Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is one of the principal treatments used in psychiatry to treat certain severe mental disorders.

ECT is recommended in patients with depressive, schizoaffective or bipolar disorders that have not improved sufficiently with other treatments. Its indication is based on the type and severity of the illness, the need for an urgent response, the impossibility of using drugs, the resistance or intolerance to other types of treatments, as well as other medical conditions and special situations (pregnancy or serious suicide risk, history of a good response in a previous episode, and the preference of the patient).

It is also employed in the treatment of catatonia, a syndrome that consists of rigidity of the body and a slowing down of movements, and in those patients who have many ideas of suicide, since it can improve the depressive symptoms much quicker than with pharmacological treatment.

It is indicated at the onset of the illness, as well as during its progression, although it depends on the type of illness. For example, when a patient has a catatonic syndrome it is recommended at the time of the diagnosis as it is more effective. However, in the case of depressive, bipolar, or schizophrenic disorders, it is indicated during the follow-up of the patients when it is observed that the medication is not sufficient to improve the symptoms.

This treatment is also used acutely when the symptoms are very severe. That is to say, in patients with depressive syndromes with delusions (that have false beliefs), suicide ideas or with a great slowing down in their functioning and, particularly, if it does not improve with the medication.

In order to avoid relapses in patients already treated with ECT that have experienced an improvement, maintenance ECT may be given. These are sessions separated in time, which achieve a reduction in the symptoms and improve the quality of life of the patient.

It consists of the administration of a small electrical stimulus that produces a mild convulsive activity. This stimulus is short and controlled, and is administered under general anaesthesia and a muscle relaxant.

A venous catheter is inserted in the hand or the arm of the patient in order to administer the anaesthesia at the time the treatment is started.

Once the patient is prepared, the ECT is started. The patient is monitored at all times, from the start of the treatment until they go home, or return to the hospital ward, if they are hospitalized. The blood pressure, heart rate, respiratory rate, and oxygen saturation are monitored.

Electrodes are placed on the forehead with a rubber strip around it where the cables are connected that, in turn, are connected to the ECT machine.

The medical psychiatrist administers the electric stimulus, which is individualised in each patient depending on their age, gender, and other clinical characteristics. The convulsion usually lasts between thirty and sixty seconds. The patients are supervised during their recovery, which usually last about 3 hours after the ECT treatment.

The patient cannot ingest solid foods until 4 hours after the anaesthesia.

In order to receive treatment with ECT, one must fast from midnight of the previous day and must arrive accompanied by a relative or carer.  

The anaesthesia required in order to perform ECT is general anaesthesia, which is performed under the direct control of the anaesthesiologist.

In order to perform this anaesthesia, the same pre-anaesthetic controls and evaluations are carried out as in any other surgical procedure. A review is made of any illnesses of the patient, the medication taken, and their history, and the risks of the procedure are assessed in order to take the necessary preventive measures.

Before the anaesthesia, the patient is monitored, as in the operating theatre, in order to monitor their vital constants during the procedure.

The general anaesthesia that is used is very short acting, about 10 minutes, which is sufficient time for the patient to suitably tolerate the ECT with the minimum effects.
Recovery is very rapid and always under the control of the anaesthesiologist, until the patient recovers a suitable level of consciousness.

ECT is currently considered to be a safe technique, and well-tolerated in the large majority of cases. Like all medical procedures that include general anaesthesia, there are potential risks that may involve the respiratory and cardiovascular systems, but they are exceptional.

The most common secondary effects are:

• Headache
• Muscle discomfort
• Nausea
• Confusion
• Difficulties in remembering

The headaches, the muscle discomforts, and the nausea, are usually mild, and can be prevented or reduced with medication.

One of the major complaints made by some patients is the memory losses. In general, they are reversed or disappear after a few weeks from completing the treatment. When the patients recover, there is usually a marked improvement in concentration and memory. It has not been demonstrated that ECT causes brain damage.

The secondary effects depend mainly on the previous condition of the patients, their age, and their personal susceptibility, as well as on the technique used, on the number of treatments given, and the administration frequency.

The most usual is to perform between nine and twelve sessions two or three times per week. Once the first sessions are done, and if it is decided to continue, they are spaced in time, first in weeks, then every two weeks and, finally, in months.

For the patients that have maintenance ECT performed to prevent relapses, the sessions are usually monthly or two-monthly.

ECT is performed in a specialist medical centre. It may be performed during a hospital admission, or you may have to go to the hospital for the day.

The anaesthetic contraindications for performing ECT are very few, and basically depend on the previous illnesses that the patient may have had and that the procedure may decompensate irretrievably (changes in intracranial pressure, heart diseases, or very severe and advanced respiratory or neuromuscular diseases, etc.).

In general, the anaesthesiologist takes the necessary measures to compensate the changes that the ECT may cause and that decompensate other diseases.

ECT is a safe and effective treatment in special populations: children and adolescents, the elderly and pregnant women.

In children younger than 13 years its use is rare, but it could be used in patients in serious situations like catatonia. In adolescents older than 13 years, it is used in very specific situations, similar to those in adult patients: catatonia, schizophrenia or resistant depression and malignant neuroleptic syndrome.

The parameters for performing the treatment (techniques and anaesthesia) are adjusted to the age of the patient, similar to that done with weight. The secondary effects are similar to those of adults, and the studies performed in this age group ensure the safety of the treatment.

ECT can also be administered in people over 65 years that meet the criteria for performing ECT. Similar to that in children and adolescents, the parameters for performing the ECT are adjusted to the age of the patient. That the patient may have other more common illnesses or conditions (hypertension, cardiac problems, etc.), does not exclude them from being able to carry out the treatment, it only has to be taken into account when monitoring the patient before and after the ECT. 

In pregnant women, who meet the criteria to have ECT performed, the treatment is very safe, both for the mother and for the foetus. The anaesthetics that are normally used for ECT have no effect on the foetus. A foetal register has to be monitored and an obstetrics control performed.

When ECT has to be administered to a patient, the medical team informs the patients and their families of what it consists. Later, the patient (or guardian, if the patient is a minor or legally disabled) must sign an informed consent sheet for the ECT procedure and for the anaesthesia.

The ECT Committee meets once a week, to which several psychiatrists attend, as well as an anaesthesiologist and a nurse, in order to follow the progress of all the patients that are on treatment, to decide treatment changes or the frequency of giving ECT, and new cases of patients to whom this therapy could be indicated are assessed.

In this sense, ECT complies with all the ethical and legal aspects. Given that there is a Committee available, it means that the decisions are supervised by different professional experts on the subject.