Electroconvulsive Therapy and Depression

Many people are surprised to hear that electroconvulsive therapy (ECT), popularly known as “shock treatments,” is still being performed. They think of it as a relic from the 1950’s, and popular opinion of it was shaped by the movie “One Flew Over the Cuckoo’s Nest” with Jack Nicholson.

The reality is that ECT is still being done and is still one of the most effective, if not the most effective, treatments for severe depression. What’s it all about?

An ECT treatment begins with an anesthesiologist starting an IV- which is the only pain the vast majority of patients feel in the whole procedure. A short-acting anesthetic and then a muscle paralytic agent are infused and the patient falls asleep. The psychiatrist then applies an electrical stimulus through the scalp which induces a seizure, which is identical to the type of seizures a person with epilepsy has. The best seizure duration for depression treatment is 25 to 120 seconds, after which the patient goes to the recovery room and after a short while either goes back to their hospital room or is released to their outpatient caregiver.

A typical acute course of ECT is 6 to 10 treatments, usually given 3 times per week. Patients sometimes begin to respond after the first treatment, more commonly after several.

How does it work? The short answer is- we don’t know. Presumably it resets the neurotransmitters in the brain, the same way medications and talk therapy do, but more quickly and effectively.

What are the risks and side effects? You have the same risks you have with any general anesthesia, but generally it’s considered a low-risk procedure medically, and has been safely given to many geriatric patients. The most common side effect is short-term memory loss and confusion around the time of the treatments, which generally resolves within a few days after the treatments are stopped.

There are some people who say things like, “my memory’s never been the same since I had those shock treatments” which is a difficult thing to evaluate in a rigorous scientific way. Human memory is an imperfect instrument which many of us complain about.

How lasting are the effects? Studies and clinical experience have shown that about 30% of people who respond to ECT will relapse even with ongoing medication treatment within 6 months of completing an ECT course. We generally pursue outpatient maintenance ECT at that point, where people come in about once a month for a “booster” treatment.

How effective is it? It all depends on the group of patients you start out studying. Research and my clinical experience suggest that 80-90% of appropriately screened patients recommended for ECT will respond- which is quite good considering these are pretty ill folks to begin with.

How much does it cost? Like everything in health care these days, it’s quite expensive, costing several thousand dollars per treatment. The good news is that insurance coverage is quite good for it- insurance companies know that it works.

Where can you get it done? In the Indianapolis area St. Vincent and IU Methodist are the two hospitals that offer it. I am most familiar with St. Vincent as I formerly worked with Dr. Class there and know he is a good practitioner, and generally refer people there.

Can it be done as an outpatient? St. Vincent’s protocol is that the first treatment has to be done inpatient, which means you have to spend at least a few days in the hospital. IU Methodist will start as an outpatient. Outpatients cannot drive the day of the procedure and must have a caregiver available to stay with them the day of a treatment.

What needs to be done beforehand? Both St. Vincent and IU require a head CT, EKG, physical exam, and screening blood work before the treatments can begin. If you have any special medical problems, for example a history of heart disease, you will need clearance from your specialist before the treatments.

Is ECT right for you or your loved one? While I have not performed ECT myself since my residency training, I have referred dozens of patients for it over the years, and have a good sense of whom is likely to respond. The biggest prognostic factor in my experience is the acuity of the illness. Someone who’s been feeling and functioning pretty well who rapidly develops a severe illness over days to weeks to months is a good candidate. If you’ve felt chronically depressed for years but are still functioning (even if at less than your best) at home and at work, then you’re unlikely to be a good responder to ECT.