By Moryt Milo
The situation was dire. Mark had been hospitalized seven times for acute psychiatric care. Several times were due to severe reactions to medication, one time for trying to take his life, others for suicidal ideation. He tried Transcranial Magnetic Stimulation (TMS), for depression. It failed. He went to multiple psychiatrists who ran the gamut of medications. Nothing worked.
He and his wife were desperate for a solution. His wife said, “His psychiatrist looked at Mark and said, ‘I don’t know what else to do. I have gone through pretty much the whole repertoire of medications I am familiar with, and nothing is working. I am starting to think you are medication resistant.’” Then the doctor recommended Mark go to El Camino Hospital and his wife said, “He told us, ‘The only thing I think might work is ECT (electroconvulsive therapy) because it reboots your brain.’”
Mark was game. His wife was hesitant. The treatment sounded scary, and she wanted to research the procedure before Mark said yes. She is not alone in being apprehensive. Doctors at El Camino, Stanford, and University of California, San Francisco hospitals said stigma is one of the barriers that prevents people who are severely depressed or treatment resistant from receiving ECT.
Although California has the strictest regulations in the nation including court approval for incapacitated individuals, multiple doctors signing off on the treatment, a 24-hour waiting period, Stanford psychiatrist Dr. Mahendra Bhati said the public has been misguided.
“ECT was first performed around the [late 1930s] about the same time people were being executed for capital crimes in the electric chair. So that’s where the stigma comes from,” Bhati, who was the founding chief of Interventional Psychiatry at Stanford, said. “People associated electric shock with being punished or treated like a criminal. No one thought of it as therapeutic intervention.”
He said that technology used in ECT is no different than a cardiac defibrillator. He added that the amount of energy used in the defibrillator is higher than the electricity used for ECT. “The technology is similar, but we think of it in vastly different ways because of the biases and the historical precedents surrounding the treatment.”
What Is ECT?
Electroconvulsive therapy, or ECT, attaches electrodes to your scalp to deliver electric current to precise areas of your brain, to induce a therapeutic seizure, which reduces symptoms of mental illness. The patient is given anesthesia prior to the procedure and a stimulus is given to trigger a seizure which can last 30-120 seconds, according to Dr.
Descartes Li at UCSF. The individual is awakened after 5-10 minutes and taken into post anesthesia care. The patient receives a series of treatments over a period of months. The process is considered outpatient surgery.
Dr. Katherine Taylor, Chief Medical Officer of Mental Health & Addiction Services at El Camino Health, who works with Mark, said it’s not about how the seizure is working, it’s the way the brain shuts off the seizure.
“ECT resets part of the brain,” she said. “It helps with neuroplasticity, making new connections in the brain. It enables the brain to heal itself more. We don’t yet really know how it works, but there are changes in blood flow and in the metabolism.”
Taylor and the staff at El Camino walked Mark and his wife through the procedure in detail, but only after the doctor concurred that Mark was resistant to medications.
“Almost immediately after I tried ECT I had results,” Mark said. “My wife noticed the difference and we decided to pursue it.”
When he stopped, Mark said he fell back into a depression and started the treatment again with positive results. That’s when he went on “maintenance,” going in every few weeks.
Doctors have noticed that after receiving ECT, medications tend to work better. Taylor said that her patients’ remission rates are usually between 50% to 60% and even higher when individuals stay on a maintenance plan and take medication.
Bhati said that if the individual has not benefited from multi anti-depression medication and tries ECT, the person has a 60% to 80% chance of going into remission. While Li said, individuals who have ECT and go on medication have a much lower relapse rate of around 39% versus 84% without medication.
ECT Side Effects
The procedure can cause headaches, nausea, muscle aches, and memory impairment. Immediately after treatment, an individual can forget things. Li said the person can feel “spaciness” or disoriented for a few days to a week. It’s common after several treatments but not the first treatment, he said. This is why the treatments are spaced out.
It is also why the procedure is first done on only one side of the scalp—known as right unilateral. This is because the right side of the brain is not the person’s dominant side, and the memory issues may not happen if treatments are only on the right side. If a patient doesn’t see results, then the procedure will be applied bilaterally—to both sides of the scalp.
Psychiatrists said that when a person is severely depressed, memory is poor, and Bhati said having depression is one of the biggest risk factors for developing dementia. “People do have memory issues with frequent treatments, but I do remind people that untreated depression has profound negative effects on memory and cognition,” Bhati said.
Mark’s wife said her husband’s short-term memory was affected by ongoing treatments. But the side effect is the tradeoff for not losing her husband, she said.
Bhati was quick to point out, “Even though I talk very highly about ECT, I don’t want to sugar coat anything. ECT is not the easiest procedure to go through. It’s the only procedure I am aware of in medicine where people have to come into the hospital several times a week and undergo general anesthesia.” He said to reduce this, Stanford will try to back off by adding medication.
However, data shows that cognitive processing does speed up and executive functions improve after ECT. Results are quicker than with medication. Yet the therapy doesn’t work for everyone. Dr. Li said about 25% of patients at UCSF don’t respond to treatment.
Is ECT the Right Choice?
One of the challenges in knowing if ECT is the right choice is whether the patient’s psychiatrist is on board. Patients may never learn about the treatment if their psychiatrist doesn’t approve of the procedure. Or the doctor may have limited knowledge of ECT to suggest it.
“Some psychiatry residents who graduate from [Stanford] may never see a single ECT case and graduate not knowing anything about ECT,” Bhati said. “Many go out into the community and treat a lot of patients and ECT is never considered an option.”
Stanford has started a fellowship program in interventional psychiatry to train physicians to be qualified in providing the treatment.
Mark was fortunate to have a doctor who suggested it and a hospital that could help him regain his life.
“I truly believe because we tried everything before, that ECT saved Mark’s life,” his wife said.
To learn more about ECT at El Camino Hospital, click here.
To learn more about ECT at Stanford hospital, click here.
To learn more about ECT, you can view Dr. Li’s series of YouTube talks on the subject.
