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ELECTROCONVULSIVE THERAPY: WHAT YOU NEED TO KNOW A PATIENT INFORMATION BOOKLET Department of Biological Psychiatry New York State Psychiatric Institute ECT : PATIENT INFORMATION BOOKLET PAGE 2 What is Electroconvulsive Therapy? Electroconvulsive therapy (ECT; called "shock treatment" by some) is an extremely safe and effective medical treatment for certain psychiatric disorders. With this treatment, a small amount of electricity is applied to the scalp and this produces a seizure in the brain. The procedure is painless because the patient is asleep, under general anesthesia. Who is Treated with ECT? ECT has been used for over 60 years. In the United States, about 100,000 individuals are estimated to receive ECT each year. ECT is most commonly given when patients have severe depressive illness, mania, or some forms of schizophrenia. Frequently, ECT is given when patients have not responded to other treatments, when other treatments appear to be less safe or difficult to tolerate, when patients have responded well to ECT in the past, or when psychiatric or medical considerations indicate that it is particularly important that patients recover quickly and fully. Why Hasn't ECT been Replaced by Medications or Psychotherapy? Not all patients improve when treated with medications or psychotherapy (talk therapy). Indeed, when illnesses such as depression become particularly severe, it is doubtful that psychotherapy alone will be sufficient. For some patients, the medical risks of medications are greater than the medical risks of ECT. Typically, these are people with serious medical problems, such as some types of heart disease. When patients have lifethreatening psychiatric problems, such as suicidal tendencies, ECT is also often recommended because it usually provides faster relief than medications. Overall, the great majority of depressed patients treated with ECT show substantial improvement. Even the majority of those who have not been helped by medications respond to ECT. This makes ECT the most effective of the antidepressant treatments. Who Administers ECT? ECT is given by a treatment team. At the New York State Psychiatric Institute, the team consists of a senior psychiatrist, an attending anesthesiologist, nurses, and technician assistants. The psychiatrists responsible for administering ECT are highly experienced specialists, who have made many of the advances that have improved this treatment over the last two decades. Each of the anesthesiologists is also highly experienced I ECT: PATIENT INFORMATION BOOKLET PAGE 3 and is a member of the Department of Anesthesiology of the Presbyterian Hospital. ECT is administered in a dedicated suite at the Psychiatric Institute. The suite contains a waiting area, a treatment room, and a recovery room. The facilities for administering ECT are state-of-the-art. How is ECT Given? Before ECT is administered, the patient's medical condition is carefully assessed. This includes a complete medical history, physical examination, blood and urine tests, electrocardiogram (EKG), chest X-ray, and other tests, as needed. The treatments are usually given three times per week - in the morning on Monday, Wednesday and Friday. Before each treatment, the patient should not eat or drink anything after midnight. Patients should also try to refrain from smoking during the morning prior to the treatment. When the patient comes to the ECT treatment room, an intravenous line is started. Sensors for recording EEG (electroencephalogram, a measure of brain activity) are placed on the head. Other sensors are placed on the chest for monitoring EKG (electrocardiogram). A cuff is wrapped around an arm for monitoring blood pressure. When everything is connected and in order, a sleeping medication (methohexital) is injected through the intravenous line that will cause the patient to sleep for 5 to 10 minutes. Once the patient falls asleep, a muscle relaxant (succinylcholine) is injected. This prevents movement, and during the seizure there are only minimal contractions of the muscles. When the patient is completely asleep and the muscles are well relaxed, the treatment is given. A brief electrical charge is applied to electrodes on the scalp. This stimulates the brain and produces the seizure that lasts for about a minute. If you were watching the procedure, you might notice that the toes wiggle, but little else. Throughout the procedure, the patient receives oxygen through a mask. This continues until the patient resumes breathing on his or her own. When the treatment is, completed, the patient is taken to the recovery room for monitoring by trained staff. Usually within 30 to 60 minutes, the patient can leave the recovery area. How Many Treatments are Needed? ECT is given as a course of treatments. The total number needed to successfully treat psychiatric disturbance varies from patient to patient. For depression, the typical range is from 6 to 12 treatments, but some patients may require fewer and some patients may require more treatments. I ECT : PATIENT INFORMATION BOOKLET PAGE 4 1 Is ECT Curative? ECT is extremely effective in providing relief from psychiatric symptoms. However, permanent cures for psychiatric illness are rare, regardless of the treatment given. To prevent relapse following ECT, most patients require further treatment with medications or with ECT. If ECT is used to protect against relapse, it is usually administered to outpatients on a weekly to monthly basis. How Safe is ECT? It is estimated that death associated with ECT occurs in one of 10,000 patients. This rate may be higher in patients with severe medical conditions. ECT appears to have less risk of death or serious medical complications than a number of the medications used to treat psychiatric conditions. Because of this strong safety record, ECT is often recommended for patients with serious medical conditions. With modern anesthesia, fractures and dental complications are very rare. What are the Common Side Effects of ECT? The patient will experience some confusion on awakening following the treatment. This is partly due to the anesthesia and partly due to the treatment. With the ECT techniques used at the Psychiatric Institute, which are designed to minimize cognitive side effects, the confusion typically clears within an hour. Some patients have headaches following the treatment. This is usually relieved by TylenolŪ or aspirin. Other side effects, such as nausea, last for a few hours at most and are relatively uncommon. In patients with heart disease, there is an increased risk of cardiac complications. Cardiac monitoring and other precautions, including the use of additional medications if required, help to ensure a safe treatment. The side effect of ECT that has received the most attention is memory loss. ECT results in two types of memory loss. The first involves rapid forgetting of new information. For example, shortly following the treatment, patients may have difficulty remembering conversations or things they have recently read. This type of memory loss is short-lived and has not been shown to persist for more than a few weeks following the completion of ECT. The second type of memory loss concerns events from the past. Some patients will have gaps in their memory for events that occurred in the weeks to months and, less commonly, years prior to the treatment course. This memory problem also improves following the completion of ECT. However, in some patients there may be permanent gaps in memory for events that ECT: PATIENT INFORMATION BOOKLET PAGE 5 occurred close in time to the treatment. However, there may be permanent gaps in memory for events that occurred close in time to the treatment. As with any treatment, patients differ in the extent to which they experience side effects, and more extensive memory loss for past events can occur. It is known that the effects on memory are not necessary to obtain the benefits of ECT. The ECT team at the Psychiatric Institute has developed techniques that minimize the effects on memory, while ensuring effective treatment. Many psychiatric illnesses result in impairments of attention and concentration. Consequently, when the psychiatric disturbance improves following ECT, there is often improvement in these aspects of thinking. Shortly following ECT, most patients show improved scores on tests of intelligence, attention, and learning. Does ECT Cause Brain Damage? The scientific evidence strongly speaks against this possibility. Careful studies in animals have shown no evidence of brain damage from brief seizures, like those given with ECT. In the adult, seizures must be sustained for hours before brain damage can occur, yet the ECT seizure lasts only for about a minute. Brain imaging studies following ECT have shown no changes in the structure or composition of the brain. The amount of electricity used in ECT raises brain temperature far less than 1/10 of a degree and is too small to cause electrical injury. How Does ECT Work? Like many other treatments in psychiatry, the exact process that underlies the effectiveness of ECT is uncertain. It is known that the benefits of ECT depend on producing a seizure in the brain and on technical factors in how the seizure is produced. Biological changes that result from the seizure are critical to effectiveness. Most scientists believe that specific changes in brain chemistry produced by ECT are the key to restoring normal function. Considerable research is being conducted to isolate the critical biochemical processes. Is ECT Frightening? ECT has often been portrayed in the movies and TV as a painful procedure, used to control or punish patients. These portrayals have no resemblance to modern ECT. One survey found that following ECT most patients reported that it was no worse than going to the dentist, and many found ECT less stressful. Other research has shown that that the vast ECT: PATIENT INFORMATION BOOKLET PAGE 6] majority of patients report that their memory is improved following ECT and that, if needed, they would receive ECT again. What are First Person Accounts of ECT? ECT is an extremely effective form of treatment. It is often safer and more effective than medications or no treatment at all. If you have any questions about ECT, please discuss them with your physician. The ECT team at the Psychiatric Institute is also available to answer any of your questions. You may also wish to read one of the following books. Both books were written by psychologists who were against people having ECT until they each had a severe depression and needed the treatment. Drs. Endler and Manning describe their illness, their experience in treatment with medication and psychotherapy, and their experience with ECT. Holiday of Darkness (revised edition) by Norman S. Endler Wall & Thompson, Toronto 1990 Undercurrents: A Therapist's Reckoning with Depression. by Martha Manning Harper, San Francisco 1995 |
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