| Paper authors: | Subha Subramanian, Ruthzaine Lopez, Charles Zorumski, Pilar Cristancho |
| Year of paper publication: | 2022 |
| Post authors: | Alice Erchov, Sarah Kessler, Fidel Vila-Rodriguez |
| Download the research article: | Subramanian et al. (2022) – Electroconvulsive therapy in treatment resistant depression |
Introduction
When all else fails, treatment-resistant depression can be especially debilitating: it is associated with recurring depressive episodes, higher risk of suicide, and a greater amount of hospitalizations. For those who fail ≥ 2 gold-standard antidepressants or otherwise have a need for rapid improvement, electroconvulsive therapy (ECT) may be the solution. ECT (in its modern sense) has been used for more than 90 years, but the persisting stigma and media portrayal related to treatment procedures mean it is rarely used in clinical treatments – even though it could help many recover from even persistent depression.
Subramian et al. (2022)’s paper is a review of past studies to create a cohesive narrative of the history, procedure, efficacy, and safety of ECT in modern-day.
History
ECT originated in the 1500s, where chemically-induced seizures were used to treat schizophrenia. Later, in 1938, the use of electrical stimulation was introduced and its safety was much improved from its chemical counterpart. However, risks were still high. A modified alternative in 1939 offered the use of anesthetic agents and muscle relaxants that prevent a majority of injuries. This modernized ECT is now the standard of care.
Procedure
Because of the anesthesia and muscle relaxant, ECT is painless. During the procedure (which lasts only 5 minutes) and up to an hour afterwards, medical professionals continuously monitor heart rate, blood pressure, breathing, and oxygen. To prevent depression relapse, after the end of treatment (usually ~10 sessions), patients may “taper” their ECT, where the time between treatments gradually increases (e.g., from daily to weekly, biweekly, and then monthly).
Efficacy
In over 250 people with depression, 75% remitted after their 10th treatment: meaning their depressive severity dropped below “clinical levels” – essentially – meaning they were cured. In those who failed 2 or more medications, remission rate was about 48%, and then increased to 63% in those 60 years old and above.
Side effects
The most common side effects of ECT are disorientation, memory difficulties, headaches, and nausea. However, research has shown that memory difficulties are temporary and usually only seen after the first two treatments. More serious cardiac (heart) side effects are only seen in about 2% of cases. The authors conclude that:
“ECT is overall considered a low-risk procedure given the brief anesthesia […] and low risk for cardiac events.” (pg. 4)
Mechanisms
It is unclear why ECT is so effective. One effect of treatment that may be responsible is an increase of volume in the brain, especially in memory and emotion-related regions. ECT has also been found to increase the connectivity between brain regions, meaning they function in a more coordinated fashion. There is also evidence that ECT may increase the function of dopamine in the brain. It is possible that it also increases serotonin and other brain “growth” substances (called brain-derived neurotrophic factor).
Conclusion
ECT has come a long way from the dangerous and medieval picture often depicted in media. In fact, it has been shown to be extremely effective in those who do not get better from antidepressants and is a nearly painless, cost-effective, and relatively safe procedure with careful medical monitoring. ECT has also been effective for a wide range of mental illnesses including depression, bipolar disorder, schizophrenia, psychosis, epilepsy, and Parkinson’s. For those who struggle with persistent and severe depression, ECT may offer new hope for recovery.