ECT in A New Light
Electroconvulsive therapy (ECT) is a non-invasive method of inducing brief seizures using an electrical current to relieve symptoms of psychiatric conditions.[1] First administered in 1938 by Italian scientists Ugo Cerletti and Lucio Bini to alleviate symptoms of schizophrenia, ECT has now evolved into a strong treatment option for people suffering from major depressive disorder (MDD).[2,3] However, while ECT has been shown to have greater efficacy than pharmacotherapy in the treatment of MDD, the misconceptions and lack of knowledge about this treatment have led it to become underutilized,[4] with Kellner et al. (2020) noting that less than 1% of depressed individuals are treated with ECT.[5]
Applications for Depression
Major depressive disorder has been on the rise over the past decade and now affects over 300 million people worldwide.[6] Those suffering from MDD will experience symptoms such as depressive mood, poor energy, thoughts of guilt or worthlessness, change in weight or appetite, or thoughts about suicide or death for over two weeks. These depressive episodes are quite common - as the National Institute of Mental Health (NIMH) reported 21 million Americans suffered from an episode of MDD in 2020.[7] Additionally, 30% of those suffering from MDD, are categorized as having treatment-resistant depression (TRD) - meaning they have failed to respond to at least two adequate trials of antidepressant medication. This is especially problematic, as Salani et al. (2023) caution that 30% of individuals with TRD have been found to attempt suicide at least once in their life.[8]
In a meta-analysis conducted by Park et. al. (2021), ECT was reported to have a response rate of 50-60% of individuals with TRD while those using antidepressants had a response rate of only 17%.[9] ECT’s effectiveness is most effective in the short term, with a response rate estimated between 80-90%; however, the relapse rate does increase once ECT is suspended. Therefore, given the high response rate of this treatment, it is best used for populations at greatest risk (i.e., those with suicidal ideation, suicide attempts, postpartum depression, and psychotic depression.).[10]
A study conducted by Husain et al. (2004) utilized over 250 participants and found over 50% improved their depression score by their third treatment session and 75% achieved remission by their tenth treatment.[11] Additionally, a 2021 meta-analysis from Park et al. (2021) reported that when ECT was administered over the course of one year, the relapse rate reached 50% while the placebo group reached a relapse rate of 84%.[12] Subramanian et al. (2022) explain that the goal is to continue acute ECT treatment until the patient has reached remission or until an improvement plateau is achieved.[13] Therefore, continued maintenance ECT allows the patient to continue the positive benefits of treatment with little to no major side effects.
The most effective treatment for MDD and TRD is actually a combination of ECT and pharmacotherapy.[14] A meta-analysis conducted by Plugims et al. (2021) found that across nine randomized trials and studies, the overall effects of antidepressants paired with ECT were greater than those compared to ECT combined with a placebo.[15] Another study by Brådvik & Berglund (2006) found similar results when investigating ECT in comparison with pharmacotherapy in patients with unipolar or bipolar disorder. They noted suicide attempts reached as low as 2% after ECT plus pharmacotherapy, 8% from ECT alone, and 20% from pharmacotherapy alone.[16] These developments in ECT in combination with pharmacotherapy give individuals suffering from MDD and TRD a new path of treatment and can allow them relief quicker than traditional therapies.
Procedure
Before a patient can be approved for ECT, they must receive a pretreatment psychiatric assessment, a medical history and physical examination, an electrocardiogram, a general anesthetic evaluation, and a laboratory evaluation of metabolic panel and urine chemistries.[17] These procedures will assist medical professionals in determining if any special attention needs to be given or if certain medical conditions will contradict the ECT. In addition, written informed consent must be acquired from the patient or court-approved legal guardian before treatment.[18]
During the treatment:
Dosage (of charges) is determined based on the type of ECT treatment and seizure threshold of the individual.
Oxygen is administered and an anesthetic and muscle relaxant are given through an IV.
Electrodes are placed on specific locations on the head.
A mental healthcare provider ensures the administered muscle relaxant is effective and that all vitals are stable.
An electrical current is sent through the electrodes into the brain causing a grand-mal seizure lasting under a minute.
The patient is then taken off anesthesia and is monitored until they can breathe unassisted. Patients wake up within five to ten minutes after the procedure.[19,20]
Depending on the patient and the severity of their depression, treatment can range from multiple sessions a week to every few months. Typically, patients will need six to twelve treatments in conjunction with the use of antidepressants or mood-stabilizing medication.[21]
Possible side effects of ECT include:
Headaches
Muscle aches
Upset stomach
Disorientation or confusion immediately following the procedure
Impaired speech fluency
Anterograde amnesia for recent information
Retrograde amnesia for long-term autobiographical information
Most side effects will subside within minutes to hours, but others, like memory loss, can last days to weeks following the procedure. However, memory loss issues are more common with bilateral ECT; therefore, unilateral ECT has become the preferred treatment as it has been shown to have less effect on one’s memory.[22]
How it Works
To date, there is no definite theory as to why ECT produces such therapeutic effects on patients. The lack of consensus can be due to the complexity of the central nervous system and the challenges faced when identifying the neurological components that are involved with ECT.[23] Nevertheless, it is increasingly important to try to make sense of this therapy's effect on the brain to lessen any misconceptions regarding this form of treatment. In particular, expanding the knowledge on the neurological components of ECT will allow the public and medical professionals to form a better understanding of ECT and why it can be so useful and effective for those suffering from mental health issues.
While there are many hypotheses that have been made to try to explain the benefits of ECT, the most notable ones include: changes in cerebral blood flow and regional metabolism, alterations in neuroplasticity, changes in the expression of brain-derived neurotrophic factors (BDNF), and alterations in the process of neurotransmitters like serotonin, dopamine, acetylcholine, and norepinephrine.[24,25]
ECT for Special Patient Groups
ECT has also been proven to be effective for patients who may not be able to take traditional medications (e.g., pregnant women, the elderly, and adolescents).[26]
Depression is one of the most common mental disorders during pregnancy, with approximately 9% of pregnant women and 50% of postpartum women experiencing MDD and ECT has been reported as generally safe to use during the entirety of pregnancy.[27] In 37 cases of pregnant women with MDD or depression, 83% reached at least partial remission. Additionally, in a study by Rundgren et al. (2018) evaluating 185 subjects, the postpartum group responded to ECT 87% more than the matched non-postpartum depression comparison group. Thus, ECT can provide a safe and effective treatment for pregnant and postpartum mothers who may not have any alternatives to their MDD.[28]
Geriatric depression has also been shown to greatly benefit from ECT. A study by Dols et al. (2017) compared those with late onset (>55 yrs. old) late-life depression were more responsive to ECT at 86.9% than those with early onset (<55 yrs. old) late-life depression at 67.3%.[29] Elderly patients who received ECT typically reached remission in approximately 3.1 weeks.[30]
ECT has also been approved for people 13 years or older, thus giving a strong treatment option for adolescents facing high risk of suicide, those suffering from primary mood disorders, catatonia, schizophrenia, or those who are resistant to other treatment methods.[31,32]
Expanding Access to ECT
While ECT has been proven to be a strong treatment for MDD, many barriers still stand in the way of expanding treatment. A nationwide survey by Wilkinson et al. (2021) found 192 ECT providers noted significant barriers to providing ECT services to patients. These barriers included: a lack of training for medical staff, transportation issues, lack of space for providing such services, concern about side effects, and stigma about ECT. The survey also found there were only 2.97 providers per 1 million individuals in each state, and states such as Alaska and Idaho had no providers at all.[33]
Stigma is a major concern for expanding ECT treatment as many misconceptions have been drawn from TV and film which portray this therapy as inhumane and harmful to individuals.[34] This misinformation can stop individuals from seeking treatment and may even cause bias in healthcare professionals. Since ECT training is traditionally not included in nursing programs, Salani et al. (2023) discusses the potential for harm to occur if a nurse unknowingly impacts the patient’s understanding of the benefits and procedure based on personal bias and attitudes toward this type of treatment.[35] By expanding training programs for nurses and mental health care providers, it will allow them to address any misconceptions they, their patients or families may hold so they can be fully informed when choosing what treatment option is right for them.[36]
If you or someone you know is struggling with depression, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.
Contributed by: Ryann Thomson
Editor: Jennifer (Ghahari) Smith, Ph.D.
References
1 Brain stimulation therapies. (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies
2 Gazdag, G., & Ungvari, G. S. (2019). Electroconvulsive therapy: 80 years old and still going strong. World Journal of Psychiatry, 9(1), 1–6. https://doi.org/10.5498/wjp.v9.i1.1
3 Salani, D., Goldin, D., Valdes, B., & De Santis, J. P. (2023). Electroconvulsive Therapy for Treatment-Resistant Depression: Dispelling the stigma. Journal of Psychosocial Nursing and Mental Health Services, 61(6), 11–17. https://doi.org/10.3928/02793695-20230222-02
4 Park, M. J., Kim, H., Kim, Y. H., Yook, V., Chung, I. W., Lee, S. M., & Jeon, H. J. (2021). Recent Updates on Electro-Convulsive Therapy in Patients with Depression. Psychiatry Investigation, 18(1), 1–10. https://doi.org/10.30773/pi.2020.0350
5 Salani et al., (2023)
6 Subramanian, S., Lopez, R., Zorumski, C. F., & Cristancho, P. (2022). Electroconvulsive therapy in treatment resistant depression. Journal of the Neurological Sciences, 434, 120095. https://doi.org/10.1016/j.jns.2021.120095
7 Major Depression. (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/statistics/major-depression
8 Salani et al., (2023)
9 Park, M. J., Kim, H., Kim, Y. H., Yook, V., Chung, I. W., Lee, S. M., & Jeon, H. J. (2021). Recent Updates on Electro-Convulsive Therapy in Patients with Depression. Psychiatry Investigation, 18(1), 1–10. https://doi.org/10.30773/pi.2020.0350
10 Park et al., (2021)
11 Subramanian et al., (2022)
12 Park et al., (2021)
13 Subramanian et al., (2022)
14 Payne, N., & Prudic, J. (2009). Electroconvulsive Therapy: Part I. A Perspective on the Evolution and Current Practice of ECT. Journal of Psychiatric Practice, 15(5), 346–368. https://doi.org/10.1097/01.pra.0000361277.65468.ef
15 Subramanian et al., (2022)
16 Park et al., (2021)
17 Salani et al., (2023)
18 Ibid.
19 Brain Stimulation Therapies (n.d.)
20 Salani et al., (2023)
21 Brain Stimulation Therapies (n.d.)
22 Salani et al., (2023)
23 Payne & Prudic (2009)
24 Ibid.
25 Singh, A., & Kar, S. K. (2017). How electroconvulsive therapy works?: Understanding the neurobiological mechanisms. Clinical Psychopharmacology and Neuroscience : The Official Scientific Journal of the Korean College of Neuropsychopharmacology, 15(3), 210–221. https://doi.org/10.9758/cpn.2017.15.3.210
26 Salani et al., (2023)
27 Ibid.
28 Park et al., (2021)
29 Ibid.
30 Salani et al., (2023)
31 Brain Stimulation Therapies (n.d.)
32 Salani et al., (2023)
33 Ibid.
34 Payne & Prudic (2009)
35 Salani et al., (2023)
36 Ibid.