Electroconvulsive Therapy - Treating Depression: Depression
Content provided by the Faculty of the Harvard Medical School
Electroconvulsive therapy
Reality often fails to jibe with movies and books. While psychotherapy and antidepressants have garnered some positive fictional portrayals, electroconvulsive therapy (ECT) typically evokes only frightening pictures. More than 30 years after One Flew Over the Cuckoo's Nest won its Academy Awards, the images from the film linger in many people's minds. Yet ECT remains one of the most effective treatments for severe depression, with response rates of 80%–90% for people with major depression. ECT may also be used to treat mania when a person fails to respond to other treatments.
Despite its effectiveness, doctors usually reserve ECT for situations in which several drugs have failed. That's partly because of its technical complexity, and partly because of its negative image.
How ECT works
The discomfort of ECT is roughly equivalent to that of a minor surgical procedure. The purpose of ECT is to induce a seizure, which acts as the therapeutic agent. Before receiving treatment, a person is given general anesthesia. Then the doctor places electrodes on the patient's scalp and administers an electric current in a brief pulse that causes a seizure. Medicine is given to prevent the muscular effects of the seizure, so there are no obvious convulsions. The seizure is evident only because it registers on an electroencephalographic monitor. The procedure takes a few minutes, after which the person is roused from the anesthesia.
On average, 6–12 treatments are given over several weeks. Contrary to what some people might expect, when there is a good response, the improvement occurs gradually over the course of treatment, rather than all at once. Generally, the response occurs faster than with medications, making ECT a good treatment for severely depressed people who may be at very high risk for suicide.
In the best-case scenario, a prospective patient is well-educated about ECT. Usually, doctors and nurses explain the treatment in detail, and often patients watch videotapes of the procedure. Sometimes other people who have had ECT explain what the experience is like to further demystify it. Patients decide if they want to try ECT only after they have been fully informed about how the procedure works and what its risks and benefits are. Most states have clear safeguards against involuntary ECT treatment.
ECT and memory
The most commonly discussed side effect of ECT is memory loss. Routinely, patients lose memories of events that occurred just before and soon after treatment. After the treatment concludes, some people will have difficulty remembering things that occurred during the course of treatment. Once all the treatments have ended, relatively few people have persistent memory problems. However, ECT may exaggerate problems in people already having memory trouble.
Other side effects are also fleeting. Some people feel a bit sedated or tired on the day of the procedure, or they might have a mild headache or nausea. However, these symptoms might come from the anesthesia rather than ECT itself. To date, no study has shown that ECT causes brain damage.
One drawback to ECT is a relapse rate of about 50% in people treated for severe depression. It may be even higher with so-called double depression (the combination of depression and dysthymia). To help avoid a relapse, a person who responds to ECT might also take an antidepressant medication or mood stabilizer. If dual treatment doesn't work, some people receive maintenance ECT on an outpatient basis about once a month. Some people with severe depression have done very well with this approach.
The ingredients of good therapyThere are many different approaches to psychotherapy, but all good therapy shares some common elements. To start with, make sure that your therapist has a state license. While psychotherapy isn't always comfortable, you should feel reasonably at ease with your therapist. In the best case, the two of you will be, or will become, a good match. Of course, both of you must respect ethical and professional boundaries. It's important that therapy provide some relief. Your therapist should not only offer reassurance and support, but also suggest a clear plan for how the therapy will proceed. You and your therapist should agree upon realistic goals for the therapy early on. While well-defined problems might be addressed relatively quickly, you may need to approach more difficult problems from many angles, which will take longer. Since mood disorders can have a broad influence on relationships, work, school, and leisure activities, therapy should address these areas when — or if possible before — they become a problem. Therapy isn't just for uncovering painful thoughts, although that's part of the work. Good therapy also addresses how you can adjust, adapt, or function better. And it helps you understand the nature of your distress. You should feel that your therapist approaches the important issues in your life in a way that's unique to your needs, not from a one-size-fits-all perspective. Pertinent issues springing from your culture, sex, and age, as well as individual differences, should shape the direction therapy takes. If a doctor other than your therapist prescribes antidepressants for you, the two should communicate. If they don't do so on their own, you may want to encourage collaboration by asking your therapist and doctor to speak regularly. Your therapist ought to understand the medication portion of your treatment, encourage you to take medications as prescribed, and help monitor your response. Although it's not uncommon to feel stuck at times, don't persist for months with that feeling. Some difficult problems take a long time to unravel, but you should sense progress. If you don't, it's a sign that the match between you and either the technique or the therapist isn't right. If four to six months have gone by and you don't feel better, it's a good idea to consult another therapist. |
| Last updated: | January 23, 2007 |
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Medical content reviewed by the Faculty of the Harvard Medical School. Harvard Health Publications, Copyright © 2007 by President and Fellows of Harvard College. All rights reserved. Used with permission of StayWell.
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