What is ECT?
Effective tx for some types of severe mental illness
Usually used when other forms of tx haven’t worked, or urgent tx needed
How is it given?
Given as a course, usually 2 treatments a week for 3-8 weeks
Given under GA - means you will be asleep
Muscle relaxant given
How is it given? 2.0
Whilst asleep, brain is stimulated with short electric pulses
Causes a fit (which lasts < 2 mins)
Muscle relaxant reduces how much body moves during the fit
What conditions can ECT be used for?
Severe depression - most common
Catatonia
Mania / mixed affective episode
Can help sx of schizophrenia - not often as unclear re long term benefits
Not recommended for anxiety / other disorders
When might ECT be suggested?
Life-threatening
Causing immense suffering
Not responded to other treatments (medication, therapy)
Has responded well to ECT in the past
How effective is ECT?
Most people see an improvement in their symptoms. In 2018-2019, 68% of people who had been treated with ECT were “much-improved” or “very much improved” at the end of treatment. Some showed no change in their condition, 1% worse.
Treating depression
Evidence: ECT > other treatment for severe depression (antidepressants, placebo, rTMS)
Lower risk of suicide
Staying well
ECT can help people who are very unwell to get better enough to have other kinds of treatments.
People who get better after having ECT: half will stay well for at least a year, more likely if then treated with other treatment e.g. antidepressants / lithium
People with severe depression which hasn’t got better following trial of two different antidepressants: 5% chance of getting better and staying well for at least a year if then try a third antidepressant.
How does it work?
Effects build gradually with each treatment
Release of certain brain chemicals: seem to stimulate the growth of some areas in the brain that tend to shrink with depression.
Also appears to change how parts of the brain which are involved in emotions interact with each other.
Ongoing research to help us understand more
Are there different types of ECT?
Changed and developed over the years e.g. amount and form of electricity used (to reduce SE)
Bilateral / unilateral
Bilateral may work more quickly, unilateral may have less effect on memory
Can ECT be used in children and young people?
Not used in children under the age of 11. Children between 11 and 18 rarely develop the kind of mental illnesses that respond well to ECT, but for a small number who do, ECT can be helpful. A formal, independent second opinion is required before it can be given.
Where is it given?
ECT suite / operating theatre
Inpatients or outpatients, if day case a responsible adult will need to accompany you to and from the ECT suite
Room to wait, room to recover
Preparing for ECT
Tests to make sure it is safe for you to have a general anaesthetic: may include record of your heartbeat (ECG) and blood tests.
You must not eat or drink anything for at least 6 hours before ECT, although you may be allowed to drink sips of water up to 2 hours beforehand. This is so you can have the anaesthetic safely.
If you would usually take medication during this time, ask the ECT team for advice on whether you should still do this.
What happens on the day?
If inpatient: staff member will come with you to the ECT suite. They will know about your illness and can explain what is happening. Many ECT suites are happy for family members to stay in the waiting room while you have your treatment.
You will be met by a member of the ECT staff, who will do routine physical checks (if they have not already been done).
You will be asked before every treatment about your memory and how good it is.
If you are having ECT voluntarily staff will check that you are still willing to have it, and will ask if you have any further questions.
When you are ready, the ECT staff will take you into the treatment area.
The staff will connect monitoring equipment to measure your heart rate, blood pressure, oxygen levels and brain waves.
You will be given oxygen to breathe through a mask. The anaesthetist will give you an anaesthetic through an injection into the back of your hand.
What happens whilst you are asleep?
Anaesthetist: muscle relaxant, mouth guard will be put in your mouth to protect your teeth.
Two metal discs will be placed on your head. In bilateral ECT, one goes on each side of your head, while in unilateral ECT both go on the same side of your head.
The ECT machine will deliver a series of brief electrical pulses, for three to eight seconds. This will result in a controlled fit which lasts for an average of 40 seconds, and may last up to 120 seconds. Your body will stiffen and then there will be twitching, usually seen in your hands, feet and face. The muscle relaxant reduces how much your body moves.
The dose of the electric pulses given is based on the amount needed to induce a fit. Your response will be monitored, and the dose adjusted as necessary.
What happens when you wake up?
Muscle relaxant wears off within a couple of minutes. Staff will take you through to the recovery area - experienced nurse will look after you until you are fully awake.
The nurse will take your blood pressure and ask you simple questions to check how awake you are. There will be a small monitor on your finger to measure the oxygen in your blood. You may wake up with an oxygen mask. It can take a while to wake up fully and, at first, you might not know where you are. After half an hour or so, these effects should have worn off and you will be asked some simple questions to check this.
Most ECT suites have a second area where you can sit and have a cup of tea or some other light refreshment. You will leave the ECT suite when your physical state is stable, and you feel ready to do so.
The whole process usually takes about an hour.
In the 24 hours after each treatment, you should not drink alcohol or sign any legal documents.
You should have a responsible adult with you for 24 hours.
How often and how many times?
Usually twice weekly, with a few days in between each treatment, can take several sessions before you notice an improvement.
Not possible to predict how many treatments you will need (on average 9 or 10 treatments in a course, although it is common to have more)
If no improvement at all after 6 treatments: treatment plan will be reviewed, ? whether to continue or change the form of ECT.
Medical team will review progress + side effects, usually every week. Memory testing.
Usually stopped soon after full recovery, or if you say you don’t want to have it anymore and are well enough to understand this decision.
What happens after a course of ECT?
ECT is one part of getting better
Usually continue / start medication
Talking therapies
Lifestyle (sleep, exercise, diet)
Sometimes continued to help stop you from getting unwell again, especially if you have previously relapsed after a course of ECT: ‘continuation’ / ‘maintenance’ ECT, and is given less often, for example every 2-4 weeks.
Contacted re memory 2 months after course has ended.
Side effects
Usually mild and short term, can be more severe and longer lasting
Increased if higher doses needed, women, elderly
Tx can be adjusted if SE
Short term SE
Immediate: headaches,
aching in the muscles and/or jaw, tiredness while the effects of the anaesthetic wear off
confusion, particularly if you are elderly (this usually wears off after 30 minutes), N+V.
Memory
Up to 40% of patients can have temporary memory problems while they are having ECT e.g. forgetting conversations with visitors during this time.
However, before having ECT about a fifth (17%) of people say that their memory was already bad enough to be causing them problems. It is difficult to separate out the effects ECT has on memory from the effects that the illnesses it is treating has on memory.
In most people, memory difficulties resolve within two months of the last treatment and do not cause problems or distress.
Long term SE
Controversial
No evidence of physical brain damage, epilepsy, stroke or dementia
Most serious potential long-term side effect of ECT is that you might forget events from your past. A small number of patients report gaps in their memory about events in their life that happened before they had ECT. This tends to affect memories of events that occurred during, or shortly before, the depression started. Sometimes these memories return fully or partially, but sometimes these gaps can be permanent. Recent research suggests that 7% of people receiving unilateral ECT report some persistent memory loss 12 months after ECT.
What can happen if you don’t have ECT?
Balance the risk of you experiencing side effects from ECT with the risk of not having ECT e.g.
prolonged and disabling mental illness
serious physical illness (and possibly death) from not eating or drinking
increased risk of suicide.
Driving and ECT
If you are severely ill enough to need ECT you should not be driving. DVLA advise that you should not drive during a course of ECT. After you have finished the course, it may be a little while before you can start driving again. The DVLA, with advice from your doctor, will make this decision.
Continuation / maintenance ECT: can normally continue to drive. Should not drive, ride a bike or operate heavy machinery for at least 48 hours after each ECT treatment.
