Overview of Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is a treatment that uses a small electric current to cause a controlled seizure while a patient is under sedation or sleeps from general anesthesia. This method is mainly used to treat patients suffering from severe depression. Though less commonly, it could also be helpful for patients with other mental health conditions, such as schizophrenia, schizoaffective disorder, catatonia, neuroleptic malignant syndrome, and bipolar disorder. However, there are misunderstandings and fears about this treatment method mainly because people don’t fully understand how it works.
Anatomy and Physiology of Electroconvulsive Therapy
In people who suffer from severe depression, there are different changes that happen in specific areas of the brain. These include less activity and a decrease in size of certain parts at the back of the frontal lobes, a part of the brain that’s largely involved in cognitive functions and judgments. Altered emotional reactions were also found in areas of the ventral and orbital frontal cortex, the lower and front areas of the frontal lobes.
Beyond the frontal lobe, structural and functional changes have also been observed in other parts of the brain like the hippocampus, a region important for creating new memories, the parahippocampal gyri, and the amygdala, typically involved with emotions, survival instincts, and memory.
Moreover, the stress-response system of the body, known as the hypothalamic-pituitary-adrenal (HPA) axis, becomes more sensitive to stress. This results in the production of higher levels of stress hormones and impaired regulation of these hormones. This HPA axis, together with our mesocorticolimbic dopamine system, which directly impacts how our body responds to stress and plays a vital role in experiencing pleasure and reward, joy, and motivation, are active in people under stress. It is believed that dopamine function isn’t working properly in people with depression, which can negatively affect important functions like concentration, motivation, and pleasure.
Electroconvulsive therapy (ECT), a medical treatment that aims to reduce the symptoms of mental disorders, produces its anti-depressive effects by causing changes in these above-mentioned systems of the brain.
Why do People Need Electroconvulsive Therapy
Electroconvulsive Therapy (ECT) is a treatment option for people struggling with severe or unresponsive depression. This type of depression, often called ‘treatment-resistant depression’, is when multiple types of antidepressant medications have not improved the condition. ECT has been suggested as a helpful treatment for other circumstances, including strong suicidal feelings, severe episodes of psychosis, refusal to eat due to depression, and a condition called catatonia, where someone becomes unresponsive.
ECT can also be used to treat both depressive and manic symptoms in individuals diagnosed with bipolar disorder. For certain patients like the elderly, those weakened by illness, pregnant women, and those nursing infants, ECT may be safer than antidepressant or antipsychotic medications.
One of the benefits of ECT is that it can rapidly decrease feelings of wanting to commit suicide. Studies have shown that after just one week, 38% of patients saw these feelings completely vanish, and this percentage increased to 61% after two weeks, and 81% after the full ECT treatment was completed.
Finally, ECT may turn out to be a good option for individuals who have had positive responses to this therapy in the past.
When a Person Should Avoid Electroconvulsive Therapy
Having a seizure from an electroconvulsive therapy (ECT), which is a treatment for severe mental disorders, can temporarily raise your blood pressure, increase the demand for oxygen in your heart, quicken your heart rate and increase the pressure within your skull. Extra caution is needed for those with heart, lung or central nervous system problems. Central nervous system refers to your brain and spinal cord.
There are certain situations when ECT should definitely not be done. One is if you have a pheochromocytoma, which is a rare tumor in your adrenal glands that can cause high blood pressure. Another is if you have increased pressure in your skull with mass effect – this means that a part of your brain is being pushed to the side by something like a tumor or swelling.
There are other situations where ECT might not be recommended, but it depends on the case. These include when there is increased pressure within the skull without mass effect, problems with the electrical activity in your heart, high-risk pregnancies, and aortic and cerebral aneurysms. Aneurysms are a bulging in your blood vessels that can be risky because they might burst.
Equipment used for Electroconvulsive Therapy
When undergoing ECT (Electroconvulsive Therapy), it’s important that the treatment and recovery environments are equipped with specific monitoring devices. These are standard tools recommended by the American Society of Anesthesiologists (ASA) and they help doctors to monitor your vital signs during the procedure.
These instruments include a stethoscope (to listen to your heart and lungs), a blood pressure monitor (to check the force of your blood against your artery walls), and an electrocardiography (EKG) monitor (which keeps track of your heart’s electrical activity).
Also required are a pulse oximeter (used to measure the amount of oxygen in your blood), a suction apparatus (a device that removes fluids from the body), and an oxygen delivery system. These tools all help doctors to keep you safe and stable during the procedure.
There should also be supplies ready for inducing anesthesia (the medicine that helps you sleep during the procedure), medication for any necessary treatments, and equipment for ventilation (helping you breathe) and resuscitation (reviving you if your heart stops).
In addition, there should be a nasal cannula or face mask that can provide extra oxygen if needed. There should also be a bag valve mask (used to help you breathe in emergencies), a nerve stimulator (used to check muscle response), an electromyograph (EMG, a test that records muscle activity), and electroencephalography (EEG, a test that records brain activity) leads. Lastly, multiple blood pressure cuffs should be available.
Who is needed to perform Electroconvulsive Therapy?
Electroconvulsive Therapy, or ECT, is a procedure that involves multiple healthcare professionals. Usually, this team is made up of three main roles: an anesthesiologist (a doctor who manages pain or puts you to sleep during the procedure), a psychiatrist (a medical doctor who specializes in mental health), and a nurse. This varied team ensures you’re comfortable, safe, and appropriately cared for during the procedure.
Preparing for Electroconvulsive Therapy
Before the procedure known as electroconvulsive therapy (ECT), your doctor will analyze your medical history and conduct a physical examination. This is to look for any potential risk factors, such as heart issues or brain abnormalities. It’s important that the history also includes the use of herbal medications like Ginkgo biloba, ginseng, St John’s wort, valerian, and kava. These could potentially interfere with the ECT treatment. There’s also the risk of a severe and prolonged seizure (status epilepticus) if the patient is taking a drug known as theophylline.
Short-lasting intravenous beta-blockers can help manage high blood pressure and fast heartbeat associated with ECT. However, it might also shorten seizure duration and impact the effectiveness of ECT. Heart medications like aspirin, cholesterol lowering drugs (statins), high blood pressure medications, heart pain relieving drugs (antianginal medications), and clopidogrel should be continued on the day of the procedure.
It’s also important that blood sugar levels are checked before the procedure and in the recovery room after ECT because such treatments can increase blood sugar levels. In the case of patients with a defibrillator (a device that helps to regulate the heartbeat), detection mode should be off during the procedure and there should be equipment for external defibrillation on hand. For pregnant patients, it’s suggested that they have noninvasive fetus monitoring after 14 to 16 weeks of pregnancy, and a nonstress test with a device called a tocometer after 24 weeks.
ECT is performed under general anesthesia, and medications used can include barbiturates like thiopental and methohexital and non-barbiturate agents like propofol and etomidate. The seizure induced by ECT should last longer than 30 seconds. Methohexital is the most commonly used induction agent due to its quick onset, effectiveness, and low cost, and it has minimal effect on seizure duration. Propofol and thiopental have been seen to reduce seizure duration, whereas etomidate has been linked with muscle spasms (myoclonus) and increased seizure duration.
How is Electroconvulsive Therapy performed
Electroconvulsive therapy (ECT) is typically performed in a specialized area like a recovery room or an outpatient surgery centre. It’s most commonly used as an outpatient procedure, meaning you’ll come in for the treatment then go home the same day. However, for individuals who are extremely weak or suffer from severe health or mental illnesses, it may initially be conducted in a hospital setting and later shifted to outpatient care, as required. Before the procedure, the patient should avoid eating or drinking for a certain period- no light meals for 6 hours, no fatty meals for 8 hours, and no clear liquids for 2 hours.
During the procedure, vital signs including oxygen level in the blood, heart, and brain activity are continuously monitored. Muscle activity in the right foot is also recorded to measure the physical aspect of seizure activity. To lessen the muscular contractions during the procedure, a muscle relaxant, succinylcholine, is used. Alternatively, a blood pressure cuff is placed around the patient’s ankle, blocking succinylcholine from entering the foot, which allows for visual monitoring of seizure activity. After sedation is induced using an IV line, a bite block is placed to protect the patient’s tongue and teeth. The start and end of a brain seizure are tracked using an EEG machine. Seizures are induced via 2 electrodes placed on the temples, or a right unilateral electrode placed on the scalp, allowing electric current to pass.
Research has shown that both moderate bilateral ECT (current passed through both sides of the brain) and a high dose of right unilateral ECT (current passed through the right side only) are effective. However, right unilateral ECT is often the preferred choice to minimize memory loss after the treatment.
The type of stimulus or electric wave used can be a brief pulse (0.5 to 2.0 milliseconds) or an ultra-brief pulse (less than 0.5 milliseconds). Brief pulse is standard however ultra-brief is often better tolerated. The administered electricity dose affects how well the treatment works, how quickly it works, and the cognitive side effects. The level of current necessary to induce a seizure is established via a trial and error process during the first treatment session. During further ECT sessions, the electricity dose for bilateral ECT is 1.5 to 2 times the seizure threshold, and 6 times for right unilateral ECT. The seizure threshold generally increases over the course of the ECT treatment sessions as the body develops resistance.
As with all procedures, the goal during ECT is to provide a safe and pain-free experience for the patient. Prior to the procedure, the patient is given oxygen through a nasal cannula or face mask, anesthetic medication is administered to induce unconsciousness followed by paralysis. To prevent irregular heartbeat, overproduction of saliva, and to reduce the size of blood vessels in the brain, a medication called an anticholinergic is given before ECT. The patient is then typically hyperventilated to intensify the seizure. The choice of anesthesia most commonly used is methohexital. Succinylcholine is the preferred muscle relaxant to minimize a motor seizure and prevent muscle and bone injuries.
Once the patient is unconscious, they’re given a muscle relaxant, followed by ventilation with 100% oxygen. The muscle relaxation is checked using a nerve stimulator and clinical assessment of foot reflexes. To prevent injuries to the tongue and teeth, a bite block is placed in the mouth since muscle relaxants cannot prevent jaw muscle contraction caused by the electric pulse.
Seizures induced during treatment usually last between 15 to 70 seconds, however, monitoring continues for about 25% longer than the duration of motor seizures using EEG recording. Seizures shorter than 15 seconds may not be therapeutically effective, while seizures that last too long may cause cognitive impairment. Electric current higher than the initial one is administered to follow up a missed or a brief seizure. In case of a prolonged seizure that lasts more than two minutes, a lower dose of anesthesia or a benzodiazepine is given to curb the seizure activity and prevent brain injury.
For pregnant women receiving the treatment, hyperventilation is avoided to prevent reducing blood flow to the placenta, which can cause lack of oxygen in the fetus. Adequate hydration and minimization of time spent fasting are vital to prevent dehydration and early uterine contractions. In pregnancies over 20 weeks, the uterus should be displaced to the left to optimize blood flow. If the fetus is considered viable (over 24 weeks), continuous monitoring should be carried out during and after each treatment. Since pregnant patients are at a higher risk of inhaling their stomach content into their lungs, medication to prevent reflux should be avoided. In such cases, a non-acidic antacid such as sodium citrate is safer to prevent this complication.
Possible Complications of Electroconvulsive Therapy
Electroconvulsive therapy (ECT), also known as shock therapy, treats depression and some other mental conditions by passing a controlled electric current through the brain to trigger a brief seizure. A study found that using ECT on both sides of the brain, or bitemporal ECT, can lead to more temporary difficulties with thinking and memory than when ECT is only used on one side. This includes troubles with overall mental function, remembering words, and recalling personal experiences, especially three days after the treatment.
The American Psychiatric Association advises that certain people might have a higher risk when receiving ECT. This includes people with serious heart condition, brain diseases that might cause an increase in pressure inside the skull, recent brain bleeding or stroke, an unstable blood-filled bulge in the wall of a blood vessel (aneurysm), severe lungs disease, or are in American Society of Anesthesiologists Class 4 or 5, which indicates very severe systematic disease.
During ECT, different stages of the induced seizure can cause various heart-related issues, although, paradoxically, these are less likely in patients with heart block or inherent arrhythmias, conditions involving an interrupted or inconsistent heartbeat. Initially, there will be a slowdown in heart rate. Following this, there is a rapid increase in heart rate and high blood pressure correlated with the seizure. Most people will have normal heart rate and blood pressure within 10 to 20 minutes after a seizure. However, some people might continue to have high blood pressure that needs medical treatment.
ECT can impact the heart, even in healthy individuals. While patients with heart disease are more likely to face complications after ECT, the treatment can also reduce the amount of blood being pumped out of the heart in healthy patients. In a study, seven out of 53 adults undergoing ECT developed new global left ventricular (LV) systolic dysfunction (a condition where the heart’s main pumping chamber can’t contract normally), and eight developed regional wall motion abnormalities (a condition where part of the heart muscle doesn’t contract properly). However, none of these patients suffered any adverse effects. In another study, high levels of a protein that signifies heart muscle damage were found in eight out of 100 ECT patients, but only two showed other signs of heart problems.
Brain blood flow and intracranial pressure, the pressure inside the skull, also tend to increase with ECT. Patients might show signs of confusion, delirium, disorientation, and memory loss. However, according to the AHA-ACC guidelines, ECT is considered a low-risk procedure because generally, it is well-tolerated, and it only causes temporary changes in blood pressure and heart functions with a low mortality (death) rate.
What Else Should I Know About Electroconvulsive Therapy?
Electroconvulsive therapy (ECT), often just called ‘shock therapy’, is a safe treatment with very little risk. It’s commonly used to treat different mental health issues like depression, severe mental disorders, refusal to eat due to depression, and a specific condition called catatonia, where a person might not move or talk much at all.
Successful treatment with ECT requires a team of medical professionals, including psychiatrists, anesthesiologists, and nurses. Generally, a patient will need multiple sessions before they start to notice lasting changes.
Many people might associate ECT with negative experiences like severe injury and memory loss, but this is mostly due to treatments from earlier periods that were administered without anesthesia. Nowadays, ECT is a significantly safer procedure. After undergoing ECT, patients might notice improvement in their symptoms relatively quickly, and the benefits can last for several years.
One thing to keep in mind is that ECT can still cause some memory loss in the long term. But, the overall risk of dying from ECT treatments is very low, especially when done in a controlled setting.
ECT is often used in pregnant patients and older adults because it allows them to avoid the side effects typically associated with one group of medications used to treat mental illnesses. The exact reasons why ECT works aren’t fully understood but it’s thought to be related to changes in the blood flow to the brain and how different parts of the brain use energy.