Electroconvulsive Shock Therapy (ECT): What do you think?

I don't think we know what exactly ECT does other than induce a seizure that somehow does something somewhere. Sure, there are multiple theories. The way it was taught to us was basically: Step 1: ECT. Step 2: ? Step 3: prof..I mean, results.

What I was trying to point out, and I don't think it came across, was that people immediately think of ECT as cruel, stressful, horrific, painful, done without consent, by not adequately trained personnel, etc. Yet when we shock hearts, noone seems to even pause to worry about those things. And I was wondering whether it was just because we understand how defib works, or whether it's because it's proven to work, or something else?

 

Well, ECT is performed under general anesthesia with muscle relaxants to prevent seizures. It is also a long way down the line of optional therapies. Defibrillation, by contrast, is the only way to save someone's live in certain circumstances. CPR is only a stop-gap measure to keep someone's brain perfused with oxygen until a defibrillator comes along. If a pill were available to instantly convert someone to normal sinus rhythm, we'd probably start thinking twice about defibrillation.

 

People's opinion on it seems to be completely controlled by seems. It seems barbaric so we start rationalizing reasons it must be so. Like others have mentions, how this shit works is as big a mystery as pretty much every psychiatric drug, but taking a pill makes it seem like we are in the hands of experts whereas ECT seems archaic. I see psychiatric drugs as one in the same as ECT. Weigh the costs against the benefit...not how it seems.

 

Didn't work on Cyril ...

 

I did not mean to make this a defib vs ECT discussion...

Correct about anesthesia, only partially about the seizures - you can still see them seizing even with muscle relaxants. Just a little arm/leg tremble, and they get teeth guards. But during the procedure, we recorded both the duration of seizure we can see, as well as duration of seizure per EEG.

You can switch people to normal sinus with drugs (pharmacological cardioversion, with adenosine), not just electricity. But this is a totally different topic, and I was just trying to understand what exactly are people afraid of, because my impression was that they go like: ELECTRICITY?! TO MY BODY?! no way!!

 

Yeah, and anti-arrhythmic agents are dangerous, cause further arrhythmias in and of themselves, and increase overall mortality. They're rarely used anymore. Medical progress is a wonderful thing: 50 years ago, people probably weren't so squeamish about lobotomies and ECT. In another fifty years, we're probably going to sit around and talk about how crazy and crude the current lineup of chemotherapy drugs are. Defibrillation, aside from actually being necessary, is seen as necessary. It's dramatic, it's sexy, it features heavily on TV shows about romanticized professions. On those TV shows, the heart is displayed as a series of beeps and fancy ECG squiggles, and handsome / sexy doctors yell "CLEAR!" to fix those beeps and squiggles. Maybe this means everyone has become accustomed to knowing that a heart is an electrical and mechanical system of sorts. Perhaps also there's a sort of latent dualism - you can shock someone's heart without it necessarily affecting an intrinsic part of themselves. But shock someone's brain and that's coming awfully close to shocking someone's soul.

 

I'm Pro-ECT. Chronic depression creates a lasting chemical change in the brain that can alter the neural pathways, and research has show that a single episode of depression is a significant predictor of heart disease. Mental illness manifests itself in a very tangible and concrete way.

If ECT provides some relief for the patient (which it has been shown to do), why not? Granted, I also believe that Vioxx should still be available for purchase, despite the increased chance for heart disease. If the patient is capable of making that decision, let the patient make the decision after weighing the benefits and risks after consulting with qualified staff members. I don't view ECT as any different from psychotropic medicine that's prescribed. These outside agents are meant to stabilize and bolster the patient, in hopes that they will respond positively to therapy and enact positive progress towards improving their mental well-being.

 

Yeah but we use defib when your heart stops. If my brain ever comes to a screeching halt, you have my permission to drop as many volts across my ears as you like.

 

This. As I understand it, if there is no rhythm whatsoever, CPR would be the first response. Defib only works if there's some sort of existing rhythm to smack back into line.

 

Being in the medical profession and having recently received my temporary licence, I figure I`d chime in with my semi-professional opinion. The basis for this is 5 years of schooling and several months clinical rotation in different departments, including psychiatry. But first:

- A defibrillator will only work if there is some electrical activity in the heart. Being myself unsure of the scope of the term cardiac arrest, it could mean that the electrical activity is heavily disorganized, to such a degree that the heart doesn´t have any output volume. This means that your circulation has ceased, and this is when you shock it back in to action. A heart without any electrical activity will be in what is know as asystole, and not respond to any jolts of electricity, and here chemical means of resuscitation will be necessary to establish it (specifically, adrenaline and atropine). Then you can attempt to defib. Mind you, management of cardiac arrest in a hospital setting is a nuanced affair, and due to the uncertainty in interpreting an ECG it is a combination of drugs, CPR, defibrillator, intubation etc. With that out of the way...

- ECT is a challenging and to a certain degree a controversial subject, but with empirical, sober use, it can be a valuable tool in the treatment of severe psychotic depression and imminent suicide and/or death by lack of nutrition. As such, the criteria for its use are strict. They include the requirement that other treatments have been ineffective (drugs, psychotherapy) and that the patient`s death can be prevented. If it is not a life-or-death situation, it requires explicit written consent and that thorough information be given to the patient.

- The patients I have talked to have informed be that it has been an effective treatment for their disease, and have had positive experiences.

- The doctors` experience has been that in several cases when nothing seems to help and multi-drug therapy has proved ineffective, many have been pulled out of their depression and had their mood stabilized with ECT.

- The treatment is usually given over several weeks with 2 or 3 treatments per week.

- The procedure can be a bit horrifying to watch. The patient is sedated and given a mouthguard. The electrode is placed on different parts of the skull until a suitable electrical resistance is found. The shock is then applied, giving the patient a moderate epileptic seizure for a few moments. Present is the specialist in psychiatry, an anesthesiologist and a nurse.

- Side-effects include short-term memory loss where trivial details over the past few weeks are lost. Essential information is usually retained; however, this is not always the case and the memory loss may be more severe. This is obviously one of the major drawbacks of ECT.

- ECT of yore is vastly different from the empirically safe practices we have today. It was given on specious grounds without any fine tuning of the voltage, in a crude and, if I didn`t know any better, sadistic manner. Make no mistake, psychiatry has in many respects a dark history and sadly uncritical and unethically experimental use of ECT is a part of it.

- The science behind its efficacy is something I know little about, but it probably has its basis in some sort of resetting of the the disturbed electrical activity in certain pathways of the brain caused by errant neurotransmitter activity.


NOTE: I live in a Scandinavian country so medical practices and attitudes here may have limited laterality in regards to other nations.

 

Interestingly, the lecture in my Med Aspects class last night was on chronic pain management, and apparently, ECT is used in some cases, especially those involving phantom pain post-amputation.

 

I think I mentioned it earlier - I'm just a medical student, but I spent 6 weeks during my psychiatry rotation at a VA that routinely performed ECTs, and have assisted during the procedures. I have seen patients so nonfunctional that it was their spouses/parents that had to make the decisions about pursuing ECT. I can't divulge patient info, you'll just have to trust me - the cases were bad, ranging from major depression to catatonic schizophrenia.

As for the procedure itself, unlike nogro, I did not find it scary to watch. That said, it might just be my training - after 2 months of trauma surgery, almost nothing scares or grosses you out anymore.

Nogro basically told you how it looks like. I thought it was quite anticlimactic, actually. All you need is a couple monitors (EEG, heart and breathing), anesthesia and a psychiatrist. Patient gets general anesthesia and muscle relaxants, and then 2 electrodes are placed on their scalp, and a seizure is induced. The intensity and duration of the electrical impulse are controlled and calibrated based on each individual. You're aiming at around a 30 second EEG seizure. As I've mentioned, all you see is some mild arm/leg shaking, usually for only around 15 seconds.

Some patients remembered me chatting with them right before the procedure, others did not remember things happening right before and right after the procedure, but otherwise their memory was fine.

Antidepressant effect of ECT is usually evident after 1 to 3 treatments, but relapse often occurs rapidly unless several additional treatments are administered. As nogro said, the frequency is 2-3 treatments/week. Some patients require maintenance ECT, which is less frequent, and does exactly what the name says - maintains the beneficial ECT effect.

And based on what I've seen, ECT is awesome. It saved a couple lives just in the short 6 weeks that I spent at that one hospital.

 

The last time I read up on ECT was about ten years ago so this might well be out of date info. Anyway, at the time drugs had a roughly 70% success rate in treating depression (and possibly anxiety) and therapy also had a 70% success rate while ECT had about an 80% success rate. It was generally a last resort treatment because of the lack of understanding of how it actually works and the possibility of some memory loss, mostly short term, but it bore almost no relation to the pop culture depiction of ECT as some sort of punitive torture. The amount of electricity, for example, is considerably less than they used to use in the 60s.

I don't think I'd like to have it done, but I suspect a lot of that worry is based on all too many instances of seeing people in movies get "eectro-shock" as a punishment doled out by an evil doctor/nurse/warden.

 

This is a pretty dumb topic. If ECT didn't work, it wouldn't continue to be used. Sure, it doesn't work for some patients, but that's the same for any other treatment. If chemotherapy only worked for the same number that ECT works for, would we consider it cruel and unusual to administer? Chemotherapy saps the energy and health out of people, and leaves them nauseous, vulnerable to sickness, ect. When it comes down to it, the chance for living a functional life is always worth the risk. The other option is normally death, or becoming a permanently invalid person.

 

It's not a dumb topic, simply because it has polarized a lot of the psychiatric community, and because there's a huge amount of stimga, ignorance and general confusion about what it does/doesn't do, or even how it works. Just look at the thread. Many people are forced to base their opinions on what they see in film, books and TV.

 

My opinion is biased by Andrew Solomon's incredible book The Noonday Demon, which takes a pretty rosy view of ECT and interviews people who were seemingly helped by it when everything else failed.

I personally wouldn't go there until all other options, including the horrifying MAOI antidepressants, had been exhausted. But if it works in extreme cases, I think it belongs in the mix. Plus, it's probably less physiologically dangerous than some of the liquor-and-pill combos I've tried, which did zip to improve my mood in the long run.