1. Demystifying
Electroconvulsive
Therapy (ECT)
Lisa McMurray, MD, FRCPC
Domenica Palermo, RN
Tanya McLendon, RN
DA
BA
Gregory McLeod, MHA

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3. Access to treatment that works
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Insert photo of
elderly woman
here

4. WHAT IS ECT?
Electroconvulsive therapy
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5. ECT Device
R (resistance in Ohms)
Ohm’s Law: I (current) = V (voltage)
R (resistance)
I (current in Amperes)
V (voltage in Volts)

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8. Peterchev A et al, 2010

10. WHY ON EARTH WOULD WE DO
THIS?
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11. Convulsive Therapies
• Insulin-induced coma and convulsions, to treat
schizophrenia, discovered in Berlin by Manfred
J. Sakel, in 1927;
• Metrazol-induced convulsions, to treat
schizophrenia and affective psychoses,
discovered in Budapest by Ladislaus J. von
Meduna, in 1934 (camphor, then
pentylenetetrazol (Metrazol), and
• Electroconvulsive shock therapy, discovered by
Ugo Cerletti and Lucio Bini in Rome, in 1937.

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13. Med Hist. 2011 July; 55(3): 407–412.

14. Electroconvulsive Therapy

15. HOW DOES ECT WORK?
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16. Neurotransmitters and receptors
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17. Brain areas with significantly higher relative regional cerebral blood
flow values during ECT
Takano H et al, British Journal of Psychiatry, Jan 1, 2007, vol 190 no. 1 63-68
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18. Fig. 3. Essential role of Gadd45b in activity-induced dendritic development of newborn
neurons in the adult brain.
D K Ma et al. Science 2009;323:1074-1077
Published by AAAS

19. Changing functional connectivity in the brain with ECT
Beall et al, 2012
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20. Patterns of use
• 1950’s to 1980: decline
– Pharmacotherapy
– Negative portrayals in media
• Stabilizing and even increasing (modestly)
since then in some jurisdictions
– Modified ECT
– Intolerance to pharmacotherapy
– Speed of action

21. One Flew Over the Cuckoo’s Nest

22. Toronto Star,
23 December 2012

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24. Declining Use of ECT in US General Hospitals

25. Contemporary use and practice of
electroconvulsive therapy worldwide (2012)
• In Western countries (Europe, USA, Australia, and New
Zealand), ECT is at large administered to elderly female
patients with depressive disorders. In those areas of the
world (Asia, Africa, Latin America, Russia), where ECT is
still often administered unmodified, it is predominantly
prescribed to younger patients (often more male) with
schizophrenia
• New trends are revealed. ECT is used as first-line acute
treatment and not only last resort for medication
resistant conditions in many countries. Other professions
than psychiatrists (geriatricians and nurses) are
administering ECT. ECT use among outpatients
(ambulatory setting) is increasing.

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28. INDICATIONS FOR USE

29. ECT works for:
• Major Depressive Episode
• Manic Episode
• Schizoaffective disorder
• Treatment-resistant Schizophenia
• Some medical conditions, e.g. Parkinson’s

30. ECT does not work for:
• Dysthymic disorder
• Anxiety disorders
• Substance abuse disorders
• Eating disorders
• Personality disorders
– But may treat depression that often comes with
these disorders

31. ECT in Major Depression
• 80-90% remission rate (vs 60-70% with
medications
• Catatonic features and delusions are
associated with good response
• Dysthymia/Persistent depressive disorder
and medication resistance are associated
with non-remission – INFORMED CONSENT
is important
• Relapse rates are high

32. When to use ECT
Primary
• Urgent need for rapid
response
• Less risky than
alternatives
• History of good
response
• Patient preference
Secondary
• Poor response to
alternatives
• Intolerant to
alternatives
• Deterioration requiring
rapid response

33. ECT with Elderly
• May be more effective than with younger
patients (van der Wurff, 2003)
• Efficacy and safety in patients with
comorbidity (e.g. dementia,
cerebrovascular disease, Parkinson’s) is
under investigation
• Increased complications but safer than
medications

34. SIDE EFFECTS
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35. Consent for ECT should cover:
• Risks and benefits of ECT
– Including cognitive adverse effects
– Including death (1/10 000 per series of ECT)
• Possibility of non-response and relapse
• Behavioural restrictions
– E.g. NPO for several hours prior to treatment
– E.g. no driving during and acute course of ECT
• Alternatives to treatment
– Including no treatment
• Individual indication and rationale for ECT
• Who can answer questions

36. Informed Consent and Cognition
• Memory loss is a common side effect of ECT
• Memory loss with ECT has a characteristic pattern
– More treatments produce more memory loss
– Worse shortly after a treatment
– Gradual improvement after ECT is discontinued
– Patchy memory loss extending for several months prior to ECT; some may return with
time
• May be left with some permanent gaps in memory
• Difficulty in forming new memories
– Temporary
– Usually disappears within a few weeks after discontinuation of ECT
• Most patients state that benefits of ECT outweigh problems with memory
• Most patients report that memory is IMPROVED after ECT
• A minority of patients report problems in memory that remain for months or years
• There is great variability between patients
• Some stimulus parameters and electrode placements are associated with more
cognitive side effects than others

37. Summary of ECT
• The best treatment we have for depression
• Works quickly
• Very safe
• Not a last resort!
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Lipsman, N et al, CMAJ, January 7, 2014, 186(1)

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45. Objective information on ECT
• https://www.isen-ect.org/websites-about-
ect
• http://www.canects.org/patients.php
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