Flow Neuroscience
June 30, 2022
What comes to mind when you think about electroconvulsive therapy (ECT) or ‘electroshock’ therapy? Perhaps dramatic images from the movie One Flew Over the Cuckoo’s Nest with screaming patients and twitching bodies or sadistic doctors in white lab coats using the procedure as punishment for bad behaviour?
During a modern ECT procedure you may spot one or two white lab coats, but the similarities with the old-fashioned stereotype basically ends there. This article will tell you about the usefulness of modern ECT as depression treatment and perhaps bust a few myths about the procedure.
You may also be interested to know that there are much gentler forms of brain stimulation for depression. The last few sections of this article will tell you about transcranial Direct Current Stimulation (tDCS) and how it can be used to treat depression at home.
What is ECT?
Let’s start from the beginning. What exactly is ECT? Well, ECT stands for electroconvulsive therapy and is a form of brain stimulation used to treat the most severe cases of depression or depression in patients who have tried other forms of treatment without result. ECT can also be used to treat other severe mental illnesses such as bipolar disorder and symptoms of schizophrenia.
During an ECT session, the patient is under general anaesthesia. A brief electric current is administered to the brain to induce a controlled seizure. Though researchers don’t know exactly how ECT works, the treatment is thought to spark electrical activity among brain cells and change the chemical balance in areas of the brain which play an important part in mood regulation.
Now, the next section will tell you about what ECT is NOT
(You can read more about different forms of depression treatments at the NHS website.)
What ECT is not - Busting the myths about ECT
Most of the stigma surrounding ECT stems from early versions of the procedure where no anaesthetic was used. To get a clearer view of what ECT is and what it’s not, let’s have a look at the difference between old-fashioned ECT and modern ECT.
ECT in 1938:
In 1938 the first course of ECT was used. It looked very different from today’s procedures. Back in 1938, doctors would run a high electric current through patients’ brains, causing whole body seizures. No anaesthetic was used, so patients would bite their tongues or even break their bones because of muscle spasms from the seizure.
ECT Upgrades:
Psychiatrist Dr. Harold A. Sackeim (PhD) describes the difference between old-fashioned and modern ECT in his article from 2017. ECT is a much safer and more comfortable depression treatment today than it was 80 years ago. Back then, patients stayed disoriented for hours after an ECT session.
Today, the procedure is done differently. The electrical dose has been adjusted and is administered in brief pulses, which allows patients to recover much faster. Most patients are able to resume daily activities within an hour after a modern ECT session.
This is what a modern ECT machine looks like:
In modern ECT treatment, general anaesthesia is a given, which means that patients are asleep and pain free during all ECT sessions. The electric pulses administered to the brain are much milder than back in 1938 and the seizure is brief and controlled. Here comes a step-by-step guide to a modern ECT session:
A modern ECT session in 7 steps:
- An ECT session is always administered at a hospital or psychiatric clinic by a team of medical professionals, usually including a psychiatrist, an anaesthesiologist and a nurse.
- The patient lies down in a hospital bed and is given general anaesthesia. The patient is asleep and pain free during the procedure, which typically lasts for 5-10 minutes.
- The patient receives a muscle relaxant to keep the body from moving during the ECT session.
- The medical team places electrodes on the patient’s head. The electrodes are most commonly placed to target the temporal cortex of the brain.
Sometimes, electrodes are placed on both sides of the head (bilateral ECT) and sometimes on just the right side of the head (right unilateral ECT). Placing electrodes on only one side of the head is associated with milder side effects. - When the patient is asleep and the muscles are relaxed, the doctor presses a button on the ECT machine and a current of around 500-900 milliampere is delivered through the electrodes into the brain for a duration of 1-6 seconds. This creates a controlled seizure which typically lasts less than 60 seconds (the patient is completely unaware of the seizure).
- A few minutes later, the anaesthetic and muscle relaxant begin to wear off and the patient is moved to a recovery room. When waking up, the patient may experience confusion for a few minutes up to a few hours. Most patients can continue with everyday activities within an hour after the ECT session.
- Some patients notice an improvement in their depressive symptoms after only one ECT session and others need treatment for weeks before noticing any effect. Patients usually go through 2-3 ECT sessions per week for 3-4 weeks.
What happens after ECT treatment?
ECT treatment usually consists of 6-12 ECT sessions. After completing these sessions, it’s important to continue with ongoing depression treatment to prevent a depressive relapse. This could mean less frequent ECT sessions, antidepressant medication and/or psychotherapy.
The next section will tell you more about the possible negative consequences of ECT and why the treatment is generally only used with severe depression and treatment-resistant depression.
The downside of ECT– side effects
Because of its side effects, ECT is most commonly used in severe cases of depression or in treatment-resistant depression (when a depressed patient has tried other treatments without results). ECT can also be used when a depressed patient needs symptom relief more quickly than usual, for example if the patient is at high risk of suicide.
Most patients report that the benefits of ECT outweigh the problems, but it’s important to be aware of the possible side effects before making any decisions about ECT treatment.
Here is a list of the most common side effects:
- Disorientation (usually lasts between a few minutes to a few hours following an ECT session)
- Aches, fatigue and nausea are other short-term side effects from ECT
- Memory loss: Memory loss is the biggest issue with ECT and a common side effect. Some people lose memories of events that took place months before they had ECT treatment and some are left with permanent gaps in memory. Most depressed patients say that the ECT treatment was worth losing a few memories over. Others report that they have lost precious memories of a family trip or even their wedding day. The memory loss is usually worse shortly after the ECT treatment and then gradually improves with time. A minority of ECT patients report memory problems that remain for months or years. Unfortunately, there is currently no way to tell who will be affected by memory problems. Memory loss is a risk for everyone who decides to go through ECT treatment.
Worth noting is that concentration difficulties and memory problems are a common symptom of severe depression. In some cases where ECT treatment has been successful and these symptoms have disappeared, patients have actually experienced that ECT improved their memory functions. - Difficulty in forming new memories: Another side effect of ECT is having difficulties creating new memories. This side effect is temporary and usually disappears a few weeks after ECT treatment.
Is ECT worth it? – The effectiveness of ECT
Researchers and healthcare professionals have observed the life-changing and life-saving benefits of electroconvulsive therapy for decades. Some of them describe modern ECT as the fastest and most effective way for patients to completely recover from depression.
“The evidence indicating that ECT is effective in the treatment of mood disorders is diverse, long-standing, and incontrovertible. In both the short term and long term, it appears to exert greater benefit than pharmacological alternatives.”
Harold A. Sackeim, PhD 2017
Different studies report different results when it comes to how effective ECT is for depression. However, most ECT-researchers seem to agree that the treatment is one of the quickest and most effective ways to lift severe depressive symptoms.
Around half of depressed patients fully recover with ECT treatment and many more are helped by it.
In 2012, a research review, including 1106 patients with depression or bipolar disorder, showed that 51% of the depressed patients and 53% of the patients with bipolar disorder completely recovered after ECT treatment.
Another study found that 75% of depressed patients fully recovered with ECT treatment and that over half of them noticed a reduction of their symptoms after only one week.
In conclusion, ECT is an effective treatment for depression and the procedure has undergone considerable changes since it first appeared in 1938.
The biggest issue with ECT is the risk of permanently or temporarily losing memories of past events.
If you’re suffering from severe depression or treatment-resistant depression, make sure to discuss risks and benefits at length with your healthcare provider before making an informed decision about ECT treatment.
Are there other forms of brain stimulation?
There are gentler forms of brain stimulation with considerably milder side effects than ECT treatment.
Transcranial Direct Current Stimulation (tDCS) is an evidence-based treatment for depression. It's gentle and non-invasive, so no anaesthesia is necessary. The tDCS current (0,5-2 mA) is 400 times weaker than the current used in ECT. It's gentle enough to use at home.
How does tDCS work?
tDCS delivers a gentle electric current through electrodes placed on the scalp. When treating depression, the electrodes are placed high up on the forehead to target a brain area called the dorsolateral prefrontal cortex (DLPFC).
Lowered activity in the DLPFC is associated with depressive symptoms such as fatigue, sleeping problems, concentration difficulties, changes in appetite and mood. The electric current stimulates brain activity in the DLPFC, thereby alleviating depressive symptoms.
A tDCS session usually lasts for 30 minutes and can be administered at home with a tDCS headset.
The recommended protocol for depression includes 5 tDCS sessions per week during the first two weeks and, after that, 2 sessions per week for as long as you need it. Most people notice a reduction of their depressive symptoms within 1-4 weeks.
Can tDCS cure depression?
tDCS doesn’t require anaesthesia or regular visits to a psychiatric clinic. It's a far more convenient treatment option than ECT, but how effective is it? Can tDCS cure depression?
It turns out that it can. In 2019, doctoral researcher Julian Mutz and colleagues compared different forms of brain stimulation for depression. The researchers concluded that tDCS was an effective depression treatment comparable to antidepressant medication and psychotherapy.
“…we found tDCS to be efficacious across outcomes in both pairwise and network meta-analyses. Given that tDCS tends to be a less expensive treatment than transcranial magnetic stimulation, ECT, or psychotherapy, this finding is particularly relevant for policy makers who might consider tDCS as a clinical therapy outside the research setting.”
Mutz et. al, 2019
Read more about the scientific evidence behind tDCS here.
Where to get tDCS?
You can buy tDCS online and use it at home to treat depression. Flow Neuroscience has developed a CE-marked and medically approved tDCS device for home use.
The Flow treatment is based on decades of clinical research and backed by more than 20 placebo-controlled trials, all published in peer-reviewed journals.
Here’s a quick guide to getting your own tDCS device:
- Order the Flow headset from the webshop.
- Download the free depression app.
- In a few days, your headset will be delivered. When it arrives, unpack your headset and start the app.
- The app will show you how to put on your headset and start the stimulation. Just follow the instructions.
In conclusion, transcranial Direct Current Stimulation (tDCS) is an evidence-based treatment for depression. While ECT is more effective, tDCS is safer and more convenient.
Thank you for your attention!