Electroconvulsive Therapy (ECT)
Severe depression can be challenging to treat, but when medication or psychotherapy do not work, electroconvulsive therapy (ECT) may help. ECT is the induction of a brief therapeutic seizure administered under general anesthesia during which the patient is continually monitored by an anesthesiologist and an ECT psychiatrist. ECT is a safe, effective, rapid-acting intervention used to treat severe acute disorders unresponsive to other treatment modalities. For patients who are suicidal, can’t take antidepressants, or have not responded to antidepressants, ECT is the standard-of-care treatment. It has a long history of effectively treating unipolar and bipolar depression, psychosis, mania, and catatonia. In fact, ECT has a well-established role in the treatment of catatonia, with a 90 percent response rate for this condition. Often patients find that ECT can alleviate symptoms that have not fully responded to other modalities when used in addition to pharmacotherapy.
What to Expect if You’re Considering ECT
The first step is a referral to the ECT program by the treating psychiatrist. After a formal consultation by a member of the ECT team, if you are determined to be a candidate for treatment, you will undergo a complete medical examination. This will include a standard preoperative medical evaluation, including a history and physical examination, routine bloodwork, and an electrocardiogram (EKG). Additional tests or consultations may be recommended as indicated.
On the day prior to the procedure, you will be instructed to have nothing to eat or drink after midnight, because you will be having anesthesia the following morning. Upon arrival at the ECT suite, after a brief re-assessment by the ECT psychiatrist and anesthesiologist, a small intravenous (IV) catheter is placed in your arm and standard monitors (EKG stickers, a blood pressure cuff, and a pulse-oximeter on the finger) are applied prior to entering the treatment area.
In the treatment area, general anesthesia will be induced by the anesthesiologist followed by a short acting muscle relaxant so that you do not move during the seizure. Once you are fully asleep and your muscles relaxed, the psychiatrist induces the therapeutic seizure via electrical stimulation through two stickers placed on your head. A few seconds of stimulation leads to seizure activity in the brain, which the medical team monitors via electroencephalography (EEG) and electromyography (EMG). The therapeutic seizure typically lasts 30-60 seconds, after which the brain terminates the seizure on its own. You will then awaken after 5-10 minutes and will be brought to a recovery area for further monitoring.
Because the treatment is performed under general anesthesia, you will have no memory of the procedure. It is as if you simply fell asleep and then woke up 10 minutes later. After a short recovery period, typically 20-30 minutes, you will be allowed to leave with an escort who will make sure you get home safely.
The treatment is typically administered two to three times per week for a total of 6-12 sessions, but occasionally patients see significant improvement after only a few sessions or require more than 12. While the exact mechanism of action is not known, we do know that ECT increases the amount of neurotransmitters available in the brain, has effects on gene expression, and causes changes in functional connectivity leading to a “re-wiring” of the brain, which affects how different parts of the brain interact with each other.
Is ECT Safe?
Research shows that for those with major depression, ECT provides significant symptom improvement in about 80 percent of cases. There are some risks, as with most medical procedures. ECT can sometimes lead to short-term memory loss, but this often improves within weeks. Rarely, some patients have reported memory issues that last much longer. The chances that this will happen can be reduced by adjusting certain treatment parameters, including the location of stimulus electrode placement, the power of the stimulus administered, and the number of treatment sessions. In every case, the treatment team will choose the lowest effective stimulus in order to minimize any side effects, especially in any patients with identified pre-existing vulnerability to memory loss.
Because the treatment is administered under general anesthesia there are necessarily risks involved with that as well. Though considered to be a very low-risk procedure, some patients may experience fatigue, nausea, headache, and confusion on the day of the treatment, which can last for a few hours. Prophylactic medications are administered prior to each treatment to mitigate these symptoms for at-risk individuals.
ECT is a low-risk procedure, but the ECT psychiatrist will collaborate closely with the medical team and any specialists to optimize you for the procedure. There are no absolute contraindications to ECT, and it is important that you, your medical providers, and the ECT psychiatrist carefully weigh the risks and benefits of the decision to move forward with ECT.
Mount Sinai Health System offers inpatient ECT to patients on both the psychiatric and medical floors at The Mount Sinai Hospital and Mount Sinai Beth Israel. Our outpatient ECT program is based at Mount Sinai Beth Israel. To make an appointment, refer a patient, or learn more about ECT, please call 212-659-8810.