History of Electroconvulsive Therapy

Unfortunately, there is a strong stigma associated with Electroconvulsive Therapy because early treatments used large electrical currents that caused strong muscular contractions that sometimes caused injury (broken bones or dislocated joints). Moreover, the patients were awake during the procedure – a terrifying experience. Everyone remembers the dramatic (but no longer accurate) scenes in One Flew Over the Cuckoo’s Nest. Over the years the process has been modified to maximize the benefit and minimize the side effects. The amount of electricity has been decreased, patients are asleep during the process, and muscle relaxants prevent muscle convulsions.

When is Electroconvulsive Therapy Used?

Doctors prescribe ECT mainly to treat depression that does not respond to antidepressant medications and/or psychotherapy. While ECT is used in some cases to treat mania, schizophrenia and catatonia, it is most useful in the treatment of depression. ECT can be the first choice of treatment for patients with psychotic depression (depression accompanied by hallucinations or delusions) and suicidal patients since it seems to start relieving symptoms after the first treatment, reducing the risk of suicide.

While the causes of depression are not known, abnormal chemical levels in the brain are believed to be involved. Electroconvulsive Therapy is a shock treatment that induces a grand mal seizure in the brain. These seizures are similar to epileptic convulsions where basically the brain’s electrical pathways all fire at the same time. The seizure alters many chemical aspects of the brain during and after the seizure activity.

For ECT to be effective a series of treatments are required and a seizure must occur with each treatment. The patient typically receives Electroconvulsive Therapy three times a week for two to four weeks (at which time the depression should be gone). After several treatments, changes build up in the brain that relieves the depression. However, the changes in the brain are generally not permanent; CT scans and MRI scans taken before and after ECT show no structural changes in patient’s brains².

What happens during Electroconvulsive Therapy?

Before Electroconvulsive Therapy, patients receive a drug to put them to sleep and a muscle relaxant to prevent them from thrashing (and possibly hurting themselves) during the treatment. Patients feel nothing during ECT treatments since they are asleep.

Electrodes are placed on the head to deliver the electricity to the brain. Other electrodes on the body monitor the heart. The brain can be stimulated on one or both sides of the head, and the stimulation lasts for four seconds or less. The electricity induces the brain seizure, which lasts from 30 to 120 seconds. After the seizure ends, patients are allowed to wake up in a recovery room, and later go home until the next treatment.

What are the side effects of Electroconvulsive Therapy?

Side effects during Electroconvulsive Therapy include increased blood pressure and pulse as well as irregular heartbeat. As with any procedure that requires anesthesia, there is a small risk of death (about 1 in 100,000). If the patient aspirates (breathes in) saliva or vomit they could develop pneumonia. In about 1 in 2,000 treatments the patient has spontaneous seizures after the end of the treatment.

When the patient wakes up after ECT, they may feel groggy, confused, nauseous, and have a headache and muscle aches. ECT also results in short-term memory loss and an impaired ability to retain new information (for example, they can’t remember a new phone number). For most patients the problems with their memory usually ends a few weeks after treatment ends. However, in some cases long-term memory loss can occur.

How effective is Electroconvulsive Therapy?

ECT effectively ends episodes of depression in about 80% of patients that finish a course of ECT.¹. However, since the brain changes that occur with Electroconvulsive Therapy are not permanent, there is a strong chance of the depression returning. In fact, with no further treatment, 90% of patients relapse in one year.¹. Therefore, patients need further treatments, whether it is antidepressants, psychotherapy or maintenance ECT (weekly or monthly ECT treatments).

Is Electroconvulsive Therapy the only choice for patients that do not respond to medication?

While ECT has been the last line of treatment for depressed patients that did not respond to antidepressant medications or psychotherapy, it does not work for all patients. A new treatment, Vagus Nerve Stimulation (also called VNS therapy), is currently being reviewed by the FDA as a new treatment for depression. The FDA approved the Vagus Nerve Stimulator for the treatment of epileptic seizures, and it has proved safe and effective for these patients. Research indicates that it can also relieve treatment-resistant depression. If approved by the FDA, the Vagus Nerve Stimulator could possibly replace ECT as the treatment of choice for depressed patients.

Both ECT and the Vagus Nerve Simulator use electrical stimulation of the brain to effect changes, but the mechanisms they use are very different. In Electroconvulsive Therapy, electrical stimulation of the brain causes a massive discharge of the nervous pathways in the brain, resulting in a grand mal seizure (similar to an epileptic seizure), temporarily altering the chemical makeup of the brain. In Vagus Nerve stimulation an implanted pacemaker stimulates the vagus nerve, which in turn stimulates specific cells in the brain. The pacemaker stimulates the vagus nerve every few minutes day in and day out. Although scientists do not know how Vagus Nerve Stimulation works, they do know that the continuous delivery of stimulation to the vagus nerve causes changes in key areas of the brain that affect depression.

One of the major problems with ECT is memory loss; the major side effect of Vagus Nerve Stimulation is hoarseness, which is mild and tends to disappear with time. ECT therapy requires multiple treatments in a hospital setting; Vagus Nerve Stimulation requires one hospital visit to implant the pacemaker-like battery and wrap the wires around the vagus nerve. While ECT has been used for decades to treat depression, it is a cumbersome technique that has a strong negative stigma attached to it. The significant side effects and high relapse rate associated with ECT make it less than ideal.

The new treatment with the vagus nerve stimulator implant procedure may someday replace ECT as the method of choice for treatment-resistant depression.