Electroconvulsive therapy

I was introduced to electroconvulsive therapy (ECT) on just the second day of my psychiatry rotation. ECT was first developed in 1938. Although no one really knows how it works, the idea is that by inducing a controlled tonic-clonic seizure with electrical current, we can "reset" the brain's pathological function, whether that's by interrupting connections between different brain regions or altering the balance of neurotransmitters. It's a lot of hand-waving.

Regardless, ECT works; in fact, it works much better than any pharmacotherapy, including selective serotonin reuptake inhibitors (SSRIs), with a 95% effectiveness. When used in depression, ECT has a recurrence rate of 50%, which is comparable to SSRIs. 100,000 people in the U.S. and 1,000,000 worldwide undergo ECT yearly, mostly for depression with psychotic features but also for schizophrenia; my attending thinks that ECT is underused.

With that background, I met my patient: an older veteran suffering from such severe recurrent depression with psychotic features that it led him to attempt suicide. He had already undergone four ECT sessions. On the morning of his fifth session, he was so nervous that he was visibly shaking. A friend held both of his hands and prayed briefly with him before we led the veteran through two locked doors and into the elevators down to the minor procedure suite. He walked bravely, as calmly as he could manage, because he knew that this treatment was necessary.

Image taken from the blog of actress Carrie Fischer, who has shared her experiences with ECT for bipolar disorder. (http://carriefisher.com)

Once he was lying on the procedure table, we placed blood pressure cuffs around both his ankles and inflated them so they would act as tourniquets to block the drugs from reaching his feet. The anesthesiologist sedated him, paralyzed him, placed a tongue guard in his mouth, and began breathing for him with a bag valve mask. Then, my attending poured gel onto two 1.5-inch diameter metal plates and secured those plates on the patient's temples with a rubber strap. The metal plates were connected to the machine that delivers a prescribed electric shock. A baseline electroencephalogram (EEG) was obtained, then the shock was delivered by simply pushing a button.

Suddenly, his toes curled and the arches of his feet flexed continually for the duration of the 8-second stimulus. I looked up at his face and was surprised to see a contorted grimace: clenched jaw and eyes shut tight. A few seconds after the stimulus ended, his feet began contracting and relaxing indicating that he was in the middle of the tonic-clonic seizure that is the goal of ECT. The foot twitching lasted about 20 seconds. The spike-wave squiggly lines coming out of the electroencephalography machine, indicating a seizure, flattened to baseline after 50 seconds indicating that the central seizure had stopped. Then the anesthesiologist woke him up. It was over.

From start to finish, the whole thing took less than a half-hour. This patient's ECT bore no resemblance to the dramatic convulsions and screaming that most people associate with ECT, thanks to Jack Nicholson's unnerving performance in One Flew Over the Cuckoo's Nest.



The addition of anesthesia to ECT protocol in the late 1960's (notably before this movie was released in 1975) has made ECT a much more humane experience. Paralytic drugs prevent the thrashing around, and some anesthetic agents can cause retrograde memory loss so the patient doesn't even remember the procedure. ECT itself can also cause retrograde memory loss as a side effect.

My patient remembered the anxiety leading up to his ECT treatment but not much else about it. We interviewed him briefly a few hours after his ECT session, and I was shocked (pun intended) by the transformation. He was freshly showered and was wearing a freshly ironed shirt that his friend brought from home; he was much more expressive and interactive, he wasn't hearing voices, he didn't have suicidal thoughts, and he said that he was actually feeling good. Despite the dramatic nature of ECT and its negative portrayal in the arts and media, it's hard to ignore such striking success.