ECT: A First-Hand Account of Modern-Day ECT

This Page Aims:

• to educate the reader on the modern use of ECT
• to provide a personal account of ECT to accompany JE’s scientific article.
• to provide a resource for patients recommended ECT, and their loved ones, that addresses common questions and concerns.

Introductions:

This article was written from the perspectives of two Psychology placement students (Holly and Hannah), who observed ECT on separate occasions for the first time. All patients gave permission for them to observe.

Preconceptions

When we were given the opportunity to shadow ECT we realised, like many people, that we had very limited knowledge about the treatment.

So, what did we know? As psychology students, we had come across ECT in our studies as a neurostimulatory treatment for life-threatening depression that involves placing electrodes on a patient’s head which pass an electric current across the brain resulting in a seizure.

Any other exposure we had to ECT came from TV shows and films, such as the famous film ‘One Flew Over the Cuckoo’s Nest’ and more recently the show ‘Stranger Things’. Often films and TV portray ECT as an outdated and barbaric process used to control patients. These representations reflect the unethical past of ECT which has made it a controversial treatment, even today.

Pre-Research

But how has ECT changed since it was first introduced in 1938? We felt it was important to research this question before we entered the treatment room. We learned that patients used to be administered an unmodified version of ECT in which they received high doses of electricity without anaesthetic or muscle relaxants. High doses of electricity lead to memory loss, lack of general anaesthetic meant patients were conscious during this distressing process and lack of muscle relaxant meant full-scale convulsion occurred sometimes leading to injuries such as fractured bones. Nowadays in the UK, ECT is always given in its modified form, in other words, general anaesthetic and muscle relaxants are used.

By shadowing ECT, speaking to the experts in the field, and doing our own research, we have been able to understand how the treatment has evolved from an unethical and dangerous procedure to a safe and life-changing treatment. Together, we have written an account of our experiences.

If you want to know more, we found the following resources useful for answering questions about ECT:

Electroconvulsive therapy (ECT) - NCMD (mood-disorders.co.uk) - which gives a useful summary of the procedure, efficacy, side effects and how it works.

Electroconvulsive therapy (ECT) | Royal College of Psychiatrists (rcpsych.ac.uk) - this leaflet covers what is ECT, the benefits, the risks and potential side effects, making decisions about ECT and more.

ECT (mind.org.uk) - this resource provides answers to questions such as What is ECT? How do I decide whether to have ECT? Consenting to ECT? What are ECT treatment sessions like? What are the side effects of ECT? What alternatives are there to ECT?

ECT - YouTube - this is a video simulating the process of ECT and the medical equipment used to deliver the therapy. (Please note that this video is only a simulation and may not accurately represent all aspects of the procedure, such as how the seizure may appear.)

Observational Experience

When we had the opportunity to shadow ECT it was interesting to see how the procedure worked in a standardised and repeated way. The process was split into 6 key components:

Team meeting: When we arrived, we had a team meeting where all the staff involved introduced themselves. The staffroom felt comfy and relaxing, and the staff were friendly and happy to have us shadowing. We hadn’t expected there to be so many staff members involved, but they were all encouraging and made us feel involved and part of the team. We went through each patient’s medical history; including details such as name and age, previous and current medications, diagnosis, and any other relevant details. This was important to ensure everyone had knowledge of the patients.

Introductions: Following this, we visited each patient in the waiting room with the psychiatrist and the specialist delivering the ECT. The waiting area itself was pleasant and relaxing. We were surprised by the variability in patients; for example, there was a young and chatty patient and another who was much older and couldn’t communicate very well. Also, we were encouraged to see those patients further into their treatment course seemed to be in a better state than those only just starting out. Each patient was introduced to the care team and made to feel at ease. The patient was also visited by a nurse who would go through some forms with the patient.

Preparations: The staff ensured all the equipment was clean and ready for use and put on the appropriate Personal Protective Equipment (PPE). We wore gloves, a mask, and an apron, which as a COVID-19 precaution we had to change every time we left/returned to the room. Once the required checks had been completed, the nurse brought the patient into the ECT room and put them comfortably on the bed which has low rails to ensure the patient would not fall. Other specialist equipment in the room includes an ECT machine and stimulation electrodes, an anaesthetic table, a ventilation mask, oxygen cylinders, and mouth guards. The room was small and felt slightly crowded, but all staff had designated areas to stand, and the room had windows that could be opened for ventilation. In the room, there was a psychiatrist, an anaesthetist, a recovery nurse, an ECT treatment nurse, the specialist delivering ECT, and sometimes a member of the patient’s care team.

The patient took off their shoes and left any bags or belongings under the bed. Most patients wore comfy clothes or pyjamas. Blood pressure, oxygen levels, brain activity, heart rate, and muscle activity were monitored throughout. Oxygen was given to the patient via a mask, before being given a short acting general anaesthetic which made them fall asleep, which means they did not feel or remember the process. Following this, a muscle relaxant was administered which sometimes caused minor spasms as the muscles contracted and relaxed while the medication was acting. A mouth guard was put in place to protect the patient’s tongue and teeth

ECT: For the ECT, two metal electrodes were placed on the patient’s head either in a bilateral (one electrode on the left side of the head, the other on the right side) or unilateral (one electrode at the top of the head and the other typically on the right side) position. The electrodes delivered a series of electrical pulses, this caused an initial increase in muscle tension. This was limited by the muscle relaxant but there was a small amount of movement in the arms and legs and a tightening in the face muscles. Having never seen this process, we found it rather overwhelming at first, because the patient’s face appeared to be grimacing with pain. However, the staff reassured me that this is simply a result of muscles contracting in response to the electrical stimulation. The patient would not be able to feel anything.

After this brief period of increased muscle tension, the patients each had a short seizure. This was sometimes quite difficult to see (because of the muscle relaxant) but consisted of fine and rapid movements most visible in the hands and feet. These seizures lasted for less than a minute. The position of the electrodes and dose of stimulation was personalized to the individual and is reviewed at every session based on factors such as seizure threshold and response to previous sessions. Information such as dose, length of the seizure, and quality of seizure were recorded after each session.

Patient responsiveness: Shortly after the ECT has finished, the muscle relaxant wore off and the patient woke up from their anaesthetic. During this process, the patient was given oxygen from a mask held to their face, which assisted breathing through the transition to wakefulness. One of us was given the chance to hold the mask on one of the patients, which required holding up the patient’s chin to clear the airway, whilst ensuring suction from the mask to the individual’s face. Patients waking up appeared dozy and tired and weren’t very chatty. Once the patient was responding and breathing properly, they were taken to a separate room for aftercare

After-care: In the after-care room, patients were monitored and provided with food and drinks. When given the all-clear, the patients left the ECT suite with the assistance from a family member, friend, or member of a care-team.

(While one patient went to the recovery room, the next patient was introduced to the specialists and brought in, and the process was repeated for all patients seen that day). The appointments were very structured and organized, and all followed the same standardized procedure.

A Patient's Experience of ECT

Click here to read a personal account of ECT from the perspective of a patient who has received the treatment.

Conclusions/Take-home message.

This experience has given us a better idea of what ECT treatment looks like in the UK today, and how life-changing it can be for some patients. We hope that by sharing our experience and providing other resources we have been able to answer some of the questions that someone considering ECT (and/or their loved ones) might have about the procedure during their decision-making process.