Sunday, October 23, 2011

ECT: Not Like the Movies

Posted by Eric Zhao at Sunday, October 23, 2011

Electroconvulsive Therapy
The media has given electroconvulsive therapy (ECT or "shock therapy") a bad rap. If you were like me and the general public, the only exposure of ECT came from the silver screen.

Clockwise from left: A Beautiful Mind, One Flew Over the Cuckoo's Nest, and Requiem for a Dream (all great movies, mind you)

ECT Reality (Content from the University of Michigan ECT Program)
What an honor to view a live ECT treatment during my psychiatry rotation. The whole procedure took only 15 minutes and looked nothing like the film scenes above.

The medical team (psychiatrist, anesthesiology, and nursing) typically reserves ECT for patients refractory to first-line interventions or for those with severe psychiatric episodes. We don't know exactly how it works but some theories suggest alterations in neurotransmitters or stress hormone regulation. The aim of ECT is to induce a seizure using a brief electrical pulse, so patients are tapered off adjunctive anticonvulsants (e.g., lamotrigine, valproic acid).

EEG showing seizure activity (top) and seizure termination (bottom)

The anesthesia team administers anesthetics, neuromuscular blockers (typically succinylcholine), and oxygen for both safety and comfort. A blood pressure cuff around the arm monitors blood pressure and a second cuff around the lower leg prevents neuromuscular blockers from traveling to the foot, allowing psychiatrists to monitor for motor seizures. That's right folks, the ankle/foot area is the only part of the body that showcases "classic" symptoms of convulsing.

Patient receiving ECT. Notice the blood pressure cuff around the lower leg to prevent neuromuscular blockers from traveling to the foot.

Unilateral vs. Bilateral
A full course of ECT typically ranges from six to twelve total ECT treatments. Bilateral treatment involves electrodes at both temples, and patients undergoing bilateral treatment typically respond quicker (i.e., less total treatments) than those who receive unilateral treatment. However, bilateral treatment is associated with more memory side effects.

Bilateral Treatment

Right Unilateral Treatment

Side Effects - Possible Short-term Memory Loss
Sometimes patients experience headache and nausea after the treatment. One of the greatest concerns of ECT patients is short-term memory loss during the period of ECT treatments (e.g., forgetting lunch or previous interactions). In some cases, patients may lose memory of past events, especially those 2-6 weeks before treatment.

Patient Response
It's hard to imagine patients responding well to ECT given its stigma and unknown mechanism of action. It's one of those things where you have to see it to believe it. I remember a patient with severe depression who no longer desired to live and was not responding to any conventional therapy (e.g., SSRIs, SNRIs, TCAs, etc.). A full course of ECT later, this patient was completely reborn: smiling, joking, and poking fun at the medical team. Forget electroconvulsive therapy; this was an electroconvulsive transformation.

-Eric Zhao

1 comment:

A Lonely Runner said...

I think A Beautiful Mind was not E.C.T. I think they used insulin to induce his seizure.

Nice post!