Key moments, in order
It arose in an era when someone admitted to an asylum with depression, schizophrenia or bipolar disorder would usually never leave.
It is given under general anesthesia with a paralytic. The patient is fully asleep and relaxed, no movement is seen, and the seizure is confirmed on EEG.
Most of psychiatry is medication, next medication, next medication, and ECT is not even in the algorithm for many prescribers.
The chance that each medication trial brings remission drops sharply with each trial: around 30 percent for the first on average, around 20 percent for the second.
Targeted neuromodulation tries to stimulate one circuit directly and bypass the receptors. ECT does the opposite: it picks no single circuit and affects all of them by inducing a seizure.
Start the conversation about ECT and other neuromodulation the moment you start medication trial number two.
By the time patients reach ECT, they have often had more than 12 medication trials and feel this is the last stop. Expect hopelessness.
Actively suicidal patients may hear there is a chance of dying under anesthesia and take that as a reason to sign up. Consent then needs a careful conversation.
Resistance often comes from the spouse or parents, who have heard it will wipe out memory or change their loved one. Address them directly.
Memory is the biggest fear, so have an explicit conversation about the memory risks as part of informed consent.
Depression with psychosis responds incredibly well to ECT and poorly to other things, and the older the patient, the better the response. In an outpatient clinic, psychotic depression in an older person should make you think of ECT right away.
There is no absolute contraindication, but every seizure brings a parasympathetic surge, with blood pressure and heart rate dropping during the seizure itself, so cardiovascular history matters.
Common side effects come from the anesthesia and paralytic: headache, nausea, muscle stiffness or soreness, and confusion on waking that usually lasts 15 minutes or less.
Memory: 30 to 40 percent of people in their index series have a better mini mental status exam score by the sixth treatment, despite the seizures and anesthesia.
Doing nothing is a treatment option, and letting the illness run its course has profound effects of its own. Say so in consent.
Major depression: expect about 12 treatments, three a week.
Bipolar disorder: whichever phase you are treating, treat to symptom remission plus three.
The goal after the index course is to stay in remission, so maintenance usually starts one month after it ends.
No driving for 24 hours after anesthesia, so ECT is not the right choice for someone trying to keep working during the course.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.