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of ECT as cruel and barbaric has persisted in films and many people, even some physicians, still see the treatment as outdated.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.