Electro - Convulsive Therapy (ECT)

INTRODUCTION:-

Electroconvulsive Therapy (ECT) is a treatment method used for people who suffer from severe depression or bipolar disorders. In this therapy, a small electric current is passed through the patient’s brain, which is under general anesthesia, for inducing a brief seizure in the brain. Inducing such seizures causes a change in brain chemistry that reduces the symptoms of some mental illness, slowly bringing back the patient to his/her original condition. ECT is preferred only when all other treatments seem to be unsuccessful.

In earlier days, people had negative feedback about ECT as it used high electric current without anesthesia, leading to many serious side effects such as memory loss and bone fractures. But now ECT is considered much safer, with less side effects as it uses a small electric current, that too with general anesthesia. ECT therapy is generally carried out by a group of trained medical professionals including a psychiatrist, anesthesiologist, and physician assistants.

HISTORY OF ECT THERAPY

ECT therapy is one of the oldest treatment methodology used in the field of psychiatry. Roman psychiatrists, Ugo Cerletti and Lucio Bini developed the first ECT machine in 1938. Patient diagnosed with Schizophrenia was first treated with this machine and it was found successful. Ugo Cerletti and Lucio Bini were awarded Nobel Prize in medicine in 1930s.

The idea of inducing epileptic seizures for treating patients was proposed by Meduna, a Hungarian neuropathologist and psychiatrist. In 1940, ECT was used worldwide and was considered an effective technique for treating severe mental illness. In the 1960s, psychiatrist Thomas Szasz pioneered the ‘anti-psychiatry movement’ which criticized psychiatry and considered ECT as inhumane and torturous. Due to this reason, ECT took a back seat during 1960-1970 but returned to the mainstream mode of treatment in the 1980s.

PSYCHIATRIC DISORDERS TREATED WITH ECT

ECT can provide significant improvement in certain mental illness conditions. ECT is used to treat:-

• Major depression, including a desire to commit suicide.
• Severe mania, it is a bipolar disorder that includes intense euphoria, agitation, or hyperactivity. Impaired decision-making, impulsive or risky behavior, substance abuse, and psychosis are other signs of mania.
• Schizophrenia, it is a disorder that affects a person’s ability to think, feel and behave properly.
• Catatonia, it is associated with Schizophrenia and some other psychiatric disorders and is characterized by lack of movements, lack of speech, fast or strange movements, etc...
• Treatment-resistant depression, depression that doesn’t get improved with other treatments.

TYPES OF ECT THERAPY

There are two types of ECT:

• Bilateral ECT: In bilateral ECT, the current is passed through both sides of the head. The position of electrodes is that one electrode is placed on the left side of the head and the other on the right side.
• Unilateral ECT: In unilateral ECT, the current is passed only through one side of the head. One of the two electrodes is placed at the top of the head and the other at the right side.

WHEN IS ECT THERAPY USED?

Electroconvulsive Therapy (ECT) is a medical treatment used to cure severe symptoms of several mental health conditions like:-

• Severe Depression:    It is a mental health issue accompanied by detachment from reality (psychosis) sleep problems and frequent thoughts of death or suicide.

• Severe Mania: It is a mental health issue that triggers a person from reality and is a state of intense euphoria, agitation, or hyperactivity. This can also occur as a part of bipolar disorder. Some other signs of severe mania are impaired decision-making, impulsive or risky behavior, substance abuse, and psychosis.

• Catatonia: Symptoms are lack of movement, fast or strange movements, lack of speech.

• Treatment-resistant depression: These are depressions that cannot be improved with medications or other treatments. ECT therapy is a good treatment option when drugs or other therapies haven’t worked. 

• So ECT is used in cases of patients like pregnant women, in older adults.

• Agitation & aggregation in people with dementia.

HOW IS ECT PERFORMED?  

• ECT is performed under the prescription of an experienced psychiatrist.

• Prior to ECT treatment, a patient is put into sleep using general anesthesia and a muscle relaxant is given. 

• Since the muscles are relaxed, the seizure will usually be limited to slight movement of the head and feet.

• After taking all the prerequisites electrodes are placed on the patient’s scalp and a finely controlled electric current is applied, which causes a brief seizure (a sudden electrical disturbance in the brain) in the brain. 

• These changes the brain chemistry that can quickly reverse symptoms of certain mental health conditions. 

• During treatment, the patient is carefully monitored by the doctor. 

• A few minutes later the patient will get awakens and he/she will not remember the events surrounding the treatment and may also feel confused for a short period of time. 

• ECT is given up to three to two times a week for 2 to 4 weeks.

• A single course of ECT is followed by psychotherapy and medicine under a psychiatrist’s care.

PREPARATIONS FOR ECT 

A full evaluation is usually needed before the first ECT treatment. These evaluation results help the Psychiatrists to make sure that ECT is safe for the patient. Some of the evaluation methods include:- 

• Psychiatric assessment 
• Medical History
• Complete Physical exam 
• Basic Blood test
• Electrocardiogram (ECG) to check the heart health
• Discussion of the risks of anesthesia

Steps to be followed before the treatment are as follows:

• General anesthesia will be given to the patient so that some dietary restrictions need to be followed . This means no food or water after midnight and only a sip of water to take any morning medications.

• A brief physical examination of lungs and heart.

• An extra IV tube is inserted into the patient’s arm through which medications like anesthesia can be provided.

• Electrode pads will be placed on the patient’s head for the treatment. Based on which ECT can be of two types unilateral and bilateral. In unilateral electric currents focus only on one side of the brain while in bilateral both sides of the brain receive focused electric currents. 

PROCEDURE OF ECT THERAPY

• When the procedure begins, the doctor can monitor seizure activity. A blood pressure cuff placed on one ankle stops the muscle relaxant medication from entering the foot and affecting the muscle there. 

• Monitors check the patient’s brain, heart, oxygen use, and blood pressure.

• Oxygen will be given through an oxygen mask and a mouth guard is also provided to protect the patient’s teeth and tongue from injury.

• When you're asleep from the anesthetic and your muscles are relaxed, the doctor presses a button on the ECT machine. This causes a small amount of electric current to pass through the electrodes to your brain, producing a seizure that usually lasts less than 60 seconds.

• The patient will remain unaware of the seizure because of the effect of anesthetic and muscle relaxant. 

• The only indication of the seizure inpatient will be a rhythmic movement of the foot if there is a blood pressure cuff around the ankle.

• As a result of the seizure, the internal activity of the brain will get increased dramatically which will be recorded using  EEG.

• The effects of the short-acting anesthetic and muscle relaxant begin to decrease after a few minutes. 

• Then the patient will be taken to a recovery area, where he/she will be monitored for any potential problems. 

• When the patient wakes up they may experience a period of confusion lasting from a few minutes to a few hours or more

RESULT

The patient’s improvement in symptoms will be incredible after six treatments with ECT. So ECT is an amazing treatment method to treat severe depression and some other mental illnesses. Many chemical aspects of the brain are changed during seizure activity as a result the symptoms of severe depression and mental illness are reduced.

To prevent the recurrence of the mental illness, mild medications or psychological counseling should be given to the patient periodically.

EFFECTIVENESS AND SUCCESS RATE OF ECT

ECT therapy has a 70 to 90 percent success rate in normal cases and this percent of success reduces  50  to 60 percent for those taking medications. Some researchers believe that ECT is so effective because it helps to correct an imbalance in the brain’s chemical messenger system. Another theory is that the seizure somehow resets the brain. Whether inpatient or outpatient ECT is given two to three times a week for a total of six to twelve sessions and these sessions help in reducing depression to a greater extent than comparing with some antidepressant drugs.

BENEFITS  OF ECT OVER OTHER THERAPIES

ECT is somewhat more beneficial and lesser side effects in comparing with medications.ECT helps many people when drugs and psychotherapy are not effective. ECT has so many advantages that it quickly relieves psychiatric symptoms, depression, or mania. Medications actually need much time to come into effect. So ECT can be especially beneficial for those who are:

• suicidal
• psychotic
• catatonic

ECT can also be safely used on pregnant women and heart patients.

RISKS AND SIDE EFFECTS OF ECT THERAPY:

Although ECT is generally safe, risks and side effects may include:

MEMORY LOSS:

Some people have difficulty remembering events that occurred right before treatment or in the weeks or months before treatment. This condition is called retrograde amnesia. You may also have trouble recalling events that occurred during the weeks of your treatment. For most people, these memory problems usually improve within a couple of months after treatment ends.

CONFUSION:

Immediately after treatment, you may experience confusion, which can last from a few minutes to several hours.  confusion may last several days or longer. Confusion is  more seen in older adults.

PHYSICAL SIDE EFFECTS:

During the days of an ECT treatment, people may experience nausea, headache, jaw pain or muscle ache. These  can be treated with medications.

MEDICAL COMPLICATIONS:

As with any type of medical procedure, especially one that involves anesthesia, there are risks of medical complications. During ECT, heart rate and blood pressure increase, and in some cases, that can lead to serious heart problems. If you have heart problems, ECT may be more risky.The most common side effects of ECT on the day of treatment include nausea, headache, fatigue, confusion and grogginess, slight memory loss, which may last minutes to hours ,muscle aches and soreness. 

PROS AND CONS OF ECT

ECT is one of the best tool for treating depression. But it is not the only way to treat, and however ECT does  have so many disadvantages on individuals. 

Firstly, ECT requires sedation which causes recovery complex and time consuming. 

Second, ECT has serious side effects on some people includes memory loss and several other health issues.

PROS OF ECT:

• It is safer today than previous ECT treatments
• No medication side effects
• It work slightly quicker than TMS

CONS OF ECT:

• May not    be  able  to do works   up to    2 weeks after treatment
• Treatment sessions are done 2    to 3   times a week for up to 4 weeks
• Requires   sedation    through anesthesia and muscle relaxers
• Confusion  post-treatment
• Typically   not     well  tolerated in   the  elderly  population
• Memory  loss (retrograde amnesia) which  usually improves within    a  couple months of the  procedure
• Physical side effects related to tension (nausea, headache, jaw aches, and muscle aches
• Not tolerated well  in people with heart problems

PRECAUTIONS

• BEFORE YOUR PROCEDURE:

Electroconvulsive therapy is performed under general anesthesia, so that you should not eat, drink, or smoke ,do not drink alcohols and certain other illegal drugs on the days of your treatments. On the day of your procedure, do not wear jewelry or contact lenses. You’ll receive an intravenous line (IV), so dress comfortably and opt for a I-shirt or tank top.

AFTER YOUR PROCEDURE:

You must have an adult present to drive you home and remain with you for the next 6-8 hours.You are not to drive over the treatment course and for two weeks after treatments end.

Article Contributers:-

1. Niya Nelson - https://www.linkedin.com/in/niya-nelson-045174200 

2. Jithi K J - https://www.linkedin.com/in/jithi-k-j-baa398195

3. Devika S - https://www.linkedin.com/in/devika-s-876b2821a