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Electroconvulsive
Therapy (ECT) Service
Who
are we?
The Electroconvulsive Therapy Service at
UNC is a consultation service in the Department
of Psychiatry specializing in evaluations
for and treatment with Electroconvulsive
Therapy (ECT). The psychiatrist currently
treating the patient must make the referral.
Telephone
919-966-5477 (for information & appointments)
Fax 919-966-5628
What
is ECT?
Stated simply: ECT is
the application of a small amount of electricity
(electro-) to the human brain to generate
a brief grand-mal seizure (convulsive).
The procedure (therapy) is done while the
person is anesthetized and the muscles are
relaxed.
Why
is it used?
ECT is the most effective treatment for
biological depression
and in many cases, the more severe the depression,
the more likely it is that ECT will work.
Response rates for an uncomplicated depression
can be as high as 90%. For refractory depressions
(those that haven't responded to conventional
medication treatment), the response rate
is still in the 70-80% range in many studies.
For depression where the diagnosis is less
clear or particularly where there may be
a combination of diagnoses, ECT may still
be effective against depressive symptoms
but the response rate is significantly lower
(50-60%) and the response is often less
satisfying to the patient. ECT has always
been relatively safe. Now that the procedure
has evolved (like most other treatments
in medicine), we are able to administer
the treatments in a way that is not particularly
stressful for the patient, making it an
increasingly sought after treatment.
How
does ECT work?
It's not clear 'how' ECT works exactly,
but then it's not clear how antidepressants
work exactly either. We can measure neurochemical
and physiological changes in the brain after
a response to ECT, which are similar to
the changes seen in patients who respond
to antidepressant medications. Also, we
know that some of the properties of the
brain clearly change during ECT, suggesting
physiological alterations and possibly system
re-regulation. For example a person’s
seizure threshold
often rises over the course of treatment,
requiring higher dosages of electricity
to generate a seizure.
ECT does
not cure Major
Depressive Disorder (MDD) or Bipolar
Disorder. It treats episodes of depression
or mania. In other
words, a response to ECT does not mean that
the person will not get sick again in the
future. Serious mood disorders are often
relapsing disorders in most people and some
preventive strategy is required even after
a response to ECT (medicines or maintenance
ECT are the two choices usually). It is
useful to think about treatment as involving
two goals: 'getting well' and 'staying well'.
How
is ECT done?
ECT is a medical procedure that is done
in the Outpatient Procedures area at UNC
Hospitals utilizing many of the same
anesthesiologists and nurse anesthetists
who work in the UNC operating rooms. The
procedure involves a 'light' anesthesia
using a short-acting anesthetic agent such
as methohexital or propofol. After a patient
is put to sleep, his (or her) muscles are
paralyzed and oxygen is administered by
mask (intubation is rarely required). A
small amount of electricity is then used
to generate a generalized seizure of about
20-60 seconds duration. The maximum amount
of electricity we use is 100 joules,
though most patients require much less than
this. (Defibrillation
is around 300 joules).
It is important
to realize that a ‘course ‘
of ECT entails a series of treatments given
2-3 times per week until maximal improvement
has occurred. Most patients require 6 to
12 total treatments. ECT is frequently given
on an outpatient basis, though at UNC we
often start patients as an inpatient. This
is especially true for older patients or
patients with complicated medical problems
so that they may be monitored for any unusual
response to ECT, including the extent of
memory impairment (if any) or other side
effects. (See below.)
What
are the side effects of ECT?
Side effects of ECT can be divided into
those due to the anesthesia and those due
to the treatment itself. . Nausea is sometimes
seen as a result of sensitivity to the anesthetic
agents used. Muscle aches from the paralytic
agents is not uncommon as well. Post treatment
sedation is of course not unexpected. From
ECT itself you see some expected cardiovascular
changes from the seizure (a sympathetic
outflow) that can cause a brief tachycardia
(increased heart rate) and/or hypertensive
response. Patients often get post-treatment
headaches (probably due to vasodilatation).
All of these side effects can usually be
successfully managed by medications as necessary.
The
biggest concern most people have about ECT
is the potential for memory loss. 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
and is the same phenomenon seen in individuals
with epileptic (grand-mal) seizures. Due
to the fact that patients getting ECT may
be having 2-3 treatments per week for a
number of weeks, this confusion can accumulate
over time so that much of the period of
time represented by the course of ECT may
remain foggy. Fortunately, for most people,
these memory problems are time-limited,
of minimal significance, can be dealt with
by anticipating them ahead of time, and
by having additional assistance available
if needed during the course of treatment.
However, some people have reported more
persistent and longer-lasting memory effects,
especially regarding personal memory of
past events. Right now, it is not possible
to predict who will have more severe memory
problems, but techniques such as using unilateral
placement instead of traditional bilateral
placement have been utilized to try
to minimize these effects. Finally, it should
also be noted that for many individuals
memory is reported to be ‘better’
after the acute course of ECT because of
resolution of the depression and its effects
on concentration.
The death
rate in ECT is about the same as the death
rate for ‘light anesthesia’,
which means it’s very rare, and about
the same as would occur in other simple
procedures such as a colonoscopy. When deaths
do occur, it is usually due to cardiovascular
complications. Certain populations, such
as those with serious heart disease, recent
stroke or heart attacks, or with brain tumors,
are at higher risk of serious medical complications.
Much of the consultation work-up is geared
towards identifying these high risk situations
and mitigating them if ECT is still to be
pursued. In some situations, we will not
do ECT because of the medical problems.
Even so, ECT is remarkably safe even in
some of the most seriously medically ill
patients who have concurrent depression.
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Final Word
ECT is often a life-saving treatment,
which has been withheld from many
until late in the course of their
illness because of the social stigma,
not because of the science. It could
very well be a first line treatment
were it not for the continuing stigma.
Future advances in technology promise
to improve the treatment further.
In fact, with experimental treatments
such as repetitive Transcranial
Magnetic Stimulation (rTMS) it
may soon be possible to induce painless
'localized' seizures in the dysfunctional
parts of the brain which wouldn't
require the patient to even be asleep!
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Why does the stigma persist?
ECT is often still portrayed in the media
in the relatively brutal way it was first
done, i.e. without anesthesia. Anesthetic
agents are anticonvulsants, and it required
an advance in the science of anesthesia
before we could anesthetize patients, generate
a seizure, and avoid the muscle movement
associated with seizures. Unfortunately,
people don't know enough about ECT and so
can be swayed by these inaccurate portrayals.
If you tried to show surgery being done
without anesthesia, people would not believe
it because they 'know better'.
Also, ECT
began to be used in this country at about
the same time we began executing criminals
with electricity in the Electric Chair.
Ever since, the notion of electricity to
the head has been seen as 'punitive'. In
fact, in many media portrayals of ECT over
the years, the treatment has been depicted
as punishment (One Flew Over the Cuckoo's
Nest for example). Combine this with the
lingering stigma of mental illness being
the patient's fault, and you can see why
the ECT stigma still persists.
GLOSSARY
Bilateral
versus Unilateral ECT: top
Refers to the placement of the stimulus
electrodes on a patient’s scalp (which
directs the current path). In traditional
bilateral ECT, the electrodes are placed
on the right and left temples, allowing
simultaneous stimulation of both sides of
the brain. This assures a good quality seizure
in the parts of the brain that need to be
affected, but also allows electricity to
pass over the left-temporal lobe of the
brain. This is where most people have their
language and memory centers. The effect
is to cause (theoretically) more memory
problems. Unilateral electrode placement
allows both electrodes to be kept on one-side
of the brain (the non-dominant side), which
avoids having electricity pass directly
through the language and memory centers
mentioned above. However it requires that
the seizure (which will now start on one
side of the brain only) to generalize or
move across to the other side of the brain.
This doesn’t always happen successfully,
leading to less treatment effect. Most new
ECT patients at UNC will be started on unilateral
ECT and switched only if not responding
adequately.
Bipolar
Disorder: top
A type of recurrent mood disorder characterized
typically by both manic episodes and depression
(See Depression). Some individuals may have
primarily manic episodes; others may have
mostly depressions with rare manic periods,
while others may have mixed symptoms of
both mania and depression. Episodes can
be infrequent or rapid-cycling (i.e. at
least 4 episodes over the last 12 months).
Lithium has been the traditional medication
used to treat this disorder though many
other agents are now available as well.
Note that ECT works very well for both mania
and depression.
ECT,
Electroconvulsive Therapy: top
A treatment modality using small amounts
of electricity to generate a grand-mal seizure
in a patient, in an attempt to treat various
psychiatric disorders, especially depression.
Depression
(Major Depressive Disorder): top
A common psychiatric illness characterized
by depressed, irritable or apathetic mood
or loss of pleasure (anhedonia) and four
or more of the following: changes in sleep
and/or appetite, loss of pleasure and/or
interest in daily activities, impairment
of concentration or memory, low energy,
agitation or mental slowing, feelings of
worthlessness or excessive guilt, hopelessness,
helplessness and/or recurrent suicidal thoughts.
Symptoms need to be present for at least
2 weeks and be severe enough to cause some
functional impairment.
Depression:
top
Depression is a medical illness known as
a mood disorder, and it is treatable. Clinical
depression should not be confused with temporary
feelings of sadness (“feeling blue”
or “down in the dumps”) that
are part of life’s disappointments.
Depression lasts longer; is far more severe;
impairs work, relationships, physical and
other activities; and it includes more than
a sad mood. Symptoms include trouble with
sleep, appetite, energy and self-esteem.
Mania:
top
A period of persistently elevated, expansive
or irritable mood that lasts for a week
of longer and includes at least three of
the following (four if irritable mood):
inflated self-worth, decreased sleep, racing
thoughts or flight of ideas, excessive of
pressured speech, hyperactivity, excess
pleasure seeking and/or distractibility.
Seizure
Threshold: top
The energy level at which electricity will
induce a seizure. This varies for individuals
and is usually higher in males and the elderly.
Certain medications and medical conditions
can alter a person's seizure threshold.
The UNC ECT service uses a 'threshold titration
model' to determine the person's actual
seizure threshold so as to minimize the
amount of electricity used for the treatments.
Joule:
top
The joule (pronounced DJOOL) is the standard
unit of energy in electronics and general
scientific applications. One joule is defined
as the amount of energy exerted when a force
of one newton is applied over a displacement
of one meter. One joule is the equivalent
of one watt of power radiated or dissipated
for one second.
Defibrillation:
top
The arrest of fibrillation of the cardiac
muscle (atrial or ventricular) with restoration
of the normal rhythm, if successful.
Transcranial
magnetic stimulation (TMS): top
TMS is the use of powerful rapidly changing
magnetic fields to induce electric potentials
in the brain by electromagnetic induction
without the need for surgery or external
electrodes. TMS was originally developed
as a tool in brain research, and has been
used to stimulate or suppress brain activity
in experiments on human subjects.
TMS is currently under study as a treatment
for severe depression and auditory hallucinations.
It is particularly interesting as it may
provide a viable treatment to certain aspects
of drug resistant mental illness, particularly
as an alternative to electroconvulsive therapy.
Although research in this area is in its
infancy, there is now strong evidence that
TMS is an effective treatment for both depression
and auditory hallucinations, with more symptoms
and disorders being researched.
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