Electroconvulsive Therapy (ECT)

What Is ECT?

Electroconvulsive therapy, or ECT, is a medical treatment option for individuals suffering from severe depression and other treatment-resistant psychiatric illnesses that have not responded to other psychiatric interventions such as medications and therapy.

Though the mechanism is not completely understood, it is thought that ECT works by affecting the signaling of certain chemicals—or neurotransmitters—within the brain.

Much of the stigma around ECT came from the earlier forms of treatment where higher doses of direct current were used and patients struggled with tolerating more than a handful of treatments. Today’s ECT looks very different from this form. Advancements in how the energy is applied and where it is applied, as well as the use of general anesthesia medications during ECT, have dramatically improved the efficacy and tolerability of treatments.

There are certain individuals who, once they have completed an ECT series, will find that their illness returns. These patients may require another ECT series to restabilize their condition later in life and may be recommended maintenance ECT.

Maintenance ECT is a unique form of ECT. It generally is recommended after an individual has a positive response to ECT, but once the series is over, the medications and therapy they receive are not enough to maintain their mood. Generally, individuals who are recommended for maintenance ECT will undergo treatments every four to six weeks, though the specific timing is tailored to the individual’s unique presentation and needs. An outpatient psychiatrist is requested to directly supervise the patient and work in conjunction with the ECT team.

Each individual who is referred to our ECT program will be seen by one of our Neuromodulation experts and an individualized treatment plan will be created specific to their needs.

Which conditions are treated with ECT?

Conditions we treat with ECT include:

• Depressive disorders
• Bipolar disorders
• Mood disorders
• Catatonia
  • Catatonia is an acute neurological condition where a patient experiences extreme immobility or extreme motor excitement, both of which can be life-threatening.

Common Symptoms of Major Depression

• Feeling deep sadness that doesn’t improve over a period of two weeks
• Loss of pleasure in life
• Feelings of hopelessness, helplessness, or guilt
• Eating more or less than you usually would
• Sleeping much more or much less than is usual for you
• Feeling tired, regardless of the amount of sleep
• Having physical symptoms, headaches, stomach upset, pain in your body that doesn’t improve over time
• Feeling “empty” or without ability to experience emotions
• Excessive crying
• Feeling that you would be better off dead or having thoughts of taking your own life

Is ECT an inpatient or outpatient treatment?

ECT can be performed both on an inpatient and outpatient basis. Typically, if an individual is starting ECT while they are in the hospital, they will stay for a few treatments until their symptoms begin to improve, before transitioning to outpatient care.

Patients can also be referred by their mental health provider and complete the series as an outpatient once they are assessed by the ECT provider.

What should patients expect if considering ECT treatments?

An individual seeking ECT must be referred by their psychiatric provider. We currently accept initial referrals from psychiatrists, psychiatric nurse practitioners and psychiatric physician assistants. Referrals from nurse practitioners or psychiatric physician assistants require an outpatient supervising psychiatrist co-signature.

Before an ECT series can begin for a patient, we take the following steps:

1. Electroconvulsive Therapy Pre-Consultation Form and ECT Review of Systems and Case Review with Referring Provider: Each patient referred will complete an Electroconvulsive Therapy Pre-Consultation Form and ECT Review of Systems that will assist in the intake evaluation completed by one of our Neuromodulation providers. Prior to the intake evaluation, the referring provider may be contacted to further review the case. For those individuals and providers who are uncertain whether ECT is the appropriate next step, our psychiatrists will review of the individual case to determine what next steps may be appropriate, not just whether the patient would be an appropriate ECT candidate.

2. Initial Assessment: During the initial assessment, a patient’s history will be reviewed. It is important that any information that may be important to review, be provided before the initial evaluation. This will assist the physician in understanding the unique history and presentation of the individual being evaluated. Aspects of this assessment and important information include:

• A review of current symptoms reported by the individual
• Previous psychiatric history including any pertinent medication trials as documented in records received
• Medical history that could potentially be impacting their psychiatric presentation
• Other testing and evaluations completed by other providers in the past
• Historical information, as provided by the outpatient referring provider, the patient, or their support person(s)
• Contact with the individuals support person(s) for collateral information (if the patient approves to this contact)
• Other neuromodulation interventions performed in the past including ECT, transcranial magnetic stimulation (TMS), ketamine, vagus nerve stimulation (VNS), etc.
• Acute stabilizations (inpatient/emergency care/PHP/IOP/RTC admissions)

In this initial visit, the patient and their support person(s) can ask any questions they may have related to ECT as well as other forms of neuromodulation such as TMS or VNS. At the end of the evaluation, the provider will discuss recommendations and next steps. Should a patient meet criteria for ECT, a review of the treatment goal, the nature and recommended timing of the procedure, potential risks and side effects, benefits, and other reasonable alternatives to treatment will be discussed in detail.

3. Medical Clearance: If the patient meets criteria for ECT, they will need to schedule and undergo a pre-anesthesia medical clearance, including having baseline lab work and an ECG with their primary care provider within 30 days of the first scheduled treatment. If additional studies/specialist clearances are needed prior to the start of treatment, these will be discussed either before or during the medical clearance appointment.

4. Medications: We will review current medications and will notify the patient of anything that must be taken or held prior to treatments. If there are certain medications that need to be discontinued prior to treatment, a discussion between our ECT psychiatrist and the outpatient referring provider will occur to discuss any recommended changes, thus ensuring that any medication changes occur prior to starting treatments. Our providers ARE NOT directly responsible for tapering/discontinuing any outpatient medications. This responsibility lies with the outpatient provider prescribing these medications.

What should patients expect during ECT treatments?

After the case review, initial assessment and medical clearance has been completed, we can then schedule the patient to begin ECT.

An Index (Acute) course of ECT is generally recommended on a schedule of two to three times per week, usually over a two- to four-week period. An index course is usually a total of eight to 14 treatments, though some individuals may require more and some individuals may require less.

On the first day of treatment, a patient and their support person(s) will meet with our staff to review any changes to their medical or psychiatric history since the initial assessment, review and complete any necessary screenings/testing, and review discharge recommendations. The ECT physician will meet with the patient and their support person(s) to review and sign the ECT informed consent, treatment plan, and answer any questions. After this consent is completed, another independent psychiatrist must meet with each patient to verify the individual’s capacity to understand and sign their consent to under ECT treatments. This specific informed consent and capacity evaluation occurs monthly or whenever there is a change to the treatment form.

It is mandatory that all patients hold food/fluids starting at midnight before their treatment day. This is to reduce the risk of risk of aspiration (choking) while under anesthesia. In addition, it is important that patients do not use nicotine products the morning of treatments, including vaping, smoking, smokeless nicotine products such as pouches (Zyns), nicotine gum, dip or snus. Nicotine puts stress on the cardiovascular system and inhaling smoke from tobacco products puts stress on the respiratory system potentially increasing your chance of complications while under anesthesia.

ECT is performed using general anesthesia in a specially appointed procedure room under the direct care of an ECT psychiatrist, an anesthesiologist, and a specially-trained nurse. After general anesthesia is achieved and the patient is asleep, a muscle relaxant is administered before each treatment is administered. During each treatment, continuous respiratory and cardiac monitoring occurs, and the ECT team monitors the electrical activity of the brain to determine when each phase of the treatment is completed.

Generally patients are “asleep” for approximately five to 10 minutes and the ECT treatment itself is less than two minutes long. Within a few minutes of the treatment’s completion, the patient begins to awaken from the effects of anesthesia. When an individual reaches an appropriate level of awareness, they are transitioned to Recovery where they will be monitored by nursing staff until deemed appropriate for discharge.

Patients are not recommended to operate vehicles, heavy machinery or perform activities where there is a risk of harm to themselves or others may be possible, while undergoing an ECT series. We require that all outpatients receiving ECT have a support person (i.e. family member/friend/caretaker) who will drive them to and from the treatments, as well as monitor for any post-ECT confusion that might occur. We are not able to accept patients who are being transported via Lyft, Uber or taxi without a companion who can monitor them given the potential confusion and fatigue that ECT and general anesthesia can produce after treatment.

What can patients expect after an initial (also called “index”) course of ECT treatment?

Patients will need to continue to take their antidepressant and other medications. They should continue to see their psychiatrist and/or therapist for regular sessions. Some patients may be recommended to transition to maintenance ECT. Typically the timing of maintenance ECT is between four to eight weeks, though the specific timing is based on the individual needs of each patient.

What are the most common side effects of ECT?

The side effects that can occur from this treatment can be from the ECT treatment itself or from the anesthesia given during the treatment. Common side effects include:

• Headache
• Nausea
• Jaw pain
• Body aches (usually only during the first few treatments)
• Confusion immediately following awakening (this tends to clear within 5-10 minutes following treatment)

These side effects tend to occur on the day of the treatment and resolve between treatments.

Memory loss, specifically short-term memory loss in and around the treatments, is also very common. Examples of this including forgetting what was eaten the day before a treatment, conversations that occurred within a few days of treatments, dates, and at times other more innocuous events like what you were watching on TV immediately before a treatment. Some patients may experience memory loss of certain events leading up the treatment series, or further back in time, though this is a rare side effect. Often individuals will report a loss of memory around the series itself. The ability to make and retain new memories though typically begins to improve within a few days of the final treatment and continues to improve daily, with full resolution occurring over a period of weeks to about three months.

The timing of memory improvement is unique to the individual and can be impacted by many things including the specific psychiatric illness that the ECT intervention is treating, prior trauma to the brain (concussions/TBI/etc.), medications that are needed to maintain stable mood after ECT in certain patients, and aspects of the ECT treatment itself.