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Vital Signs

Summer 2011

ECT Has Proven to Be Effective Treatment for Severe Depression


Electroconvulsive therapy (ECT) has a controversial past, but for more than 50 years it has been both a safe and highly effective treatment for severe depression and certain other conditions. ECT affects brain chemistry associated with depression by applying a small amount of electrical energy to the brain to induce a brief seizure — without associated body convulsions.

“The best analogy is to rebooting a computer,” says Randall Espinoza, M.D., M.P.H., medical director of the Electroconvulsive Therapy Program at the Stewart and Lynda Resnick Neuropsychiatric Hospital at UCLA. “When a computer freezes, you have to reboot the system, and that is essentially what ECT is doing for a person who is in a state of depression.”

Patients with unremitting severe depression, especially when accompanied by significant physical complications, suicidal thinking or psychosis, are most likely to benefit from ECT. Evidence suggests that for patients who have not improved with up to three antidepressant medications, ECT is significantly more likely to be effective than having the patients try another medication. A major clinical trial called STAR-D found that the likelihood of depressed patients improving when trying their third medication trial is 17 percent; by contrast, approximately 50 percent of these patients can improve after ECT.

At the same time, Dr. Espinoza notes that ECT should not be considered a treatment of last resort — offered only after patients have failed to benefit from medications or psychotherapy. “Decisions have to be made on an individual basis,” he says. “There is no requirement that a patient undergo multiple trials of medications or be depressed for months or years before being considered for ECT.” In California, which highly regulates ECT practice, ECT should be considered the least drastic treatment alternative at the time.

Before a patient receives ECT, he or she should be extensively evaluated to ensure that it is the appropriate treatment for his or her condition. Treatment typically occurs in two phases. The initial series is comprised of six to 12 sessions over two to four weeks, and these can be delivered either on an inpatient or outpatient basis, depending on the illness severity of the patient. The second phase is optional and determined for the individual patient. In this maintenance phase, ECT is administered with decreasing frequency and may continue for weeks, months or years, depending on individual needs of each patient.

Despite its long record of safe and effective use, ECT continues to be stigmatized by its past history and misconceptions about what it involves. One of the reasons for the misperceptions about ECT is because, at around the time it was developed, other more barbaric treatments were being used, such as insulin shock and frontal lobotomy, Dr. Espinoza says. Although these treatments were quickly discredited and abandoned, they are still often confused with ECT. Moreover, early administration of ECT involved high doses of electricity given without anesthesia or muscle relaxation; this application produced significant side effects, both cognitive and physical. While the therapy has not been applied that way since the mid-1950s, Dr. Espinoza says, misconceptions persist.

VS-Summer11-Severe DepressionSide effects of today’s ECT treatment are well understood and mostly time-limited. There is a period of disorientation immediately after the therapy; this usually resolves over the course of the day, Dr. Espinoza explains. In addition, two main types of memory problems are associated with ECT. Anterograde amnesia, or the inability to create new memories, is common during the initial treatment phase, but generally ceases to be a problem once the ECT stops, and it resolves by about two to three months. By contrast, a degree of retrograde amnesia — the inability to recall information from the past — occurs in most patients as they complete their initial phase of treatment; it can take six to 12 months to dissipate, although 25-30 percent of patients continue to report memory gaps after a year.

“Importantly, if these patients have responded to ECT and are no longer depressed, they do not find this type of memory loss functionally impairing,” Dr. Espinoza says. “And increasingly we recognize that many of the persisting memory problems ECT patients report are actually related to the depressive illness itself.”

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