When severe depression doesn’t respond to antidepressants and psychotherapy, electroconvulsive therapy (ECT) may be the next step. ECT is typically prescribed for severe depression, particularly for treatment-resistant depression, a disorder that still persists after several adequate trials of medication. (Less often it’s used to treat mania.)
In ECT, two electrodes are placed on a patient’s scalp, which deliver an electrical current that induces a short seizure in the brain. Researchers aren’t sure exactly how it lifts depression, but possible explanations include release of critical neurotransmitters and alterations in brain metabolism and excitability, according to W. Vaughn McCall, MD, MS, professor and chair of the Department of Psychiatry and Behavioral Medicine at Wake Forest University Health Sciences and editor-in-chief of The Journal of ECT.
ECT usually works quickly in most people who try it, which is especially critical for people with acute suicidal thoughts and behaviors.
Numerous studies have demonstrated ECT’s effectiveness, yet it’s still viewed as a murky treatment, often misunderstood and mired in controversy. Mention the letters “ECT,” and you’ll likely get a variety of negative reactions.
But today’s ECT is radically different from the unregulated treatment of the 1940s and ‘50s. Below, Dr. McCall shares five of the most common myths about ECT.
1. ECT is excruciating.
According to Dr. McCall, ECT is commonly misconstrued as “a painful, bone-breaking experience, associated with violent body movements.” But patients don’t feel anything during the procedure. Before ECT is performed, patients are given a muscle relaxant to prevent significant movement. They also receive general anesthesia so they’re asleep for the entire ECT session. Immediately following ECT, patients may be confused and disoriented and have a headache for a short period of time.
2. ECT damages the brain.
Studies that have used magnetic resonance imaging (MRI) to look at the brain haven’t found any evidence that ECT changes brain anatomy, McCall said. (1-3) Animal studies have found that ECT may even promote growth of brain cells. (This 2007 study found that the animal model of ECT encouraged cell growth in an area of the brain responsible for processing emotions.)
3. ECT makes people feel worse.
The research on ECT is extensive and demonstrates that ECT is safe and effective for severe depression. For instance, a 2008 meta-analysis found ECT was superior to sham ECT, placebo and antidepressants.
In McCall’s own research, about 80 percent of people who have ECT report improvements at six-month follow-up. “On the average, the 20 percent who do not respond or stay well after ECT have a quality of life that is unchanged from their pre-ECT condition,” he said. (4-6)
4. ECT erases memory.
“ECT has always been associated with some degree of memory loss,” according to McCall. But “Progressive improvement in technology has led to a progressive decrease in memory loss as a [significant] problem.” Most patients experience short-term memory loss. Some patients experience memory loss of events that happened weeks or months before ECT.
But it’s rare for people to have decades of memories wiped out, he said. More common are difficulties with short-term memory, and the ability to concentrate and pay attention after ECT treatment.
Still, some patients report extensive memory loss. When McCall consults with patients, he explains that while research hasn’t substantiated dramatic memory loss, a small number of individuals do claim considerable loss. It’s unclear how this occurs. Improperly administered ECT may be one reason. “The likelihood of significant memory loss is highly dependent upon ECT technique,” McCall said. (7-8) So it’s important to see a physician who specializes in ECT.
5. ECT is curative.
On the one hand, ECT is viewed as ruining people’s lives, but on the other, it’s seen as a cure-all for depression. But while ECT is effective, its benefits are short-lived, McCall said. In fact, one of the greatest challenges is identifying how to prolong ECT’s gains, he said.
“It’s rare for someone to be well in fewer than four sessions.” Often one course of ECT is around six to eight sessions. Some patients may be given 12 to 15 sessions, but beyond 15 is unusual, he said. While patients undergo treatment, it’s critical for the administering physician to continually assess their progress, he said.
Multiple courses also might be necessary. These additional courses might increase the risk for memory loss and other side effects. McCall treated a 92-year-old woman with late-onset depression who received 91 sessions in the last 22 years of her life. Before she passed away, she donated her brain for research. McCall and his colleagues examined her brain and found no microscopic changes that would suggest damage from ECT. (9)
The need for more ECT courses speaks less about the treatment’s success, McCall said, and more about depression’s high relapse rate.
“Overall, we have to remember that whatever warts ECT has, it’s a treatment for a serious illness,” he said. ECT isn’t indicated for mild depression, as McCall stressed; instead it’s used to treat a severe depression that destroys lives. Opposition to ECT may, in part, stem from people’s misunderstanding of acute depression, McCall said.
Severe depression is disabling and potentially deadly, he said. People become so despondent they can’t get out of bed let alone go about their day. They can lose their appetite and drop weight dramatically. Marriages fall apart. Older people lose their independence and are unable to take care of themselves. Others contemplate or try to commit suicide. For these individuals, ECT provides the necessary relief. For these individuals, the benefits outweigh the risks, McCall said.
1. Coffey CE, Weiner RD, Djang WT, et al. Brain anatomic effects of electroconvulsive therapy. A prospective magnetic resonance imaging study. Arch Gen Psychiatry 1991;48: 1013-1021.
2. Devanand DP, Dwork AJ, Hutchinson ER, et al. Does ECT alter brain structure? Am J Psychiatry 1994;151: 957-970.
3. Wager T, Atlas L, Leotti L, et al. Predicting individual differences in placebo analgesia: contributions of brain activity during anticipation and pain experience. J Neurosci 2011;31: 439-452.
4. McCall WV, Rosenquist PB, Kimball J, et al. Health-related quality of life in a clinical trial of ECT followed by continuation pharmacotherapy: effects immediately after ECT and at 24 weeks. J ECT 2011;27: 97-102.
5. McCall WV, Reboussin BA, Cohen W, et al. Electroconvulsive therapy is associated with superior symptomatic and functional change in depressed patients after psychiatric hospitalization. J Affect Disord 2001;63: 17-25.
6. McCall WV, Prudic J, Olfson M, et al. Health-related quality of life following ECT in a large community sample. Journal of Affective Disorders 2006;90: 269-274.
7. Sackeim HA, Prudic J, Nobler MS, et al. Ultra-Brief Pulse ECT and the Affective and Cognitive Consequences of ECT. Journal of ECT 17:77, 2001.
8. Sackeim HA, Dillingham E, Prudic J, et al. Effect of concomitant pharmacotherapy on electroconvulsive therapy outcomes. Archives of General Psychiatry 2009;66: 729-737.
9. Scalia J, Lisanby Dwork A, Johnson J, et al. Neuropathological examination after 91 ECT treatments in a 92 year old woman with late-onset depression. Journal of ECT 2007;23: 96-98.