-4 weeks for several months (maybe years for some patients),

Side effects include : headache, muscle pain, feeling sick, and memory impairment. Following acute ECT the ability to form new memories is impaired. This usually improves over days/weeks. 30% of patients have problems recalling past memories pre-ECT and some of these patients are left with permanent gaps in their memory.

It is uncertain how ECT works. It changes patterns of blood flow in the brain [6]. It may stimulate the development of new brain cells (neurones) and promote changes in how brain cells communicate with each other. ECT floods the brain with chemicals (neurotransmitters) such as serotonin and dopamine, which are known to be involved in depression [7].

ECT is safe and effective, however it requires repeated anaesthetics and patients often relapse fairly quickly. It is a treatment that is currently underused.

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