Is ECT for Bipolar an Option?
Although few people have actually experienced electroconvulsive therapy (ECT), most of us have vivid images of the experience — images that are a vestige to the nightmarish era of institutionalized mental health when patients were subjected to experimental (and often inhumane) treatments.
ECT is a treatment whereby the brain is exposed to a small amount of electrical shock that produces a short epileptic seizure to alleviate depressive or psychotic symptoms. The treatment is repeated on a regular interval, up to six to 12 times.
Up until the 1980s it was known as shock treatments, which were one of the most prevalent of these controversial treatments.
ECT was discovered in Europe back in the 1930s, and within a few years the treatment was used in the United States and became a commonly used treatment for decades.
There was plenty of evidence to support the notion that a depressed or psychotic brain could benefit series from epileptic seizures. However, the manner in which the treatments were given during the institutional era were problematic:
- Many patients were given ECT without consent.
- The amount of electrical current was experimental — it was later discovered that in many cases the current exceeded the therapeutic amount.
- Patients were not given preliminary baseline tests to ensure their body could withstand both the electrical shock and the epileptic seizure.
- Patients were not given muscle relaxants, resulting in violent shakes and broken limbs.
- Most importantly, patients were given minimal sedation and often had full memory of the epileptic seizure.
The prevalence of ECT began to decrease in the late 1970s when improvements in pharmacology provided alternatives to ECT. As the number of ECT treatments decreased, more research and regulation was done to make the treatments more humane.
By the early 1990s, ECT had radically changed. It was no longer seen as a first line therapy — in fact it is now used as a last option, except among suicidal patients who are at high risk and cannot wait to try several therapies.
While times have changed, many people still associate the practice with the scene from One Flew Over the Cuckoo’s Nest, where a healthy man is coerced into treatment. But things have changed for the better:
- Patients must provide informed consent.
- The amount of electrical shock given to patients has been better tested and optimized.
- At most hospitals patients are given a battery of tests including MRI, EKG and echocardiogram to ensure the patient is fit for the procedure.
- A muscle relaxant is given.
- The patient is under general anesthesia and has no memory of the seizure.
How Is ECT Administered?
A standard ECT cycle lasts three to eight weeks and consists of six to 12 treatments. Treatments are given two to three times a week in the beginning and can be stretched out in longer intervals toward the end.
Treatments are given both in inpatient and outpatient settings — sometimes treatments begin in an impatient setting and then change to outpatient. This is done so doctors can monitor the patient’s response and ensure there are no problems.
ECT is halted if there are complications, if the patient shows no progress or if the patient reaches recovery prior to the last scheduled treatment.
How Effective Is ECT?
When the guidelines for treatment are closely followed, ECT is an effective treatment for both bipolar depression and mania. The remission rate for both unipolar and bipolar depression is about 50 percent, meaning there is a 50-50 chance ECT treatments will be successful.
This remission rate is greater than many alternate therapies. For patients with depression, ECT is sometimes given with antidepressants.
The goal is to keep them on the antidepressant therapy after the ECT is finished, in the hope of a longer remission trajectory. Sometimes maintenance ECT is given with the same intent to increase the remission trajectory.
The remission rate for manic patients is even greater, with remission rates well close to 70 percent, even in those with treatment resistant mania.
ECT and Adverse Events
ECT can be administered to both sides of the brain (bilateral ECT) or to just one side of the brain (unilateral ECT). Both types of administration are associated with memory loss.
Bilateral is more effective for psychotic symptoms, but it is associated with a higher chance of long-term memory loss. Patients must weigh the high chance of remission against the chance of long-term memory problems.
For those receiving the unilateral treatments, memory loss is generally short-term and recovers several weeks or months after treatment. In both modes of treatment, patients are asked to write down passwords for all important accounts, as well as any critical information prior to treatment as a precaution and to avoid any future problems.
In addition to memory loss, other adverse events include cardiac events or auto accidents, even though patients are told to refrain from driving both during treatment and a few weeks after treatment.
ECT Myths and Facts
The term ECT still elicits imagery from the institutional era of psychiatry. The following myths and facts should help set the record straight on the current state of the treatment.
Myth: ECT is dangerous and painful
Fact: The most painful part of an ECT treatment is the needle required to start a central IV line. If you can handle this, you can handle the treatment.
Myth: ECT is a pseudo-scientific procedure and is not evidence-based
Fact: ECT induces a short epileptic seizure, which has been proven to help reduce symptoms of both depression and mania. Furthermore, it has been proven that for both depressive and psychotic patients, ECT is more effective than most alternate pharmacology-based therapies.
Myth: ECT always causes long-term memory loss.
Fact: Most ECT is unilateral and has minimal risk of long-term memory loss. The risk in bilateral ECT is greater but has not been quantified.
Myth: ECT can cause brain damage.
Fact: Given the improved dosage of electrical current, there is absolutely no evidence of brain damage in those who have had ECT.
ECT can be a safe, effective therapy for bipolar patients. If you feel you might be a good candidate for this therapy, talk with your psychiatrist.