ECT is indicated for patients with symptoms of depression, mania, psychosis, or catatonia who have failed to benefit from previous medication trials. It may also be used for patients who require rapid improvement in symptoms because of the severity of their condition, such as acute suicidality.
What is a typical course of ECT?
ECT is performed at UNC Hospital and can be scheduled as an inpatient or outpatient. The initial treatment course, or index series, involves ECT scheduled two or three times weekly. This will continue for roughly 3-5 weeks or until the maximal therapeutic benefit is seen.
Following completion of the index series, the team may recommend continuing ECT treatments on a reduced frequency. The purpose of this is to help lower the risk that depression or other symptoms will recur. This continuation phase tends to start at once a week and progressively spaces to longer and longer intervals between treatments. How long this continuation phase would go on for depends on individual factors, such as symptom severity prior to treatment and history of previous relapses.
Due to the requirement for anesthesia, patients are restricted on eating and drinking prior to treatment. Patients are required to have transportation and refrain from driving until the next day after ECT.
Is ECT safe?
The risk of general anesthesia, which is needed for ECT, is similar to the risk of anesthesia with other minor procedures. Patients’ heart rate, blood pressure and respiratory status are monitored constantly throughout the treatment. Medical complications such as heart attack, stroke, or death from treatment are extremely rare.
In addition to the anesthetic, patients are given medication that relaxes the muscles to prevent movement and injury during the seizure.
What are the benefits and risks of ECT?
ECT is one of the most effective treatments for severe depression, with approximately 80% of patients seeing significant improvement in their symptoms. It may be effective in the treatment of depression, mania, catatonia or psychosis that has been refractory to past medications. While not all, many patients experience improvement within the first two weeks of treatment.
There are possible side effects, including muscle aches, headaches, and nausea or vomiting on the days of treatment. These may be treated with as-needed medication given during or after treatment.
Patients receiving ECT may experience temporary memory loss and difficulty with learning new information. There may be difficulty remembering events that occurred in the weeks or months prior to treatment. In most cases, memory problems improved after completion of the index series. However, some patients experience longer lasting problems, including permanent gaps in memory.
GLOSSARY
Refers to the placement of the stimulus electrodes on a patient’s scalp (which directs the current path). In traditional bilateral ECT, the electrodes are placed on the right and left temples, allowing simultaneous stimulation of both sides of the brain. This assures a good quality seizure in the parts of the brain that need to be affected, but also allows electricity to pass over the left-temporal lobe of the brain. This is where most people have their language and memory centers. The effect is to cause (theoretically) more memory problems. Unilateral electrode placement allows both electrodes to be kept on one-side of the brain (the non-dominant side), which avoids having electricity pass directly through the language and memory centers mentioned above. However it requires that the seizure (which will now start on one side of the brain only) to generalize or move across to the other side of the brain. This doesn’t always happen successfully, leading to less treatment effect. Most new ECT patients at UNC will be started on unilateral ECT and switched only if not responding adequately.
Refers to the placement of the stimulus electrodes on a patient’s scalp (which directs the current path). In traditional bilateral ECT, the electrodes are placed on the right and left temples, allowing simultaneous stimulation of both sides of the brain. This assures a good quality seizure in the parts of the brain that need to be affected, but also allows electricity to pass over the left-temporal lobe of the brain. This is where most people have their language and memory centers. The effect is to cause (theoretically) more memory problems. Unilateral electrode placement allows both electrodes to be kept on one-side of the brain (the non-dominant side), which avoids having electricity pass directly through the language and memory centers mentioned above. However it requires that the seizure (which will now start on one side of the brain only) to generalize or move across to the other side of the brain. This doesn’t always happen successfully, leading to less treatment effect. Most new ECT patients at UNC will be started on unilateral ECT and switched only if not responding adequately.
A treatment modality using small amounts of electricity to generate a grand-mal seizure in a patient, in an attempt to treat various psychiatric disorders, especially depression.
A common psychiatric illness characterized by depressed, irritable or apathetic mood or loss of pleasure (anhedonia) and four or more of the following: changes in sleep and/or appetite, loss of pleasure and/or interest in daily activities, impairment of concentration or memory, low energy, agitation or mental slowing, feelings of worthlessness or excessive guilt, hopelessness, helplessness and/or recurrent suicidal thoughts. Symptoms need to be present for at least 2 weeks and be severe enough to cause some functional impairment.
Depression is a medical illness known as a mood disorder, and it is treatable. Clinical depression should not be confused with temporary feelings of sadness (“feeling blue” or “down in the dumps”) that are part of life’s disappointments. Depression lasts longer; is far more severe; impairs work, relationships, physical and other activities; and it includes more than a sad mood. Symptoms include trouble with sleep, appetite, energy and self-esteem.
A period of persistently elevated, expansive or irritable mood that lasts for a week of longer and includes at least three of the following (four if irritable mood): inflated self-worth, decreased sleep, racing thoughts or flight of ideas, excessive of pressured speech, hyperactivity, excess pleasure seeking and/or distractibility.
The energy level at which electricity will induce a seizure. This varies for individuals and is usually higher in males and the elderly. Certain medications and medical conditions can alter a person’s seizure threshold. The UNC ECT service uses a ‘threshold titration model’ to determine the person’s actual seizure threshold so as to minimize the amount of electricity used for the treatments.
The joule (pronounced DJOOL) is the standard unit of energy in electronics and general scientific applications. One joule is defined as the amount of energy exerted when a force of one newton is applied over a displacement of one meter. One joule is the equivalent of one watt of power radiated or dissipated for one second.
The arrest of fibrillation of the cardiac muscle (atrial or ventricular) with restoration of the normal rhythm, if successful.
TMS is the use of powerful rapidly changing magnetic fields to induce electric potentials in the brain by electromagnetic induction without the need for surgery or external electrodes. TMS was originally developed as a tool in brain research, and has been used to stimulate or suppress brain activity in experiments on human subjects.
TMS is currently under study as a treatment for severe depression and auditory hallucinations. It is particularly interesting as it may provide a viable treatment to certain aspects of drug resistant mental illness, particularly as an alternative to electroconvulsive therapy.
Although research in this area is in its infancy, there is now strong evidence that TMS is an effective treatment for both depression and auditory hallucinations, with more symptoms and disorders being researched.
