Electro-Convulsive Treatment of Depression

Electro-Convulsive Treatment (ECT) or Shock Therapy uses a jolt of electricity to induce a seizure while the patient is asleep and totally relaxed under the influence of an anesthetic. Many studies of ECT have shown it to be a successful treatment for depression. Typically, for severe depression, patients will receive from six to 12 treatments over a two to three week hospital stay. Indeed, most studies show a higher response rate from ECT than from any single trial of an anti-depressant medication. ECT is quite popular in certain East and West Coast areas, especially among private practice psychiatrists where the psychiatrist can make a better income with ECT than other treatments.

The drawbacks of ECT are several. In most instances, it is delivered only on an in-patient basis which dramatically increases its costs and inconvenience. Even where it is available on an out-patient basis, it requires anesthesia and an anesthesiologist. The cost per treatment for out-patient ECT will often exceed $1000 per treatment. Because of the ECT and the anesthesia, if done on an out-patient basis, the patient will need someone else to drive him home.

Patients frequently complain of memory loss after ECT. It is very well documented that patients will permanently lose their memories for many events that occurred within several months of the ECT treatments. Although a large number of studies show that patients suffer little or no measureable impairment of their ability to form new memories or to recall more distant memories when tested a couple months after treatment, up to 50% of patients still complain that they don’t feel their memory is working quite right up to three years later. Unilateral ECT probably gives rise to fewer of these long term complaints. Some psychiatrists who are very favorable to ECT seem not to be able to find these patient complaints.

Another major problem with ECT is that, when it is used for patients not responding to medication treatments, these more difficult to treat patients will often relapse within six months of the original course of ECT despite taking anti-depressant medication after receiving the ECT treatment in an effort to reduce the rate of relapse. While some psychiatrists accept this high rate of relapse as simply the cost of treating severe illness, such problems make rTMS and other strategies much more appealing. A single ECT treatment each month after initial recovery has been successfully used to prevent these relapses. The same is true for rTMS although the frequency for rTMS is usually every three weeks.

A fourth problem with ECT is that many psychiatrists who use ECT will use it before giving patients adequate alternative treatments. While most patients receiving ECT have been tried on at least one anti-depressant treatment, usually an SSRI or two different SSRIs, it is safe to say that 95% of patients receiving ECT have never received fish oil, folate, thyroid, or exercise supplementation, or an MAO inhibitor. Probably the majority have not been treated with tricyclics, venlafaxine, bupropion, lithium, or some of the other often effective medication alternatives. Virtually none of the ECT patients, except those in a few research studies, have ever received rTMS despite its much lower cost, greater convenience, and very rare side-effects.

I, myself, do not find much need for ECT. In my experience, the small numbers of patients not responding to any of the other interventions rarely do well with ECT either. While ECT should definitely be offered to these patients, but it is no miracle treatment and is considerably overused by some psychiatrists, especially when it is more profitable than other possible treatments. For these severely treatment-refractory patients, if they respond to ECT, they should probably receive it on an indefinite monthly basis as an out-patient to prevent relapse.

High ECT Relapse Rate; Lithium-Nortriptyline Helped Some: Open study of 290 MDD referred and treated with ECT. 159 remitted. 88 put in DB PC with nortriptyline and lithium-nortriptyline groups. Over the 24-week trial, the relapse rate for placebo was 84% (95% confidence interval [CI], 70%-99%); for nortriptyline, 60% (95% CI, 41%-79%); and for nortriptyline-lithium, 39% (95% CI, 19%-59%). All but 1 instance of relapse with nortriptyline-lithium occurred within 5 weeks of ECT termination. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. Sackeim HA, Haskett RF, Mulsant BH, et al. New York State Psychiatric Institute, JAMA 2001 Mar 14;285(10):1299-307.

Thyroxine Reduces ECT Cognitive Impairment: A preliminary study showed that adjunctive use of thyroid hormone significantly improves cognitive functioning in patients taking lithium. An animal study and two double-blind, placebo-controlled clinical studies examining the adjunctive use of thyroid hormone (T3) and ECT have confirmed that T3 significantly protects against ECT-related memory impairment compared to placebo. Tremont, Int J Neuropsychopharmacol 2000 Jun;3(2):175-186

ECT Maintenance: Retrospective study. 58 pt. All received ECT for unipolar or bipolar depression. Half followed only on meds, half meds plus monthly ECT. At 2 yr 93% ECT relapse free vs. 52% med only. At 5 year 73% vs. 18%. Gagne, Amer J Psychiatry 00;157:1960, Brown U. Case report of severely treatment resistant bipolar manic in Bangkok treated clozapine 150/d plus 5 ECT sessions monthly for 18 months. J ECT 00;16:204

ECT Side-Effects Common: Twenty patients (38%) developed adverse reactions from the ECT treatment. Impaired memory (14%), confusion (6%), and hypertension (6%) represented the most common. U Tromso, Clinical outcome and adverse effects of electroconvulsive therapy in elderly psychiatric patients. Kujala L, Rosenvinge B, Bekkelund SI. J Geriatr Psychiatry Neurol 2002 Summer;15(2):73-6

ECT Memory Effects Strongest on Impersonal Information: 55 MDD pt receiving bilateral or RUL ECT and normal controls tested. At the 2-month follow-up, patients had reduced retrograde amnesia, but continued to show deficits in recalling the occurrence of impersonal events and the details of recent impersonal events. The amnestic effects of ECT are greatest and most persistent for knowledge about the world (impersonal memory,) compared with knowledge about the self (personal memory), for recent compared with distinctly remote events, and for less salient events. Bilateral ECT produces more profound amnestic effects than RUL ECT. NYSPI, The effects of electroconvulsive therapy on memory of autobiographical and public events. Lisanby SH, Maddox JH, Prudic J, Devanand DP, Sackeim HA. Arch Gen Psychiatry 2000 Jun;57(6):581-90

ECT Bilateral > Unilateral Memory Difficulty, High Relapse: Double-blind, 80 depressed patients were randomized to RULECT, with electrical dosages 50%, 150%, or 500% above the seizure threshold, or BL ECT, with an electrical dosage 150% above the threshold. High-dosage RUL and BL ECT were equivalent in response rate (65%) and approximately twice as effective as low-dosage (35%) or moderate-dosage (30%) unilateral ECT. Two months after ECT, retrograde amnestic deficits were greatest among patients treated with BL ECT. Thirty-three (53%) of the 62 patients who responded to ECT relapsed, without treatment group differences. The relapse rate was greater in patients who had not responded to adequate pharmacotherapy prior to ECT. NYSPI, A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Sackeim HA, Prudic J, et al. Arch Gen Psychiatry 2000 May;57(5):425-34

ECT vs Sham on Memory at 6 Months=No Difference But No Benefit: In a 70-patient DB PC study, half received real ECT. Although ECT patients had more memory problems after ECT, at 6 months there were no signficant differences. A subgroup of ECT patients who had not responded did have more memory difficulties. Effects of ECT and depression on various aspects of memory. Frith CD, Stevens M, et al. Br J Psychiatry 1983 Jun;142:610-7; Altho depressed ECT patients improved more initially in this study, no difference could be measured at 1 and 6 month follow-up! The Northwick Park electroconvulsive therapy trial. Johnstone EC, Deakin JF, et al. Lancet 1980 Dec 20-27;2(8208-8209):1317-20

50% ECT Patients Complain 3 Years Later: Self-reports of memory problems have been evaluated prospectively in depressed patients receiving bilateral ECT or unilateral ECT, and in depressed patients receiving treatments other than ECT. Depressed patients did not complain of poor memory at seven months after hospitalization. Compared to bilateral ECT, right unilateral ECT was associated with only mild memory complaints. At three years after treatment approximately one-half of the persons who had received bilateral ECT reported poor memory. These reports seemed to be influenced by three factors: (1) recurrence or persistence of conditions that were present before ECT; (2) the experience of amnesia initially associated with ECT and a subsequent tendency to question if memory had ever recovered; and (3) impaired memory for events that had occurred up to six months before treatment and up to about two months afterwards. Electroconvulsive therapy and complaints of memory dysfunction: a prospective three-year follow-up study. Squire LR, Slater PC. Br J Psychiatry 1983 Jan;142:1-8; Also, Squire’s self-rating scale detected memory complaints different from those before ECT persisting when measured at 6 months. Memory complaint after electroconvulsive therapy: assessment with a new self-rating instrument. Squire LR, Wetzel CD, Slater PC. Biol Psychiatry 1979 Oct;14(5):791-801

Long-Term Memory Complaints Common; Test Measures Find No Difference: One hundred and sixty-six patients who had ECT in either 1971 or 1976 were interviewed. The 1976 samples represented 89 per cent of those available for interview. Their experiences of ECT and their attitudes to it are described. They found ECT a helpful treatment and not particularly frightening, but side-effects, especially memory impairment, were frequent. ECT: I. Patients' experiences and attitudes. Freeman CP, Kendell RE. Br J Psychiatry 1980 Jul;137:8-16; The same authors found no cognitive impairment at 7 month follow-up on formal testing. ECT: III: Enduring cognitive deficits? Weeks D, Freeman CP, Kendell RE. Br J Psychiatry 1980 Jul;137:26-37; 26 complainers studied in depth. It appeared some of their impairment was due to ECT. ECT: II: patients who complain. Freeman CP, Weeks D, Kendell RE. Br J Psychiatry 1980 Jul;137:17-25