There are few depression treatments as polarizing as electroconvulsive therapy (ECT). It’s been more than 80 years since Ugo Cerletti sent the first electric currents through a human brain in the name of medicine, and today, electroshock therapy has been deemed one of the most “stigmatized treatments available in psychiatry.” Sensationalized film representations such as those in The Snake Pit and One Flew Over the Cuckoo’s Nest, as well as the reality of notorious early medical trials have shrouded electroshock therapy in controversy.
In the intervening decades, much has changed about ECT. In recent years, we’ve seen a gradual resurgence in the treatment as patients seek options to relieve severe depression symptoms, with some countries recording more than a 10 percent annual increase. ECT is a fast-acting treatment for depressive individuals experiencing catatonia or psychosis, but electroshock therapy isn’t for everyone.
There are many short-term and long-term risks associated with electroshock therapy. On the other hand, transcranial magnetic stimulation (TMS) is an increasingly popular noninvasive option for those suffering from severe and/or treatment-resistant depression.
What is shock therapy? Let’s take a look.
ELECTROCONVULSIVE THERAPY WAS ONCE REFERRED TO AS ELECTROSHOCK THERAPY
Electroconvulsive therapy (archaically referred to as electroshock therapy or electric shock therapy) is a psychiatric treatment notorious for its long list of severe potential side effects. Despite its murky history, more than 100,000 individuals undergo ECT in the United States annually. How exactly does ECT work? Let’s start with a quick history lesson.
In the early 1930s, researchers noticed the positive effects schizophrenic patients with epilepsy experienced immediately following epileptic seizures. In an attempt to duplicate these results, medical professionals began using chemicals (namely Metrazol) to artificially induce grand mal seizures in patients for temporary symptom relief. Unfortunately, patients frequently reported extreme dread, and even outright terror per some reports, prior to the onset of these chemically induced seizures. Looking for a more humane alternative to Metrazol, a team of Italian researchers proposed the idea of sending electric currents through the brain to produce the intended grand mal seizure. This led to the popular common phrasing of “electroshock therapy.”
Early electric shock therapy was administered without anesthesia or muscle relaxants, meaning patients were often fully conscious and alert during the entire procedure. This so-called “unmodified ECT” set the therapeutic precedent for decades, with often gruesome and even deadly results. Without the use of muscle relaxants and anesthesia, musculoskeletal complications were common among patients, including broken bones and ligament damage. ECT in its modern “modified” form uses many previously absent safety guidelines (including anesthesia and muscle relaxants) to minimize the inherent risks of the unmodified variation.
Today, ECT is employed in the treatment of severe depression when other medical options have failed to yield positive results. During a typical ECT procedure, the patient is given muscle relaxants and put under general anesthesia to minimize convulsions and general discomfort. Next, the medical professional overseeing the treatment places a set of electrodes along the patient’s head. These electrodes are used to send a series of controlled electric currents through the individual’s brain, to stimulate the neurons and chemicals of the brain and induce a controlled grand mal seizure.
Incremental jolts of electricity (up to 100 joules at a time) are passed through the patient’s brain to produce a seizure, and each of these seizures is sustained for approximately 20-60 seconds. Muscle relaxants administered prior to the introduction of the electric currents minimize the potential for muscle convulsions, however, some convulsion and muscle contractions may still occur. The electrode sites along the head naturally stimulate the jaw and mouth muscles, so biting and jaw clenching are expected. Protective mouth guards ranging from gags and rubber bite blocks to gauze wrapped tongue blades are inserted into the patient’s mouth to prevent injuries to teeth and oral tissues. Individual ECT therapy sessions last about one hour and need to be administered two to three times per week, totaling six to twelve sessions.
ECT is by no means a cure for depression. To maintain the positive effect of electroshock treatment, patients may need to return for electric shock therapy sessions multiple times a year.
ELECTRIC SHOCK TREATMENT HAS SERIOUS POTENTIAL SIDE EFFECTS
Typically, electroshock therapy is a last-ditch effort used when all other treatment options have failed to offer symptom relief to those suffering from severe depression, bipolar disorder, schizophrenia, or other serious and debilitating mental illnesses. The current “modified” procedure for administering electric shock therapy is certainly more humane than earlier variations, however, the treatment still comes with a rather extensive list of long-term and short-term side effects. When faced with these possible side effects, patients are often forced to make hard choices about whether or not electroshock therapy is worth the risk.
Side effects associated with ECT are rare but typically include prolonged seizure, stroke, cardiovascular complications, blood pressure changes, dental damage, physical trauma, and, in some cases, even death.
Cardiovascular complications are rare, but when they occur are a common cause of ECT-related death. Other cardiovascular complications (namely hypertension, arrhythmia, and hypotension) can also occur as a result of electric shock treatment.
One of the most common electroshock therapy side effects is short-term memory loss. According to the University of North Carolina School of Psychiatry: “It is normal to have some impairment in memory after a seizure. For example, a person may forget what happened right before the seizure (retrograde amnesia) and have trouble remembering what happened in the time period right after waking up (anterograde amnesia). This is to be expected in all persons to some degree.” Long-term memory loss is less common but may still occur.
Furthermore, a typical ECT regimen will typically involve up to three treatments each week, for multiple weeks. Therefore, memory loss can accumulate quickly, covering vast swaths of time over a short period. Although it is common for individuals to regain these memories in the following days and weeks, even temporary confusion and amnesia can be frustrating and unsettling for many patients.
Again, despite the use of neuromuscular blocking agents, dangerous muscle contractions can still occur. These contractions may result in physical trauma ranging from bone fractures and dental damage to skin burns and tongue lacerations. Muscles of the jaw and mouth are reflexively stimulated by the electrical current during ECT sessions (irrespective of any administered muscle relaxants), so expected clenching is buffered by mouth guards and bite blocks, but these can only offer so much protection.
First-degree and second-degree burns during ECT therapy, while rare, have also been widely documented. Poor contact between the skin and the ECT electrodes can result in burns at the electrode connection sites around the head, face, ears, and scalp. Hair may also be inadvertently ignited during treatment, leading to burning or singeing.
The use of general anesthesia also carries its own inherent risks, which apply to all treatments that require it, including ECT. To minimize these health risks and side effects, a pre-ECT screening should include a blood pressure assessment and an electrocardiogram, as well as a general information about the patient’s medical history. Chest X-rays may be used to predict and prevent pulmonary complications, including prolonged apnea or aspiration.
There is a risk of prolonged seizures during ECT, and physicians typically rely on electroencephalogram (EEG) monitoring during ECT treatment to detect and prevent them.
TRANSCRANIAL MAGNETIC STIMULATION IS A MILD AND EFFECTIVE TREATMENT FOR DEPRESSION
If medications haven’t adequately treated your depression symptoms, and you are considering ECT, it’s important to know that there are other options. Transcranial magnetic stimulation (TMS) is an increasingly popular noninvasive treatment for individuals suffering from severe and treatment-resistant depression.
TMS does not involve anesthesia or seizure induction, and it comes without many of the severe side effects of electro shock therapy. With TMS, there are no electrodes and no convulsions, and you are free to drive yourself home after treatment.
TMS was approved by the US Food and Drug Administration (FDA) in 2008. While electric shock therapy uses direct currents of electricity to induce seizures, TMS uses a magnetic field to stimulate a region of the brain known as the dorsolateral prefrontal cortex. This region of the brain controls mood regulation and cognitive memory, and is involved in our daily decision-making processes.
Prior to the first treatment, TMS physicians and technicians will work together to pinpoint the exact location along the scalp to target for optimal TMS treatment. This location is where they will eventually position the overhead magnetic coils for the treatment sessions themselves. During TMS therapy, a rapidly alternating magnetic field increases brain cell activity, and repeated sessions have been shown to reduce depression symptoms. It’s important to understand that, unlike electric shock treatment, TMS does not induce a seizure, and the patient is conscious during the entire process.
A typical TMS session lasts about 20 minutes. For optimal results, most treatment plans require four or five weekly treatments for up to six weeks. Between these individual treatment sessions, patients will note their progress and symptoms (or lack thereof), to help their doctors determine if the regimen requires adjustment.
A recent Harvard study analyzed patients suffering from depression, whose symptoms had not been adequately relieved by a range of medications. Between 50 and 60 percent of these individuals received a ”clinically meaningful response” with TMS. Furthermore, the same study found that one-third of participants went on to experience a full remission after TMS treatment.
There are a few mild side effects associated with TMS treatment, and the most common occurrences include headache, neck pain, and general scalp irritation near the treatment site. Over-the-counter medications can be used to relieve the most common TMS side effects, namely discomfort along the stimulation site.
If you or a loved one have tried other medications and treatment without positive results and are contemplating ECT, be aware that there are other options with fewer potential long-term side effects. Consider TMS, a noninvasive, FDA-approved option with clinically proven effectiveness, and ask yourself: is ECT worth the risk?
What are the most common side effects of ECT?
The most common side effects of ECT are confusion, short term memory loss and muscle aches.
What is the length of ECT treatment?
Treatment is determined on a case by case basis but it’s likely to be delivered 2-3 times a week over a period of several weeks.
Is ECT a controversial treatment?
ECT has been portrayed in media and films negatively often because historical ECT treatments were non consensual and didn’t include the use of anesthesia and muscle relaxants to minimise trauma and side effects.
Is TMS the same as shock therapy?
No. Shock therapy induces a seizure which has to be induced under anesthetic and with muscle relaxants; memory loss and confusion are common side effects. Patients must be monitored post treatment. TMS used magnets to stimulate the brain; there are no drugs involved. Patients may experience a headache or scalp discomfort but are otherwise able to directly resume normal activities.
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