Treating depression with electroconvulsive therapy.
Many myths
exist surrounding the use of electroconvulsive therapy (ECT), which is a
procedure that induces a seizure in the brain through an application of
an electric current through the scalp. Although ECT is not a first-line
treatment (and is typically only offered after several failed medication
trials/repeated hospitalizations), it is a very effective treatment. It
is very safe and is not painful. The patient is given anesthesia and a
muscle relaxant for the procedure. For some patients, ECT is safer than
medications, particularly for those with serious medical conditions for
whom medication can be contraindicated and for pregnant woman who may not
want to expose the fetus to a certain medication (e.g., lithium). ECT is
growing in use in older depressed patients because of higher rates of
concurrent medical illness and risks of toxicity from medication.
Psychotic depressions are often refractory to medication, and thus, ECT
may be considered early on in the treatment to avoid a prolonged course
of medication trials.
The risk of serious complication from ECT is 1 in 1,000. Cardiac
complications are the most common adverse effects, which is why a pre-ECT
evaluation includes evaluation of the cardiac system. Most potential
cardiovascular complications can be avoided with the use of appropriate
medications. Confusion and/or memory loss are also often common.
Confusion is usually transient. Memory deficits may be for events before
or after the procedure. Memory deficits usually resolve over weeks to
months after, although occasionally there are more persistent memory
difficulties.
Although ECT provides rapid improvement in symptoms of depression, there
is a high rate of relapse - up to 50% within 6 months - and thus, either
continuation/maintenance ECT or medication is recommended after the
treatment course. Continuation ECT is usually provided only if
continuation medication has not successfully prevented relapse or
recurrence of depression in the past.
ECT is usually done in a hospital setting as an inpatient (outpatient ECT
may be provided for maintenance ECT). Medications are typically tapered
and discontinued before the treatment, and this process may need to occur
in a hospital setting because of the risk for worsening depression and/or
suicidal. ECT providers have received specialized training and
certification. Although protocols may vary from state to state, usually
more than one physician needs to evaluate the patient and determine that
ECT is clinically appropriate.
Unfortunately, because of the media's negative portrayal of ECT over the
years, even with the safety features in place, this very effective
procedure is highly stigmatized and even illegal in some jurisdictions.
