There are many ways ECT may work. It may be related to changing the brain cell network communications that can be over-connected in depression. ECT appears to increase neurotransmitters, such as serotonin and dopamine. ECT also increases BDNF, brain derived neurotrophic factor, which can help the brain cells grow.
ECT is used in people with treatment-resistant depression, mania, and psychosis from schizophrenia. Most people are receiving ECT for treatment-resistant depression, when antidepressant medication and psychotherapy have not worked. ECT is commonly done on an outpatient basis, but may be done as inpatient treatment when patients require hospitalization due to severe suicidality or inability to eat.
The night before ECT, patients are asked not to eat or drink anything after midnight and until after their ECT treatment the following day is completed. The morning of ECT, patients arrive to the waiting area and generally complete a clinical survey. The patient enters the ECT suite and meets with the ECT nurse, psychiatrist, and anesthesiologist. Monitors are placed on the patient’s chest and head, and an IV is placed in the arm. During the procedure, the patient receives a brief-acting anesthetic, which puts the patient to sleep for approximately 7 minutes. A muscle relaxant is given shortly after the anesthesia to loosen the patient’s muscles so that there are no motor convulsions during the therapeutic seizure. Patients are not awake for the actual seizure as they are under anesthesia. The seizure itself tends to last 20 to 60 seconds, but can last as long as 3 minutes. Patients wake up several minutes after the seizure stops. Patients are then transferred to the recovery area. They stay until blood pressure and alertness have returned to normal, which usually takes about 20 minutes.
An ECT session takes about one hour total. There is time for patient assessments before treatment, receiving treatment (20 minutes), resting in the recovery area (20 minutes), and getting transferred back to a unit (inpatient) or to the driver's vehicle (outpatient). Generally, ECT is given three times a week for a total of eight to twelve sessions. Some patients may need more or fewer treatments.
ECT eliminates a depressive episode in over 55% of patients with a marked reduction in depression in another 20 to 30% of patients. ECT remains the most effective antidepressant treatment, with a greater response rate than antidepressant medication. Although ECT is effective in the short-term to get out of depression, patients can relapse quickly, sometimes within months or weeks if they are not taking antidepressant medication during and after ECT. For this reason, we request patients take antidepressant medication during and after ECT. Some patients may continue receiving ECT periodically to prevent relapse.
An acute series of ECT involves a patient receiving ECT three times a week for 6 to 12 treatments for treatment-resistant depression or other conditions that respond to ECT.
Maintenance ECT is for patients who cannot remain well after an acute course of ECT. Generally, we will offer an acute series of ECT only. Many patients remain well while staying on antidepressant therapy, such as nortriptyline and lithium. For patients who relapse back into severe depression within a year, we commonly will offer another acute course of ECT followed by maintenance ECT. The maintenance schedule is a taper of ECT with a goal of once-per-month ECT to maintain benefit. The ECT taper from an acute series to a maintenance schedule is generally once a week for 4 treatments, then every 2 weeks for 4 treatments, then every 3 weeks for 4 treatments, then every 4 weeks. There is no limit on how long a patient can receive maintenance ECT provided the treatment is effective.
Patients are not allowed to drive during the entire ECT course and for 2 weeks after the last treatment in an acute series of ECT. An acute series is usually 3 treatments a week for 6 to 12 treatments. Patients who receive maintenance ECT can drive except on the day of ECT.
The immediate side effects of the procedure may include:
The ECT treating team requests the family’s feedback in assessing a patient’s improvement. Families can assist with transportation and supportive care after ECT. Families commonly are able to see progress in the patient’s activity before the patient actually feels better. Family can also let the ECT nurses and physicians know of any concerns they may have about the patient’s care.