Modern electroconvulsive therapy (ECT), in which electricity is used to induce a convulsion, was introduced into psychiatric practice in the 1930s in Italy. By 1940, ECT had made its way into US psychiatric practice. With the advent of modern psychotropic medications, and because of its indiscriminate use in some state hospitals, ECT began to fall out of favor. ECT overcame its tarnished image and has been reintroduced as an important treatment in the therapeutic toolkit. Approximately 100 000 people in the United States receive ECT treatments annually. It is the most effective treatment available for refractory major depression (i.e., depression that recurs and does not respond to other modalities). Some psychiatric researchers consider ECT as the standard against which other somatic therapies, including medication and other forms of somatic therapies, are compared.

37.2.1 Indications

Generally, ECT is used in patients for whom all other therapeutic interventions have failed and whose lives are at risk. Approximately 85% of patients receiving ECT have major depression as the indication for use, with the remainder having schizoaffective disorders, mania, schizophrenia, and occasionally Parkinson’s disease.

37.2.2 Pretreatment Evaluation

Assessment of patients for whom ECT is a consideration should happen as close to the first treatment with ECT as possible. From a medical standpoint, patients should undergo a complete health history and physical examination. Minimum laboratory and diagnostic tests should include a blood count, evaluation of electrolyte levels, complete metabolic panel, ECG, and chest x-ray. Patients should be evaluated as to their ability to tolerate anesthesia. From a psychiatric standpoint, a baseline of symptoms should be recorded against which the clinician can monitor progress and symptom alleviation. Patients are generally asked to fast after midnight the day of the procedure.

37.2.3 Procedure

Prior to the procedure, the patient undergoes brief general anesthesia with succinylcholine to prevent severe muscle contractions that might result in muscle or bone injuries. Some patients receive anticholinergic medications to dry secretions that might interfere with respiration. Ultrabrief anesthetic agents are used to induce unconsciouness.

ECT itself involves placing an electrode on the temple of the patient and inducing a grand mal seizure. Bilateral stimulation, or placement of electrodes on both temples, has beenused in the past (and sometimes now), but it has more associated adverse side-effects such as memory loss.

An electric current is passed through the electrode for between 100 ms and 1 s, and the patient experiences a convulsion that lasts approximately one minute. During this entire time the patient is oxygenated, and clinicians monitor oxygen saturation and cardiac functioning.

Typically ECT is given twice weekly on nonconsecutive days. Treatments may range from a few to 15 sessions, depending on the patient’s response. The entire procedure lasts less than one hour, although each patient’s recovery time after the procedure varies. When repeated episodes of depression or serious other life-threatening symptoms occur after a series of treatments with ECT, the physician may opt to taper ECT over several weeks to months. Typically, a tapering schedule will be once a week for 1 month, once every 2 weeks for 2 months, once every 3 weeks for 2 months, and once every month for 2 to 4 months. This kind of tapering may help to prevent rehospitalization. Occasionally, patients relapse and have to return for maintenance treatment.

37.2.4 Mechanism of Action