Why is electroconvulsive therapy treated as a treatment of last resort?

Factual Questions
1

A few psychology classes and some reading seems to indicate to me that ECT is an extremely effective treatment for long term major depression. Somewhere around 60-80% of patients with major depression have significant improvement of their symptoms under ECT, far more than respond to medication, and in general, ECT often treats people effectively who do not respond at all to medication.

As far as I understand, the risks are very limited. Some people lose memories leading up to the treatment within the past weeks prior to treatment, but even in those patients, it usually comes back. As far as I can tell, there’s no evidence of brain damage or other physiological problems caused by ECT. Aside from the memory disruption, it seems low risk and harmless.

And yet my understanding is that it’s only considered a treatment of last resort, after months or years of therapy, and usually several types of antidepressant medication failing.

This doesn’t add up to me. I know ECT has a bad rep in the mind of the public, because it dates back from the primitive days of psychological treatment, and it entered the public consciousness in a very negative way because of an inaccurate portrayal in One Flew Over the Cuckoo’s Nest. But this is public perception. Doctors know better.

So, a few questions: 1) Am I correct in assessing that it is one of the most effective, if not the most effective treatment for long term major depression?

  1. Am I correct that the negative effects are very limited and it is not a particularly risky procedure?

  2. Am I correct that it is generally treated as a treatment of last resort (or nearly so, maybe before surgical options like DBS), with many many other treatments tried before ECT is considered an option?

  3. If all of that is correct, then why is it only used as a last resort? It seems obvious to me that ECT should be given to people earlier in the process. It creates a more dramatic recover, much quicker than antidepressant drugs. And time can be of the essence when there’s a risk of suicide. It also does not require the same level of ongoing treatment - one series of treatments may alleviate symptoms for life, and if not, usually only requires maintenace treatment every few years. It seems to be more life changing. Drugs do help people, but often they make symptoms more manageable and cause a lot of side effects that make the treatment overall a mixed bag. Whereas with people who get ECT often describe it as having their problem cured or fixed. Like they got a new lease on life, and now their brain works life. It seems much more dramatic.

The only explanations I can come up with are that my understanding is wrong, or that there’s some sort of systemic bias against “old” treatments from the dark ages of psychiatric treatment, with their association with horrifying sanitariums and such. So doctors are willing to discount ECT as primitive in the same way we now look at lobotomies as primitive, except ECT is actually a great treatment.

2

Honestly, part of the reason is that it’s highly stigmatized. You can take Prozac, and most people don’t think twice, but having had ECT is something you can’t mention at a job interview. In fact, people I know who have had it have gone out of their way to make sure that it couldn’t be tracked if they used their insurance, if their insurance was through their work.

Another issue is that ECT is expensive. Insurance companies want you to try the cheaper approaches first.

3

There’s evidence that ETC causes permanent brain damage, manifesting for many people as a permanent flatting of affect and emotional depth (you feel less of everything and come across that way to others) and permanent memory loss (people have reporting losing access to their professional and personal competencies, significant memories and sense of connectedness in their family and other relationships.

4

One of the people I know who had ECT was extremely sensitive. She experienced a slight flattening of affect, but to her, it was just coming down to where everyone else already was. She went from being high-strung and overly sensitive, to experiencing emotion in a way the seemed more in sync with the rest of the world.

She was very glad she did it.

It was very long-lasting, but not completely permanent. She initially had six shocks over two weeks (M, W, F, two weeks in a row). Ten years later, she went back for just two treatments, because her feelings of being overly sensitive and out of sync had returned.

She said she had no memory of anything that happened immediately before the treatment, and a few hours before, and the whole two weeks of treatment was “through a bubble,” but she there was no apparent problem with her long-term memory.

She was really satisfied with the treatment. The high-strung, overly sensitive, out-of-syncness was the basis of an anxiety disorder that had her on a buttload of medication most of which she was off of, by three months after treatment, and she lost 40 lbs. as a result of being off the medication. She also was not experiencing depression, which was probably a side effect of the medication, although no one was really sure-- a sustained high anxiety state could be depressing by itself.

YMMV.

5

I review all manner of mental health records. While ECT is uncommon, I’ve not noticed any consistent history of treatment before ECT is tried. Similar to other health conditions - sometimes I see spinal surgery recommended and performed pretty darned quickly, w/ what appears (to my non-medically trained eyes) relatively limited signs/findings/attempts at progressive treatment.

In fact, tho I haven’t studied the literature, my impression was that ECT was gaining support, and being perceived as one effective component of treatment for certain patients w/ certain pathologies.

I’m not sure how rapidly the OP suggests ECT should be tried. I think at least SOME history would be warranted to assess the likely benefit, rather than just hooking up the jumper cables at the first visit.

6

I can’t provide a cite, but I do recall that patients consider ECT to be a treatment of last resort also. It also has limited efficacy, 50% success rate, with 50% of those successes resulting in a relapse in less than a year.

7

Now that there have been some non-anecdotal posts:

I have one friend who had ECT. I now still have that person as a friend, but they are IN NO WAY the same person they were before. They suffered severe memory loss that has not returned (as far as I can tell) in the 15 years since they had ECT.

They also struggle to form new memories - they often repeat themselves from visit to visit without recognizing that they’ve already told a particular anecdote, for example - a behavior they didn’t exhibit before ECT.

As RivkahChaya says, your mileage may vary, and I try to be cognizant that my friend’s experience is just that - the experience of a single person - but to me ECT deserves the incredibly bad reputation it has. Now, of course, there are people like RivkayChaya’s friend, for whom it was a pretty successful treatment, but I can’t get past the fact that it permanently changed the person I knew, so much so that I genuinely think of them as different people before and after ECT.

(And, it’s worth noting that it didn’t do much to cure or even affect my friend’s severe depression, so it was a loss on that front, too.)

8

I have been an observer during ECT treatments a few times when I worked at an inpatient psychiatric unit, but this was 25+ years ago, so my knowledge is outdated. The psychiatrists did not often use ECT, only resorting to it after trying numerous medications over an extended period of time. The procedure itself was relatively unremarkable, and the whole process was over in few minutes. The anesthesiologist would administer a general anesthetic after putting a cuff on the patients calf so their foot would be unaffected. The psychiatrist would administer the shock, with the only visible reaction being that the patient’s foot would wiggle. There were none of the whole-body convulsions like you see in movies. The patient was only under the effects of anesthesia for a short length of time and was up and around again fairly quickly. Patients were a bit groggy or loopy afterward, but I don’t know whether that was due mostly to the ECT or to the anesthesia. Most could not remember things that had occurred within an hour or two before the treatment. Depression symptoms seemed improved after treatments, but since I only saw patients during the few days they were in the hospital, I never got to see what long-term benefits or side effects they might experience. I think the main reason we had observers during the ECT treatments was to help dispel some of the stigma. If patients asked staff what an ECT was like, we could describe the process to them. There are similar treatments that are also used, with transcranial magnetic stimulation being the main one I am aware of. The National Institute of Mental Health has information about various brain stimulation therapies that are in use. https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml

9

ECT is not dangerous, but the side effects are profound. Somebody close to me underwent ECT, so this all information gained by speaking to the psychiatrist in charge, and being the minder for the patient.

The psychiatrist in charge of the ECT clinic was of the opinion that other treatments should be tried first. If a patient’s depression is treatable with medication and therapy, then ECT is not called for. He was also of the opinion that ECT is almost always delayed too long, resulting in unnecessary suffering.

It is used as a last resort because of the side effects, the disruption the treatment causes, and because it is very effective, so once complete it’s not necessary to do anything else (other than ongoing medication and therapy). The patient cannot work during most of the course of treatment, which may take months. The patient will require care on all treatment days, and full time during the heaviest parts of the treatment.

During those heaviest stages of treatment, when shocks are being administered 2-3 times per week, the patient is in a dementia state characterized by confusion, inability to form new memories, and requiring 24 hour supervision. This may go on for six weeks. As treatments are reduced to once every 1-2 weeks the dementia will lift.

Memory loss is often not just a few hours before treatment, but a total loss for the entire course of treatment. Loss of memory from before the treatment varies, and can range from small amounts to large and permanent losses.

They say it comes back, but (and this is just my opinion) it does not come back on its own. As the patient hears stories about things which have been forgotten, new memories are formed. This is how memory works anyway.

All of that being said, ECT is incredibly effective for treatment resistant depression. The results I saw were incredible. Years of depression had been lifted, leaving behind the person I used to know.

10

It is also worth noting that severe and refractory depression is not just someone feeling down interminably, or being at ongoing risk of suicide. People with severe depression may not eat or drink, and slowly waste away and die. They may be so immobile that they develop pneumonia, 'pressure ulcers, and more. As in any potentially fatal disease that is refractory to usual therapies, ‘treatments of last resort’ can be the only remaining option.

11

Liz Spikol wrote at length about her experience with ECT in her column The Trouble With Spikol. While it helped her, possibly saving her life, she also sees it as a horrible thing.

Also, I never felt that the depiction in One Flew Over The Cuckoo’s Nest was all that inaccurate.

12

Two friends of mine, fellow physicians both, underwent ECT after years of failed treatment for depression. They considered it the last resort, and afterwards both wished they’d have sought it out sooner. They considered it life saving. I’d spent extensive time with them both before and after their ECT, and they are notably more relaxed, more content people. One is over 20 years out from it, the other is 3 years out.

They do agree other treatments should be and were (in their cases) tried first, but they regret the stigma associated with it kept them from acting on earlier recommendations to undergo it.

Their experiences reflect what I’ve seen in the literature.

13

I have a friend who underwent ECT around 20 years ago, so I’m not sure how closely it resembles the procedure as performed today. He is diagnosed at bipolar and had trouble finding medications that would keep working over extended periods of time. The ECT had some severe short term effects, but it “reset” his brain, allowing medications to work better. He’s been in a much better place for the past 20 years, and hasn’t needed any additional ECT treatments.

14

The very first time I read any non-fictional account of ECT was the story of a woman who was voluntarily going for additional ECT treatment. She had found the period of time following the previous treatment had been the best part of her life, free from depression and associated issues. I think that may have been just a couple of years. She knew full well that further treatments would be detrimental to her on a short term basis, she even suffered great anxiety knowing what was coming, but she was very clear that she would rather endure the ECT and the after effects in exchange for a life free of the horror of acute depression. I don’t find that difficult to understand.

Much of the bad press for ECT came from what was publicized as involuntary treatments. I have no idea how much of that was fact or fiction, but I don’t find it difficult to understand how that can terrify the public.

15

Another thing to know about ECT in the bad old days of 40-50+ years ago was that it was highly unselective, just delivering large shocks to the whole brain, often without adequate pre-medication. Now, much lower voltages are delivered to specific brain areas where it’s felt to be more helpful while doing less injury, and proper pre-medication helps with this too.

16

My grandmother developed extremely severe depression at 81 after my mother died (and probably had been getting there for months prior.) Not just “boy, life sucks” but with symptoms like late Alzheimer’s–not knowing where she was or who people were, and having delusions. I finally had no choice but to have her admitted to the geriactric ward at the nearest nuthouse. Several weeks of drugs and talking did very little, and when they finally decided to try ECT I had to make the decision (and watch a video) because she wasn’t competent to decide on a breakfast cereal at the time. There were a total of I think 5 sessions, and it was like someone restored her brain from a backup. Over those few days she went back to mostly normal. There was a good bit of memory loss from the last few months, but that was probably a good thing.

17

I don’t know enough about ECT to support or condemn its use in major depression.

One thing to note is that major depression itself tends to significantly impair cognitive function, including memory. There are studies showing that while there’s commonly short-term memory loss after ECT, the overall effect of treatment was improvement in a number of measures of brain functioning, including memory, when compared to status before treatment.

We have an understandable tendency to value personal anecdotes. PubMed is a lot more useful.

18

I don’t know much about it now. I saw it used a few times as a medical student.

  1. The history and stigma are not great. Hollywood has been unhelpful in its portrayal. It is now done with sedation. So people don’t want it for mild depression.

  2. How does it work? What changes will happen? The side effects may not be trivial. One compares these risks to the severe problems of catatonia, not eating, etc.

  3. Not all doctors know the latest research on it. I sure don’t, and I work hard to keep up to date. It is probably only offered in bigger cities? There may be insurance issues?

  4. I have seen it work well, anecdotally, but did not know the patients well enough to fairly evaluate it or the gains and losses.

19

I am currently undergoing ECT. So it’s all anecdotal, but from direct experience.

I started with three times a week and now do it once a week after, I believe, I told the doctor that the memory issues were intolerable. It was also (I think) bilateral before and is right unilateral now.

As far as I’m aware, I never had to be under 24/7 supervision except while I was in the hospital, when I was anyway. Memories from that time, such as they are, are like a dream- there are maybe little bits and pieces, but not enough to make a story. I don’t remember leaving the hospital at all. I know it’s not like it was my wedding day and those are memories I wanted to have forever, but it’s still incredibly disconcerting. It feels like I don’t have control of my own actions because I don’t know what I myself did last week or whatever. And I’m normally an organized person who keeps a good schedule and remembers obligations and such and now… I’m a mess.

Now… despite all that, I think next time I go, I may ask about upping the frequency again. Because this really is my last resort. I’ve been doing it since… beginning of August or so. And maybe it’s helped a little? But… I mean, in short, I still hesitate before making any kind of solid plans for too far in the future because I’m not in any way ready to commit to still being around. If this doesn’t work, that’s it.

I think a big part of the decision to do ECT in my case is that I am at “not much left to lose” stages- unemployed, disabled, and essentially housebound (with some good friends on whom I depend heavily). If I were trying to juggle this with a job/career, where the Swiss Cheese Brain, the stigma, and the missed days of work were going to be a big problem, I might have hesitated more to do it in the first place and may be less able/willing to tolerate the side effects.

More generally, though, ECT is a pain in the butt and consumes a lot more of your life all at once than, say, trying Zoloft. I mean, just having to go for anesthesia once (or three times) a week ends up being pretty inconvenient. So if whatever drug seems as likely to work, it makes sense to try that first.

20

I think ECT should be available to people as a resort — not even necessarily a last one — if they think it will help them dig out of their personal mire. But they should consent as fully informed consenting people. They should get the opportunity to read the materials written by Dr. Max Fink and others of his ilk, but also the personal accounts of people like Linda Andre and Marilyn Rice.

I am absolutely 100% against it ever being used on people on an involuntary basis the way it was used on Paul Henri Thomas. That should be illegal everywhere.