Electroconvulsive Therapy Deemed Safe Despite Stigma

The mention of “shock therapy,” as electroconvulsive therapy (ECT) was once known, can still elicit a cringe response despite drastic improvements in treatment methods over the years. While often misjudged, ECT has proven to be a highly effective treatment for severe, treatment-resistant depression, according to a new study.

Because the stigma surrounding ECT continues to act as a major barrier to patients getting help, a group of researchers from the University of Toronto reviewed ten years’ worth of data to set the record straight, as ECT has shown to be both safe and effective for individuals with treatment-resistant depression.

What Is ECT?

Electroconvulsive therapy is a procedure done under general anesthesia that intentionally triggers a brief seizure by passing small electrical currents through the brain. This process has proven to change brain chemistry in such a way that symptoms of certain mental health conditions are quickly reversed.

As with any medical or psychiatric treatment, ECT might not work for everyone. But it has proven effective when other treatments have been unsuccessful and the full course of treatment is completed.

The Research

The review, published in The Lancet Psychiatry, examined the psychiatric records of more than 10,000 patients who had been hospitalized for at least three days due to severe symptoms of depression.

They then compared the risk of medical hospitalization or death within 30 days for patients who underwent ECT against those who did not. Of the 5,008 patients who underwent ECT, patients received eight sessions on average.

The findings revealed no clinically significant increased risk for serious medical events like hospitalization or death with exposure to ECT, and the risk of suicide significantly decreased. Researchers concluded that the benefits of the treatment outweigh the risks.

But coming to this same conclusion involves a complex decision-making process for patients, notes lead study author Tyler Kaster, MD.

"Numerous studies support the efficacy of ECT for depression, and our study provides reassuring evidence regarding the medical safety of ECT that can be used by individuals to make informed decisions about pursuing treatment," Kaster says.

Overcoming the Stigma

Much of the stigma surrounding ECT comes from aspects of the treatment that were historically true, such as lack of consent and treatment without general anesthesia. In the early years, high doses of electricity administered without anesthesia lead to fractured bones, memory loss, and other serious side effects.

Another source of stigma is that much of the public's perception of ECT is formed through movies or television.

“The prejudice and discrimination surrounding ECT is likely related to media portrayals such as in ‘One Flew Over the Cuckoo’s Nest,’” Kaster says. “These depictions of ECT often portray ECT as being delivered as a form of punishment to individuals while fully conscious and appearing to cause significant pain. In reality, ECT is provided after an individual is fully asleep and does not cause pain during the procedure.”

Today, ECT is much safer. Modern treatments involve significantly lower energy in a controlled setting to increase benefits and limit risks.

“Everything in medicine is about cost benefit,” says Sina Nikayin, MD, assistant professor and attending physician at the Yale Interventional Psychiatry Service. “For patients who are suffering from severe disorders and have failed other modalities of treatment, ECT is a life-saver, sometimes literally.”

Despite advancements that produce substantial improvement in about 80% of patients, according to the American Psychiatric Association, only about 10% of hospitals in the United States offer ECT. And of patients who could benefit from this treatment, only about 1.5% of them undergo it. That number is even lower for non-White individuals without private medical insurance. Lack of access and awareness act as additional barriers to this potentially life-saving treatment.

When Is ECT Appropriate?

As a physician who provides psychiatric treatments like ECT to patients on a regular basis, Nikayin has seen great success with ECT in patients for whom many treatments have failed. These are the only patients who are prescribed ECT, Nikayin says, as the treatment is never recommended for patients who haven't yet tried other methods of treatment.

“If you can fix something with a pill, you'd never go for a surgery,” Nikayin says. “But sometimes surgery is needed. Without that surgery, you would do worse. Similarly, if someone gets to the point where they require a higher level of treatment, ECT is very effective and works really well.”

It's also important to note that ECT is not a regular or indefinite treatment. Protocols vary, but patients typically undergo 6–12 sessions spread over the course of weeks or months. Once the patient has shown improvement, maintenance treatments are administered before treatment stops completely and other modalities are recommended. Ideally, a patient will have experienced six months of wellness before stopping treatment, Nikayin says.

“The most important metric we have in medicine is quality of life,” he says. “If we are not improving someone’s quality of life, what are we doing? People who are suffering, we see that they improve significantly. Many times, they go into remission.”