What is electroconvulsive therapy (ECT)?

WHAT IS ELECTROCONVULSIVE THERAPY (ECT)?

What is Electroconvulsive Therapy (ECT)?

21 September, 2020
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Author's Note: This post has been updated as of September 2020 to reflect personal experiences regarding the effectiveness of electroconvulsive therapy (ECT). This information does not change the statistics and facts about ECT or my decision to start this treatment, which was made on my own without pressure from anyone – including my doctors.

I've added this information as a way to update readers on the longer-term effects ECT had on my life. These long-term side effects are drastically different from what I experienced at the start of treatment, and I never could've predicted this is how things would end up. Because I feel so strongly about being honest and transparent around my mental health journey and treatment I receive, I felt I was doing readers a disservice by not updating the post with the most recent information.


Electroconvulsive Therapy at Tufts Medical Center in Boston, MANovember 25, 2019 at 11:30am. 

I walked into my psychiatrist’s office, hands shaking, clutching my phone in my hands. Like with nearly every appointment, I had a note in my phone that listed all the side effects I experienced from the medication I was put on just two weeks prior. 

Dry mouth. Nausea. Loss of appetite. Weight loss. Stomach pain. Insomnia.

I sat down in the chair next to my psychiatrist’s desk, and like always, he sifted through his handwritten notes in my file and asked, “So tell me: How’s it going?”

Without hesitation, I pulled up my list and read off all the side effects.

“Insomnia – really? That’s unreportable with Lamictal, meaning it happens in less than 3% of patients. We never see this. Wow! Well, let’s stop taking it then.”

My heart instantly sank, and I felt that lump in my throat that signaled the tears were about to start. It was a crushing blow to my treatment and recovery, given that I had seen some benefits from Lamictal when I took it in the summer of 2018. Lamitcal – like all the others – was supposed to be the medication that worked. It was supposed to help me get better. I needed it to work...and it didn’t.

My face must’ve said it all.

Because all of a sudden, my doctor put down his pen, got quiet and pushed back his chair. He looked at me with a face I had never seen before. Without hesitation, he said something to the effect of, “I have to say this – because I’d be a bad doctor if I didn’t – but have you considered ECT?”

He was referring to electroconvulsive therapy.

What is electroconvulsive therapy (ECT)?

According to the Mayo Clinic, electroconvulsive therapy is a medical procedure done under anesthesia in which small electric currents are passed through the brain, triggering a brief seizure. 

Patients are also given a muscle relaxant or paralytic so that the seizure is limited to the brain. A blood pressure cuff is often placed around one ankle, which stops the muscle relaxant from entering that foot and affecting the muscles. When the procedure begins, this allows the doctor to monitor seizure activity by watching for movement in the foot.

Statistics vary when it comes to the effectiveness of ECT, but it’s still widely considered one of the most effective forms of treatment – especially for people who haven’t responded to medications or other forms of treatment. 

The University of Utah Health puts it this way:

“For patients with the crippling diagnosis of severe depression, bipolar disorder, or psychosis, Electroconvulsive Therapy (ECT) can be a life-changing procedure. Not only does it work better than medications (according to Dr. Howard Weeks, medications have a success rate of 50-60% of patients getting better, while ECT succeeds at a rate of 70-90%), it works faster. Medications typically take up to eight weeks to show improvement.”

Conditions ECT helps treat

ECT is considered a “last resort treatment” and is typically used when other treatments and medications are unsuccessful. Electroconvulsive therapy can provide rapid and significant improvements to people living with severe mental health conditions such as:

  • Severe depression, especially when accompanied by detachment from reality (psychosis), suicidal ideation or actions, or refusal to eat. 
    • This is the most common reason people are referred to for ECT, accounting for more than 80% of use.

  • Treatment-resistant depression (or bipolar depression), which is a severe type of depression that doesn’t improve with medications or other treatments.
    • Statistics show that approximately 20% of Americans who suffer from depression – around four million people – do not respond to antidepressants or cannot tolerate the side effects.

  • Severe mania, which is a state of intense euphoria, agitation or hyperactivity that occurs when a patient lives with bipolar disorder.
    • People with mania or bipolar disorder account for only 3% of ECT patients.

  • Catatonia, which is characterized by lack of movement, fast or strange movements, lack of speech and other symptoms. It is often seen in patients with schizophrenia.
    • Patients with schizophrenia make up fewer than 1 in 10 ECT patients, a dramatic dropoff from the 1930s when they were the most frequent users/patients.

  • Agitation and aggression in people with dementia, which can be difficult to treat and negatively affect a person’s quality of life.

Statistics show that more than 100,000 Americans a year get ECT, with 10-20 times that many getting the treatment worldwide. Electroconvulsive therapy – although highly stigmatized – is now as common as hysterectomy and twice as common as knee replacement surgery. The difference is we openly talk about those other procedures but feel like we need to stay silent when it comes to ECT.

My hope is that this blog serves an important first step in opening up the conversation about electroconvulsive therapy among my family, friends, colleagues and those in/around my social circle.

What happens during an ECT treatment?

From start to finish, the entire treatment takes around 15 minutes. It’s administered by a team of trained medical professionals that includes a psychiatrist, anesthesiologist and nurse (or physician's assistant).

ECT treatments are typically performed on an outpatient basis unless the patient is in an inpatient treatment facility where ECT is also performed. When ECT treatments are done in a hospital setting, they happen in the post-anesthesia care unit (PACU) early in the morning since surgeries for the day haven’t started, and it’s the perfect place for patients to rest after coming out of anesthesia. Some hospitals, like McLean Hospital outside of Boston, have their own ECT clinics where treatments are performed.

Before the ECT procedure

  • The patient has a brief physical exam to check your heart and lungs.
  • The patient has an IV line inserted so that the anesthesia and muscle relaxant can be administered. 
  • Electrode pads are placed on the patient’s head, typically on or around the temple(s). Each pad is about the size of a silver dollar.

At the start of the procedure

  • At the start of the procedure, the patient is given general anesthesia to make them unconscious and a muscle relaxant to minimize the seizure and prevent injury.

During the procedure

  • A blood pressure cuff is often placed around one ankle to stop the muscle relaxant from entering the foot. This allows the doctor to monitor seizure activity by watching for movement in that foot.
  • Monitors check the patient’s brain, heart, blood pressure and oxygen.
  • Patients may be given oxygen through an oxygen mask.
  • Patients may also be given a mouth guard to protect the teeth and tongue from injury.

Inducing a brief seizure

Once the patient is asleep, the doctor presses a button on the ECT machine. This causes a small amount of electric current to pass through the electrodes and into the patient’s brain, which produces a seizure that typically lasts 60 seconds or less.

Because the patient is under general anesthesia, they remain unaware of the seizure, and because of the muscle relaxant, the only outward indication that a seizure occurred is from movement in your foot if a blood pressure cuff is placed around the ankle.

Internally, brain activity increases dramatically. During the procedure, a test called an electroencephalogram (EEG) records the electrical activity in the patient’s brain. The EEG shows increased activity at the beginning of the seizure followed by leveling off that signifies the seizure is over.

Within minutes, the effects of the short-acting anesthesia and muscle relaxant begin to wear off. At that point, the patient is taken to a recovery area where they’re monitored for potential problems and/or pain.

A typical series of ECT treatments

In the United States, ECT treatments are generally given two to three times a week for three to four weeks. The average course of treatment is six to 12 sessions. The number of treatments a patient needs depends on the severity of symptoms and how rapidly they improve.

Electroconvulsive therapy is not a one-and-done series of treatment, and it generally requires follow-up or maintenance treatments. The frequency of these treatments varies from patient to patient and can be anywhere from once every other week to once a month.

What are the side effects of ECT?

Because today’s electroconvulsive therapy treatments are performed under anesthesia and the amount of electricity passing through the brain is closely monitored, ECT is considered generally safe. However, that’s not to say it doesn’t have risks and side effects, which include:

  • Physical side effects like headaches, muscle pain and jaw pain on the days of ECT treatment. These are easily treated with medications administered via an IV.

  • Confusion. Immediately after treatment, patients may experience confusion, which may last from a few minutes to several hours. Very rarely, it may last several days or longer. This side effect is generally more noticeable in older adults.

  • Memory loss. Some patients have trouble remembering events that occurred the night before treatment or even in the weeks and months before. Rarely, patients experience memory loss that goes back several years, which is known as retrograde amnesia. For most patients, memory loss problems usually improve within a couple of months after treatment ends.

    However, in the book Shock: The Healing Power of Electroconvulsive Therapy by Kitty Dukakis and Larry Tye, Tye says, “Memory problems are far worse than most ECT doctors acknowledge but not as bad as many critics charge. More can and is being done to limit [memory] loss.”

    Opponents to ECT also insist that ECT causes brain damage. While there’s compelling evidence that ECT does change one’s brain chemistry, there’s little proof that it amounts to brain damage. In fact, the changes that occur in the brain might actually be beneficial for patients – especially in the short-term.

How does ECT work? And when does it start working?

According to research, many people begin to notice improvements to their symptoms after about six treatments with electroconvulsive therapy. Full improvement may take longer and/or require maintenance treatments. It’s also important to note that ECT may not work for everyone.

Doctors aren’t completely certain how ECT helps treat severe, treatment-resistant mental illnesses. Although the proof is compelling that not only does it work, but it works faster and more steadily than medication or talk therapy. 

What is also known, though, is that many chemical aspects of brain function are changed during and after the seizure. Essentially, the seizure rewires your brain chemistry. Over time, these changes build upon one another and somehow reduce symptoms of severe mental illness. 

Even after symptoms improve, most patients still need ongoing treatment – through ECT, medications and/or psychotherapy – to prevent a recurrence or relapse. 

Mental health relapse after electroconvulsive therapy

The most profound limitation to ECT is that even when it works, the effects typically don’t last long on their own. Studies have shown that more than half of depressed patients treated with ECT experience a return of symptoms within a year – generally within a few months.

And with medication-resistant patients who respond to ECT, the relapse rate is roughly twice as high meaning that most (if not all) can expect their illness to come back quickly – and with a vengeance. Much of this likely has to do with the fact that while many patients can use antidepressants and other psychiatric medications, this approach won’t work with this group, making their only options psychotherapy and continued ECT treatments.

Still, many patients say it’s worth it because ECT gave them their life back...literally.

The stigma surrounding electroconvulsive therapy (ECT)

Much of the stigma surrounding ECT is based on early treatments where high doses of electricity were administered to patients without anesthesia – often without their consent – which led to memory loss, fractured bones and other serious side effects. In fact, Robert Whitaker, author of the exposé Mad in America, estimates that more than one million patients received “forced electroshock” in the 1940s and 1950s.

And then there’s ECT’s portrayal in movies, books and pop culture.

The book and movie One Flew Over the Cookoo’s Nest (1975) is one of the most well-known portrayals of electroconvulsive therapy in pop culture – but it’s also one of the most inaccurate (for present-day standards) and ultimately, stigmatizing.

In the movie, Randle McMurphy, played by Jack Nicholson, fakes insanity to avoid hard labor in prison. He ends up in a mental institution and – like some of the other patients – is forced to undergo ECT without anesthesia as punishment for his snarky defiance. He’s also held down as the treatment is carried out. Later, McMurphy is given a prefrontal lobotomy.

Sylvia Plath’s account of ECT in the book The Bell Jar (1963) is just as intense. When describing ECT, which was administered without general anesthesia, the protagonist says: “With each flash, a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant.” It’s important to note that later in the novel, ECT is administered again, but this time with general anesthesia and a muscle relaxant, which is the standard of care today.

Another movie with an inaccurate depiction of ECT is Shock Corridor, which was released in 1963. In the movie, a reporter is held down by attendants as a rolled-up towel is stuffed into his mouth after he goes into a mental hospital undercover. He then screams for his girlfriend as electricity is sent through his fully-awake body. It’s a scary image...more so if it were true.

The reality is the reporter would've blacked out before having the seizure regardless of whether he received anesthesia and a muscle relaxant. But in 1963, he would’ve gotten both.

And this is just the beginning. Pop culture can’t seem to get enough of portraying ECT in books and movies – and a stigmatizing, inaccurate portrayal at that – given that over 22 films have featured ECT between 1948 and the turn of the century, and more come out every year. (Source: Shock: The Healing Power of Electroconvulsive Therapy by Kitty Dukakis and Larry Tye).

Although Hollywood is fiction – not fact – these depictions of ECT are troubling. Two Australian psychiatrists analyzed every film they could find with ECT in it as well as every aspect of the treatment’s depiction. Their conclusion? Electroconvulsive therapy is not portrayed with authenticity.

Whereas most psychiatrists are kind, gentle and empathetic, in movies they become cruel and the embodiment of evil. In the real world, ECT is generally used to treat depression or psychosis. In Hollywood, it’s prescribed as punishment or as a way to overcome antisocial behavior. And while anesthesia and muscle relaxants have been the standard since at least the 1950s to prevent the body from convulsing and sustaining fractures, films often show patients fully awake and in terror – making many of these films inaccurate depictions of ECT for their time.

My journey to electroconvulsive therapy

When my doctor mentioned ECT to me on that November morning, I knew very little about the procedure. I had a general idea of how the treatment worked, but other than that, my knowledge was limited. 

During my time at McLean Hospital, I met a few people who had undergone ECT treatments, and they didn’t have a ton of positive things to say. However, I wanted to make an informed decision, which meant doing my own research and meeting with the doctor who oversees ECT at the hospital.

A few weeks later – on my 30th birthday (December 16th) – I met with an ECT doctor at Tufts Medical Center to talk about my past, my experience with medications and what led me to explore ECT. Although I had spent weeks researching ECT to the point of exhaustion, I still wanted to hear it all from the doctor. 

Most importantly, I wanted to know if I was a good candidate for ECT. Could ECT do what all 24 medications couldn’t and help reduce – or even eliminate – the symptoms of my treatment-resistant bipolar depression?

The answer wasn’t as clear-cut as I had expected it to be. The doctor basically told me:

“I’ll never say no to someone willing to try ECT, especially if they’ve experienced little to no improvement on medication. But just know going into it that with your history of complex trauma and the fact that you’re younger, it may not be as successful as it would be in older patients. However, I’ve been surprised before by seeing great success in patients I didn’t think it would work for, so you could very likely fall into that category.”

In other words, I’m a candidate but only because I’m willing to give it a try. 

I held back tears the entire way home, and I had a knot in my stomach all night.

Happy birthday to me...right?

Making the decision to move forward with ECT

I wish I could say that I was always hopeful that ECT would work or that I never doubted my decision to move forward with this treatment, but both of those things would be a lie. Even after doing a ton of research and meeting with the psychiatrist who oversees ECT at Tufts Medical Center, I still wasn’t 100% sure it was the right treatment for me. 

But then I thought back on the past two years. I thought about all the medications that didn’t work...or didn’t work as well as they should have. I thought about the results of the genetic testing I had done at McLean Hospital in April 2019. I thought about how frustrating it’s been to start a new medication and push through the side effects...only to go off of it a few weeks later. 

And I realized that I could keep going on that path – the path that involved me starting a new medication every two to four weeks (or less) – or I could try ECT. It was a scarier option but somehow, it felt safer.

So, I went to the doctor and got a physical, blood work and EKG. I talked to my manager and HR generalist at work about taking a leave of absence. I had my psychiatrist fill out the FMLA paperwork. I submitted a short-term disability claim with our short-term disability provider. And when it was all said and done, I started my leave of absence on February 3, 2020. 

So, did ECT work?

Update: September 20, 2020

After nearly 30 ECT treatments, I made the decision stop treatment on June 26, 2020. While I saw initial success with ECT, ultimately, it didn't work for me. In the end the side effects of the treatment – significant memory loss, rise in my anxiety (and panic attacks), newly developed anger/rage and severe physical pain the day of and the day after treatment – no longer outweighed the minor benefits I experienced.
 
And truthfully, by the time I stopped treatment, I really wasn't seeing the benefits anymore. I was extremely depressed and suicidal while also having panic attacks nearly every day. All coping mechanisms I learned through dialectical behavior therapy were gone. I couldn't remember anything I learned in my DBT skills practice. And after 500+ days clean, I started self-harming again because life was so overwhelming, and I couldn't handle the emotional pain. 
 
My short-term memory was destroyed. Even the simplest of things – like where I kept certain foods in the cabinet or where I put the laundry detergent – were impossible to remember. My speech was impaired, and I developed a minor stutter – likely due to the memory loss and not being able to figure out what I was trying to say. 
 
All of this to say: Although I saw initial success with electroconvulsive therapy, in the end, it was not a successful treatment for me. However, even with all that said, I don't regret giving ECT a try. Not for a single second. Because had I not done it, I would've spent every day since wondering, "What if I tried? And what if it worked?"
 
While I would still encourage others in a similar situation to explore ECT because it is a highly effective treatment and I've seen it work for many people, I'd also encourage people to think it through. To get a second opinion. To do your research. To weigh the pros and cons. And to ask themselves: If this doesn't work, and all those side effects they talk about happen to me, will I be able to live with all of that and still be okay?
 
 I definitely let the excitement and hope of it all get to me. If I asked myself those questions, I might not have jumped into it so quickly. But I still would've done it. No questions asked.
If I could go back and do things differently, I would. Mostly, I would've paused, thought it through and not rushed into a decision. But I can't change the past. So the only thing I can do now is to forgive myself and stop beating myself up for the decision I made because I made that decision clear-headed, armed with knowledge and full of hope. I have to live with that decision, but I don't have to let it ruin me.
 
Instead, I'll find ways to cope with the pain, the memory loss, the emotional distress, the anxiety and the anger. I'll find ways to keep living when I really don't feel like life is worth living for.
 
I'll do the best I can every single day and believe that it's enough. Because it is enough. And I know that if I live in the past, I'm not really living at all. 
 
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So, did ECT work? - Original Update: February 22, 2020

As of today – February 22, 2020 – I’ve had seven ECT treatments (and I still have three more next week before we decide when/how we'll start maintenance treatments).

And I can say, without a shadow of a doubt, that ECT is working for me. In fact, I’d go as far to say that it's saved my life.

If I look back to a few weeks ago, I understand now just how bad things had gotten. I struggled to get out of bed, to walk the dogs, to workout, to focus at work, to write for this website/blog, and to be a productive member of society. I had absolutely no motivation. I didn’t want to socialize, hang out with friends, meet new people or do fun activities at work. 

Everything – and I mean everything – was a challenge.

The thoughts of harming myself were constant, and I truly felt that the world would be a better place if I didn’t exist. In the back of my head, I always wondered if I needed to be in inpatient treatment because I didn’t believe I could keep myself safe. I was struggling far more than I ever wanted to admit.

But today, I walk around with the biggest smile on my face and laugh louder than I ever have – and it’s 110% genuine. I have a positive outlook on life. I no longer just say that things will get better; I truly believe it. I believe that the best is yet to come, and I’m so excited to see where life takes me next.

So instead of beating myself for letting things get “so bad” or for “spiraling,” I’m reminding myself that some of it was beyond my control. I did the best I could with what I had in the moment, and now that I have the knowledge – and mindset – to do things differently, I can make plans and take steps in the right direction. I can start working out again to prepare for mud runs. I can eat healthier again. I can participate in social activities and make new friends.

The world is my oyster, and that’s a really beautiful thing.

What about ECT memory loss?

Despite seeing some pretty incredible results from ECT, I’ve also experienced the dreaded side effect of memory loss. 

It’s mostly little things: like walking directions to a favorite store or restaurant that I used to go to all the time, passwords that I used to know by heart, commuter rail train times, where in my apartment I store preventatives for my dogs, morning/evening routines, favorite essential oil blends, etc.

However, like my therapist told me: I learned it once, and I’ll learn it again. And who knows, maybe I’ll learn it differently/better/more efficiently next time.

Truthfully, what I’m most worried about is memory loss when it comes to things like work. I’m currently on a medical leave of absence, and all I can think about is: Will I remember how to do my job when I get back? Will I remember how to use our software (that I’ve been using for 5+ years)? Will I be the consultant my customers need me to be?

My customers pay a lot of money to work with me, and they deserve to work with a consultant that knows her stuff and can help them grow their business. I'm afraid I might not be that person anymore. I'm afraid I won't live up to the high expectations they have for me.

I know I’m likely putting too much pressure on myself right now. Only time will tell how the memory loss impacts my job – if at all. There’s still a strong chance that it won’t or that the effects will be very minimal. And if it’s more than that, I know my manager will work with me to explore options like dropping into new hire training or watching training/certification videos.

I’ve said it once and I’ll say it over and over again: As precious as some of those lost memories were, what matters even more is that I’m still alive. ECT – without a shadow of a doubt – saved my life. Memory loss is a small price to pay, and I’d go through it all over again to feel this way and get these results. No questions asked.

Christina Bockisch

When others are silent, I am loud. I'm a passionate advocate for mental health, and I believe that sharing my story is the best way to break the stigma surrounding mental illness so that people can get the help they deserve. My strengths are my dogs – Hendrix, Khaleesi and Benny – and my hope is that tomorrow can be different.

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