What is electroconvulsive therapy?

Electroconvulsive Therapy (ECT) is a safe, efficient and sometimes life-saving treatment used to treat specific mental health conditions. It has been practiced for the last 75 years. During ECT, a small dose of well-controlled electric current is administered near the forehead of a patient to stimulate his/her brain cells. This produces convulsions (seizures) for a few seconds. This procedure is done under anesthesia so that the patient is unaware of the passage of electrical current and the convulsions are suppressed. The entire process lasts for a few minutes; and patients generally regain consciousness in about 15 – 20 minutes.

Doctors consider ECT as an option for patients with a severe mental disorder like depression, schizophrenia or mania. They prescribe this treatment after taking into account many issues including its safety, patients’ or family's preference, need for quick relief from the psychiatric condition and lack of response to psychiatric medications. Generally, ECT is used in the following situations:

• When the psychiatric condition (particularly depression) is severe and there is high risk that the patient would attempt suicide.

• When patients, due to severe psychiatric conditions, refuse food and fluids, which could harm their physical health.

• When patients become so ill that they become mute and immobile – a condition called “catatonia.”

• When patients become highly excited or agitated endangering their own or others’ safety.

• When medications are unable to relieve psychiatric symptoms.

• The prescribed medications cause serious side effects and hence, cannot be continued.

When psychiatrists decide that ECT is needed for a patient, they explain the procedure, its advantages and disadvantages, and alternative approaches to the patient and his or her family. ECT is administered only after the patient and the family have provided written consent for the procedure. When the patients are so ill that they cannot comprehend the details and provide valid consent, then consent of their family members is sought. Patients and family members can refuse to provide consent. They can also withdraw their consent before starting the treatment or at any point during the course of the treatment. In such a case, they would receive the next best possible treatment.

Psychiatrists respect the decision of the patients and relatives. They would manage the psychiatric condition with other available methods. However, these treatments may take longer time to show their effect, resulting in longer hospital stay. Doctors may have to use higher doses of medications to control patients’ excitement, agitation, or other symptoms.

ECT can be safely given to elderly persons when due precautions are taken. In fact, in some countries, majority of the patients that receive ECT are the elderly. In children, it is considered as a last option and is used only after discussion among a panel of doctors. At NIMHANS, Bangalore, more than hundred children have received ECT without serious adverse effects.

For such a patient, psychiatrists make detailed assessment of the patient's medical condition and obtain opinions from different experts, including that of anaesthesiologists. They also monitor the patient's condition closely during the ECT procedure. Most patients with cardiac, neurological, or respiratory problems have received ECT without adverse effects.

When proper precautions are taken, ECT is a safe procedure to treat pregnant and nursing women. In fact, since a number of psychiatric medications cannot be prescribed to women in such a condition, ECT is actually preferred when the psychiatric condition needs to be treated urgently.

Many people have this misunderstanding that once a person receives ECT, they would need it every time they fall ill. This is not true. In most cases, after patients have received ECT, psychiatrists would treat them with medications to prevent relapse of the condition. Even if there is a relapse, and if the condition is mild, then it is treated with medication and ECT will not be administered. There are rare instances, where the psychiatric condition responds only to ECT and no other interventions. It is only in such cases that ECT is administered repeatedly.

The effect of ECT is not permanent. Patients would need medications to maintain the improvement achieved by the use of ECT. Rarely, despite the use of medications, the improvement achieved with ECT is ill-sustained – in such cases, ECT may have to be continued, albeit less frequently – about once a fortnight or once a month.

It is important to tell the doctor about the patient’s past and current medical illness, especially those related to heart, lungs, blood pressure, or bones. Any history of having undergone surgeries under anaesthesia as well as presence of loose teeth or dentures also needs to be provided to the doctor. It is important to let the doctors know about the medications the patient is taking. Doctors generally examine the patient in detail and perform a few blood tests and electrocardiogram (ECG). The doctors may also recommend a brain scan.

The most important thing is to not eat or drink anything for 6 hours before the ECT. The doctors may also ask the patient to shampoo and keep the hair oil free and wear loose fitted clothes. One should remove ornaments, contact lens, dentures and hearing aids, if there is any. It is also important to pass urine just before going to the ECT room. If patients are taking medications, the doctor would advise them about which medicines are to be taken before and after the ECT session.

ECT is administered by a team consisting of experienced psychiatrists, anesthetist and nurses. The patient is first given injection to induce sleep. During this time, oxygen is provided using a mask. Once the patient is sedated an injection is used to relax the muscles in order to make the convulsions mild. A small current is then passed near forehead for about two to four seconds. This induces convulsions that last for twenty seconds to about one minute. The doctors assist the patient's breathing till he starts breathing on his own. The doctors closely monitor the patient’s pulse, blood pressure, and oxygen content in the blood throughout this procedure. ECT is not painful because a person is under deep sleep when electrical stimulus is administered.

Patients generally become completely alert after a few hours following ECT session. The nursing staff needs to be consulted about when it is okay to have breakfast or morning medications after ECT. It is advisable not to drive any vehicle for a few hours after ECT. Apart from this, they can continue with their daily routine as usual. It is best that one does not make any major decisions such as signing contracts or any business agreements until after the full course of treatment is completed.

ECT is administered twice or thrice a week. Most patients receive about 6-12 treatment sessions. Depending on the response to ECT, doctors may decide to administer more or less ECT sessions.

ECT is usually administered in the room especially equipped for monitoring a person’s condition during anesthesia and ECT treatment. Separate rooms are there for patients to wait, have their treatment and recover from the procedure.

Most people start showing improvement after two to four ECT sessions. However, a few may not get significant benefit until later in the treatment course. There have been rare cases when the patient has not experienced any improvement.

It is believed that ECT causes some chemical changes in the brain leading to the development of new connections across different nerve cells. Scientists have found that after ECT, there are changes in the levels of neurotransmitters in the brain. These may be responsible for the improvement seen with ECT. However, the exact mechanism about how ECT works is still not clear and is a subject of continued research.

ECT is a fairly safe procedure as doctors take the necessary precautions. ECT generally causes temporary side effects. Some may have headache or body aches, which may require painkiller medications. The patient may experience confusion lasting for a few minutes. There may be also some lapse in memory of a few events or incidents that happened immediately before and after the treatment. General intelligence and memory for events and facts learnt long back are not generally affected by ECT. Like any other medical treatment, the range and extent of side-effects vary from one person to another. With proper medical care, serious side effects affecting the heart or nervous system are very rare, and are managed by the ECT team even if it occurs. With the use of modern techniques, dental, bone and joint complications have become extremely rare.

ECT procedure has been refined to reduce side effects including memory deficits without compromising on efficacy. The selection of those refinements is done based on the desired rate of recovery, existing physical illness, age and past experience of ECT.