Why Do We Use Shock Therapy?

What many people probably envision when they think of shock therapy is a vivid scene from the 1975 flick One Flew Over the Cuckoo’s Nest. The movie (based on the Ken Kesey novel) portrayed the treatment as a torturous procedure that caused patients to writhe, red-faced, in pain.

In fact, that image is an accurate portrayal of what shock therapy—medically known as electroconvulsive therapy, or ECT—was like when it was used to treat mental illness in the 1950s and ’60s.

“When it was first developed, it was administered without anesthesia,” says Irving Reti, an associate professor in the departments of psychiatry and neuroscience and director of the Electroconvulsive Therapy (ECT) Service at Johns Hopkins Hospital in Maryland. “[ECT] caused seizures with a lot of motor activity, and people had a higher rate of joint dislocations and fractures. It was an unpleasant treatment.”

In the decades since, however, shock therapy has been well-studied and improved, and it looks much, much different than it did in Cuckoo’s Nest. Now, patients are placed under general anesthesia and given a muscle relaxant to suppress movement that would lead to any dislocations, fractures, or bodily injury. The electric current is delivered more carefully and with more control. According to the American Psychiatric Association, ECT is a safe and effective treatment for some psychiatric illnesses.

ECT and Depression

In modern medical practice, ECT is most commonly used as a treatment for depression and other mental illnesses in cases where medication and talk therapy don’t work.

“ECT is used widely with people with severe, difficult-to-treat depression,” says K. Ranga Rama Krishnan, a psychiatrist and dean of Rush Medical College in Chicago. Studies have shown that anywhere from 50 to 70 percent of patients suffering from depression who don’t respond to medication experience significant improvement with ECT.

What’s more, ECT works a lot more quickly—patients usually see dramatic relief from their symptoms in about one week, rather than the four or five weeks that medications can take. “Patients will often report improvement even after one ECT treatment,” says Reti. For severely sick patients who have spent months trying medication after medication, or for patients who may be suicidal, something that kicks in fast is critical.

The current used in ECT triggers a surge of electrical activity in the brain, causing a seizure. (The anesthesia administered by doctors prevents the physical symptoms typically associated with seizure, but the activity that occurs in the brain is similar, though it’s much more controlled than if it occurred naturally.) That seizure activity causes a cascade of changes in the brain, and researchers think those changes help alleviate the symptoms of mental illness.

However, they’re still trying to figure out exactly what those changes are and why they work. They do know that ECT triggers an increase in the number of connections between neurons in certain regions that are important for mood. It also spurs the hippocampus—an area of the brain connected to regions involved with emotion, and which shrinks during depression—to return to its normal size. The electrical charge has been shown to cause changes in brain chemistry and gene expression in mice, too.

“It’s almost like [ECT is] restoring a lot of things in the brain,” says Krishnan. “The question is, in the patient, which of those things is important for treating symptoms? That we don’t know yet.”

The amount of current used in ECT is tailored to individual patients, because each person has a different tolerance. Doctors also want to use the lowest amount of charge possible, which ranges from about 50 to 500 millicoulombs. (For comparison, a bolt of lighting carries about 25,000 millicoulombs.)

“It’s almost like ECT is restoring a lot of things in the brain. The question is, in the patient, which of those things is important for treating symptoms?

Most research shows that ECT does not cause any physical damage to the brain. But there are some side effects of treatment, like headaches, muscle soreness, and nausea. The most serious side effect observed in patients is memory loss. Patients might experience short-term memory loss during the period of treatment, and they can be foggy about things that happened a few weeks or months prior to treatment. For most patients, such memory problems subside a few months after treatment ends, according to the Mayo Clinic. Depending on the type of ECT administered, however, memory loss of events stretching months or even years before treatment can also occur. (You should talk with your healthcare provider about ECT treatment options and risks.)

Refinement of the ECT treatment—like shortening the length of electrical pulses and changing up electrode placement—have helped to minimize memory loss in patients, according to Reti.

Nona McNatt, 67, is a patient of Reti’s and has been treated with ECT for about 10 years for the depression that’s symptomatic of bipolar disorder.

“I guess I’m a long-term user,” she says. “The ECT treatment brought me out of a severe manic episode [10 years ago].” She has used it since then on an ongoing basis to control her depressive episodes.

McNatt had been on a series of antidepressant and antipsychotic medication before beginning ECT—“anti-everything,” she says—but none worked well. Adding ECT as part of her medical regimen caused a dramatic change in her symptoms.

“There have been times when I’ve gone to the treatment in a depressed episode, and within two days have become normal again,” she says.

ECT and Autism

Doctors are also beginning to use ECT as a treatment for some symptoms associated with autism. Reti treats young patients with autism who have problems with self-injury—which entails repetitive motions, such as self-directed biting, hitting, or head banging—that can cause serious harm. This clinical use of ECT is relatively new, but there are a number of case studies describing its efficacy.

Reti says that patients with autism who self-injure are “not trying to get anyone’s attention; it’s not suicidal behavior. They’re almost like automatons with the self-injury.” (It’s unclear what’s happening in the brain to drive those behaviors.)

The first autistic patients that Reti treated were originally receiving ECT for a behavioral syndrome called catatonia. Catatonia is typically characterized by mobility problems, such as inability to move or involuntary repetitive motions. “Catatonia is classically treated with ECT,” he says.

But some of Reti’s patients had also demonstrated self-injury, and he noticed that ECT was effective at halting that behavior as well.

“Some patients, and even some health care professionals, will say things like, ‘I didn’t even know ECT was still available.’”

Why the therapy works is still in question, says Reti. He thinks that the electrical activity might somehow change the way the basal ganglia—the brain region that coordinates movement—interacts with the rest of the brain.

While ferreting out an explanation will take more time, to Reti, it’s clear that ECT “makes an enormous difference in the lives of these patients.”

Logistical barriers, however, can prevent some young patients with autism from getting this treatment. In some states, kids under 18 aren’t allowed to receive ECT and must cross state lines for treatment. And for that treatment to be effective, they need to receive it often. Unlike depression—which can be managed with occasional ECT—these patients depend on more frequent treatments, “even as frequently as once every week, long-term,” says Reti. “We know of cases of patients who we have treated who have had to fly interstate on a weekly basis to receive ECT.”

Reti is trying to find a way to cut down on the number of ECT doses these patients with autism need. “The long-term consequences of such frequent ECT starting at a very young age really aren’t well-described,” he says.

His lab recently developed a mouse model of autism and self-injury (the mice perform repetitive self-grooming that leads to lesions), and they are hoping to use the research to learn more about the treatment.

Fighting a Stigma

Although ECT has proven helpful for a wide range of patients, misconceptions and a certain level of stigma remain. “Sometimes families are hesitant to encourage them to come to ECT,” Reti says.

For Nona McNatt, the idea of receiving a treatment that’s applied to the brain was scary, and some friends and family were concerned. However, her need for treatment outweighed those misgivings. “I think in the situation I was in, the episodes were severe enough that we were sort of looking for anything,” she says.

McNatt has a background as a nurse and midwife, and she was familiar with ECT as a treatment option for severe mental illness. But some people aren’t aware of that fact.

“It’s amazing. Some patients, and even some health care professionals, will say things like, ‘I didn’t even know ECT was still available; I thought that went out 50 years ago,’” says Reti. “It’s probably partly related to the stigma, and [to] movies portraying ECT the way it was delivered 70 years ago.”

Despite the apparent lack of public awareness, however, most of the major psychiatric organizations—like the American Psychiatric Association and the American Psychiatric Nurses Association—support its use.

And patients like McNatt are pleased with the results.

“It’s been a lifesaver for me,” she says.