Electroconvulsive therapy: Myths and Reality

If ever one is asked what they think about Electroconvulsive therapy (ECT), most individuals will claim that it is a dangerous treatment, most probably used to treat a dangerous prisoner or punish a patient. Others envision the therapy to be very painful and causing unlimited life threatening seizures. Everyone has certain ideas about ECT and the majority of individuals have a lot of misconceptions about the treatment. Despite, the treatment being more than 70 years old, the myths surrounding ECT continue to grow.

Electroconvulsive Therapy, more commonly known as "ECT," is a medical treatment performed only by a psychiatrist. Its therapeutic benefits in treating depression and other mental disorders have been recognized by the American Psychiatric Association, the American Medical Association, the National Institute of Mental Health, the Food and Drug Administration, the US Surgeon General's office, and similar organizations in and many other countries. ECT treatments are not life long like medical therapy but consist of six to twelve sessions spread over a few months interval. Treatments are usually given two-three times a week for a month or less. Most patients receive general anesthesia and a muscle relaxant. When the patient is sedated, the brain is stimulated with electrodes which are placed in specific locations and a controlled series of electrical current is delivered. The electrical current causes a seizure which lasts about 45-60 seconds. Because of the anesthesia and muscle relaxant, you will have no pain and the convulsion is not visible. After a period of 5-10 minutes, you will be woken up from anesthesia, like any minor surgery procedure. The majority of individuals receive ECT as an outpatient. ECT is believed to work by causing stimulation of a large part of the brain by the release of numerous neurotransmitters. What transmitter and where the effects take place remain unknown. The treatment has undergone a revolution in the past 2 decades and for some disorders is considered the primary and first choice therapy. In those individuals with acute suicidal tendencies and depression, ECT can be life saving. In some individuals with depression who have no response to standard anti depressant medications, ECT may be an alternative. For others, with an acute episode of psychosis, ECT may be helpful. Electroconvulsive therapy still remains a controversial and enigmatic treatment in the field of psychiatry. Even though the technique has been refined and has become very safe, opinions about this therapy are divergent. Some claim it is effective and useful and other claim that is useless and dangerous. The medical literature is full of the pros and cons of ECT. Currently, when the assessments about CT are done by doctors, the results are always great, when the assessments are done by the consumer, the results lack credibility. Deciding when or whether to have ECT therapy has always been difficult because of the controversies surrounding it. Should ECT be the initial treatment of choice? Or should it only be a last resort? Will it work? Is it painful? Will it cause lasting side effects? Will it make me a zombie? Will I be normal afterwards? All these questions have made the population confused and ambivalent about ECT. The only way to make a valid decision about this therapy is to be well informed.

To mimic ECT, in the old days, physicians’ injected patients directly with the potent chemicals (neurotransmitters and a whole assorted of other chemicals) and these chemicals caused numerous deaths- this bad reputation has been carried over for the past 50 years. Once it was recognized that injection of chemicals was not only dangerous but ineffective, the use of electrical currents to treatment mental disorders was initiated. However, administration of electrical currents was not a fine art 60 years ago. Basically these physicians shocked the living life out of the patients. There was little choice then because no other drugs were available during that time period. ECT was the only therapy for most mental health disorders and most patients were scared shit of all doctors. In addition, anesthesia was primitive in the early days of ECT therapy and there was little monitoring of the patient. The convulsions were induced without the aid of any drugs and this was a painful procedure (like being hit on the head with a baseball bat, over and over again). The body was rocked with uncontrolled seizures with no way of controlling them. Fractures of the bones and facial trauma were a common scenario—any wonder doctors had a bad rap. These horror images are still carried out in movies. Electroconvulsive therapy is different today, although it still does pose a risk of side effects and complications, such as memory loss and confusion. Yet the procedure has become refined, with precisely calculated electrical currents administered in a controlled medical setting to achieve the most benefits with the fewest risks.

In general, there is no doubt that ECT has some benefit in the treatment of mental health problems, especially depression. However, its effectiveness on mania and schizophrenia are not widely accepted and the results still remain inconclusive. There is enough evidence to show that ECT is a good treatment for depression and in some cases has been shown to be more effective than the standard anti depressant drugs. Trials in the past have shown that entire brain stimulation was better than just exciting one half of the brain and a higher current was better than a lower current. However, all these are data from the past decades and determining of cognitive and mental effects of the therapy was not evaluated thoroughly. However, despite use of ECT over the past 30 years with better techniques of treatment and more thoroughly evaluation of the individuals, there is a consensus that ECT is effective in depression and individuals treated with ECT do not become monsters. The major reason why ECT has received a bad image is because of results obtained during the evolution of the therapy. In the past, many psychiatrists failed to maintain safety standards in terms of the electrical delivery and management of the patient during the procedure. And definitely, the complications of the therapy were severe and bordered on dangerous practice of medicine. So what has changed today?

ECT in the present era of medicine is safe and a bona fide therapy. The reason for this bad reputation is because the delivery of ECT in the older days was never controlled and complications were never anticipated. Today, a lot more is known about the therapy and both delivery and safety have been refined and improved to near perfection.

ECT is most commonly recommended for individuals who: - have severe depression, accompanied by psychosis or suicidal intent - have failed to respond to anti depressant drugs - are unable to tolerate anti depressant drugs - have psychosis which is not severe enough for medical therapy - have depression but have failed all forms of other therapies ECT is the most effective and most rapidly acting treatment available for severe major depression. ECT also helps patients who suffer with most forms of mania (a mood episode which is associated with grandiose, hyperactive, irrational, and destructive behavior). When it comes to the treatment of other mental disorders (bipolar disorder, schizoaffective disorder, catatonia, and Parkinson's disease), the role of ECT therapy is questionable. ECT is a very under utilized form of therapy in the USA even though there are close to 9 million America who suffer from depression, less than 33,0000 received ECT. In most cases ECT is done as an outpatient procedure

All individuals who are scheduled to have ECT must undergo a complete history and physical examination in addition to a psychiatric exam. All individuals are also seen by an anesthesiologist to ensure that they are not a high risk for anesthesia. Some baseline blood work and an ECG are typically done before the procedure. Like any surgery procedure, ECT is also considered an invasive procedure and requires the routine consent and understanding of what the procedure entails. The procedure is generally done as an outpatient procedure. And it takes about 10-15 minutes to perform. On the day of the procedure, you will be asked to lie down on a bed and be comfortable. An intravenous line and heart monitors are placed on you. One should not eat the night before the procedure. Electrodes will be placed on the head. In some cases only one side of the brain will receive the electricity and in some cases the entire head will receive the jolt of electricity. The procedure is done under general anesthesia and just before the start of the procedure, you will be administered a muscle relaxant to prevent the violent convulsions. Other medications may be administered as needed. Because one tends to bite on the mouth and tongue during a convulsion, you may be given a mouth piece to prevent biting trauma to the gums or the tongue. Once you are all connected and the monitoring is ready, the ECT machine delivers an electrical current to your brain which typically lasts anywhere from 45-60 seconds. During the procedure you will be completely unaware of the entire proceedings. The physician may feel the leg or foot move but that is about all. When the ECT is delivered, the brain electrodes record the entire activity. The EEG will record the delivery and cessation of the seizure activity. A few minutes later, the effects of the short-acting anesthetic and muscle relaxant begin to wear off. You're taken to a recovery area, where you're monitored for problems. Upon awakening, you may experience a period of confusion lasting from a few minutes to a few hours or more.

Improvement after a single session of ECT is not always guaranteed and some individuals will require several sessions. The maximal improvement in symptoms after ECT require at least a few days to weeks. How ECT improves depression is not really known but is linked to the release of neuro chemicals from the nerves. In most individuals, ECT is most effective after multiple sessions. Some individual require 2-3 sessions a week for up a month. However, only 80% of individuals who receive ECT benefit from the treatment. Today ECT is never the sole therapy and in many instances it is combined with anti depressant medication or psychotherapy.

Like everything in medicine, ECT also has its fair share of complications. Even though rare, one needs to be aware of the following side effects: Mental confusion: soon after the ECT the majority of individuals develop mental confusion and clouding. There is immediate loss of concentration, thought and awareness- this mental clouding lasts anywhere from a few minutes to a 48 hours. As one has more ECT treatment, this phase of mental confusion always is prolonged in duration. In all cases, the mental clouding improves with time. Memory loss: Memory loss is a common side effect of ECT. Right after therapy, most individuals have difficulty remembering for weeks to months. The treatment also makes one forget recent events up to a few months prior to the procedure. Remembering events and individuals may be difficult for weeks or months. However, all the memory loss gradually improves over the first few months. But this is not always the case and some individuals have permanent memory loss. Medical: In some individuals the ECT may precipitate an increased heart rate and blood pressure. Those with heart problems may be at risk for heart damage and even a heart attack. ECT also carries a very small risk of death, about the same as with other procedures in which anesthesia is used. Generalized pain: After the ECT a seizure is induced which causes all the muscles in the body to contract violently? After the procedure, most individuals will complain of nausea, and generalized body and muscle aches. Headaches are common for a few days.

ECT is not a common form of therapy but still every year close to 100,000 individuals in North American undergo this treatment each year. Because of the misconceptions and myths associated with therapy, many individuals do not know that the therapy is safe and beneficial. For those who may want to consider ECT, discuss with your doctor and consider the following: - rapid relief of symptoms - alternative therapy drug therapy fails - unable to tolerate side effects of drugs - had good prior experience with ECT

ECT therapy is not used to punish any individual and like any procedure requires consent and approval. The patient has the absolute right to refuse the procedure. Not the government, doctor or any other person can force this procedure on anyone. Under the APA's recommended "informed consent" protocol, permission to administer ECT is usually thoroughly reviewed and each case is individually analyzed. The consent is not just an oral mumbling of vague dry confusing concepts. It is the psychiatrist’s responsibility to detail and explain the basic principles of ECT and the possible benefits and risk that may occur. The individual and the family members need to be informed of when, where, and by whom the treatment will be administered and the number of treatments expected. Unlike the days gone by, just simple signing a consent does not give the doctor permission to perform an ill understood procedure and thus all questions must be asked. The patient has the complete right to withdraw a consent and seek alternative care. No consent is binding to the extent that the patient has no choice. Gone are the days when doctors were the sole decision makers. Today, patients have more rights than they care to know.

SO far, ECT has been thoroughly analyzed and there is no evidence to reveal that the procedure causes brain damage. Even though the procedure does induce a seizure, the brain is not damaged. CT scans, MRIs and PET scans have revealed that there is no structural damage after ECT. Most studies indicate that the amount of electricity induced to cause the seizure is not harmful to the brain because of its short duration and intensity. The myth that most people turn into brain damaged zombies is absolute nonsense. There are many different views and many different reasons why people object to ECT and it is wrong to generalize. However, many say that ECT is an inhumane and degrading treatment which belongs to the past. They claim that the side effects of ECT are severe and that these are hidden from the public. They also claim that patients are locked up against their will and continually shocked. Various claims of brain damage are made they would like to see ECT banned. Unfortunately, the individuals who make such statements do not have a clue about psychiatry-much less know the difference between the anus and the mouth. Psychiatrists may not know a lot about mental health disorders, but what little they know. has made the discipline far safer and effective than all the previous decades.

ECT may have been a dangerous procedure in the past century but today it is a safe and an effective procedure. Unlike what is depicted din the movies, ECT is not a sadistic procedure and it is absolutely painless. Most of the myths surrounding ECT are based from the 1950s. However, most of medicine and surgery was pretty well primitive at that time and this is no different for ECT Today, the American Psychiatric Association has very strict guidelines for ECT administration. This organization supports use of ECT only to treat severe, disabling mental disorders; never to control behavior. Despite its dubious past, electroconvulsive therapy is now a relatively safe and effective procedure. ECT can often work faster than psychiatric medications or psychotherapy can, and it can help when other treatments have failed. The risks are real but usually small. ECT is used much less today compared to the past few decades and this is mostly now a treatment for severe acute depression. This is almost certainly because modern treatments for depression like anti-depressants, psychotherapy (talking treatments) and other psychological and social supports are much more effective than in the past. Even so, depression can take an acute turn for the worse with the individual going downhill fast and not eating, talking or even communicating. Some may develop acute psychosis and delusions and become very suicidal. In these cases, ECT may offer a rapid therapeutic benefit compared to what is available and may be an excellent alternative. All current scientific data indicate that for acute depression with suicidal tendencies, ECT is an excellent form of therapy. Many individuals who have had ECT in the past have found it helpful and seek the treatment when they feel depressed again.

The costs for ECT therapy is variable, depending on the state and the psychiatrist administering it. Usually, however, ECT costs range from $8-1000 per treatment. The cost covers the fee for the anesthesia, the psychiatrist and the hospital admission. The average number of treatments may range from 6-8. The cost of ECT may be partially reimbursed by most insurance plans offering coverage for mental disorders. Definitely not cheap by any means, ECT may however, may be a better alternative for depression when compared to drug therapy which is also quite expensive.