Medical Technology

Despite the Stigma, ECT Remains a Gold Standard

For Clayton Lively, electroconvulsive therapy, or ECT, has been a lifesaver.

“ECT was like a last resort to treat mania and psychosis for bipolar disorder,” said the 31-year-old financial firm associate who lives in Silver Spring, Maryland. “I had tried lots of different medications.”

The first course of treatments — three times per week for several weeks — was in 2005. They helped tremendously. “I came down from my mania,” Lively said. “The hallucinations stopped. The psychosis disappeared.”

He reached a point where medications and psychotherapy worked again. And for a decade, his condition was under control.

But in 2017, another episode of hallucinations and mania jolted him off course. Intrusive thoughts returned. For instance, while driving, he would visualize veering off the road. The thoughts were jarring, and yet, he couldn’t stop them from recurring.

“I wasn’t sleeping, and it just kind of wreaked havoc on my life,” Lively recalled. “I ended up being hospitalized again.”

Once again, ECT came to the rescue — and yet again, in 2018. Now, he’s on an effective maintenance regimen, receiving ECT once every 4 weeks, after tapering down from more frequent sessions.

When a combination of antidepressants and psychotherapy fails to control severe mental illness, there’s hope on the horizon. ECT can be a reliably safe and effective option.

For some patients, using it as maintenance therapy makes sense, said Vaughn McCall, MD, editor-in-chief of The Journal of ECT and professor and chairman of psychiatry at the Medical College of Georgia in Augusta. “I would think of it the same way as you have to treat any chronic illness,” such as blood pressure medicine to keep hypertension in check and dialysis to prevent kidney failure.

Despite a cacophony of contrarian voices — mainly from the Church of Scientology — “the number of psychiatrists who see controversy in ECT is vanishingly small,” McCall said. “Within the discipline of psychiatry itself, there really is no controversy.”

In weighing the pros and cons of ECT, he noted that “when you’re trying to decide if it’s worth doing a treatment, you’re looking at the effectiveness on one hand and the side effects on the other hand.”

The answer to that emerges from several scales measuring patients’ quality of life by posing questions such as: “After receiving ECT, are you more able or less able to take care of yourself, to work and enjoy the company of other people?”

In the end, McCall said, “we’ve applied these scales in probably half a dozen studies or more, and they always show that the patients’ qualify of life as a group is improved.”

A recent study published in The Lancet Psychiatry provides a significant degree of reassurance that ECT — also called “electroshock” or colloquially just “shock” therapy — does not increase the risk of serious medical side effects. In fact, the study suggests a potential benefit in reducing suicide risk.

First performed in 1938, the treatment has been well documented in the medical literature. But negative portrayals in books and movies, such as the 1975 film “One Flew Over the Cuckoo’s Nest,” have contributed to casting it in an unfavorable light.

“Unfortunately, over the past decades and years, there’s a lot of stigma and fear around the treatment,” said the study’s lead author, Tyler Kaster, MD, a psychiatrist and clinical fellow in brain stimulation at the University of Toronto, Ontario, Canada.

For the study, Canadian investigators reviewed the admission records of 10,000 patients hospitalized for at least 3 days due to a severe depressive episode. Nearly two thirds of the patients were women, and the average age for the entire group approached 57 years.

While half of the patients underwent ECT, the others received medication and psychotherapy. Researchers found that the group undergoing ECT did not have a heightened risk of death over the next 30 days and were not any more likely to be hospitalized for a medical problem.

Previous ECT comparative studies were at high risk of bias due to their inability to sufficiently account for confounding variables and differences between those who received the treatment and those who did not. The current study employed “rigorous methods with careful attention to bias and confounding to overcome limitations of previous work,” the authors write.

They used propensity score matching, which included more than 75 variables, such as measures of cognitive impairment, depression severity, medication use, other illnesses, and use of psychiatric and various medical services, capacity to consent to treatment, and sociodemographic factors.

“This is really a landmark study in terms of showing the medical safety of ECT,” said Mark S. George, MD, professor of psychiatry and neurology at the Medical University of South Carolina, Charleston, who was not involved in the study.

He added that “ECT is a life-saving treatment” for individuals with severe depression. “It’s good that we have this option for our patients.”

The authors highlight that depression is a major cause of illness and disability worldwide, with many individuals failing to achieve remission from initial therapies. Treatment-resistant depression is often described as being nonresponsive “to two or more medication trials of adequate dose and duration from different classes,” they write. In these instances, the authors point out, there is little evidence that psychotherapy would be helpful.

“The reason we consider ECT is someone has very severe depression that hasn’t responded to medications and talk therapy,” Kaster said. “The advantage of ECT is that it’s very effective in those circumstances.”

Of all therapies for treatment-resistant depression, ECT has the highest success rate, with 60% of patients attaining remission, according to the study, which cites prior research.

Compared with neurosurgery, the procedure is not invasive but requires general anesthesia. While the patient is asleep, Kaster said, the treating clinician places an electrical stimulus on the patient’s scalp, causing a generalized seizure inside the brain that lasts from 15 seconds to 2 minutes. 

A course of ECT usually takes a total of eight to 12 treatments, delivered two to three times per week over a month to a month and a half, George said. 

Some patients need a new course of ECT if they relapse after several months. Others are unable to control their depression in between courses and require repeated doses for maintenance. The time between these ECT sessions varies for each individual, George said, but is typically one session every 3 to 4 weeks. 

To improve the odds of staying well, patients typically need to continue taking antidepressants and engaging in psychotherapy.

“It helps improve the efficacy of ECT and also down the road helps prevent relapse,” Kaster said while noting that “depression is, unfortunately, a chronic illness. We don’t have a cure.”

Murat Altinay, MD, associate professor of psychiatry at the Cleveland Clinic, Ohio, and a mood disorders specialist, said his patients generally need to demonstrate a lack of response to at least three or four antidepressants before he considers recommending ECT.

Confusion, short-term memory impairment, and muscle aches and pains may occur after the procedure, but they are relatively mild. Patients are monitored in a recovery room before discharge from the hospital, Altinay said.

The first few treatments will affect everyday function. After that initial period, however, people can resume most of their daily activities, he said.

“Maybe they won’t be able to work full-time right away, but anecdotally, we have had patients who were able to go back to the workforce relatively quickly or while they’re getting ECT,” Altinay said.

More significant adverse events are very rare, he noted, although heart rate and blood pressure can become elevated due to the electrical stimulus.

Altinay said he is pleased that the large-scale journal article has been published to help dispel myths surrounding ECT. While psychiatrists feel that ECT is generally safe and effective, the public maintains a negative view.

“It is an underutilized treatment,” he said. “In the media, it is almost depicted as a barbaric and archaic treatment in psychiatry.”

Patients are afraid of major side effects such as personality changes. Some fear they will forget someone’s birthday or other important factual information, “but that kind of stuff obviously does not happen,” Altinay said.

Sometimes it’s not only the patients who are hesitant to try ECT; it’s the family members who express concerns, said Irving Reti, MBBS, professor of psychiatry and neuroscience and director of the brain stimulation program at the Johns Hopkins University School of Medicine in Baltimore, Maryland.

“It varies from one patient to another how agreeable or reluctant or cautious they are about their treatment if the doctor thinks it’s indicated for them,” Reti said. “Family members’ concerns may be very legitimate but may also be influenced by stigma and misunderstanding about the treatment. They may also not fully appreciate the severity of their loved one’s depression that warrants the administration of ECT.”  

Hospitalized patients who are at risk of suicide have benefited from ECT. “It’s very effective,” he said. “I think it’s still the gold standard for severe treatment-resistant depression and also particularly helpful in people who are acutely suicidal.”

George cautioned that psychiatrists and the public should beware of questionable online sources that attempt to discredit ECT. “A quick Google search will find plenty of nonmedical doctors, many funded through Scientology, who will speak poorly of ECT. But they do not use evidence-based arguments and commonly do not treat patients,” he said.

“All good practicing psychiatrists that I know are in favor of ECT, as it clearly saves lives,” George added. “We all hope that the future will provide refinements of ECT, or even disruptive technologies that are more effective and with less hassle and will make ECT as we do it now obsolete. But we are not there yet.” 

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