Download Electroconvulsive Therapy (ECT)

Electroconvulsive Therapy
(ECT)
Fact sheet 48
Electroconvulsive Therapy (ECT) is a procedure
used to treat certain psychiatric disorders.
It involves passing a carefully-controlled electric
current through the brain, which affects the
brain’s electrical activity and aims to relieve
severe depressive and psychotic symptoms.
Modern day ECT is safe and effective. It can
relieve symptoms of the most severe forms of
depression more effectively than medication or
therapy, but because it is an intrusive procedure
and can cause some memory problems, ECT
should be used only when absolutely necessary,
and always with the full understanding and
consent of the person involved.
WHEN IS ECT USED AND WHY?
ECT is used for fast treatment of severe depressive, manic or
psychotic symptoms, or after all other treatment options have
failed, or when the situation is thought to be life-threatening.
For example, ECT may be used:
• as a first option, to treat a person with severe depression
who is experiencing psychotic symptoms such as delusions
or hallucinations
• as a last option, to treat a person with severe depression
and intense suicidal thoughts who has not responded to
antidepressant medication or psychotherapy
• to stabilise the condition of a person with prolonged or
severe mania who is at immediate risk and cannot be left
untreated while medications are under trial.
“I don’t think I would be here today if it was not for the
treatment that I received, including ECT. I was severely
depressed, an involuntary patient who was suicidal, and was
resistant to treatment.”
CARLEEN, 54
“ECT was very effective and was responsible for my recovery.
I was very treatment resistant and this was what I needed to
‘kick start’ my recovery.”
NAOMI, 31
HOW IS THE DECISION TO USE
ECT MADE?
Decisions to use ECT are always made very carefully. In
partnership with the person wherever possible, a mental health
specialist (e.g. psychiatrist) considers whether ECT may be
necessary to reduce life-threatening symptoms.
The person is given a psychiatric evaluation and a physical
examination. Full information about the procedure (including the
risks, benefits and possible side-effects) and the person’s legal
rights are provided to the person and his/her family or carers.
The decision is made by weighing the risks for the person
against the potential danger of leaving his or her condition
untreated. It is important to remember the person can seek a
second opinion from another doctor.
Before ECT can go ahead, the person must give informed
consent showing that he/she understands the risks and
benefits, if able to do so. If the person is not able to consent (for
example because he/she is unable to speak, is unresponsive
or is severely delusional), the psychiatrist will seek independent
authority from the mental health authority in that state (often
called the Guardianship Board) to proceed in the person’s best
interests, in consultation with family or carers – and taking any
advance directives (e.g. the person’s previously stated wishes)
into account.
If the person has been able to provide informed consent, he or
she can withdraw consent at any stage in the process.
WHO ADMINISTERS ECT?
ECT is always administered by a psychiatrist (usually the person
who prescribed the ECT) and an anaesthetist.
WHAT HAPPENS DURING ECT?
Before the ECT procedure, the person is given a general
anaesthetic and a muscle relaxant. Electrodes are placed on
one (unilateral) or both (bilateral) sides of the scalp and a small
electric current is passed between these until a brief generalised
seizure occurs. The person does not feel anything due to the
anaesthetic, and does not convulse due to the muscle relaxant.
The person wakes up five to 10 minutes after treatment and is
usually clear headed within 30 minutes. Often, people do not
clearly recall the time around the ECT treatment and, at first,
may have little memory about the period of illness around the
treatment. Often, memory of these events gradually returns (see
overleaf for more information on side-effects).
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Electroconvulsive Therapy
(ECT)
Fact sheet 48
If ECT is done on an outpatient basis, a family member or friend
must drive the person home after the procedure (driving is not
allowed in the 24 hours following an ECT session) and stay until
he or she goes to sleep that night.
WHAT ARE THE RISKS AND SIDE-EFFECTS
OF ECT?
Typically, treatments are given two to three times a week for
three to six weeks, although the exact course of treatment
depends on the nature of the illness and the person’s response
to treatment. The person should be re-assessed after every
session of ECT.
The greatest risk with ECT is associated with the anaesthetic,
which has a very small risk of death (often quoted as one in
100,000). Like any procedure involving an anaesthetic, ECT
involves this small amount of risk, but overall, it is regarded as
a very safe treatment. Despite the myths about ECT causing
brain damage, MRI studies have shown that it does not change
the brain anatomy in any way, as the strength of the electrical
current is too low to harm brain tissue.
Generally, symptoms start to improve after two sessions.
The treatment should be stopped as soon as the person has
responded adequately, if there are adverse effects, or if he/she
withdraws consent.
Risks
Side-effects
It is not understood exactly how ECT works to treat depression
and the outcomes may vary from person to person.
Immediate effects of ECT may include:
“I have to say that it helped – in what way I don’t know, but it
was like a cloud was lifting, letting me see the sunshine, not all
the black.”
• heart rhythm disturbances
CARLEEN, 54
“Would I have it again? No. Was it effective? No. It was not
a ‘bad’ experience as such, but nor would I say that it was a
positive experience.”
ANNE, 53
“I had ECT and it definitely turned me around and out of a
severe depressive condition. I do not know what would have
happened if I had not undertaken ECT.”
ANDREW, 40
“Unlike other people I have met, I found ECT to be an intensely
debilitating experience. I needed a circuit breaker and ECT
provided that ... I did actually feel better for a few months, but
I felt that respite had been gained at too great a cost.”
ANNE, 51
• loss of memory about the events immediately before and
after ECT
• low blood pressure
• headaches
• nausea
• sore muscles, aching jaw
• confusion.
Generally, these resolve within a few hours, although some
memory loss may persist.
Some people who have undergone ECT recommend writing
down passwords, PINs, phone numbers and special dates, and
keeping them in a safe place in case they cannot be recalled
after the treatment.
A common and significant side-effect is difficulties with memory
– this is reported by at least one in three people1 who have ECT.
It can be hard to work out which memory changes are caused
by ECT and which by the mental health condition itself – but it is
clear that ECT can lead to both loss of memories and difficulty
in creating new memories.
“I recall that the treatment was painless, brief and successful.
However, I recall that it caused headaches afterwards and a
temporary loss of memory, as well as further long-term memory
disruption.”
MICHAEL, 52
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Most research demonstrates that memory loss is very restricted
and usually temporary. However, memory changes may last
for some weeks after treatment and a few people experience
long‑term or even permanent loss of memories. The more
treatments a person has, the greater the effect on the person’s
memory and, if the ECT is bilateral rather than unilateral, is likely
to affect a person’s memory more as well.
People differ in the amount of memory loss they report from
ECT and how they feel about it. While some people find ECT
to be a beneficial and lifesaving treatment, others find their
memory loss distressing and for them, this outweighs any
benefit from ECT.
“I have lost so many memories. Do I regret it? I can’t — if I had not
gone through this process, I would not be alive today. Now I don’t
have all my memories, but I have the time to make new ones.”
CARLEEN, 54
“My memory is absolutely shot to pieces, but I don’t let that
worry me because I’d rather be well and not in a severe
catatonic depression.”
ANDREA, 43
“I have no real short-term memory and cannot remember large
chunks of my life …If I could go back, I would never sign the
consent forms because the side-effects [of ECT] have taken
parts of me I can’t get back.”
KATE, 22
WHAT IS THE EVIDENCE FOR THE USE
OF ECT?
There is strong evidence that ECT is effective in treating severe
depression in the short term. It improves depression in 70–90
per cent2 of severely depressed people, which is a very high
response rate. However, as with other therapies for depression,
relapse is common. Some people may need to have ECT on
a regular or ongoing basis (such as fortnightly or monthly),
especially if they do not respond to medication.
KEY POINTS
• ECT involves passing a carefully-controlled electric
current through the brain. ECT attracts very mixed
responses – its supporters say that it is beneficial and
lifesaving, while its critics say that it is invasive and
unnecessary.
• Modern ECT is a safe procedure, which is used to treat
the most severe forms of depression (including psychotic
depression) and severe manic symptoms, or after all
other treatment options have failed, or when the situation
is thought to be life-threatening. ECT can reduce severe
depressive symptoms more effectively than other
treatments.
• ECT is not a “cure”, but can be useful in the short term
because it works more quickly than antidepressants or
other medications.
• The main side-effect of ECT is memory loss, which
usually resolves after a few weeks, but can last longer.
People have varying degrees of memory problems after
ECT, and different reactions to it. For some people, the
benefits outweigh the side-effects, while others find the
loss of memories very distressing.
• Due to its side-effects, ECT can be used only with the
full understanding and consent of the person involved,
if he/she is able to consent. Where people are not able
to provide consent, their family and carers help the
psychiatrist to make a decision in their best interests
and in these instances, approval from the mental health
authority is usually required.
ECT can also be effective as an alternative treatment for bipolar
disorder, especially in people with chronic, recurrent illness or in
those who cannot tolerate medications.
There is no clear evidence that ECT is useful for treating
schizophrenia.
ECT is not effective in all cases. Where this occurs, it is the
treating health professional’s role to look at different treatment
options and develop a new treatment plan.
The development of this information paper included a
consultation with blueVoices – beyondblue’s national reference
group – in February 2010. Feedback was collected from
members who have received ECT treatment, their families and
carers. beyondblue is grateful to the participants for sharing
their experiences.
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Electroconvulsive Therapy
(ECT)
Fact sheet 48
MORE INFORMATION
Black Dog Institute
beyondblue: the national depression initiative
www.blackdoginstitute.org.au
Information about depression and bipolar disorder
1300 22 4636 or www.beyondblue.org.au
Information on depression, anxiety and related disorders,
available treatments and where to get help
Youthbeyondblue
www.youthbeyondblue.com
beyondblue’s website for young people – information on
depression, anxiety and how to help a friend
Lifeline
13 11 14
Counselling, information and referral
headspace – Australia’s National Youth Mental
Health Foundation
www.headspace.org.au
Information, support and help for young people
Kids Helpline
1800 55 1800
Counselling for children and young people aged between
five and 25
MensLine Australia
1300 78 99 78
Support for men and their families
Suicide Call Back Service
1300 659 467
Telephone support for those at risk of suicide, their carers and
those bereaved by suicide
Multicultural Mental Health Australia
(02) 9840 3333 or www.mmha.org.au
Mental health information for people from culturally and
linguistically diverse backgrounds
Relationships Australia
1300 364 277
Support and counselling for relationship issues
Carers Australia
1800 242 636
Information, referral and support for carers
SANE Australia
1800 18 7263 or www.sane.org.au
Information about mental illness symptoms, treatments, where
to go for support and help for carers
SOURCES AND FURTHER INFORMATION
1 Rose D, Fleischmann P, Wykes T et al (2003) ‘Patients’ perspectives on
electroconvulsive therapy: systematic review.’ BMJ 326:1363 (21 June), doi:
10.1136/bmj.326.7403.1363.
2 Reti IM Electroconvulsive therapy today http://www.hopkinsmedicine.org/
bin/e/s/DepBulletin407_ECT_extract.pdf
Fink M, Taylor MA (2007) ‘Electroconvulsive therapy: evidence and challenges.’
JAMA Jul 18; 298(3):330-2.
Jorm, AF, Allen NB, Morgan AJ, Purcell R (2009) A Guide to What Works for
Depression. beyondblue: Melbourne, August 2009.
beyondblue: the national depression initiative
Info line 1300 22 4636 or [email protected]
www.beyondblue.org.au
© Beyond Blue Ltd
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Pagnin D, de Queiroz V, Pini S et al (2004) ‘Efficacy of ECT in depression:
a meta-analytic review.’ J ECT 20(1):13-20.
Sane Australia fact sheet Electroconvulsive therapy http://www.sane.org/
factsheets/electroconvulsive_therapy_(ect).html
Visit www.beyondblue.org.au Call 1300 22 4636 Email [email protected]
BL/773 08/10
National Institute for Clinical Excellence (2003) Guidance on the use of
electroconvulsive therapy. Technology Appraisal 59 April 2003: 1-37.