Concerns with Electroconvulsive Therapy for Depression
Electroconvulsive therapy (ECT) is one of the most rapid and effective ways for inducing complete remission of major depression symptoms. ECT is rarely used as the first line of treatment for depression and is usually tried as a last resort for patients who have had no success with conventional treatment, including antidepressant drugs, psychotherapy, and TMS.
Although ECT is effective, it’s not recommended for certain patients. Also, patients with severe depression who would typically benefit from ECT may be concerned about the side effects. But in most cases, ECT is an effective treatment method for people who do not respond to antidepressant medications. ECT may also be a favorable alternative to people with severe depression where suicide is a risk, or in pregnant mothers who do not want to expose their babies to medications.
How does ECT work for treating depression?
There is no singular cause of depression. Instead, the disorder happens because of a unique combination of genetic factors, temperament, environmental stress, and neurochemical vulnerabilities. ECT cannot treat the first three depression causes, but it is sufficient for addressing neurochemical imbalances that are known to play a role in depression. Since a combination of known factors causes depression, depression treatment is most successful when methods are tailored to the patient and utilized as a multi-pronged approach for treatment. Patients need medications, deep brain stimulation techniques, and also therapy to treat symptoms and prevent relapse. Drugs, therapy, and ECT alone are usually not enough for alleviating the disorder.
With antidepressant medications, the drugs block the brain from reabsorbing vital neurochemicals that play a role in depression symptoms. These chemicals are dopamine, serotonin, and norepinephrine. The unfortunate thing about medications is that they take several weeks to take effect. Also, up to 30% of patients won’t find any relief with medications, and they will need to try alternative therapy methods, including deep brain stimulation techniques.
When ECT is administered, the patient’s brain is immediately and rapidly flooded with neurotransmitters. Thus, patients will experience a complete and total reduction in symptoms in up to 90% of ECT cases.
What type of depression patients can benefit from ECT?
- Patients who’ve tried at least one antidepressant and experienced no symptom reduction.
- Patients with depression so severe and dangerous that they need immediate relief.
- Patients who’ve benefited from previous ECT treatments.
What happens during an ECT treatment session?
Because patients are given a sedative, ECT patients must not eat or drink after midnight the night before an ECT treatment session. Patients are given a short-acting sedative and a muscle relaxer. Doctors will place cardiac monitoring pads on the patient to monitor cardiac activity during and after the session. Next, doctors will put four electrodes on the patient’s head. Two of them will monitor brain waves, and the remaining two are used to deliver electrical pulses to the patient’s brain to induce a seizure.
Patients do not convulse or feel pain during the procedure because of the sedative and muscle relaxers. After the session, patients are monitored in a recovery room for about a half hour until their blood pressure, pulse, and breathing rates return to baseline levels.
ECT is performed on an outpatient basis, and patients will need someone to drive them home and stay with them after the procedure. Patients are not permitted to drive for 24 hours after a treatment session.
ECT sessions are usually performed three times per week for three to four weeks. For depression, most patients will go through a total of six to twelve treatments before experiencing remission of symptoms.
Why would someone not want to try ECT for depression?
Unfortunately, ECT comes with several significant and potentially debilitating side effects and concerns. It is also an invasive procedure because it requires sedation. Patients also cannot drive after a session of ECT, and they cannot be left alone on the night following the process.
The most common side effects of ECT include mild headaches, muscle pain, and nausea. These side effects are easy for most patients to manage and do not last for very long, usually a few minutes or hours after a session. But most patients also experience slight amnesia remembering what happened in the days, weeks, or months leading up to the first ECT session. A minority of ECT patients will experience significant retrograde amnesia after ECT sessions. Retrograde amnesia can indicate that ECT induces permanent structural brain changes, but current research is lacking and cannot say definitively if ECT causes permanent brain changes.
In extremely rare cases, ECT can cause myocardial infarction, stroke, and death. This is why patients who are recommended for ECT must undergo an electrocardiogram to rule out any cardiovascular issues before ECT treatment.
What patients should not try ECT?
Not everyone is a candidate for treatment even if they believe ECT could help them. For example, children under age eleven cannot undergo ECT for mental health disorders. People with heart conditions and people who cannot handle short-acting sedatives or muscle relaxers should not undergo ECT treatments.
In pregnant patients, ECT does not pose any serious risk to the fetus, or the expectant mother. For pregnant women suffering from severe depression or mania, ECT may be safer for their babies than medications. If a pregnant woman needs to undergo ECT treatment, she must be intubated for the procedure, because pregnancy can cause an ECT patient to regurgitate and risk asphyxiation.
Patients with treatment-resistant depression or severe mental health disorders who aren’t candidates for ECT can also benefit from other deep brain stimulation techniques, including TMS. TMS is proven effective for a variety of mental health disorders, including severe depression. The procedure is less invasive than ECT and does not require anesthesia, nor does it require cardiac monitoring. Mental health patients with cardiovascular issues can safely undergo TMS treatment.
The Drawbacks of ECT
In summary, patients can expect some of the following drawbacks from ECT treatment:
- Significant time commitment: Since ETC treatment typically occurs three times per week and requires 30 minutes of monitoring after each session, this type of treatment can demand a significant time commitment, which can interfere with other life activities.
- Disruption to work schedules: Keep in mind that patients are advised not to drive in the 24 hours following ECT. With three weekly sessions, this can make it difficult to make it to work, especially for those who have long commutes.
- Relatively invasive procedure: While ECT is completed on an outpatient basis, it does require anesthesia, which can make it feel more invasive than other office procedures, such as talk therapy or TMS.
- Unpleasant side effects: Side effects of ECT, which include headaches, nausea, muscle pain, and confusion, can be rather unpleasant.
- Short-term cognitive impairment: A review of the research with patients receiving ECT for depression found that short-term cognitive impairments, including memory deficits, could be present for up to a month, which may make it difficult to perform mentally challenging tasks or stay engaged at work or school when undergoing ECT.
- Relapse is high. Studies show that a relapse of depression symptoms is common after people discontinue ECT, so follow-up sessions may be needed from time to time. While this can be the case with any depression treatment, follow-up sessions can be difficult to maintain since ECT requires a significant time commitment and time away from driving.
ECT vs. TMS
Since both ECT and TMS can be effective for cases of treatment-resistant depression, people may wonder how the two treatments compare. Consider the following:
- Research shows that ECT tends to cause more side effects when compared to TMS.
- One study found that patients preferred TMS to ECT.
- A study in the journal Biological Psychiatry found that TMS and ECT were equally effective for treating major depressive disorder.
- Another study found that while ECT was more effective than TMS for treating depression overall, the two were equally effective on some measures of depression. For instance, according to patients’ results on the Hamilton Depression Rating Scale, ECT and TMS showed similar remission rates, as well as similar rates of improvement over the course of treatment.
While ECT may be slightly superior to TMS for the overall improvement of depression, the additional benefits conferred from ECT compared to TMS may not be worth the side effects that come with ECT. In fact, in one study, patients who had responded to ECT switched to TMS to maintain their mental health because they preferred TMS or could not tolerate the side effects of ECT. At the conclusion of the study, all patients had maintained their improvement in depressive symptoms, and in some cases, they saw further improvement with TMS.
In the studies mentioned above, reasons for switching from ECT to TMS were as follows:
- Intolerance of the cognitive side effects of ECT
- Fear of undergoing anesthesia
- Too much time commitment with ECT
- The stigma of undergoing ECT
Based upon this finding and the other comparisons between ECT and TMS, it seems that TMS is a viable alternative to ECT for cases of treatment-resistant depression. TMS is just as effective as ECT in many respects, and it does not come with the same side effects or time commitment that ECT can bring.
If you or a loved one is suffering from severe depression, there are options. The helpful technicians at Pulse TMS are standing by to answer your questions about effective deep brain stimulation techniques for mental health disorders. Please reach out to them today to discuss your treatment options.