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The Department of Psychiatry at Suburban Hospital offers these questions and answers about Electroconvulsive Therapy (ECT). If you have questions about inpatient or outpatient ECT services, please call Gloria Martin, RN, MPA, CAC, Program Director, at 301.896.2331.
ECT, or electroconvulsive therapy, is a treatment that causes the brain to have a generalized, or "grand mal" seizure under medically controlled conditions. It is performed under the guidance of two doctors, a psychiatrist and an anesthesiologist. Each treatment is done while the patient is asleep (with general anesthesia), and takes only minutes to complete. A series of treatments can be performed on an inpatient or outpatient basis, depending on the need of the patient.
Indication for ECT treatment includes but is not limited to patients who have:
Failure to respond to medication and/or psychotherapy
Are pregnant or have other medical conditions that limit the use of medications
Cannot tolerate medications
Convulsive therapy was introduced in 1934 by a Hungarian neuropsychiatrist Ladislas J. Meduna, who observed that patients with both psychotic disorders and epilepsy seemed to improve psychiatrically after having an epileptic seizure. He theorized that schizophrenia and epilepsy were antagonistic disorders, and induced seizures with first camphor and then metrazol (cardiazol). Although his theory was incorrect, his observation that mood improved with seizures was accurate, and thus a new treatment option was born.
Within three years, metrazol convulsive therapy was being used worldwide. In 1937, the first international meeting on convulsive therapy was held in Switzerland by the Swiss psychiatrist Muller. Italian professor of neuropsychiatry Ugo Cerletti and his colleague Lucio Bini developed the idea of using electricity as a substitute for metrazol in convulsive therapy. In 1937, they introduced the use of electricity induced seizure in humans. Cerletti and Bini were nominated for a Nobel Prize. Throughout the 1940s and 1950s, ECT was the preferred treatment for mood disorders, and provided many patients real relief from their symptoms in a time when few effective treatments were available.
Today, the premise of ECT – causing the brain to have a seizure – is the same as it was in the days of Dr. Meduna, but the procedure has entered the age of modern medicine. Modern ECT is performed under general anesthesia, with constant monitoring of brain and body systems. Two doctors are in attendance – a psychiatrist and an anesthesiologist – as well as specially trained nurses to assist in the procedure. The equipment is state of the art, ensuring that the delivery of an electrical stimulus to the brain is highly controlled and can be easily customized to match the physiology of each patient.
The process involves:
A referral from your physician.
A consultation with one of our ECT physicians to collect clinical data and ensure that ECT is the right treatment option.
Preauthorization of hospital and professional services, if required by your insurance company.
Medical examination and clearance, including and history and physical exam, blood tests, and EKG within 30 days of starting ECT treatment. You may obtain this through your primary care provider, or use Suburban Hospital’s Pre-testing Center. Other tests, such as head imaging and X-rays can be arranged if medically indicated.
A consent form signed by the patient for the ECT procedure.
In order to ensure a voluntary consent to ECT treatment, the patient must be informed of the risks, benefits, and prognosis both with and without ECT treatment as well as alternative treatments and their risks and benefits. Sometimes a patient is not able to make an informed choice and has legally designated someone to make medical decisions for him/her. In this case, the legal decision maker will make the informed consent for treatment.
ECT is provided on both an inpatient and outpatient basis. The treatment is administered in Suburban Hospital’s 4th floor Minor Procedure Suite, which is staffed with nurses and aides specially trained to care for ECT patients.
ECT is typically administered in the early morning, Monday through Friday.
Make sure you let the ECT psychiatrist and anesthesiologist know of all your current medications. Any medication that might cause problems during the treatment may need to be discontinued or carefully monitored.
Because general anesthesia is used, patients are required not to eat or drink (including water) anything after midnight before their scheduled ECT procedure.
The night before treatment, the patient’s hair should be thoroughly washed and no creamy hair products or skin lotions should be applied afterward.
If you are receiving ECT on an outpatient basis, you must make arrangements to have someone drive you to and from your ECT procedure. Your recovery period will occur in the Minor Procedure Suite or, in situations requiring a later pick-up to take you home, you may stay on the inpatient Behavioral Health Unit. You should also have someone stay with you at home for the first 12 to 24 hours after an ECT treatment. Please also see outpatient ECT pre-procedure instructions detailed in the last question.
ECT is performed by a team of medical professionals specifically trained in the delivery of ECT. This team consists of a psychiatrist, anesthesiologist, and nursing staff. The anesthesiologist administers general anesthesia as well as other medications needed during the treatment. He/she also monitors body systems, including blood pressure, heart function, and oxygenation. The psychiatrist delivers the ECT stimulation and monitors brain activity. The nurses prepare the patient for treatment, assist in the procedure, and provide recovery room monitoring and care of the patient.
The patient is put to sleep with a short-acting anesthetic through an intravenous line. In addition, you may be given other medications, depending on any health conditions you have or your previous reactions to ECT. Throughout the procedure, the patient wears monitoring sensors on the head, chest, and finger. These devices allow for the painless monitoring of brain waves, blood pressure, heartbeat, and oxygen saturation during the procedure. A muscle relaxant is then administered. A soft protective mouthpiece is used in the patient’s mouth to prevent dental complications and protect the tongue from injury.
Once the patient is asleep, a small, carefully controlled amount of electricity is passed between two electrodes on the patient’s head. Depending upon physician orders, a patient will receive either bilateral or unilateral ECT. When the electrical current is passed, a generalized seizure is produced in the brain. The seizure will last for one minute or less, during which time the patient is given oxygen to assist in breathing. The muscle relaxant in the patient’s system ensures that the muscular contractions associated with the seizure are mild.
When the procedure is completed and the anesthesia wears off, the patient will awaken and be transported to the recovery suite for observation until departure. The procedure and recovery take approximately 45 minutes. ECT is theorized to improve the chemical pathways in the brain, permitting an adjustment of nature’s neurotransmitters that affect mood and behavior.
The actual electrical stimulus to the brain can be given to both sides of the brain (bilateral ECT) or just one side (unilateral ECT), although both bilateral and unilateral treatment with result in a seizure to the whole brain. The differences between these two techniques include the area of the brain stimulated, timing of response, and potential for side effects. Your ECT psychiatrist will decide which type is right for you.
The number of treatments recommended for each patient is based on the individual patient’s needs and responsiveness to the procedure. The ECT psychiatrist will evaluate the patient’s progress after each session. Generally, patients receive three treatments in one week. Most patients receive a total of six to twelve treatments per episode of care. Occasionally some patients require more than 12 treatments to feel better. Some patients need maintenance ECT, since 20 to 50 percent of the people who respond well to ECT may relapse within six months. Therefore, a maintenance treatment of medications and/or ECT is usually clinically indicated.
Suburban Hospital’s ECT technology allows treatment with ultra-brief stimulation down to 25ms pulse width. This ability to control the parameters of the electrical stimulus is paramount in minimizing the risk of memory impairment, a side effect more commonly associated with higher pulse widths of energy delivery.
ECT is considered one of the safest treatment options for medically fragile patients, including the elderly, pregnant women, and patients who have limited tolerance to some psychiatric medications. As with all forms of medical treatment, some patients may experience adverse side effects. There is a potential for memory problems, headache, or short-term confusion in some patients. Other side effects may include muscle soreness, nausea, temporary irregularities in heart rate, and, in a few instances, damage to fragile teeth. Nationally, an estimated one procedure per 50,000 patients treated may result in fatality.
ECT is a cost-effective and efficacious treatment for some psychiatric disorders, especially when a faster response is needed. Many people begin to notice an improvement in their symptoms after two to four treatments with ECT. Full improvement may take longer. Response to antidepressant medications, in comparison, can take several weeks or more.
No one knows for certain how ECT helps treat severe depression or other mental illnesses. Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive. What is known, however, is that many chemical aspects of brain function are altered during and after seizure activity. Researchers theorize that when ECT is administered on a regular basis, these chemical changes build upon one another, somehow reducing symptoms of severe depression or other mental illnesses.
Recently, the National Institute of Clinical Excellence reviewed in detail the use of ECT and agreed it is an effective treatment for severe depression, severe mania, and catatonia. In general, ECT is used for severe depression, although some research suggests it may be helpful in Parkinson’s disease and other neurological conditions.
ECT is routinely covered by insurance companies, including Medicare, medical assistance, and private insurance plans. The staff at Suburban Hospital will work with the patient to verify their third party insurance coverage and explain any patient liability.
Suburban Hospital bills a hospital charge and your ECT psychiatrist will bill their professional charge. The anesthesiologist group submits a separate bill. In addition, there may be charges from Suburban Hospital for the pre-testing medical clearance. All Suburban Hospital charges are regulated by Maryland’s Health Services Cost Review Commission.
ECT is performed in the specially equipped Minor Procedure Suite on the 4th floor of Suburban Hospital, 8600 Old Georgetown Road in Bethesda.
The internet has many sites discussing ECT that are produced by professionals, organizations, people who have had ECT, or others with particular opinions. There are both negative and positive Web sites. You may wish to get information from several sources before making up your own mind.
Since people often forcefully express their views (either pro or con) on ECT, it can be hard to know what to believe. Most do agree, however, that people who are considering ECT – and their families and others – should try to understand as much as possible about it to make an informed decision.
Our staff is here to assist you in providing information and guidance regarding ECT. Patients, families, or mental health professionals may make inquiries regarding ECT. A referral is required from your psychiatrist. Inquiries or referrals can be directed to the Department of Psychiatry at Suburban Hospital, ECT Services, 301.896.2331
Prior to your scheduled treatment, arrange to have someone to bring you to the hospital and take you home from the hospital. Either have that person come with you or bring their name and telephone number with you. If they are to pick you up, tell them to be available approximately 45 minutes to an hour after your scheduled ECT procedure.
DO NOT eat food or drink fluids after 12 midnight on the night prior to the ECT treatment.
DO NOT take any medications unless directed to do so by your physician. Please bring your diabetic medication with you and give it to the nurse.
Register in the Admitting Department in the front lobby of the hospital at the time the doctor tells you to arrive.
Proceed to the 4th floor Minor Procedure Suite waiting room (4200 Unit).
The staff will bring you to the room where the treatment will be done. You will change from street clothes into a hospital gown. Your recovery may last for 30 to 45 minutes.
You will be discharged once you are fully recovered and given discharge instructions and the date, if needed, to return for ECT.
You need to drink sufficient fluids and if you are able, you may eat.
The amount of time you will be at the hospital depends on how many patients are being treated and if you have transportation from the hospital.
The process may take 1 to 2 hours but the treatment itself only takes a few minutes.
You will receive anesthesia. Regulatory policy REQUIRES that you MUST arrange transportation home with an adult. You can NOT drive for 24 hours after the treatment. We can NOT allow you to leave unattended, even in a taxi. Failure to adhere to this policy might require that your procedure be cancelled and/or we may not approve you to be scheduled for future ECT procedures.
It is also the patient's responsibility to make arrangements for someone to be with you at your home during the first 24 hours after your ECT procedure. One option in arranging for transportation and/or home-based assistance for those first 24 hours following a procedure is to work with at your cost an area home health agency such as Potomac Home Support (301.896.6990).