Electroconvulsive Therapy (ECT) Has Changed: What You Should Know

Electroconvulsive therapy (ECT), a psychiatric treatment that involves sending electrical currents through the brain, has had to overcome what Yale psychiatrist Robert Ostroff, MD, says are “criticisms based on non-medical opinions rather than scientific evidence.”

Used to treat severe depression, bipolar disorder, and catatonia (when someone is awake but unresponsive), ECT has often been negatively depicted in movies, books, and TV shows. That, says mental health experts, is unfortunate because it is a safe and highly effective treatment. Plus, the way ECT is administered today has changed drastically since it was first performed nearly 100 years ago.

“Modern ECT is much safer and more controlled, with rigorous guidelines and patient consent protocols in place,” says Dr. Ostroff, who is medical director of the Mood Disorders Unit and co-medical director of the Interventional Psychiatry Service at the Yale Psychiatric Hospital, which is part of Yale New Haven Hospital. “ECT is a treatment that is very burdened by bad publicity and public perception. Our best estimate is that half of the people who could benefit from having ECT are not getting it because of these factors.”

ECT is commonly associated with the 1975 film One Flew Over the Cuckoo’s Nest, starring Jack Nicholson. In the movie, Nicolson’s character is subjected to ECT as a punishment, and he also receives a lobotomy against his wishes. “A central theme of the movie was the abuse of power, which resonated with America ending the Vietnam War and has forever been associated with ECT as an abusive treatment,” Dr. Ostroff says.

ECT was developed in the late 1930s by an Italian neurologist named Ugo Cerletti, who saw that patients in sanitariums receiving “rest cures” for depression (then called melancholia) who also had epilepsy seemed to experience mood improvements following their seizures, Dr. Ostroff says. Dr. Cerletti thought that if he could use mild electrical currents to induce a brief seizure, which causes chemical and electrical changes in the brain, it might help quickly reverse symptoms of certain mental health conditions, like severe depression.

ECT came into use in the United States in the early 1940s, but Dr. Ostroff says it wasn’t until the 1960s that general anesthesia was given to patients before treatment.

Today, ECT is offered in the Interventional Psychiatry Service, which provides procedure-based treatments to patients who have not been helped by commonly used medications and other techniques. Ketamine (an intravenous medication), esketamine (a derivative of ketamine delivered by nasal spray), and transcranial magnetic stimulation (TMS, a technique in which electromagnetic pulses are delivered to the brain via a coil worn on the scalp) are also forms of interventional psychiatry.

Below, Dr. Ostroff answers common questions about ECT, including what it’s like to receive the treatment today.

Typically, ECT is for people ages 18 and older with severe depression who have tried multiple treatments, including antidepressant medications, but experienced no or insufficient improvement. We call this ‘treatment-resistant depression.’ It’s especially useful for those with severe depression accompanied by delusions, a lack of responsiveness to medications, or a need for rapid symptom relief. It's also the first-line treatment for catatonia.

ECT can be used to treat bipolar disorder, which is characterized by extreme mood shifts, particularly during manic or depressive episodes that do not respond to other treatments. It is sometimes also used to treat individuals with chronic delusions and/or hallucinations.

Before the procedure, patients are given a general anesthetic and a muscle relaxant to ensure comfort and prevent injury. Patients are then hooked up to an EEG, a test that measures electrical activity in the brain, and we monitor their cardiac and respiratory functions during the treatment.

We use a device that administers an electric current directly to the central nervous system through a pair of electrodes placed on the patient’s scalp. The electrodes induce a generalized seizure that lasts 60 seconds or less, and people tend to be asleep for five to 10 minutes—at the most—afterward.

Roughy 90% of treatments are done on an outpatient basis. We try to have people in and out in an hour. It’s so brief that many patients don’t even believe they’ve been treated.

The introduction of general anesthesia in the 1960s made it a better-tolerated and physically safer treatment. Over the next 30 years, a multitude of refinements improved safety and reduced side effects.

One major change has been the placement of the electrodes to induce seizures—originally, electrodes were placed on both sides of the head, which can be effective but has a higher risk of cognitive side effects. Now, electrodes are often placed in different positions, which reduces cognitive side effects while still being effective for many patients.

Also, advances in ECT machines allow for better control over electric currents, minimizing side effects. And there have been refinements to the parameters of the electric current used to induce seizures—using tailored treatment plans with lower electrical doses, as appropriate, for instance, may minimize cognitive effects.

We also can better identify those patients who might benefit the most from this therapy, thereby improving outcomes.

Finally, there has been enhanced training for practitioners and standardized guidelines to ensure a consistent and safe application.

At first, treatments are typically administered three days a week—on Monday, Wednesday, and Friday. On average, people need between six and 10 treatments before they start to feel better.

Then, if they've had a robust response to ECT, we will start to spread out the treatment. So, instead of doing it three days a week, we might go down to two and then to one, say, on Friday. Then, every other Friday, every third Friday, and every fourth Friday.

Typically, we get treatment down to a frequency of once a month and then treat people several more times. From there, we make a decision on whether or not to stop after six months.

The most common ECT side effects are related to receiving general anesthesia. Usually, it's tolerated fairly well, but some people get muscle soreness and aches after the first treatment or two. Some people get nauseated, though that’s much rarer because we don't use very high doses of anesthesia.

Short-term memory loss can occur with ECT in about 10% of patients. When someone has a seizure, they can have amnesia for up to an hour before and after treatment. They won't always remember the conversation they had with their significant other while driving to the hospital, for example, and they may not remember events immediately after ECT.

Long-term memory loss, where you forget what we call autobiographical memory, does happen, too—also in about 10% of patients—but it tends to be a narrow period of time and not involve large blocks of information. For example, you wouldn’t forget where you went to college or where you grew up, but you might forget that you went to a friend's graduation party two months ago. Sometimes, those memories come back; sometimes they don't.

However, it’s hard to know how much memory is affected by ECT compared to the depression itself, which also affects memory functioning. In fact, if you look at memory functioning two months before and after ECT, it tends to improve. And that's because the depression has improved.

In general, ECT is effective in about 60% of patients. Many patients experience significant improvement after a series of treatments. And it is generally most effective in people who have what's called psychotic depression, which means they have either hallucinations or delusions. It may seem counterintuitive, but we’ve found that the more severely ill the patient is, the more likely they will benefit from ECT.

By comparison, the response rate to the first treatment with an antidepressant is typically about 30%. The response rate to a second one is about 25%. And after that, the response rate to the third one is about 10%. So, overall, we know that roughly 30% to 35% of people don't respond to traditional medication treatment.

So, in that context, the response rate of 60% to ECT is significant.

We do a series of tests. We measure the level of depression by asking a variety of questions and rating the patient's response. We also ask the patient to complete a self-rating form that captures their perspective.

We did a head-to-head, multicenter study comparing intravenous ketamine infusions and ECT, but we excluded the older population and those with psychotic features because ketamine may induce psychotic symptoms. So, there was a concern that it could exacerbate those symptoms in patients.

The study showed that ketamine was not inferior. In other words, it was essentially as good as ECT in a population with depression, excluding older adults and those without psychosis.

TMS is a noninvasive procedure that uses electromagnetic pulses to stimulate nerve cells. It is an evolving treatment. It's effective for major depressive disorder, but the body of scientific literature needs to be expanded before it becomes a treatment of choice for treatment-resistant depression.

However, many people are using it for treatment-resistant depression because it may have an augmentation effect on existing medications. But there hasn't been the same level of studies done comparing ECT to TMS as there are comparing ECT to ketamine.

I think the holy grail now is to find a treatment that's as effective as ECT without having to induce a seizure.

There are a number of efforts now to find ways of optimizing TMS or other experimental electrical treatments that would be able to reduce the cognitive side effects of ECT—the confusion and memory problems—and essentially replace it as a treatment.

Yes, more than it was 30 or even 20 years ago. I think the stigma in general about treating severe depression has changed significantly in the last 20 years, and that includes ECT.