Electroconvulsive Therapy (ECT): Understanding Its Purpose, Procedure, Benefits and Potential Risks

Electroconvulsive therapy (ECT) is a medical procedure that utilizes electric current to treat several mental health conditions. The treatment entails the administration of an electric current to the brain. This process induces a transient increase in electrical activity within the cerebral cortex, which is clinically recognized as a seizure.  

What is ECT?

Electroconvulsive therapy, often referred to as ECT, is a psychiatric treatment that involves passing a controlled electric current through the brain to induce a brief seizure. This seizure is believed to alter brain chemistry, leading to improvements in mood and other mental health symptoms.

Purpose of ECT

ECT is most commonly used to treat severe mental health disorders that have not responded to other treatments, including medication and psychotherapy. ECT is usually used to treat the following conditions:

• Severe depression: ECT is very effective in some cases of major depressive disorder that have not responded to multiple antidepressant medications or those at high risk for suicide.
• Bipolar disorder: ECT is effective in treating severe manic or depressive episodes in people with bipolar disorder.
• Schizophrenia: ECT may be utilized to treat extreme symptoms of schizophrenia, for example, catatonia or serious distress.
• Catatonia: A condition characterized by unresponsiveness or lack of movement that may occur in multiple psychiatric disorders. ECT has a very high efficacy in treating catatonia.
• Parkinson’s disease: In certain instances, ECT may be beneficial for treating the psychiatric symptoms suffering from Parkinson’s disease.

ECT preparation  

Before ECT, the individual has to undergo a complete medical evaluation. Here are some of the measures followed:

• Medical history: The healthcare provider will assess for significant risk factors, such as cardiac ischemia, arrhythmia and heart failure.  
• Medication review: The doctor also monitors the ongoing medications and advises on dosage modifications if necessary. In addition, the doctor will also determine a detailed history of herbal medications, as they may interfere with ECT results.
• Blood glucose monitoring: A blood sample may be taken to check serum glucose levels both before the procedure and in the recovery or observation room, as ECT treatments can raise blood glucose levels.
• Pre-procedure fasting: The individuals are instructed to avoid eating, drinking and smoking 8 hours prior to the procedure day.
• Comfort and safety preparations: The ECT procedure is conducted in hospital settings. The individuals are provided with a hospital gown, and safety precautions are taken to prevent any complications after the procedure. The individuals are advised to remove jewellery, contact lenses and any other removable items.
• Consent and education: The patient and their attendee will be provided with a consent form to review and sign prior to the treatment.

ECT procedure

The ECT procedure is typically performed in a hospital setting in a dedicated unit on an outpatient basis. For patients with severe debilitation, whether due to significant medical or psychiatric illness, the procedure may begin as inpatient and later transition to outpatient care as the condition improves. Generally, the ECT procedure comprises the following steps:

• Preparation: Before the procedure, the patient is given general anesthesia to ensure they are asleep and do not feel any pain. A suitable muscle relaxant may be administered to prevent the body from convulsing during the seizure. ECT is performed by a team of health professionals, which comprises an anesthesiologist, a psychiatrist and a nurse.
• Electrode placement: Electrodes are attached to the scalp, either on one side of the brain, which is termed unilateral, or on both sides, which is called bilateral. A bite block is used to protect the patient’s tongue and teeth. The start and end of the cerebral seizures are monitored using an EEG, with electrodes that are strategically placed. To induce cerebral vasoconstriction via hypocarbia and increase seizure intensity, the patient is often hyperventilated using a bag valve mask before the electrical stimulus is delivered.
• Electric current: A controlled electric current is passed through the electrodes, which triggers a brief seizure in the brain. Seizures are induced using either two temporal electrodes or a single right unilateral electrode, which allows electrical current to pass through the scalp. The seizure usually lasts for about 30 to 60 seconds.
• Monitoring: During the procedure, the patient’s vital signs, including heart rate, blood oxygen saturation, blood pressure and muscle activity, are closely monitored. The patient is pre-oxygenated with a nasal cannula before anaesthetic induction to prevent hypoxia. An anticholinergic medication is injected to prevent arrhythmia. The onset and conclusion of seizures are monitored using EEG, which allows precise tracking of seizure activity.
• Recovery: After the procedure, the patient is transferred to the observation or recovery room, where they are monitored until they wake up from the anaesthesia.  

The healthcare provider ensures that every step of the ECT procedure is conducted in a safe and controlled environment by closely monitoring vital signs and seizure activity throughout the procedure.

Benefits of ECT

Studies indicate that individuals with severe depression and who are unresponsive to medication significantly improve their well-being for a longer period when treated with ECT. Listed below are the benefits of ECT:  

• Rapid symptom relief: One of the most effective benefits of ECT is its ability to provide rapid relief of symptoms, often within a few treatments. This is particularly important for individuals who are at high risk of suicide or who have not responded to other treatments.
• High efficacy: ECT has a high success rate, with many patients experiencing enhanced improvements in their mental health symptoms.
• Safety: When performed by trained professionals, ECT is generally considered safe. The use of anaesthesia and muscle relaxants minimises the risk of physical injury.
• Flexibility: ECT can be used in concomitant therapy with other treatments, such as medication and psychotherapy, to provide a broader approach to mental healthcare.

Potential risks and side effects

While ECT is generally safe, like any medical procedure, it does come with some potential risks and side effects:

• Memory loss: One of the most common side effects of ECT is temporary memory loss. Some patients may experience difficulty recalling events that occurred before or after the treatment. In most cases, this memory loss is short-term and improves over time.
• Confusion: Immediately after the procedure, patients may feel a headache, confusion or disorientation. This usually resolves within a few hours.
• Physical side effects: Some patients may experience physical side effects such as headaches, muscle aches and nausea. These symptoms are usually mild and can be managed with medication.
• Anesthesia risks: As with any procedure involving general anaesthesia, there is a small risk of complications, such as allergic reactions or breathing difficulties.
• Long-term effects: While rare, some patients may experience long-term memory loss or cognitive changes. However, these effects are not common and are typically more associated with older, less controlled forms of ECT.

How does ECT therapy work?

The impact of ECT accumulates progressively with every session. ECT triggers the release of specific neurotransmitters, which appear to encourage the development of certain brain regions that often diminish due to depression. Additionally, ECT seems to alter the interactions among brain areas associated with emotional processing.

Types of ECT

There are two main types of ECT:

• Bilateral ECT: In this type, electrodes are placed on both sides of the head. This method is designed to affect the entire brain and is often used for more severe cases of depression.
• Unilateral ECT: Here, one electrode is placed on the top of the head and the other on one temple, usually on the right. This method targets one side of the brain and tends to have fewer cognitive side effects compared to bilateral ECT

The doctors consider several factors when deciding which type of ECT to use. Some of the factors include:

• Severity of symptoms
• Medical history of patients
• Response to previous treatment
• Patient’s overall health

Who should consider ECT?

Individuals who have not responded to other therapies or who are in a life-threatening situation as a result of their mental illness are often advised to undergo ECT. A complete evaluation by a mental health specialist is required to evaluate whether ECT is the best treatment choice.

ECT recommendation during pregnancy

ECT is recommended during pregnancy when women face severe psychiatric distress that poses a significant danger to themselves, the foetus and others. ECT is considered a lifesaving procedure in urgent situations requiring suicide prevention. The following points highlight the consideration of ECT during pregnancy:

• Safety: ECT treatment remains generally safe for the developing foetus and does not typically cause risk during labour. However, potential complications such as bradyarrhythmias and transient pulse decreases due to hypoxia should be monitored.
• Premature labour: ECT treatment will not directly damage the uterus, but it may lead to premature labour through changes in hormones that happen after stimulation. The body experiences peak oxytocin production right after ECT delivery, which could trigger uterine contractions. To mitigate this risk factor, the doctor can administer medications intended to minimise the likelihood of uterine contractions.

Moreover, research has shown that when other treatments, such as medication or therapy, are ineffective or pose risks to the foetus, ECT can offer rapid relief from debilitating symptoms. The procedure has a well-documented safety profile for pregnant women, particularly in cases where the benefits outweigh potential risks. Furthermore, delaying treatment for severe psychiatric conditions can lead to worsening symptoms and increased danger not only to the mother but also to their child.  

In such scenarios, medical professionals must weigh the immediate need for intervention against any potential complications that may arise from pregnancy. This careful consideration underscores ECT’s role as a valuable option in safeguarding both maternal and foetal well-being. It is essential to approach this topic with sensitivity and awareness of individual circumstances.

Each case should be evaluated by a multidisciplinary team consisting of psychiatrists, obstetricians, and other relevant specialists who can collaboratively determine the best course of action tailored to each woman’s needs. By prioritising both mental health and foetal safety through informed decision-making processes involving ECT when necessary, we can ensure that mothers receive comprehensive care during one of life’s most critical periods.

ECT and its use in children

ECT is contraindicated for children under the age of 11. For those aged between 11 and 18, ECT is rarely necessary because the types of severe mental illnesses that respond well to ECT are rare in this age group. For those few young people with such conditions, ECT can be a helpful treatment option. Children and adolescents must be provided, prior to the ECT, with a ‘formal second opinion’ by an independent clinician to guarantee that ECT is appropriate in the case. This extra step is vital for protecting the young patient’s best interests and making sure that all other treatment alternatives have been fully explored. ECT is an option for young people with severe depression, bipolar disorder, psychosis or other serious psychiatric conditions that haven’t responded to medication or psychotherapy. ECT is used only in carefully reviewed circumstances, weighing the potential benefits and risks as well as the individual needs and particular situations of the patient.

Why is ECT often vilified?

ECT is usually criticised, though it is one of the most effective treatments in psychiatry. Research does not support this negative perception and constantly contests the concerns of critics.  

Combating the stigma: The stigma of mental illness can make psychiatric treatments, including ECT, seem like a threat to an individual’s autonomy. This sense of threat is particularly intense when the issue involves the mind, leading to a persistent stigma associated with mental health treatments. As more people seek mental healthcare, this stigma may gradually decrease.

Education and awareness: To combat the stigma associated with ECT, education is key. Psychiatrists need to inform patients with severe depression and their families about all available treatment options, including ECT. Educational videos have been suggested as a tool to change patient perceptions, though this approach has not been widely tested.

Addressing misconceptions: It’s important to address misconceptions about ECT. Despite its negative reputation, ECT is a safe and effective treatment for many severe psychiatric conditions. By providing accurate information and addressing fears, healthcare providers can help reduce the stigma and encourage more people to consider ECT as a viable treatment option.

It is important to understand the stigma and promote awareness against such misconceptions so that more patients can benefit from the treatment.

Conclusion

Among psychiatric therapies, ECT is considered one of the most effective treatments for serious mental health issues. While it has risks and adverse effects, the advantages can be transformative for many people. If you or a family member or a friend is thinking of getting ECT, you should have an open and honest talk with your healthcare physician to thoroughly understand the potential advantages and hazards. With proper information and support, ECT can be an effective aid in the route to mental health rehabilitation.