Electroconvulsive Therapy (ECT )
INFORMATION ON ECT
This leaflet is for anyone who wants to know more about ECT (Electro-convulsive therapy). It discussed how it works, why it is used, its effects and side-effects, and alternative treatments.
ECT remains a controversial treatment and some of the conflicting views about it are described. If your questions are not answered in this leaflet, there are some references and sources of further information at the end of the leaflet.
Where there are areas of uncertainty, we have listed other sources of information that you can use. Important concerns are the effectiveness and side-effects of ECT and how it compares with other treatments. At the time of writing, these references are available free and in full on the Internet.
What is ECT?
ECT is a treatment for a small number of severe mental illnesses. It was originally developed in the 1930s and was used widely during the 1950s and 1960s for a variety of conditions. It is now clear that ECT should only be used in a smaller number of more serious conditions.
ECT consists of passing an electrical current through the brain to produce an epileptic fit – hence the name, electro-convulsive. On the face of it, this sounds bizarre. Why should anyone ever have thought that this was a sensible way to treat a mental disorder? The idea developed from the observation that, in the days before there was any kind of effective medication, some people with depression or schizophrenia, and who also had epilepsy, seemed to feel better after having a fit. Research suggests that the effect is due to the fit rather than the electrical current.
Q How often is it used?
It is now used less often. Between 1985 and 2002 its use in England more than halved, possibly because of better psychological and drug treatments for depression.
Q How does ECT work?
No-one is certain how ECT works, and there are a number of theories.
Many doctors believe that severe depression is caused by problems with certain brain chemicals. It is thought that ECT causes the release of these chemicals and, probably more importantly, makes the chemicals more likely to work and so help recovery.
Recent research has suggested that ECT can stimulate the growth of new blood vessels in certain areas of the brain.
Q Does ECT really work?
It has been suggested that ECT works not because of the fit, but because of all the other things – like the extra attention and support and the anaesthetic – that happen to someone having it.
Several studies have compared standard ECT with "sham" or placebo ECT. In placebo ECT, the patient has exactly the same things done to them – including going to the ECT rooms and having the anaesthetic and muscle relaxant – but no electrical current is passed and there is no fit. In these studies, those patients who had standard ECT were much more likely to recover, and did so more quickly than those who had the placebo treatment. Those who didn't have adequate fits did less well than those who did.
Interestingly, a number of the patients having "sham" treatment recovered too, even though they were very unwell; it's clear that the extra support has an effect. However, ECT has been shown to have an extra effect in severe depression – it seems, in the short term, to be more helpful than medication.
Pros & Cons of ECT
Q Who is ECT likely to help?
The National Institute of Health and Clinical Excellence (NICE) have looked in detail at the use of ECT and have said that it should be used only in severe depression, severe mania or catatonia. ECT is most often used for severe depression, usually only when other treatments have failed.
Q Who is ECT unlikely to help?
ECT is unlikely to help those with mild to moderate depression or most other psychiatric conditions. It has no role in the general treatment of schizophrenia.
Q Why is it given when there are other treatments available?
It would normally be offered if:
several different medications have been tried but have not helped
the side-effects of antidepressants are too severe
you have found ECT helpful in the past
your life is in danger because you are not eating or drinking enough
you are trying to kill yourself
Q What are the side effects of ECT?
ECT is a major procedure involving, over a few weeks, several epileptic seizures and several anaesthetics. It is used for people with severe illness who are very unwell and whose life may be in danger. As with any treatment, ECT can cause a number of side-effects. Some of these are mild and some are more severe.
Many people complain of a headache immediately after ECT and of aching in their muscles. They may feel muzzy-headed and generally out of sorts, or even a bit sick. Some become distressed after the treatment and may be tearful or frightened during recovery. For most people, however, these effects settle within a few hours, particularly with help and support from nursing staff, simple pain killers and some light refreshment.
There may be some temporary loss of memory for the time immediately before and after the ECT.
Older people may be quite confused for two or three hours after a treatment. This can be reduced by changing the way the ECT is given (such as passing the current over only one side of the brain rather than across the whole brain).
There is a small physical risk from having a general anaesthetic – death or serious injury occurs in about 1 in 50,000 treatments – less than the risks in childbirth.
The greater concern is that of the long-term side effects, particularly memory problems. Surveys conducted by scientists and clinical staff usually find a low level of severe side-effects, maybe around 1 in 10. User-led surveys have found much more, maybe in half of those having ECT. Some surveys conducted by those strongly against ECT say there are severe side-effects in everyone.
Some difficulties with memory are probably present in everyone receiving ECT. Some people – some would say many – also have problems with memory for past events, even very significant ones such as the birth of a child. Most people find these memories return when the course of ECT has finished and a few weeks have passed. However, some people do complain that their memory has been permanently affected, that their memories never come back. It is not clear how much of this is due to the ECT and how much is due to the depressive illness or other factors.
Some people have complained of more distressing experiences, such as feeling that their personalities have changed, that they have lost skills or that they are no longer the person they were before ECT. They say that they have never got over the experience and feel permanently harmed.
What seems to be generally agreed is that the more ECT someone is given, the more it is likely to affect their memory.
Q What if ECT is not given?
You may take longer to recover.
If you are very depressed and are not eating or drinking enough, you may become physically ill or die.
There is an increased risk of suicide if your depression is severe and has not been helped by other treatments.
Q What are the alternatives?
If someone with severe depression refuses ECT there are a number of possibilities. The medication may be changed, new medication added or intensive psychotherapy offered, although this should already have been tried. Given time, some episodes of severe depression will get better on their own, although being severely depressed carries a significant risk of suicide.
Deciding to have (or not to have) ECT
Q Giving consent to having ECT
Like any significant treatments in medicine or surgery, you will be asked to give consent, or permission for the ECT to be done.
The ECT treatment, the reasons for doing it and the possible benefits and side-effects should be explained in a way that you can understand. If you decide to go ahead, you then sign a consent form. It is a record that ECT has been explained to you, that you understand what is going to happen, and that you give your consent to it. However, you can withdraw your consent at any point, even before the first treatment.
Q What if I really don’t want ECT?
If you have very strong feelings about ECT, you should make them known to the doctors and nurses caring for you, but also friends, family or other advocates who can speak for you.
Doctors must consider these views when they think about what to do.
If you have made it very clear that you do not wish to have ECT then you should not receive it. It may be helpful to write an ‘advance directive’ to make clear how you want to be treated if you become unwell again.
Q Can ECT be given to me without my permission?
Most ECT treatments are given to people who have agreed to it. This means that they have had:
a full discussion of what ECT involves
why it is being considered in their case
the advantages and disadvantages
a discussion of side-effects.
It is the responsibility of the doctors and nurses involved to make sure that this discussion has been had – and to document it.
Sometimes, however, people become so unwell that they are unable to take on board all of the issues – perhaps because they are severely withdrawn or have ideas about themselves that stop them fully understanding their position (e.g they believe what is happening to them is a punishment they deserve).
In these circumstances, it may be impossible for them to give proper agreement or consent. When this happens, it is still possible to give ECT. The legal provisions for this differ from country to country, even within the United Kingdom.
In England and Wales the patient must first be assessed by their own GP (family doctor) and a social worker, and then must have a second opinion from an independent specialist who is not directly involved in their care. The clinical team should also speak to family and other carers, to consider their views and any views the patient may have expressed before. So, if someone is judged to lack the ability to give consent, it is possible to give them ECT even if they are refusing it. In 2002 about 1 in 6 people who had ECT were judged to be not able to give consent to it, but it is not clear how many of these were actively refusing.
How is ECT given?
ECT should only used to treat severe illnesses, so usually the person having it will be in hospital, although a few people have found it helpful to have ECT as day patients.
The seizure is made to happen by passing an electrical current across the person’s brain in a carefully controlled way from a special ECT machine.
An anaesthetic and muscle relaxant are given so that:
the patient is not conscious when the ECT is given;
the muscle spasms that would normally be part of a fit – and which could produce serious injuries - are reduced to a flicker of the eyelids.
By adjusting the dose of electricity, the ECT team will try to cause a seizure between 20 and 50 seconds long.
Q Is there any preparation?
In the days before a course of ECT is started, your doctor will arrange for you to have some tests to make sure it is safe for you to have a general anaesthetic. These may include:
a chest X-ray
a record of your heart working (ECG)
You will be asked not to have anything to eat or drink for 6 hours before the ECT. This is so that that the anaesthetic can be given safely.
Q Where is ECT done?
ECT should always be done in a special set of rooms that are not used for any other purpose, usually called the “ECT suite”. There should be separate rooms for people to wait, have their treatment, wake up fully from the anaesthetic and then recover properly before leaving.
There should be enough qualified staff to look after the person all the time they are there so that any confusion or distress can be helped.
Q What happens during ECT?
You should arrive at the ECT suite with an experienced nurse who you know and who is able to explain what is happening. Many ECT suites are happy for family members to be there. You should be met by a member of the ECT staff who will do routine physical checks if they have not already been done. The staff member will check that you are still willing to have ECT and if you have any further questions.
When you are ready you will be accompanied into the treatment area and be helped onto a trolley.
The anaesthetist and anaesthetic assistant will connect monitoring equipment to check your heart rate, blood pressure, oxygen levels, etc. You may also be connected to an EEG machine, to check the brain waves.
A needle will then be put into your hand, through which the anaesthetist will give the anaesthetic drug and, once you are asleep, a muscle relaxant. While you are going off to sleep, the anaesthetist will also give you oxygen to breathe.
Once you are asleep and fully relaxed a doctor will give the ECT treatment. The muscle relaxant wears off quickly (within a couple of minutes) and, as soon as the anaesthetist is happy that you are waking up, you will be taken through to the recovery area where an experienced nurse will monitor you until you are fully awake.
When you wake up, you will be in the recovery room with a nurse. He or she will take your blood pressure and ask you simple questions to check on how awake you are. There will be a small monitor on your finger to measure the oxygen in your blood and you may wake up with an oxygen mask. You will probably take a while to wake up and may not know quite where you are at first. You may feel a bit sick. After half an hour or so, these effects should have worn off.
Most ECT units have a second area for light refreshments. The person will leave the suite when their physical state is stable and they feel ready to do so.
The whole process usually takes around half an hour.
Q. What are bilateral and unilateral ECT?
In bilateral ECT, the electrical current is passed across the whole brain; in unilateral ECT, it is just passed across one side. Both of them cause a seizure in the whole of the brain.
Bilateral ECT seems to work more quickly and effectively and it's probably the most widely used in Britain; however, it seems to cause more side effects. Unilateral ECT has fewer side-effects, but may not be as effective; it is also more difficult to do properly.
Sometimes ECT clinics will start a course of treatment with bilateral ECT and switch to unilateral if the patient experiences side-effects. Alternatively they may start with unilateral and switch to bilateral if the person isn’t getting better.
Q How often and many times is ECT given?
Most units give ECT twice per week, often on a Monday and Thursday, or Tuesday and Friday. It is impossible to predict how many treatments someone will need. However, in general, it will take 2 or 3 treatments before any effect is seen, and 4 to 5 treatments for noticeable improvement.
A course will, on average, be 6 to 8 treatments, although as many as 12 may be needed. If someone has shown no response at all after 12 treatments it is unlikely that ECT is going to help. A doctor should see the person after each treatment and their consultant should see them after every two. ECT should be stopped as soon as the person has made a recovery or if they say they don't want to have it any more.
Q What happens after a course of ECT?
Even when someone finds it effective, ECT is only a part of recovering from depression. Like antidepressants, it can help to ease problems so that the sufferer is able to look at why they became unwell. Hopefully they can then take steps to continue their recovery and perhaps find ways to make sure the situation doesn’t happen again. Psychotherapy and counselling can help and many sufferers find their own ways to help themselves. Certainly people who have ECT, and then do not have other forms of help, are likely to quickly become unwell again.
The ECT Controversy
There are many areas in which people disagree over ECT, including whether it should even be done at all. People tend to have very strong feelings about ECT, often based on their own experiences. The main areas of disagreement are over whether it works, how it works and what the side effects are.
Q Why is ECT still being given?
ECT is now used much less and is mostly a treatment for severe depression. This is almost certainly because modern treatments for depression like psychotherapy (talking treatments), antidepressants and other psychological and social supports are much more effective than they were in the past.
Even so, depression can for some people still be very severe and life-threatening, with extreme withdrawal and reluctance, or inability to eat, drink or communicate properly. Occasionally people may also develop strange ideas (delusions) about themselves or others. If other treatments have not have worked, it may be worth considering ECT.
Q What do patients think of ECT?
A UK review of a number of studies in 2003 found that the proportion of people who had had ECT and found it helpful ranged from a low of 30% to a high of over 80% in another. The authors commented that studies reporting lower satisfaction tended to have been user-led, those reporting higher satisfaction tended to have been doctor-led. In both user and doctor-led studies between 30% and 50% complained of memory loss.
Q What do those in favour of ECT say?
Many doctors will say that they have seen ECT relieve very severe depressive illnesses when other treatments have failed. Bearing in mind that 15% of people with severe depression will kill themselves, they feel that ECT has saved patients' lives, and so that the overall benefits are greater than the risks. Some people who have had ECT will agree and may even ask for it if they find themselves becoming depressed again.
Q What do those against ECT say?
There are many different views and many different reasons why people object to ECT. Some say that ECT is an inhumane and degrading treatment, which belongs to the past. They say that the side-effects are severe and that psychiatrists have either accidentally or deliberately ignored how severe they can be. They say that ECT permanently damages both the brain and the mind, and if it does work at all, does so in a way that is ultimately harmful for the patient. Many would want to see it banned.
Q What happens in other countries?
At the moment, ECT is part of standard psychiatric practice in Britain and the majority of countries worldwide. Some countries (and some states in America also) have restricted its use more than in the UK.
Q How do I know if ECT is done properly locally?
The Royal College of Psychiatrists has set up the ECT Accreditation Service (ECTAS) to provide an independent assessment of the quality of ECT services. ECTAS sets very high standards for ECT, and visits all the ECT units who have registered with it. The visiting team involves psychiatrists, anaesthetists, nurses and lay people. It publishes the results of its findings and also provides a forum for sharing best clinical practice. Membership of ECTAS is not compulsory but every ECT unit should be able to tell you:
if they have signed up to ECTAS;
the result of their most recent report;
who to speak to if you are concerned that your local unit has not been assessed.
Q Where can I get more information?
Many ECT suites provide their own information packs and they should be able to give written information to patients or their family/carers before a course starts. The information in these packs is often strongly in favour of ECT.
The Internet has many sites discussing ECT that are produced by professionals, organisations, people who have had ECT, or others with particular opinions. There are more negative than positive websites.
Updated May 2008
National Institute for Health and Clinical Excellence (NICE).
Electroconvulsive therapy (ECT): the clincical effectiveness and cost effectiveness of electroconvulsive therapy (ECT) for depressive illness, schizophrenia, catatonia and mania. www.nice.org.uk/guidance/TA59
Scottish ECT Accreditation Network (SEAN).
A site designed to complement the work of SEAN, by enabling communication of the latest information on ECT in Scotland. http://www.sean.org.uk/
Electroconvulsive Therapy Accreditation Services (ECTAS).
Launched in May 2003, ECTAS aims to assure and improve the quality of the administration of ECT; awards an accreditation rating to clinics that meet essential standard. www.rcpsych.ac.uk/crtu/centreforqualityimprovement/electroconvulsivetherapy.aspx
Ebmeier, K. et al (2006) Recent development and current controversies in depression. Lancet, 367,153-167
Eranti,S. V. & McLoughlin, D.M (2003) Electroconvulsive therapy - state of the art. the British Journal of Psychiatry 182: 8-9
Rose, D., Fleischmann, P., Wykes, T., Leese, M. & Bindman, J. (2003) Patients' perspectives on electroconvulsive therapy: systematic review
Scott A.I.F. (2004) The ECT Handbook (Second edition): The Third Report of the Royal College of Psychiatrists’ Special Committee on ECT. Royal College of Psychiatrists: London
UK ECT Review Group. (2003)
Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 361: 799-808
Department of Health Statistical survey (2007) Electro Convulsive Therapy: Survey covering the period from January 2002 to March 2002, England. DH: London
This leaflet was produced by the Royal College of Psychiatrists' Public Education Editorial Board.