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My doctor thinks I should have electroconvulsive therapy. I thought that was no longer used. What is it and what does it do?

Many myths exist surrounding the use of electroconvulsive therapy (ECT)[1], which is a procedure that induces a seizure in the brain through an application of an electric current through the scalp. Although ECT is not a first-line treatment (and is typically only offered after several failed medication trials/repeated hospitalizations), it is a very effective treatment. It is very safe and is not painful. The patient is given anesthesia and a muscle relaxant for the procedure. For some patients ECT is safer than medications, particularly for those with serious medical conditions for whom medication can be contraindicated and for pregnant woman who may not want to expose the fetus to a certain medication (e.g., lithium). ECT is growing in use in older depressed patients because of higher rates of concurrent medical illness and risks of toxicity from medication. Psychotic depressions are often refractory to medication, and thus ECT may be considered early on in the treatment to avoid a prolonged course of medication trials.

The risk of serious complication from ECT is 1 in 1,000. Cardiac complications are the most common adverse effects, which is why a pre-ECT evaluation includes evaluation of the cardiac system. Most potential cardiovascular complications can be avoided with the use of appropriate medications. Confusion and/or memory loss are also often common. Confusion is usually transient. Memory deficits may be for events before or after the procedure. Memory deficits usually resolve over weeks to months after, although occasionally there are more persistent memory difficulties.

Although ECT provides rapid improvement in symptoms of depression, there is a high rate of relapse—up to 50% within 6 months—and thus either continuation/maintenance ECT or medication is recommended after the treatment course. Continuation ECT is usually provided only if continuation medication has not successfully prevented relapse or recurrence of depression in the past.

ECT is usually done in a hospital setting as an inpatient (outpatient ECT may be provided for maintenance ECT). Medications are typically tapered and discontinued before the treatment, and this process may need to occur in a hospital setting because of the risk for worsening depression and/or suicidality. ECT providers have received specialized training and certification. Although protocols may vary from state to state, usually more than one physician needs to evaluate the patient and determine that ECT is clinically appropriate.

Unfortunately, because of the media's negative portrayal of ECT over the years, even with the safety features in place, this very effective procedure is highly stigmatized and may even be illegal in some jurisdictions.

I understand there are newer brain therapies approved for the treatment of depression other than ECT. What are they and should I consider them if I'm not getting better?

There are two new therapies approved by the U.S. Food and Drug Administration (FDA) and one that remains experimental but has been performed in Canada. The first two are transcranial magnetic stimulation (TMS) and vagal nerve stimulation (VNS), whereas the third is deep brain stimulation (DBS).

TMS

TMS is a noninvasive procedure that applies weak electric currents to the head, thereby exciting neurons in the brain. If performed repetitively, TMS can be used as a therapeutic tool to produce longer lasting changes. This is also referred to repetitive TMS, or rTMS. Potential therapeutic uses include the treatment of migraines, stroke, Parkinson's disease and other movement disorders, as well as depression. With respect to depression, a large number of studies have demonstrated at most a very modest effect, and none compared favorably with ECT. However, in October 2008 the procedure was approved by the FDA for use in adults with major depression who failed to improve with medication. The short-term risks are minor. There can be mild pain in the area of stimulation to the scalp and rarely mild burns from over-heating when used in conjunction with electroencephalographic electrodes. In patients with epilepsy there is a very low risk of seizure induction. Other discomforts are hearing the noise generated by the machine, somewhat similar in experience to the knocking sound of an MRI machine. The long-term risks are currently unknown, but so far there is no evidence of cognitive impairment from receiving this treatment. In conclusion, the treatment is benign and its benefits modest at best.

  • [1] a procedure that induces a seizure in the brain through an application of an electric current through the scalp, that is used to treat depression.
 
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