Electroconvulsive Therapy (ECT), also known as “shock therapy,” is a highly effective medical treatment for certain severe psychiatric disorders. Contrary to its portrayal in media and films, modern ECT is a safe, humane, and strictly controlled procedure performed under general anesthesia.

What is ECT and How Does It Work?

ECT is a procedure in which a short, controlled electrical current is passed through the brain via electrodes placed on the scalp. This current induces a brief, therapeutic seizure (lasting about 30 to 60 seconds). Due to general anesthesia and the use of muscle relaxants, the patient feels no pain and their body does not experience violent convulsive movements.

The exact mechanism of action of ECT is still not fully understood, but the leading theories include:

• Changes in Neurotransmitters: The seizure induced by ECT causes widespread and rapid changes in brain chemicals such as serotonin, dopamine, and norepinephrine. These changes are similar to what antidepressant medications achieve over several weeks, but ECT accomplishes this much more quickly.

• Neurogenesis and Neuroplasticity: Evidence suggests that ECT can promote the growth of new nerve cells and new connections between them, particularly in brain regions like the hippocampus, which can atrophy (shrink) in severe depression.

• Changes in Brain Blood Flow and Metabolism: ECT alters blood flow and energy consumption in specific areas of the brain, which is associated with the improvement of mood symptoms.

 Who is a Candidate for ECT?

ECT is not a first-line treatment. It is typically recommended when other treatments (such as medication and psychotherapy) have failed or when the patient’s condition is extremely acute and urgent.

The primary indications for ECT are:

1. Severe, Treatment-Resistant Depression: This is the most common reason for using ECT. Patients who have not responded to multiple trials of antidepressant medications often show significant improvement with ECT.

2. Depression with Psychotic Features: Such as delusional beliefs or hallucinations.

3. Severe Suicidal Ideation or Attempts: ECT can reduce suicidal thoughts in a very short period, making it a life-saving intervention. It is one of the fastest treatments for this condition.

4. Bipolar Disorder: Especially during severe manic or depressive episodes that do not respond to other treatments.

5. Catatonia: A condition where a person becomes immobile, mute, and unresponsive to their surroundings. ECT is the most effective treatment for catatonia.

6. Schizophrenia: Particularly when accompanied by severe mood symptoms or catatonia, or when it is resistant to antipsychotic medications.

7. Pregnant Women: Women suffering from severe depression who cannot take psychiatric medications (due to risks to the fetus) can safely undergo ECT. It is considered one of the safest options during pregnancy.

8. The Elderly: Older adults who cannot tolerate high doses of medication due to side effects or drug interactions are often good candidates for ECT.

 What is the ECT Process Like? (Step-by-Step)

A course of ECT typically consists of 6 to 12 sessions, administered 2 to 3 times per week.

Before Treatment Begins:

• Full Medical Evaluation: This includes blood tests, an electrocardiogram (ECG), and a physical exam to ensure the patient’s cardiac and overall health.

• Psychiatric Assessment: To confirm the diagnosis and the necessity of ECT.

• Consultation Session: The psychiatrist explains the procedure, benefits, and risks to the patient and their family, and written informed consent is obtained.

• Fasting: The patient must not eat or drink for 8 to 12 hours before the treatment session.

During Each Treatment Session:

1. Preparation: The patient lies on a bed. Monitoring equipment is attached to track heart rate, blood pressure, oxygen levels, and brain waves (EEG).

2. Anesthesia: An anesthesiologist administers a short-acting anesthetic (usually propofol) intravenously. The patient falls into a deep sleep within seconds.

3. Muscle Relaxant: Immediately after anesthesia, a muscle relaxant (like succinylcholine) is given to prevent strong muscle contractions and potential fractures during the seizure. Only minor twitching in the fingers, toes, or facial muscles may be visible.

4. Application of Electrical Current: The psychiatrist places the electrodes at specific locations on the head (e.g., unilateral or bilateral). A very brief electrical current (lasting about 1 to 4 seconds) is then applied.

5. Therapeutic Seizure: This current induces a controlled seizure in the brain that lasts for about 30 to 60 seconds. The medical team monitors and records the seizure via the EEG machine. The patient is completely unconscious and feels nothing.

6. Recovery: After the seizure ends, the effect of the anesthetic wears off quickly, and the patient wakes up within 5 to 10 minutes. They are moved to a recovery room and monitored for about 30 to 60 minutes.

The entire process, from entering the treatment room to leaving the recovery room, usually takes less than an hour.

 Benefits of ECT

• High Speed of Onset: ECT works much faster than medications. Significant improvement is often seen after the first few sessions. This feature is vital in urgent situations, such as high suicide risk.

• High Efficacy: The response rate for severe depression is around 80% to 90%, which is much higher than that of antidepressant medications.

• Safety: Modern ECT is a very safe procedure. The risk of death is extremely low (about 1 in 10,000 patients), which is comparable to the risk of general anesthesia in minor surgery.

• A Good Option for Special Populations: As mentioned, it is an excellent choice for pregnant women, the elderly, and patients who cannot take medication.

 Side Effects and Risks of ECT

Like any medical procedure, ECT has side effects. Most are short-term and manageable.

Common, Short-Term Side Effects (usually occurring on the day of treatment):

• Headache

• Muscle Aches

• Nausea

• Confusion: Immediately after waking up, the patient may feel disoriented or confused. This usually resolves within an hour.

Memory-Related Side Effects (the most significant concern):

• Retrograde Amnesia: This is the most common memory side effect. The patient may have difficulty recalling events from the weeks or months before the ECT course began. These memories may gradually return, but some memory gaps may be permanent.

• Anterograde Amnesia: The patient may have trouble remembering new information during the course of ECT. This problem typically resolves after the treatment course is completed.

Important Note: The severity of memory problems varies from person to person. Newer techniques such as Unilateral ECT and Ultra-brief pulse stimulation can significantly minimize these side effects.

 Misconceptions about ECT

• Misconception: ECT is a brutal and painful procedure.

  • Fact: The patient is under full anesthesia and feels no pain. Muscle relaxants prevent any violent physical movements.

• Misconception: ECT damages the brain and causes brain cell death.

  • Fact: Extensive studies have shown no evidence of structural brain damage or nerve cell death. On the contrary, there is evidence that ECT promotes neurogenesis (the growth of new cells).

• Misconception: ECT changes a person’s personality.

  • Fact: ECT does not alter personality. By treating the underlying illness (like depression), it helps the person return to their true, healthy self.

• Misconception: ECT is a permanent cure.

  • Fact: ECT is an “acute” treatment, not a “maintenance” one. After the ECT course is finished and symptoms improve, the patient must continue with maintenance therapy—either with medication or with periodic “maintenance ECT” sessions (e.g., monthly)—to prevent a relapse.