For more than a year and a half, Hank Greely, a Stanford law professor, watched as an elderly family member slipped further and further into depression. One time, when another family member said a chore would become a problem if it wasn’t done in the next week, the reply came: “there won’t be a next week.” The implications were clear. And in a later visit with a psychiatrist, the person revealed suicidal thoughts and plans.
The person was admitted into hospital, where “more and more hallucinations and delusions” began to surface. Greely’s wife is a retired physician and “was very heartened by published results about the success of electroconvulsive therapy (ECT), particularly in geriatric depression.” The elderly patient didn’t think ECT would help, but they agreed to try the treatment at the request of family members. (Greely has asked the name, age and gender of the patient not be revealed for privacy reasons.) But in part because California has one of the most restrictive laws regulating ECT, it took four weeks for the individual to meet the many competence, consent and other requirements and to start treatment.
Electroconvulsive therapy has come a long way since its depiction on the 1975 film One Flew Over the Cuckoo’s Nest. Unfortunately the portrayal of ECT as cruel and barbaric has persisted in films and many people, even some physicians, still see the treatment as outdated.
“It’s frustrating to me that a procedure that seems to work better than all the alternatives for major depression remains so discouraged and disfavoured,” says Greely.
Zafiris Jeffrey Daskalakis, head of the Temerty Centre for Therapeutic Brain Intervention at the Centre for Addictions and Mental Health (CAMH) in Toronto, is part of a team that treats around 250 patients a year with ECT. “I can’t tell you the number of people who have visited our centre who are surprised to hear that we still do ECT; they think of it as an antiquated treatment.”
And while the media on the whole has reported on technological improvements in the procedure and ECT’s effectiveness in treating severe depression, the odd article focusing prominently on the critics of the procedure haven’t helped. A 2012 article in the Toronto Star – though reasonably calling for more standards for ECT – described the procedure as a “brute force assault on the brain” that works by “damaging the brain”.
“The cultural portrayal of ECT is very dramatic,” says Murray Enns, head of the Department of Psychiatry at the University of Manitoba and lead author of the Canadian Psychiatric Association’s position paper on ECT. “It’s seen as being done by providers who are at best indifferent, and at worst hostile agents of control.”
In reality, patients are informed of the pros and cons of ECT and consent to it. (In Canada and in many US jurisdictions, where a person doesn’t have the mental competence to consent to the treatment – because of psychosis, for example – a substitute decision maker can consent on the person’s behalf.) “While people can have bad side effects in rare cases, the majority of people have an improvement in an extremely debilitating condition and a number of lives are saved from suicide because of it,” says Daniel Blumberger, a scientist appointed in CAMH’s Brain Stimulation and Geriatric Mental Health Programs, and head of the Late-Life Mood Disorders Clinic. Many medical treatments unfortunately run the risk of rare but significant risk of side effects or harms.
Electroconvulsive therapy: What happens and how it works
ECT is not for most people with depression. Instead, it aims to treat those with severe and long-term depression, with symptoms that haven’t responded to antidepressants, counselling or psychosocial interventions.
“The typical ECT candidate has a very severe or profound level of depression symptoms, commonly with catatonia, psychotic features and a pressing suicidal risk,” says Enns. The procedure, he says, is often the “umpteenth treatment” they’ve tried.
ECT involves inducing a seizure in the brain. Patients are given a muscle relaxant and are under anesthesia during the procedure, so they don’t feel anything. While scientists know the seizure is necessary to improve symptoms, they don’t know exactly why, says Enns. “We know that there are neurotransmitter changes in the brain following ECT,” says Enns, but scientists don’t yet know which brain changes are responsible for alleviating symptoms, and which are simply a side effect of treatment.
The mystery behind how ECT works could be leading to more reluctance on patients and providers to pursue the treatment, but Enns points out “there are lots of things in medicine where we know that they work but we don’t know exactly how they work.” He points to digoxin, derived from the foxglove plant, which was long used as an effective heart medication before experts had any insight as to why it helped.
Usually, the first time a patient undergoes ECT (known as the acute phase), the person will receive two or three ECT treatments a week. Patients with major depressive disorder or bipolar disorder typically need six to 12 treatments during this acute phase, according to Enns.
ECT is not a cure, however, and patients usually need ongoing treatment. This treatment could include antidepressants or counselling, but the best way to prevent a relapse into major depression is through maintenance or continuation of ECT, says Enns. In maintenance ECT, a single ECT treatment is given anywhere from once a week to once a month to a few times a year.
The procedure has become more refined over the years, with a better understanding of precisely how much electrical current is needed to induce a seizure. “The amount of energy delivered is far less than it used to be,” says Blumberger.
Pros and cons of ECT
For those with long-term major depression that hasn’t responded to medication, ECT is considered the best option. One systematic review found that the procedure improved the average participant’s depression score by 10 points on a commonly used scale for depression (anything below 7 on the scale is considered normal and anything above 20 is considered moderate to severe depression). The same review showed ECT was about twice as effective as medications for treating depression. The American Psychiatry Association reports that 80% of patients who undergo ECT see substantial improvements in their symptoms.
There are side effects to the treatment, however. “The memory side effects can range from being relatively mild to, at times, people having a great deal of difficulty recalling information before the ECT or retaining new information after the procedures,” says Daskalakis. In Greely’s relative’s case, for example, the hours just before and after the treatment are often hazy, “though it doesn’t seem to have had any affect at all on longer term memories,” he says.
While people might have difficulty recalling the time around their treatments, “their ability to remember new things generally recovers within three to six months,” says Blumberger. That’s true even for those who continue with maintenance ECT, “it’s just their memory recovery is slower.” A systemic review reported no overall effect on people’s ability to learn or retrieve memories six months after the treatment, but in rare cases, cognitive effects have continued.
Daskalakis says that the memory side effects of ECT have reduced over the last two decades as the technique has been improved. And he is quick to stress that there is no evidence that the memory loss is a result of brain damage. Brain scans of those who have had ECT don’t show any physical signs of damage.
Beyond mood, ECT can help with other symptoms that can occur with depression. “Depressed people often don’t focus well, they don’t put the energy and effort into memorizing things,” Enns points out. “Those particular kind of memory problems typically improve with ECT.”
Barriers to treatment
According to a Health Quality Ontario report, there are an estimated 100,000 to 200,000 patients with treatment-resistant depression in any given year in Ontario alone. But only about 1,000 Ontarians will receive ECT in a year, says Blumberger, meaning only 1% of the people who could benefit from ECT actually get the treatment.
There are variety of reasons for the low numbers. The negative popular culture portrayals have played a role in patients’ not wanting to seek out the treatment. And some patients turn down the treatment out of fear of the cognitive effects, says Daskalakis.
But it’s not just patients. “Sometimes, even physicians are not supportive of it,” says Daskalakis. In other cases, physicians don’t suggest ECT because “they believe that their patient will find it unacceptable,” says Enns. More awareness training is necessary among the medical community to address this reluctance, says Enns.
Geographical and funding barriers are also an issue. There are no available statistics on wait times for ECT in Canada, according to Nicholas Delva, head of the department of Psychiatry at Dalhousie University and lead author of a 2011 survey on access to ECT. But Delva’s survey found that about 16% of Canadians are more than an hour’s drive away from a centre that performs ECT, with 5% of Canadians more than two hours’ drive away. There are no ECT-performing centres in the territories, so people have to be flown to provincial centres. And many centres only perform in-patient ECT, and don’t provide ECT for patients who haven’t been admitted to a psychiatric unit, says Delva.
A lack of caregiver support or transportation on the part of patients poses another barrier. “If you’re an outpatient, you have to have someone waiting to take you home. A taxi isn’t appropriate. For someone who is socially isolated, that can be difficult,” says Blumberger.
Beyond drive times, around 29% of the centres surveyed reporting not having the funds for adequate staff and 14% reported not being able to purchase up-to-date equipment. Another survey reported concerning variations from centre to centre in regards to consent procedures and protocols, and called for the accreditation of ECT centres to ensure adherence to standards around consent and treatment protocols.
Given that ECT has been described as “the most stigmatized treatment in medicine,” much work remains to be done. Greely thinks the stigma has led people who have had success with ECT to keep quiet about it, while those who have had negative experiences with ECT are much more likely to reach out to the media.
That’s why he’s happy to share his family member’s story. “After five sessions spread over 12 days, [the person] was recovery was almost total,” says Greely. The family member currently receives ECT treatments three or four times a month to avoid relapse. Greely’s family can now chat and joke with the person just as they had in the past.
“Really serious clinical depression strips you of who you are and for many people it leads directly to suicide, or a lack of care for themselves that accelerates their death,” says Greely, pointing to poor nutrition, exercise, or social interaction habits of severely depressed people. “Drug treatments help some people but there’s an awful lot of people they don’t help.”
“It’s frustrating because there are tens of thousands or more people in North America who could benefit from this procedure who are not getting it because of outdated stereotypes,” he says.
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Thank you for your informative and thoughtful reflection on ECT.
I live in British Columbia Canada and feel inspired to share part of my story with you.
Depression has been part of my life I believe since my birth when I was surrendered for adoption and placed in foster care. Not only have traumatic environmental factors impacted me throughout life, upon meeting my biological mother at 27 and having a relationship with her for just a few years, I believe hereditary factors are present as well.
Skipping ahead, on October 1, 2017, I was attending the Route 91 Music Festival in Las Vegas Nevada with my boyfriend. He surprised me with the trip, two weeks after I completed an intensive two-month traumatic stress recovery program at a mental health treatment centre in Ontario.
While enjoying the concert, shots began to ring out.
My boyfriend, an RCMP officer, knew what to do and saved my life, along with many other lives.
We were fortunate to survive the shooting massacre which ended 59 lives and injured more than 900 that night.
Surviving such a horrific event however, brought about new challenges for my mental health and the mental health of my partner.
In June 2018, my partner shot himself.
I quickly began to spiral downward.
By September I was hospitalized after sitting in my car, in my garage, contemplating starting the ignition and ending my life. I am a mother of two teenagers and thankfully had the foresight to seek help.
I began my first acute course of ECT treatment shortly after.
I believe around Christmas I relapsed and became suicidal again.
This prompted a second complete round of ECT.
My memory from September to now is still sparse, so specific dates and exact events are sketchy, but I just completed my second course of acute treatment and now am on a maintenance schedule which consists of treatment once a month.
As with many things in science, they work, we just don’t know exactly how.
I am not only alive but actually feeling happy and hopeful most of the time.
I am starting a new job, part-time, as a wine tour guide in the beautiful Okanagan Valley.
I honestly don’t think I would be here now if it weren’t for the amazing doctors and health care professionals at Kelowna General Hospital.
I am 51 years old and over the course of my life have been prescribed at least 150 different psychiatric medications, 12 simultaneously.
Now is the most stable, consistent and healthy I have been.
I am blessed to live in a country where advanced medical healthcare is not only offered to everyone but affordable.
I actually didn’t know ECT was still a treatment option, but fortunately, my psychiatrist ordered it and I would consider it a miraculous success!
I have experienced the stigma you speak of from people not equipped with adequate modern medical knowledge, but this means nothing to me as it is my life being saved, not theirs.
I welcome the opportunity to speak more openly and directly about my experience but don’t want to bore anyone with irrelevant details.
Please contact me if you feel there would be any benefit in doing so.
I feel part of my recovery and duty includes serving others and sharing my story with the hope it will help even one person.
I look forward to your response.
Sincerely and blessings,
Diane Hutchinson
Thank you for this article, I am severely depressed and anxious, and my meds have stopped working. I receive my first ECT treatment tomorrow, and you have alleviated my worry.
Hi Erika
I hope your treatment is going well. ECT has probably saved my life and am on a maintenance schedule of one treatment every 3 weeks. The stigma of ECT is so unfair. I manage to work part time and live a pretty normal life. Most people would be astounded if they knew I had regular ECT as it works well at maintaining my mood. Yes, it has taken me a long time to get to this place where I’m pretty stable but I hate the fact I have to hide it from people.
All the best.
When I agreed to ECT, I couldn’t have cared less whether I lived or died, so its (unwarranted) reputation didn’t matter to me. I was warned about the short term memory loss, but in honesty hadn’t made that many memories within the time frame concerned. I like literally everybody at the clinic, and am starting to have a personality again, after literally six years (this time). I get a bit angry when I see people denigrate the treatment based on things they maybe read on the walls of public toilets, because I believe suicide has far more profound side effects. ECT isn’t offered to people who haven’t tried an awful lot of other things (including rTMS in my case: three times) and for good reason. I personally found the side effects of (ineffective) medication more difficult to work around than taking notes is.
Thank you for sharing a real and personal story.
After being misdiagnosed and harmed in the ER I was put into a psych facility under the false pretense of mental illness. ECT done on me without my consent imo to disable any memory I was starting to regain about what was done to me medically in the ER and the rest. To further block things its been made sure I cannot get legit radiology reports to show the extent of the damage done to my body. Found out about illegally access of my medical records where a test was accessed and images replaced..
Class action filed around devices used in electroshock (ECT). Representation for Canadian ECT patients also in place. See ectjustice.com on blog section with link to filing of suit.
Deborah This is June Merritt
I have tried and tried to find you. You sent a letter card picture to me 2 years ago, but I had no address for you on your letter. I hope you get this dear precious friend. I tried to find your phone number. I had nothing except you wrote this on the card you sent. ECT justice.com
Wow…. you are quite involved and I had not idea about this being done to people. Why would they even invent such a thing to do this to the brain. I hope and pray your are find.
Please email if you can to me ephsiansfullarmor@gmail.com I will get back to you. Love you. :}
National class action filed around devices used in electroshock. Devices called into question and so then is procedure. Anticipate a landslide of medical and nursing malpractice to come. That is my goal.
National class action suit around electroshock devices filed. Next we are going for medical malpractice suits. They know they are creating traumatic brain injuries by their own literature. Has been going on for decades. Psychiatry getting rich at expense of vulnerable patients. Media very interested in exposing this. Based in mechanism of injury/ trauma THEY have to prove it DOESN’T cause damages. I smell sweet justice in the air in a landslide of medical malpractice to come. See ectjustice.com
My 80yr mother was suffering from depression/anxiety, then the delusions began. Five different anti-depressants, over 16 wks. She was getting worse, down to 88 lbs, diapers, liquid diet. Meds were not working. We didn’t want to do ECT, but we were losing her. 12 treatments later, she is 100 lbs, no diapers, quality of life greatly improved. My mother is back. Thanks to ECT. I’m sharing her story, maybe I can help more people regain their life after depression/anxiety almost took her away.
Calling it ECT is a joke, unless the T stands for torture and trauma. Shock always has and continues to cause brain damage. The most recent Canadian study shows it causes permanent cognitive and memory deficits in about one third of patients who also are unable to return to work. It is barbaric; it is an assault on a delicate brain; an assault on ones sense of self. Patients are rarely informed of the REAL risks of shock and the brain damage it causes. Nurses and doctors seem to be unaware that the stunned calming of patients or their mild euphoria are signs of brain injury, not “improvement” in mood. They need to stop lying to their victims and themselves.
Amazing article. I currently undergo ECT on a maintenance schedule now monthly. I have asked my Doctor if I can video record it to educate and end the stigma. This is a very accurate and excellent article!!!
Thanks for sharing.
Electroshock class action suits are being reviewed by firms currently. This procedure produces acquired traumatic brain injuries similar to the NFL players only this mechanism of trauma is electrical verses blunt force trauma, but outcomes the same. In 1990 the APA decided together to withhold brain damage from consent. Emergency medicine, neurology, and even psychiatry in the dsm4 recognize electrical injury inducing Neuro/cognitive damages. Please see ectjustice.com
Very bad procedure. I can not express how cognitive damage b/o it can be called a treatment.
If you divide the meaning of the word:”treatment” maybe you find something like that: “Meant to be a treat”.
From my experience: it is induced Tragedy to human lives.
I would like my preexistng normal brain life to be back.
That is all I can think of.
I’m pretty sure my illness hasn’t left much room for anything else to do damage to my cognitive abilities. If I’m going to be frustrated and unable to live the life I was “suppose to have” I’d at least like to do it with some stability.
The movie “One Flew Over the Cuckoo’s Nest” really did a great disservice to patients and its effects have lasted 40 years. Too bad.
The exact reason I avoided seeking any form of care for a long time, and then avoided emergency services, and when I finally ended up for a short stay on an inpatient locked ward I realized that the only truth in that movie was that the ward was full of people who were misunderstood and were not getting enough help from overworked and distraught staff.