Electroconvulsive therapy (ECT)
Explains what electroconvulsive therapy is, what it is for and what happens during the treatment.
What is ECT and what is it used for?
ECT involves sending an electric current through the brain to trigger an epileptic fit, with the aim, in most cases, of relieving severe depression. It is occasionally used to treat mania or catatonia. The treatment is given under a general anaesthetic and uses muscle relaxants, so that the muscles only twitch slightly, and the body does not convulse during the fit.
ECT is used if you:
- have severe, life-threatening depression
- have not responded to medication or talking treatments
- have found it helpful in the past and have asked to receive it again
- are experiencing a manic episode which is severe or is lasting a long time
- are catatonic (staying frozen in one position for a long time; or repeating the same movement for no obvious reason; or being extremely restless, unrelated to medication)
- have severe postnatal depression. Because, when it works, ECT usually works very quickly, it can minimise the time that you are not able to care for and bond well with your baby (see postnatal depression).
It can be an effective treatment if you are seriously depressed, and no other treatment has worked for you. It is also suitable when it is important to have an immediate effect; for example, because you are so depressed that you are unable to eat or drink, and are in danger of kidney failure.
Why is ECT controversial?
In the past, ECT was used far more than it is now. It was done without anaesthetic and also could be given without consent. Many people experienced it as more of a punishment than a treatment, and were very opposed to its use. Some people think it is still administered in the same way, and it has also been depicted in quite barbaric ways on film. So people often have a false impression of what ECT is really like now.
Also, people’s experience of ECT varies enormously. Some people find ECT the most useful treatment they have had, and would ask for it again if they needed treatment for depression; others feel violated by it, and would do anything to avoid having it again. The main side effect is memory loss, which is usually short-term, but can be significant in some people and is often something that causes worry.
Is ECT effective?
The ECT Accreditation Service (ECTAS) did a survey between September 2004 and February 2006:
- 72 percent of service users said that ECT had been helpful
- 20 per cent said that it had had no effect
- 5 per cent said they would not want it again
- 14 per cent believed that it had changed or saved their lives.
It saved my life. I was in the darkest place I've ever been and it was my only hope. Compared to the tablets I'd tried, the side effects were mild and brief. For me, it gave me back the life I'd once had but that seemed gone forever.When ECT works, it usually works quickly, so that you feel very much better. But often, the effects don’t last long, and it can’t address any underlying despair or life problems you may have, or prevent future depression.
Therefore, it is important that you are offered other types of treatments in the period following ECT so that you can make the most of any improvement it has given you. These might include talking treatments or arts therapies which you may have been too depressed to make use of before.
ECT sometimes prevents death when someone is so profoundly depressed that they have stopped eating and drinking and looking after themselves. It may also help to lift suicidal feelings, but there is no good evidence that it prevents suicide. (For help with suicidal feelings, see 'Useful contacts’ and How to cope with suicidal feelings and How to support someone who is suicidal.)
Some people find the experience of ECT overwhelmingly negative, and may feel worse after treatment, especially if they regret having consented to it.
When should I avoid having ECT?
Before a course of ECT treatments, you will need a full medical
examination. You will be asked about:
- your medical history – if you have any physical problems, these should be treated, as far as possible, before you have ECT. If you have heart or circulation problems, or breathing problems, both the ECT itself and the anaesthetic may be more dangerous for you
- whether you are pregnant – ECT may be used in pregnancy, but the anaesthetist may not be happy about giving a general anaesthetic to a pregnant woman, except in a medical emergency
- any medicine you are taking – some prescribed drugs affect your response to ECT: some antidepressants (such as fluoxetine) may cause the fit to last longer than normal; some drugs, including benzodiazepine tranquillisers, also make it more difficult to induce a fit so that a higher dose of electric current has to be used
- any drug allergies.
The National Institute for Health and Clinical Excellence (NICE) says that before you are offered ECT, doctors should consider the risks of the treatment. These include:
• the risk of general anaesthetic
• other medical conditions you might have
• possible adverse effects, especially memory loss
• the risks of not having treatment.
Extra caution should be used in the following groups, as the risks of ECT may be higher for:
• pregnant women
• older people
• children and young people (it should not be used for depression in children under the age of 12).
After each ECT session, you should be assessed, and you should not receive any more ECT if:
• you have had a positive response so that more treatment is unnecessary
• you show signs of serious adverse effects, such as memory loss.
If you have had ECT for depression before and it did not help, you should only be given it again if:
• you and your doctors are sure that all other possible treatments have been tried
• you have discussed the possible benefits and harms with the doctor and also with a friend or family member, if you want them to be included.
How ECT treatment is given
Where will I have my treatment?
People usually receive ECT as inpatients in a hospital, although outpatient treatment is possible. (If you are an outpatient, you will need to have someone with you to accompany you home. You should not drive afterwards, and you should not return alone to an empty house.)
The ECT treatment centre should consist of a suite of three rooms: a waiting area, a treatment room and a recovery room. The suite should be organised so that patients are able to move easily from waiting room, to treatment room, to recovery room. The waiting area should be comfortable and provide a relaxing environment. In the treatment room, in addition to the ECT machine, there should be all the equipment required for monitoring and resuscitation.
The ECT Accreditation Service (ECTAS), which is run by the Royal College of Psychiatrists, sets standards for the administration of ECT, and has a list of participating clinics, and the standards they have met, on their website (see ‘Useful contacts’).
What should I expect from a treatment session?
The staff should consist of:
- nurses, including a trained nurse manager in overall charge of the ECT session; a nurse, who you know and trust, who is with you during all stages of treatment; a nurse trained in resuscitation.
- a medical team consisting of a senior psychiatrist, a senior
- an anaesthetist, and an assistant to the anaesthetist.
ECT is carried out under a general anaesthetic and with a muscle relaxant. Because of the anaesthetic, you must not eat or drink anything (except a few sips of water) for at least six hours beforehand.
You should not be wearing any hairspray, creams, make-up or nail polish, or have any metal slides or grips in your hair.
• You will lie on a bed, and your jewellery, shoes and any dentures will be removed and kept safe for you.
• Once you are comfortable, you will be given a general anaesthetic, via an injection.
• While you are unconscious, you will receive an injection of muscle relaxant to minimise the convulsions caused by the electric current. Because of the muscle relaxant, you will be given oxygen, and the anaesthetist will look after your breathing, using a face mask and a pressure bag.
• Two padded electrodes will be placed on your temples, either one on each side of your head (bilateral ECT), or both on the same side (unilateral ECT).
• A mouth guard will be placed in your mouth, to stop you biting your tongue.
• The ECT machine will deliver a series of brief, high-voltage, electrical pulses – about 60 to 70 pulses a second, for three to five seconds, causing you to have a seizure, or fit. This will cause you to stiffen slightly, and there may be twitching movements in the muscles of your face, hands and feet. The seizure should last 20 to 50 seconds.
Bilateral or unilateral ECT
ECT may be given by placing one electrode on each temple (bilateral) or by placing both electrodes on one temple (unilateral), and this makes a difference to the effect ECT will have. Bilateral placement is usually used because it is more effective, but it may cause more side effects. You may receive unilateral ECT if you have had unpleasant side effects after bilateral ECT, or if you have responded well to unilateral ECT in the past.
The seizure threshold
The strength of electric current needed to produce a fit is called the seizure threshold. This varies from person to person. It is higher in men than in women, and it increases with age, meaning that older people need a stronger electric current to produce the desired effect. Other things that affect it are the exact position of the electrodes on your head, the amount of anaesthetic you have been given, and other medication you may recently have taken.
The ‘dose’ of electric current given to you will be adjusted to take all of these things into account. If the dose is too low (below the threshold), there will be no benefit from the ECT. But the higher the dose, the greater the risk of unpleasant side effects, so it’s important that the dose is kept as close as possible to the threshold.
Immediate after effects
After the seizure, the mouth guard is removed and you will be turned on your side. The anaesthetist will provide oxygen until the muscle relaxant wears off (after a few minutes) and you start breathing on your own again. You will slowly come round, although you may feel very groggy. You may sleep for a while after treatment. (See next tab for a list of possible side effects.)
You will need to recover from the general anaesthetic as well as the ECT treatment itself.
How many treatments will I need?
There should not be a pre-set number of treatments, although a maximum number (usually 12) may be prescribed beforehand. You should be assessed after each treatment to see if another one is necessary.
The treatments should normally take place twice a week, although three treatments may be given in one week if you have a severe or life-threatening illness.
Side effects and alternatives
What are the side effects of ECT?
The most important side effect of ECT, and the one which causes most concern, is memory loss. (This is also a recognised effect of fits caused by epilepsy.) It is usually a short-term effect, and most people find their memories gradually return as they recover from ECT. However, for some people, memory loss can mean both losing personal memories, and having difficulty remembering new information. Some people have been so badly affected that they have lost key skills or knowledge.
Other side effects that may occur immediately after treatment are:
- drowsiness (you may sleep for a while)
- feeling sick
- aching muscles
- loss of appetite
Very rarely, people may experience prolonged fits, especially if they are taking drugs or have medical conditions which lower the seizure threshold (see 'How ECT is given').
Some people have had injuries to their teeth or jaw, or other muscles, but physical injury from the convulsions should be minimised by the muscle relaxant.
The general anaesthetic (as for any procedure where it is used) carries a risk of illness and a very small risk of death, separate from the ECT treatment itself.
Some people may become very confused between treatments, and on rare occasions may become restless or agitated.
Some of the symptoms listed above may subside quickly, but some may last for weeks, months, or even permanently.
Longer term effects include:
- apathy (loss of interest in things)
- loss of creativity, drive and energy
- difficulty concentrating
- emotional blunting
- learning new information
- memory loss.
I did experience short term memory loss following the treatment but that gradually faded with time… I would choose to have the treatment again if I needed it.
What are the alternatives to ECT?
If the NICE guidelines are being followed, you will only be offered ECT (in most cases) if you have tried other treatments and found them unsuccessful, unhelpful or unacceptable. These should have included talking therapies, antidepressant drugs, and perhaps arts therapies. (See depression, talking treatments, antidepressants and arts therapies for more information.)
Another physical treatment which is considered to be comparable to ECT is transcranial magnetic stimulation, a technique which stimulates the brain using magnetic fields. This is still being researched, and is not generally available in the UK at the moment, unless you are taking part in research.
In addition, if nothing else has helped and you are still severely depressed, you may be offered neurosurgery for mental disorder, vagus nerve stimulation, or deep brain stimulation. See neurosurgery for mental disorder for more information on these treatments.
Consent to ECT
Is it my decision whether I have ECT or not?
Consent under the Mental Health Act 1983
Under the Mental Health Act 1983, ECT can normally be given only if you consent and the treatment is appropriate, whether or not you are detained under a section of the Act.
If you are so ill that you do not have the capacity to consent, ECT may be given under special conditions. If you need treatment urgently, ECT can only be given when it is immediately necessary to save your life or to stop you getting any worse.
If you know that you would not want ECT treatment if you should become severely ill in the future and lack the capacity to consent, you can make an advance decision. This is legally binding under the Mental Capacity Act. The advance decision must meet special conditions if you do not want treatment even if it is necessary to save your life. For more information about this, see our legal briefing on the Mental Capacity Act.
For more information on the Mental Health Act, and consent to treatment generally, see the Mind guide to the Mental Health Act 1983, Mind rights guide: consent to treatment, and Amendments made to the Mental Health Act 1983 by the Mental Health Act 2007.
Making an informed choice
The law states that you have the right to make an informed decision about which of a number of treatment options to choose, and whether or not to accept the treatment a doctor suggests. To consent properly to a particular treatment, you need enough information to be able to weigh up the risks and benefits of having it.
Before any treatment begins, the doctor should provide you with full information, in language you can understand, about the specific nature of the treatment, any side effects or risks involved, how the treatment will be given, and what the alternative treatments are, including the alternative of having no treatment at all.
It can be hard to take in a lot of new information in one go, especially if you are very depressed and taking medication. You should not be afraid to ask your psychiatrist, or another member of staff, to explain it to you more than once. The Royal College of Psychiatrists recommends that you have a friend, relative or advocate with you, when you are given the information, so that they can go over it with you again. (See The Mind guide to advocacy for more information.)
You should be allowed time to decide whether or not to go ahead with the treatment, before signing a written consent form. The Royal College of Psychiatrists also recommends that, if your relatives or close friends disagree with your treatment, this should be recorded in your notes, together with the reasons for going ahead with it.
If you have signed a consent form, you should be informed that you can change your mind at any stage in the treatment and that, if you do, the treatment will be stopped. You should also be told how you can tell staff if you have changed your mind. At each stage of the treatment, the doctor should confirm with you that you are continuing to consent.
Questions for your doctor
If ECT is recommended, you might want to ask the following questions:
• What is the reason for suggesting I have ECT?
• What are the risks for me if I have ECT?
• How could ECT help me?
• What are the side effects?
• Are there any long-term effects?
• Have I been offered every available alternative treatment?
• What treatment will I be offered in addition to, and after, ECT?
• What is the risk that I will feel worse afterwards?
• How many treatments are suggested?
• How will the dosage be decided?
• What will happen to me if I refuse this treatment?
The Association for Post Natal Illness
helpline: 020 7386 0868
Advice and support about postnatal depression.
tel: 020 7931 6480
For people affected by bipolar disorder.
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
For a list of accredited therapists.
British Association for Counselling and Psychotherapy (BACP)
tel: 01455 88 33 00
Lists details of local practitioners.
helpline: 0845 123 2320
Information, support and understanding for people with depression.
Self-help support groups and free information.
National Institute for Health and Clinical Excellence
For guidelines on treatment.
Rethink Mental Illness
advice line: 0300 5000 927
For everyone affected by severe mental illness.
Royal College of Psychiatrists
Information on conditions and treatments, and access to the
ECTAS list of accredited ECT services.
To be revised 2015