Electroconvulsive Therapy (ECT): definition, application and effectivity

Electroconvulsive therapy involves placing electrodes on a person’s head to induce seizures that will manage symptoms of mental health conditions such as depression. it’s among the oldest procedures in psychiatry. General anesthesia is used so that the patient doesn’t feel anything. Electroconvulsive therapy is both safe and effective.

Many people can benefit from this procedure. The most common uses of electroconvulsive therapy are for the management of depression, bipolar disorder, and schizophrenia. It is particularly useful for treatment-resistant cases.

What is Electroconvulsive Therapy?

Electroconvulsive therapy (ECT) is a therapy or more of a procedure that sends electrical currents through the brain to trigger a brief seizure in order to help manage a specific mental health problem.

Interestingly, electroconvulsive therapy is one of the oldest treatments in psychiatry. It was developed in 1938 by Ugo Cerletti, a professor of neuropsychiatry, and his assistant Lucio Bini at the Sapienza University of Rome.

Even before Cerletti and Bini, physicians experimented with inducing seizures to treat psychiatric conditions. These practices date back to the 16th century. In the 18th century, more precisely in 1785, the first therapeutic use of seizure induction was documented. Even Benjamin Franklin wrote about a woman whose hysterical fits were cured by an electrostatic machine.

Hungarian neuropsychiatrist Ladislas J. Meduna was the first to introduce convulsive therapy back in 1934 after he mistakenly believed that epilepsy and schizophrenia were antagonistic disorders. Meduna’s therapy relied on the use of camphor and later metrazol (cardiazol).

What made Cerletti and Bini different is that they used electricity as a substitute for metrazol, a stimulant drug. The idea to use electricity to produce seizures came to Cerletti when he saw how pigs were put in an anesthetized state with an electric shock before they were butchered.

It didn’t take long for ECT to replace the above-mentioned metrazol therapy across the globe because it was more affordable, less frightening, and more convenient.

Electroconvulsive therapy is not a common procedure because it’s usually not the first-line treatment for mental health problems. A therapist may recommend ECT when other approaches fail to deliver desired effects.

How does Electroconvulsive Therapy work?

Electroconvulsive therapy works by inducing a small generalized tonic-clonic seizure. During the procedure, a small electric pulse is delivered to the brain for a few seconds. As a result, the brain cells fire in unison. That’s how a seizure happens.

The exact mechanism through which ECT and seizure work is unknown. The therapy changes how the brain works. In a way, it’s similar to restarting a computer after a small glitch appears. The electric pulse is believed to trigger an instant increase in serotonin and dopamine levels. These neurotransmitters regulate mood, and their imbalance contributes to depression and other problems.

At the same time, electroconvulsive therapy propels a release of endorphins (mood-elevating chemicals) and some hormones.

A review article in the journal Clinical Psychopharmacology and Neuroscience mentions various studies that show ECT improving cerebral blood flow and glucose metabolism. Electroconvulsive therapy can trigger changes in the volume of the whole brain and its components, such as grey matter, white matter, and others. All these effects can explain why ECT helps reduce symptoms of mental health disorders. Depression and other conditions are linked to changes in the brain’s structure and function.

Where is Electroconvulsive Therapy used?

1. Depression

Depression is a mood disorder characterized by persistent and overwhelming feelings of hopelessness, sadness, and social isolation. People with depression experience other symptoms as well. Depression harms the overall quality of life. A person with depression loses interest in activities they used to enjoy.

The main treatment routes for depression management are antidepressants and therapy. In some cases, electroconvulsive therapy is recommended, particularly when depression is severe and accompanied by psychosis, refusal to eat, and suicidal ideation. People with treatment-resistant depression may also benefit from electroconvulsive therapy. Also, this therapy is particularly useful for patients aged 60 or older.

Electroconvulsive therapy helps treat depression by changing some connections in the brain. It can be compared to rebooting a computer. Also, researchers at Johns Hopkins Medicine found that new brain cells develop in the hippocampus after ECT.
A paper from the Frontiers in Psychology explains that electroconvulsive therapy is associated with neurogenesis and increased volume of specific regions of the brain. This led to improvements in behavior and neuroplasticity. Electroconvulsive therapy can work on its own or in combination with antidepressants.

The specific number of sessions in the treatment of depression varies from one patient to another. Six to 12 sessions may be necessary, but some patients need less or more than that. Patients usually receive therapy two to three times a week. More precisely, the number of sessions necessary for recovery is similar for all uses of ECT.

2. Bipolar Disorder

Bipolar disorder is a mental health condition that causes extreme changes in behavior from symptoms of depression to euphoria (mania). People experience intense emotional or mood-related highs and lows. When left untreated, bipolar disorder can cause complications such as poor work or school performance, damaged relationships, legal and financial problems, substance abuse, and suicidal thoughts and tendencies.

Patients with bipolar disorder usually receive a combination of medications and therapy to overcome the symptoms they experience. Electroconvulsive therapy is also a viable strategy for the treatment of bipolar disorder, especially its depressive episode. It can help with mania, too.

A paper from Current Neuropharmacology confirmed ECT was safe and effective for all phases of severe and drug-resistant bipolar disorder. The therapy can also reduce the admission rate and the length of hospitalization for this mental health condition.
The mechanisms of action of electroconvulsive therapy are still unknown, but a theory is that it helps manage bipolar disorder by changing the brain’s chemistry.

How long it takes to recover from symptoms of bipolar disorder with ECT varies from one patient to another. The severity of symptoms and whether a patient is using medications are important factors. Six to 12 treatments two to three times a week are usually necessary.

3. Schizophrenia

Schizophrenia is a serious mental illness that changes a person’s perception of reality. People with schizophrenia tend to experience symptoms such as hallucinations, delusions, paranoia, disorganized speech and thoughts, and others. This mental illness has a major impact on a patient’s daily functioning, and it can be disabling.

While schizophrenia strongly affects someone’s quality of life, the symptoms are manageable. Electroconvulsive therapy is an important treatment strategy for patients with schizophrenia, and the evidence confirms it.

For example, a review from the Acta Neuropsychiatrica confirmed that ECT is not only beneficial as an augmenting strategy for treatment-resistant schizophrenia, but it can be used to treat patients with schizophrenia in other situations too.

Doctors usually recommend ECT to patients with schizophrenia to augment their pharmacotherapy. Other common reasons are the urgency of therapeutic response and treatment resistance. Electroconvulsive therapy is particularly effective in the treatment of catatonic schizophrenia.

The therapy may change the function of certain areas of the brain that are associated with schizophrenia symptoms. By acting on these areas, ECT can help lower the frequency and intensity of the symptoms faster than medications do.

The doctor or therapist determines the ideal number of therapy sessions to treat schizophrenia. Patients usually need two to three sessions a week for four to six weeks to experience significant improvements in their recovery. Some people with schizophrenia may need a total of 20 sessions of ECT. A higher number of sessions is associated with better improvement of symptoms.

What are the benefits of Electroconvulsive Therapy?

The benefits of electroconvulsive therapy are numerous and confirm why it’s an important component for the improvement of mental health in people with specific illnesses. The advantages of electroconvulsive therapy outnumber and outweigh the risks. Common benefits of electroconvulsive therapy are listed below:

• Effectiveness: electroconvulsive therapy is among the most effective treatments for mood disorders and psychosis. It is particularly important for people whose mental health problem has become treatment-resistant.
• Works quickly: people who undergo this therapy usually experience improvements in symptoms of their mental illness after a few sessions only.
• Safety: electroconvulsive therapy carries a low risk of adverse reactions meaning it’s safe for most people. Even people with heart problems could be able to do ECT after certain adjustments to their medications or with close monitoring. The best testament to the safety problem of ECT is its safety during pregnancy.
• Helps people to whom other treatments aren’t available: sometimes, people have health conditions that don’t allow them to take medications to manage their mental health problems. But they can still do ECT.
• Can be used in combination: electroconvulsive therapy is effective in combination with other medications. This gives patients higher chances of improving successfully.

What are the risks of Electroconvulsive Therapy?

The risks of electroconvulsive therapy are fewer than all the benefits this treatment provides. The likelihood of side effects is low, but in some cases, they can happen. The risks of electroconvulsive therapy are listed below:

• Memory loss: some patients experience difficulty remembering events just before the procedure. Sometimes they can’t remember events that happened weeks or months before the treatment. In rare cases, patients forget events that occurred in previous years. Memory problems tend to improve within a couple of months after the completion of the treatment. Memory loss happens because the brain area that retrieves memories is strongly affected by electrical stimulation. To avoid that problem, practitioners make treatment patient-centric. In other words, they modify the type of anesthesia, placement of electrodes, and the time between two sessions.
• Confusion: right after the treatment patients tend to experience confusion. At that point, they don’t know where they are or why they’re in a hospital. Rare are the cases when confusion lasts longer than a few hours. Older adults are more likely to have confusion after ECT.
• Medical complications: every procedure carries a certain risk of medical complications, especially when it involves general anesthesia. Electroconvulsive therapy isn’t an exception. This therapy may lead to serious heart problems because heart rate and blood pressure increase during the session. For that reason, ECT could be risky for people who have heart disease.
• Physical adverse reactions: some people may experience side effects such as headache, nausea, muscle ache, temporary anxiety, shakiness, fatigue, and jaw pain. They tend to occur after the procedure and may last a few days, but it’s possible to manage them with medications.

What is the process of Electroconvulsive Therapy?

The process of electroconvulsive therapy lasts five to 10 minutes. The first part of the process accounts for preparation. This is when a patient is put under general anesthesia.

The patient may also need a brief physical exam whose main purpose is to check their lungs and heart. Before the procedure, the medical team inserts an intravenous (IV) line through which medications and fluids are given. Preparation involves placing electrodes on a patient’s head.

When a patient is asleep, and their muscles are relaxed, the doctor presses the button on the ECT machine to induce a brief seizure. A small amount of the electric current is passed through the electrodes to the brain. The seizure lasts less than 60 seconds.

After the short procedure, a patient is taken to the recovery area, where the medical staff monitors them for potential problems. After waking up, a patient may feel confused for a few minutes up to a few hours.

Electroconvulsive therapy isn’t painful, especially because it’s done under general anesthesia meaning the patient is asleep the whole time.

What does an Electroconvulsive Therapist do?

The electroconvulsive therapist performs a thorough psychiatric assessment to ensure a patient can truly benefit from this therapy. The ECT itself is performed by a medical team consisting of a psychiatrist, anesthesiologist and nurse or physician assistant.

In other therapies, it’s just a patient and a therapist. Since ECT is different, not talk therapy, a small medical team is necessary to implement it.

The main role of a psychiatrist is to direct the whole treatment. The psychiatrist determines how many treatment sessions are necessarily based on the patient’s symptoms and the severity of their condition.

The description of a psychiatrist’s role in ECT is also to recommend other treatment approaches they deem helpful for a patient. They may combine ECT with other types of therapies to prescribe some medications.

How is Electroconvulsive Therapy done?

Electroconvulsive therapy is done when a patient is hospitalized or in an outpatient setting. For example, if a patient is hospitalized for severe symptoms of schizophrenia or other mental illness, they may receive ECT to reduce their severity. The patient continues their hospital stay until they are discharged. When ECT is done in the outpatient setting, a patient leaves the hospital or clinic on the same day.

As mentioned above, for ECT, electrodes are placed on the patient’s head. The placement of electrodes depends on the specific needs of each patient. The healthcare provider also makes sure to choose a placement with the lowest risk of side effects. It can be done in three ways.

The first way to place electrodes is called right unilateral, meaning both of them are placed on the right side of the head. One electrode is placed between the temple and the end of the eyebrow, whereas the other is attached near the top of the patient’s head and above the right ear.

The second way is called bifrontal, meaning electrodes are placed on the opposite sides of the forehead above the end of the eyebrows.
The third way to place electrodes is called bitemporal. That means electrodes are aligned within the temple region on both sides of the head.
To prevent irritations and skin burns, the doctor coats electrodes with conductive gel.

How many sessions are required for Electroconvulsive Therapy?

Multiple sessions are required for electroconvulsive therapy. The specific number of sessions may vary from one patient to another depending on the severity of their condition, but it can range from four to 20. Most people need between six and 12 sessions. The ECT sessions usually take place three times a week.

In a retrospective study published in the Neuropsychiatric Disease and Treatment, elderly patients needed more ECT sessions than others.

Is Electroconvulsive Therapy Effective?

Electroconvulsive therapy is highly effective for the treatment of mental health illnesses such as major depression. The Journal of ECT published a study that found this therapy is still highly effective in severely treatment-resistant depression. More than half of patients with depression resistant to treatment achieved remission with ECT.

Additionally, a review of evidence on this subject, published in Experimental and Therapeutic Medicine, confirmed that ECT is effective and safe for patients with depression. The therapy is particularly effective when combined with other treatment approaches.

Electroconvulsive therapy is effective for the management of bipolar disorder and schizophrenia as well. For many people, ECT is a good way to reduce the intensity of their symptoms because they don’t respond to other treatment options.