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depression

Electroconvulsive Therapy (ECT): How it Works and What to Expect

Conditions such as treatment-resistant depression, bipolar disorder, schizophrenia, and dementia may benefit from electroconvulsive therapy (ECT). By learning about its effectiveness, risks, and how it works, you can decide if it’s right for you.

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What is electroconvulsive therapy (ECT)?

Electroconvulsive therapy (ECT) is a psychiatric treatment that uses electrodes to deliver a mild electrical pulse to the brain, inducing a quick seizure. Decades of evidence reveal ECT to be highly effective in treating conditions such as depression.

Researchers aren't entirely sure why ECT works. What is known is that the electrical pulse creates a sudden burst of brain cell activity. Some studies show that ECT increases blood flow in different regions of the brain. It might also stimulate the growth of neurons or improve connectivity between neurons. These factors might be the cause of ECT’s therapeutic effect.

Despite its effectiveness, there's plenty of fear and stigma associated with this treatment. Part of that fear is rooted in the actual history of the practice. In the earliest versions of the treatment—now known as “unmodified ECT”—patients would experience severe seizures, sometimes resulting in hairline fractures in the shoulders, hips, or spine. The procedure was also often used on patients without consent and even as part of a Nazi euthanasia program in World War II.

Media portrayal of ECT has also contributed to its stigma. In the 1975 movie, One Flew Over the Cuckoo’s Nest, the procedure was depicted as barbaric and torturous. Terrifying scenes like that have stuck in the public’s imagination, often overshadowing the reality and effectiveness of the treatment. The stigma may also discourage people who could benefit from ECT from undergoing the procedure.

Today, electroconvulsive therapy is only used on consenting patients and the addition of modern anesthesia and muscle relaxants prevents physical thrashing or pain. This is known as “modified ECT.”

If your doctor has suggested ECT as a possible treatment option, it’s understandable if you feel hesitant to agree to the procedure. By learning more about how ECT is used and what the treatment involves, however, you can better decide if it’s right for you.

What is ECT used for?

In many countries, ECT is used to treat a limited number of conditions, including:

Some evidence suggests it might also be useful for agitation in dementia patients.

When a condition is severe and resistant to medication and therapy, a specialist might propose ECT. It might also be recommended for older individuals who could experience life-threatening side effects from medications such as antipsychotics.

The American Psychiatric Association and the American College of Obstetricians and Gynecologists also considers ECT a safe and effective treatment for pregnant women who can't take certain medications due to the potential impact on the baby.

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ECT limitations

ECT is often thought of as a last resort treatment because it has some drawbacks. It can result in memory loss which can last for weeks, months, or even be permanent. On the other hand, the main benefit of the procedure—its therapeutic effect—may last for less than a year. Without follow-up treatment, nearly half of all people who undergo ECT for depression experience a relapse within six months.

The availability of ECT and regulations on its usage can also vary depending on where you live. In the United States, for example, certain states place more restrictions on its use than others.

The most common uses for ECT, though, include the treatment for the following conditions:

ECT for depression

Depression comes in different levels of severity. Symptoms of mild and moderate depression—the most common types—can leave you feeling feel hopeless, helpless, fatigued, and even interfere with your daily functioning.

Major depression is rarer, but comes with intense, relentless feelings of despair. The despair can make it difficult to focus or even lead you to consider suicide. You and your loved ones will likely notice a major decline in your ability to socialize, work, or even enjoy your favorite hobbies.

If major depression doesn’t lift after multiple attempts at psychotherapy, medication, and self-help, it may be considered treatment-resistant depression. You may fear that you’ll never be free of the disorder or feel like yourself again. At this point, your doctor may direct you towards ECT.

Research points to ECT being a more effective treatment option for major depression than antidepressants or psychotherapy. Some studies indicate a 70 to 90 percent response rate in patients. ECT also seems to reduce the long-term risk of suicide.

ECT vs. TMS for depression

Transcranial magnetic stimulation (TMS) is a procedure that sends magnetic energy pulses to specific regions of the brain. The treatment is painless for the patient, but evidence shows the magnetic pulses can alleviate symptoms of depression—as well as obsessive-compulsive disorder (OCD). It's also used to help smokers break their addiction.

As is the case with ECT, researchers don't completely understand how TMS is able to improve mental health conditions.

When compared to TMS outcomes, ECT appears to be equally or more effective in treating depression in the short term. But, in one study, ECT patients were more likely to report short- and intermediate-term side effects, including memory impairment, following their procedure. TMS patients reported minor side effects like short-term headaches. Overall, patients preferred TMS.

TMS has a few other advantages as well. It tends to be cheaper than ECT and doesn't require the use of anesthesia. Still, a doctor might recommend ECT over TMS if you have a pacemaker or any other device that can be affected by the magnetic pulses.

To learn more, read: Transcranial Magnetic Stimulation (TMS) Therapy.

ECT treats depression on a biological basis, causing changes to your brain’s chemistry. However, psychological and social factors can also contribute to depression. So, whether or not you undergo ECT, you can take self-help steps and make lifestyle changes to improve your mood.

[Read: Coping with Depression]

Rely on social support. Don’t allow negative self-talk to discourage you from reaching out and connecting with others. Face-to-face interactions can improve your mood and outlook. Just being around family and friends can calm your nervous system and make you feel supported.

Stay active. Exercise increases “feel-good” hormones, such as serotonin and dopamine, in the brain. From daily walks to swimming or weightlifting, find a routine that works best for you.

Practice challenging negative thinking. Thought patterns such as all-or-nothing thinking and overgeneralizations are cognitive distortions that affect your outlook. Learn to identify those types of thoughts and challenge their truthfulness. If you believe your friends secretly dislike you, ask yourself if there's evidence to back that up or if you're overlooking evidence to the contrary.

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ECT for bipolar disorder

Mania is one phase of bipolar disorder. You might experience sudden rises in mood, accompanied by impulsivity, high energy, or even delusions. These episodes often lead to problems like poor decision-making. During a manic episode, you may quit your job, spend your life savings, or lash out at friends. You may also struggle with racing thoughts and a lack of focus. Bipolar disorder mania can then spiral down into depression, giving you a sense of emotional whiplash.

If your bipolar disorder symptoms appear resistant to multiple types of medication, or if you experience severe symptoms such as suicidal ideation, ECT could be the solution. One study found that about 68 percent of patients with bipolar disorder responded to ECT, with the procedure being slightly more effective in reducing manic episodes than depressive episodes.

Research also suggests that ECT is equally or more effective than medication in treating bipolar disorder.

Treatments that involve medication can result in mood instability. It’s possible for medication to induce a manic phase while treating depressive symptoms and vice versa. ECT, on the other hand, seems to have a mood-stabilizing effect. It can be useful in treating manic, mixed, and depressed phases of bipolar disorder.

[Read: Bipolar Disorder Treatment]

As with depression, you can also combine ECT treatment with self-help measures to further ease bipolar disorder symptoms.

ECT for catatonia

Once believed to be a type of schizophrenia, catatonia is a condition that’s marked by immobility or unresponsiveness. Although it can occur with schizophrenia, it's now understood to accompany other conditions as well, including bipolar disorder, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).

If someone has catatonia, they have a rigid, unmoving posture and lack of reaction to their environment. They may be unable to speak, eat, or talk. Sometimes people experiencing catatonia mimic the words or movements of others or they may engage in seemingly pointless movements. When left untreated, catatonia can lead to serious issues such as dehydration and malnutrition.

Seeing a loved one with catatonia can be frightening. However, it is possible for them to make a successful recovery. In potentially life-threatening situations, such as dehydration and severe weight loss, medical professionals can offer supportive measures for a person with catatonia. Medication such as benzodiazepines may be the first treatment option.

If a person with catatonia doesn't respond to medication, ECT may be the next option. It's also used if a person has a severe underlying condition like psychotic depression or if the person is experiencing an irregular heartbeat or other life-threatening condition. ECT is effective in treating 80 to 100 percent of catatonia cases.

ECT for schizophrenia

Schizophrenia is a brain disorder that can come with a range of difficult symptoms. You could experience paranoid delusions and auditory or visual hallucinations. You may have difficulty expressing emotion or have disorganized speech, leaving you feeling fearful and confused. You may go through periods of deep depression, during which you self-isolate from loved ones out of shame.

A doctor might suggest ECT if your schizophrenia symptoms seem resistant to initial treatments, such as medications and psychotherapies. It’s also a potential option if you're experiencing severe symptoms like extreme agitation, suicidal behavior, or catatonia.

ECT for schizophrenia isn't used as a substitute for medication, but it can work alongside medication (and self-help or lifestyle changes) to manage specific symptoms and reduce the risk of relapse.

[Read: Schizophrenia Treatment and Self-Help]

While ECT can improve depression within the first several treatments, it can take a longer course of treatment to see improvement in symptoms of schizophrenia. In some cases, you may have to undergo up to 20 ECT treatments before your doctor can determine if it's proving effective.

ECT for dementia symptoms

When people think of dementia, such as Alzheimer’s disease, they often think of memory loss. Although that’s a prominent symptom of different types of dementia, personality changes are also common. If your loved one has dementia, you might notice them become increasingly agitated or aggressive during bouts of confusion.

Depression can also be common, as your loved one grapples with despair and the fear of losing their sense of self.

How ECT may help

ECT may help reduce some of the behavioral and psychological symptoms of dementia. One review of research showed that 90 percent of people with dementia saw a reduction in behaviors like verbal and physical aggression after ECT treatment. It can also be useful in reducing depression and suicidal behavior among people with dementia.

ECT for dementia is reserved for situations when symptoms don't respond to initial treatments or when severe symptoms need to be quickly treated. If your loved one consistently seems to be at risk of harming themselves or others—even after multiple drug prescriptions—ECT could then become an option.

Improvement might be noticeable after somewhere between three and nine ECT sessions. The benefits may be short-term, however, so follow-up treatments are often needed. There are also simple changes you can make in the caregiving environment that can help ease your loved one’s stress and address behavior problems.

[Read: Alzheimer’s and Dementia Behavior Management]

Future trials may help researchers better understand the potential risks that ECT may pose to older adults with preexisting health conditions.

What to expect during ECT treatments

Depending on the condition being treated and its severity, you’ll likely be scheduled for multiple ECT sessions. For example, you might be scheduled for three sessions each week for four weeks, 12 treatments total. The procedures may be done on either an inpatient or outpatient basis.

You’ll likely be instructed to avoid eating or drinking after midnight the night before your procedure. Once you arrive at the clinic, the medical team will insert an IV in your arm and place electrodes on your head and chest. They’ll also add other devices to monitor your blood pressure and blood oxygen level. An anesthetic will be administered so you sleep through the procedure, and a muscle relaxant will prevent any involuntary movements.

While you sleep, the electrodes on your head will deliver short, electrical pulses to induce a generalized seizure. You won’t feel it due to the anesthetic, but this part of the procedure will only take a few minutes.

Once you wake up, you’ll be allowed to rest in the recovery room for about 20 to 30 minutes and then be released. Overall, you’ll spend about an hour at the clinic per session.

When to expect improvements

Depending on the condition being treated, some people will notice an improvement after the first couple of ECT sessions. Others will notice a gradual improvement throughout the additional sessions. If you’re using ECT to treat mood disorders or catatonia, you’ll likely experience faster and better results than if you’re using it to treat schizophrenia.

Relapse of symptoms can occur in the months following the treatment. Your doctor might recommend continued treatment through additional ECT procedures or with medication or other therapies to reduce the risk of relapse.

ECT risks and side effects

You might wake up from the treatment in a confused state, due to the anesthesia as well as the ECT itself. You may also experience nausea, fatigue, muscle aches, and headache. All of these side effects are temporary and usually subside within hours.

For many people, the most concerning side effect is short-term memory loss. Some people who undergo ECT treatment have difficulty remembering things that occurred shortly before or after the treatment. While your memory may fully recover after you've finished your treatments, one review found that one-third of ECT patients experienced persistent or permanent memory loss following treatment.

Because each session involves anesthesia, it's also important to consider the risks that come with that, such as allergic reactions or breathing problems during and following the procedure. Accidental awareness, a distressing situation in which you are aware but unable to move during the session, is also possible, although unlikely.

The possibility of undergoing ECT treatment might not arise until you’ve exhausted all of your other options. But, if your doctor does recommend ECT, you’ll need to carefully weigh all of the risks against the potentially life-changing benefits of the treatment

Author: Sheldon Reid

Get more help

An underused option for severe depression – A new study supports the use of noninvasive brain stimulation in people with severe depression who haven't responded to medication. (Harvard Health Publishing)

ECT, TMS and Other Brain Stimulation Therapies – Understanding the different forms of brain stimulation. (NAMI)

Electroconvulsive Therapy (ECT) – What it is and why it's controversial. (Mental Health America)

Last updated: November 1, 2022