human behavior

ECT for You and Me

Posted in Health & Medicine by humanb on November 7, 2009

Disclaimer: I am not a doctor, and the following post is categorically not medical advice. If you believe you suffer from a mental illness, please consult your doctor. Your doctor is best qualified to advise about the most appropriate treatment.

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I really need to watch (or read) One Flew Over the Cuckoo’s Nest because patients with mental illness at my hospital know it well, and it’s the reason for their suspicion of electroconvulsive therapy (ECT). After watching this clip, I would be horrified at the prospect of ECT too.

But that was ECT of yesteryear. Today’s ECT is different.

ECT entered clinical use in the late 1930’s. It was shown to be so effective for some mental illnesses, that by the 1950’s it was used indiscriminately in some places. In the early days, the doses were strong and long, and you were awake and restrained. That doesn’t happen anymore (in Australia anyway).

ECT is now reserved for severe forms of mental illness – especially depression – that are not responsive to other treatments like antidepressants, mood stabilizers and other drugs. In the most severe form of depression (melancholic depression), a patient may exhibit psychotic features like delusions and auditory hallucinations, as well as psychomotor features like muteness and catatonia. They may stop eating, speaking, and moving. And this isn’t something one chooses to do because he’s sad. This is biochemical.

There are also laws governing the use of ECT in Australia, detailed in the Mental Health Act 2007 (pdf). These laws concern patients’ rights and requirements for the procedure itself. For example, ECT must be administered under general anesthesia (GA) with an anaesthetist and psychiatrist present.  And the doses these days are individualized. The whole procedure lasts only a few minutes during which the patient is unconscious.

The purpose of ECT is to induce a seizure. The patient receives a muscle relaxant to subdue the muscle response and is not restrained. After the brief seizure, the patient is awoken fairly quickly. The most common complaint after ECT is headache for several hours. The principal side effect of ECT is memory loss around the time of the ECT. You don’t forget your 2nd grade teacher, but you might forget who you spoke to the day before, and you might find it harder to remember new information for a while. Most people recover from any deficits in their short-term memory over the following weeks. There is no evidence of long-term memory impairment from modern treatment protocols. A typical course may be 6-8 treatments over 2-3 weeks.

Studies have shown ECT to be 70-80% effective for the treatment of major depression. Antidepressants are 30-70% effective. In those for whom antidepressants were ineffective, ECT is effective in 50%. A strong response from an antidepressant may take 4-6 weeks, and many patients will actually feel worse for the first 2 weeks. In ECT, a strong response may take 2-3 weeks, and many patients will actually begin to feel better sooner. And while the principle side effect of ECT is headache and short-term memory impairment, the side effects of antidepressants are many, and there is always the risk of drug-drug interactions. Antidepressants are still the first-line treatment, and there are many types. All antidepressants won’t work for a given patient. The trick is finding the right antidepressant for a given patient. And even for those who complete a series of ECT treatments, antidepressants are prescribed to prevent relapse.

I can recall a patient so severely depressed that he barely spoke. His face was a mask of nothingness. He was slow in his movements, and unresponsive to any attempts at socialization. This was a typical guy with no underlying schizophrenia or other mental illness. He just developed depression, like so many of us do, although his was particularly severe. Antidepressants hadn’t worked. I watched his ECT in the operating theater on one occasion, and was struck by how simple and painless it was. He had about 12 visits to the operating theatre over a few weeks. The last time I saw him, he was walking about, communicating, accepting visitors, socializing with patients, and anxious to get home to his dogs. He was a man transformed.

I’ve seen other patients with depression just as severe or worse, whose families were adamantly opposed to ECT. They can remember an uncle or other relative back in Europe having received ECT in its more brutal incarnation at high doses and without anesthesia. The doctors tried to explain that ECT had changed, and that it wasn’t just a treatment for the insane, but a proven treatment like antidepressants for severe depression. They wouldn’t consent. I accept that. I get it. But it is sad to think that our ignorance about modern ECT, our knowledge of past medical abuses, and our love of movie classics, have made many of us refuse to consider a treatment that can produce remarkable results.

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The author of this post is a medical student with no conflicts of interest. This post is not an endorsement of ECT over other interventions for major depression. It is intended for entertainment and to encourage further learning about an accepted medical treatment.

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One Response

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  1. mike rankin said, on November 10, 2009 at 1:00 am

    this is why we are bring LSD back for clincal trials.

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