Electroconvulsive therapy (ECT) is one of the most controversial treatments in psychiatry, and perhaps it deserves to be. It has a long history of abuse and unfavorable media presentation, and there are clearly signiﬁcant side effects, especially acute confusion and memory deﬁcits. ECT, however, is also the most effective treatment currently known for severe depression, even though patients tend to prefer drugs because of their fear of ECT. On the other hand, drugs and traditional therapy take far longer to work, and some drug treatments offer more serious side effects. Widely viewed by the general public as a relic of a bygone age, ECT is actually still practiced in a majority of psychiatric units in hospitals and mental institutions. The actual story of ECT differs dramatically from the horror tales presented in the media.
ECT involves the induction of a grand mal seizure, similar to those experienced in epilepsy, by the brief (usually one second or less) presentation of an electrical current across the brain. Evidence that the seizure is occurring can include twitching toes, an increased heart rate, clenched ﬁsts, or a chest heave. Clinically effective seizures generally last from about thirty seconds to just over one minute. Because of the use of muscle relaxants and intravenous anesthesia, the patient’s body does not convulse and the patient feels no pain. Seizure activity is monitored on an electroencephalogram (EEG). As the patient awakens, there may be headache, nausea, temporary confusion, and muscle stiffness. Contrary to popular belief, it is the convulsion (seizure) activity, and not the electricity, that cures the depression. Inpatient treatment is often given three times weekly for six to twelve treatments, depending on how rapidly the depression improves. ECT can be either unilateral or bilateral, meaning it can involve one or both hemispheres of the brain. One-sided treatment and brief pulse, instead of continuous, electrical impulse have decreased side effects without interfering with the anti-depression effect.
ECT is given annually to over 100,000 patients in the United States alone. ECT is generally used in severely depressed patients for whom psychotherapy and medication have not worked. It is also indicated when there is an imminent risk of suicide or the patient is otherwise in danger due to other depressive symptoms, such as refusal to eat, because ECT often has much quicker results than antidepressant drug remedies. In patients for whom antidepressants have failed (approximately 20 percent of all who try them), ECT is successful in at least 60 percent of them. More generally, after two to four weeks of treatment, 80 percent of patients show marked improvement, with no evidence of brain damage. Although the mechanism by which ECT actually works remains a mystery, it clearly can be very effective.
Some of ECT’s negative image has to do with the early days of the treatment. The earliest use of electricity as a cure for mental illness dates back to early sixteenth century attempts to treat headaches using electric eels. ECT originates from research in the 1930s on people with schizophrenia. These earliest attempts induced the seizures with drugs, especially high doses of camphor. Attempts were also made that involved insulin. The ﬁrst electrical induction of a seizure in a schizophrenic patient was accomplished by two Italian researchers—Ugo Cerletti and Lucio Bini in 1938—via a technique which was therefore known for a while as the Cerletti and Bini method. After eleven treatments, they described the man as fully recovered, which led to a rapid spread of the use of electricity to induce convulsions in the mentally ill. This was not without its risks. Prior to the development of effective muscle relaxants, for example, it was not unusual for patients to suffer broken bones. The negative image of ECT was not helped by Ken Kesey’s very grim and widely read portrayal of ECT as a tool for controlling difﬁcult patients, in One Flew over the Cuckoo’s Nest—although this is no longer done, it is unfortunately true that in the 1940s and 1950s the treatment was in fact occasionally used in this way.
Today the American Psychiatric Association has strict guidelines that must be followed in the application of ECT. It is to be used only to treat severe, debilitating mental disorders and never to control behavior. Written informed consent is also required, or a legal guardian must consent in cases where the patient is unable to do so. The procedures, and the reasons for their being considered, are always explained in detail to the patient and/or the patient’s family, along with the potential side effects.
The best-documented side effect of ECT, and surely the most worrisome to potential patients, is memory loss. There are varying opinions as to how ECT affects the memory. In most cases, the only memory loss reported is for events that occurred in the hours or days surrounding the ECT. More rarely, the span involved is weeks or even months. This is an effect common to events that disrupt memory consolidation and is often reported by accident or crime victims as well. As in those cases, many of these memories may return, although not always. Some patients have also reported that their short-term memory continues for months to be affected by ECT, although they may be blaming the wrong thing, as this type of amnesia is not infrequently associated with severe depression, whether ECT has been used or not.
Testimony of patients who have beneﬁted from ECT differs rather dramatically from the media portrayals. In one survey, 54 percent of elderly patients reported that a visit to the dentist induced more anxiety than ECT treatment did. Perhaps the negative image will eventually be dispelled by the introduction of a kinder, gentler variation on ECT. A painless procedure performed while the patient is fully awake, repetitive transcranial magnetic stimulation (rTMS) also seems to improve depressed moods. It is performed by administering repeated pulses from a magnetic coil held close to the skull, above the right eyebrow. Unlike ECT, it produces no memory loss and does not require a seizure. As more research is performed on rTMS, it may supplant ECT, while bringing along none of the historical baggage.
- Bergsholm, P., Larsen, J. L., Rosendahl, K., and Holsten, F. “Electroconvulsive Therapy and Cerebral Computed Tomography.” Acta Psychiatrica Scandinavia, 80 (1989): 566–572;
- Coffey, C. E., ed. Clinical Science of Electroconvulsive Therapy. Washington, DC: American Psychiatric Press, 1993.