Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is a procedure used to treat certain psychiatric conditions. It involves passing a carefully controlled electric current through the brain, which affects the brain’s activity and aims to relieve severe depressive and psychotic symptoms.

Modern day ECT is safe and effective. It can relieve symptoms of the most severe forms of depression more effectively than medication or therapy, but because it is an intrusive procedure and can cause some memory problems, ECT should be used only when absolutely necessary.

Feedback was collected from members of blueVoices – beyondblue’s national reference group – who have received ECT treatment, their families and carers to help develop the information below.

"I don't think I would be here today if it was not for the treatment that I received, including ECT."

Carleen, 54


"I had ECT and it definitely turned me around and out of a severe depressive condition.''

Andrew, 40

''I did actually feel better for a few months, but I felt respite had been gained at too great a cost."

Anne, 51

When is ECT used and why?

ECT is used for fast treatment of severe depressive, manic or psychotic symptoms (e.g. catatonia). It may be used when the situation is thought to be life-threatening or after all other treatment options have failed.

How is the decision to use ECT made?

Decisions to use ECT are always made very carefully. Together with the person wherever possible, a mental health specialist (e.g. psychiatrist) considers whether the procedure may be necessary to reduce life-threatening symptoms. Following a psychiatric and physical examination the person/family member/carer is provided information about the procedure and their legal rights.

The decision is made by weighing the risks for the person against the potential danger of leaving the condition untreated. It is important to remember the person can seek a second opinion from another doctor. 

Informed consent must be gained by the person, if able to do so. If the person is not able to consent (for example is unresponsive or is severely delusional), the psychiatrist will seek independent authority from the mental health authority in that state (often called the Guardianship Board) to proceed in the person’s best interests, in consultation with family or carers – and taking any advance directives (e.g. the person’s previously stated wishes) into account.

If the person has been able to provide informed consent, they can withdraw consent at any stage in the process. 

 

Who administers ECT?

ECT is administered by a medical practitioner (usually the treating psychiatrist) and an anaesthetist in a hospital environment. 


What happens during ECT?

Before the ECT procedure, the person is given a general anaesthetic and a muscle relaxant. Electrodes are placed on one (unilateral) or both (bilateral) sides of the scalp and a small electric current is passed between these until a brief generalised seizure occurs. The person does not feel anything due to the anaesthetic, and does not convulse due to the muscle relaxant. 

The person wakes up five to 10 minutes after treatment and is usually clear headed within 30 minutes. Often, people do not clearly recall the time around the ECT treatment and, at first, may have little memory about the period of illness around the treatment. Often, memory of these events gradually returns (see below for more information on side-effects).

If ECT is done on an outpatient basis, a family member or friend must drive the person home after the procedure (driving is not allowed in the 24 hours following an ECT session) and stay until he or she goes to sleep that night.

Typically, treatments are given two to three times a week for three to six weeks, although the exact course of treatment depends on the nature of the illness and the person’s response to treatment. The person should be re-assessed after every session of ECT.

Generally, symptoms start to improve after two sessions. The treatment should be stopped as soon as the person has responded adequately, if there are adverse effects, or if he/she withdraws consent. It is not understood exactly how ECT works to treat depression and the outcomes may vary from person to person.





What are the risks and side-effects of ECT?


Risks

The greatest risk with ECT is associated with the anaesthetic, which has a very small risk of death (often quoted as one in 100,000). Like any procedure involving an anaesthetic, ECT involves this small amount of risk, but overall, it is regarded as a very safe treatment. Despite the myths about ECT causing brain damage, MRI studies have shown that it does not change the brain anatomy in any way, as the strength of the electrical current is too low to harm brain tissue.

Side-effects

Immediate effects of ECT may include:

  • loss of memory about the events immediately before and after ECT
  • heart rhythm disturbances
  • low blood pressure
  • headaches
  • nausea
  • sore muscles, aching jaw
  • confusion.

Generally, these resolve within a few hours, although some memory loss may persist.

Some people who have undergone ECT recommend writing down passwords, PINs, phone numbers and special dates, and keeping them in a safe place in case they cannot be recalled in the period after the treatment.

A common and significant side-effect is difficulties with memory – this is reported by at least one in three people1 who have ECT. It can be hard to work out which memory changes are caused by ECT and which by the mental health condition itself – but ECT may lead to both loss of memories or difficulty in creating new memories.

Most research demonstrates that memory loss is very restricted and usually temporary. However, memory changes may last for some weeks after treatment and a few people experience long-term or even permanent loss of memories. People differ in the amount of memory loss they report from ECT and how they feel about it. The more treatments a person has, the greater the effect on their memory and, if the ECT is bilateral rather than unilateral, is likely to affect a person’s memory more as well. While some people find ECT to be a beneficial and lifesaving treatment, others find their memory loss distressing and for them, this outweighs any benefit from ECT.



What is the evidence for the use of ECT?

There is strong evidence that ECT is effective in treating severe depression in the short term. ECT can also be effective as a treatment for severe depression and/or mania in bipolar disorder.2 However, as with other therapies for depression, relapse is common. Repeated courses of ECT may be considered for individuals with severe depressive illness who have previously responded well to ECT.

ECT is not effective in all cases. Where this occurs, it is the treating health professional’s role to look at different treatment options and develop a new treatment plan.

Key points

  • ECT involves passing a carefully controlled electric current through the brain. ECT attracts very mixed responses – its supporters say that it is beneficial and lifesaving, while its critics say that it is invasive and unnecessary.
  • Modern ECT is a safe procedure, which is used to treat the most severe forms of depression (including psychotic depression) and severe manic symptoms, when the situation is thought to be life-threatening or after all other treatment options have failed. ECT can reduce severe depressive symptoms more effectively than other treatments.
  • ECT is not a 'cure', but can be useful in the short term because it works more quickly than antidepressants or other medications.
  • The main side-effect of ECT is memory loss, which usually resolves after a few weeks, but can last longer. People have varying degrees of memory problems after ECT, and different reactions to it. For some people, the benefits outweigh the side-effects, while others find the loss of memories very distressing.
  • Due to its side-effects, ECT can be used only with the full understanding and consent of the person involved, if he/she is able to consent. Where people are not able to provide consent, their family and carers help the psychiatrist to make a decision in their best interests and in these instances, approval from the mental health authority is usually required.

Sources and further information

1 Rose D, Fleischmann P, Wykes T et al (2003) ‘Patients’ perspectives on electroconvulsive therapy: systematic review.’ BMJ 326:1363 (21 June), doi: 10.1136/bmj.326.7403.1363.

2 UK ECT RG 2003 The UK ECT Review Group. 'Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis.' Lancet 2003; 361 (9360):799–808

Fink M, Taylor MA (2007) ‘Electroconvulsive therapy: evidence and challenges.’ JAMA Jul 18; 298(3):330-2.

Jorm, AF, Allen NB, Morgan AJ, Purcell R (2009) A Guide to What Works for Depression. beyondblue: Melbourne, August 2009.

National Institute for Clinical Excellence (2003) Guidance on the use of electroconvulsive therapy. Technology Appraisal 59 April 2003: 1-37.

Pagnin D, de Queiroz V, Pini S et al (2004) ‘Efficacy of ECT in depression: a meta-analytic review.’ J ECT 20(1):13-20.

Sane Australia fact sheet Electroconvulsive therapy http://www.sane.org/factsheets/electroconvulsive_therapy_(ect).html

beyondblue is grateful to our blueVoices participants for sharing their experiences.





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