Yes, they still do that . . . . and it works

This morning I went with one of my patients for his ECT, or electroconvulsive therapy. Yes, it is probably what you're thinking it is, though it may not look like what you imagine. So what is it? Most simply, it is when a patient's brain receives a series of electronic pulses which cause a seizure, and for unknown reasons, that seizure causes changes in the brain which are known to be effective for certain psychiatric conditions. In fact, studies have shown that it is the most effective treatment for refractory (meaning not responsive to other treatment) depression.

Here's what happens: the patient goes down to the anesthesia recovery room where they get an iv and have their vital signs monitored. A series of sensors which monitor brain electrical activity are put on the patient's head (EEG), and an adhesive pad is put on their temple. The anesthesiologist administers one drug for pain, another to make the patient unconscious, and the third to paralyze him. At this point the patient cannot breathe on his own and has to be "bagged". The psychiatrist, who has already adjusted the settings of the device which supplies the shock, then pushes a button and the shock begins. The patient then has a seizure, which since he is paralyzed, is seen primarily on the readout on the EEG, but can also be seen by sustained contractions of some facial muscles and neck. The seizure lasts from 25 to 90 seconds and the "quality" of the seizure correlates with the success of the treatment. After a few minutes, the patient awakens, remembers nothing, and suffers no ill effects aside from a temporary difficulty with memory acquisition.

How ECT works is not known exactly, but as it was explained to me, there are two main theories. The first is that the brain is like the heart, and like cardiac myocytes, neurons work in synchronous electrical harmony which can sometimes become out of sync. Like shocking a heart beating arrythmically, "shocking" the brain may re-synchronize neuronal electrical activity (an oversimplification of course). The second theory is that the increase in some neurotransmitters which is clearly seen after the seizure is responsible for the therapeutic effect. Regardless, it is well recognized that ECT is the best treatment for depression and is an excellent option for some chronic, severely depressed patients.

You'll no doubt be happy to know that ECT these days is never performed against the patient's will and doesn't resemble what you remember from One Flew Over The Cuckoos Nest. But it can be an excellent choice for some patients and it still done every day at Harborview.