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Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is a modern and sophisticated treatment for specific mental illnesses. In the course of the treatment, the patient is given a short anaesthesia, the muscles are relaxed and the body is supplied with sufficient oxygen, before a short stimulation of the brain is applied. The brain reacts to this with strong activation, after which various, mainly chemical, reactions of the nervous tissue develop, which ultimately lead to recovery. To that extent, ECT resembles to a defibrillation treatment of the heart, which corrects severe cardiac arrhythmias, but ECT requires much lower amounts of electricity. In the following frequently asked questions about ECT are answered.

Electroconvulsive therapy (ECT) at a glance

  • Affective psychoses:
    • Depression, especially treatment resistant (Largest patient population >80% of all ECT patients)
    • Mania, mixed states
  • Schizophrenia, especially with acute symptoms (positive symptoms)
  • Rarely in: puerperal psychoses, during pregnancy (avoidance of medication) and children, pernicious catatonia, malignant neuroleptic syndrome, severe psychotic compulsive symptoms, Parkinson’s disease, status epilepticus
  • Clinical:
    • Primarily in the case of life-threatening exacerbations, also suicidality, if indicated also at the express request of the patient,
    • Secondarily in the case of pharmacoresistance
  • Tied to a generalized seizure
  • Not the seizure itself, but the induced neurochemical and neurophysiological processes
  • Compensation of disturbed neurotransmitter functions (serotonin, dopamine)
  • Recovery of disturbed brain functions (frontal cortex)
  • Likely also positively neurotrophic
  • One of the safest therapy methods (when considering the treated risk patient population)
  • Mortality < 2/100 000 (mainly due to cardiovascular complications)
  • Memory impairment (anterograde, persisting only for hours, retrograde rarely in individual cases persisting)
  • The ability to learn is retained and usually improves during the course of the treatment
  • Very rarely persistent loss of individual content (but also interferences with underlying disease)
  • Volatie neurophysiological failures (aphasia, apraxia, agnosia); short and mostly incomplete paresis
  • Postictal confusion and slow reorientation, rarely prolonged seizure or delirium
  • Postictal cardiac arrhythmia, hypertension
  • Headache, nausea, vomiting (due to the anaesthesia), sore muscles (due to the relaxants)
  • No absolute counter indication
  • Cerebral infarcations <3 months
  • Intracerebral mass with a tendency to edema formation (e.g. metastases)
  • Relative counter indication: Unstable vascular malformation (angioma, aneurysm), pheochromocytoma
  • Retinal detachment, acute glaucoma
  • Severe cardiovascular disease (risk of anaesthesia >3 ASA)
    • Congestive heart failure
    • Heart attack <3 months
    • Dangerous cardiac arrhythmias (cardiologist if necessary)
    • Disrupted hypertension
  • Before ECT
    • Thorough psychiatric examination (anamnesis and findings, see counter indications)
    • General physical and neurological examination, dental status
    • Laboratory (Blood Analysis and serum, urine), ECG
    • Depending on the situation, not routine, chest X-Ray, EEG, CCT/MRI
    • Patient information (see below) see below and consent (ECT and anaesthesia)
  • To ECT (only in appropriate spatialities with possible emergency treatment)
    • 8 hours fasting
    • Medication continue: e.g. Antihypertensives, bronchodilators (except theophylline: proconvulsive!), acid blockers, steroids, antiarrhythmics, cave b-receptor blockers (asystole, possibly atropine); Only give after treatment: e.g. Antidiabetics, diuretics, cholinesterase inhibitors (glaucoma); Discontinue if possible: e.g. previous psychotropic drugs, lithium (cognitive side effects), or omit > 24 h, level < 0.4 mmol / l, anticonvulsants, benzodiazepines (sedation preferably with neuroleptics)
  • Treatment
    • Preparation, removal of jewelry, dentures, access, cleaning and application of stimulation- (UL, BT, BF, see above) and monitoring electrodes
    • Preoxygenation, induction of anesthesia (methohexital, thiopental, etomidate, propofol), relaxation (succinylcholine)
    • Stimulation, if necessary, titration, UL high stimulus dosage, BL lower
  • After ECT
    • Awakening phase up to protective reflexes, if necessary, keep the airways clear (relaxation)
    • Monitoring for about 2 hours, then breakfast and participation in therapies
    • Investigation (side effects, effectiveness)
  • Clearly defined and standardized, while being appropriate and individual
  • General: Indication, side effects, especially memory disorders (see Side effects)
  • Individual: Why ECT, alternatives, risks/benefits, possible revocation
  • Start with 2-3 treatments per week, mostly UL (non-dominant hemisphere-, right RUL if right-handed, left LUL if left-handed)
  • In the case of severe illness, start of BL (BT, BF) if necessary
  • Treatment cycle 6-12 treatments, less or more depending on the diagnosis
  • If rapid relapse after discontinuation, maintenance ECT (EEKT), about 1st month 4/month, 2nd-3rd Month 2/month, then 4th-6th Months 1/month (very variable according to course)
  • If there is no effect:
    • Switch to BT after 4-6 unsuccessful UL treatments
    • Check diagnosis
    • Concomitant diseases (addiction, internal medicine?, concomitant medication? (especially benzodiazepines)
    • Possibly pausing, second series (BT)
    • Augmentation (antidepressants, neuroleptics)

Electroconvulsive therapy (ECT) Questions and Answers

Is ECT even a recognized treatment method?

ECT has now been used for over 70 years and during this time has been further developed into a state-of-the-art therapy. It has proven itself countless times in the treatment of severe, sometimes life-threatening mental illnesses. It is accepted by all scientific societies as an effective and indispensable treatment method for certain mental illnesses (e.g. depression, mania and schizophrenic psychoses). There are various statements by recognized professional societies at national and international level.

Is ECT still necessary with increasingly effective drugs?

There is no doubt that medication and psychotherapeutic procedures usually help with mental illnesses. Most diseases can be treated successfully with it. In comparison, ECT is rarely used. Despite modern medication, there are always diseases that do not respond sufficiently to this therapy and where ECT still proves to be very effective. In addition to those patients who show insufficient improvement under medication, ECT is also used at the very beginning in case of very dangerous and serious illnesses (e.g. with a risk of suicide).

How does ECT relate to psychotherapy?

There are various psychotherapeutic methods that are successfully used to treat mental illnesses. As a rule, ECT is embedded in an overall treatment plan that also includes psychotherapeutic treatment. In the case of particularly severe symptoms of the disease, ECT is often indispensable to produce sufficient improvement so that psychotherapeutic treatment can be carried out effectively again.

What diseases is ECT used for?

Major depression, which often responds poorly to medication, is the most common condition treated with ECT. The patients show a deeply depressed mood, are desperate, can no longer feel normal feelings, have no appetite and sleepless, sometimes have strong feelings of guilt, no zest for life and think about suicide. In addition, mania and certain schizophrenic psychoses can also be treated well with ECT.

Who applies ECT?

A typical treatment team includes doctors, nursing staff and an anaesthesiologist. In addition to sufficient experience with this treatment, specific spatial and technical pre-conditions are required, that is why this treatment usually takes place in specially equipped clinics.

How is ECT performed?

The patient, who is lying as relaxed as possible, is injected with an anasethetic, after which he falls asleep for a few minutes. Shortly thereafter, the muscles are relaxed with muscle relaxant and the patient is given pure oxygen to breathe. When an optimal oxygen saturation level of the blood is reached and the body is completely relaxed, the brain is stimulated with short electrical impulses applied through electrodes on the head (usually in the forehead and vertex area). The brain reacts to this with a strong and steady activity that lasts about 30-60 seconds and then stops on its own. During and especially after this activity, various chemical and electrical reactions are initiated that are important for the recovery. Brain activity can sometimes be recognized by slight muscle twitches. After about 3-6 minutes, the patient wakes up and is monitored by specially trained personnel for the next few minutes until he regains complete consciousness.

How many treatments are carried out?

As a rule, 6-12 treatments are necessary, rarely more, occasionally less. After the first series of treatments has been carried out, it may be necessary to continue treatment at rare intervals (one to four times a month) for a certain period of time in order to maintain success.

Leads ECT to healing?

Most mental illnesses have the characteristic that they return after a shorter or longer period of time. Therefore, drug therapy is usually necessary after ECT to prevent from relapse.

Is ECT safe?

ECT is indisputably one of the safest medical treatment methods of all. The risk of a serious complication is far lower than with a normal birth and is ultimately related to the risk of anaesthesia, which cannot be completely avoided. The fact that ECT is now only carried out under optimal conditions (technically and in terms of personnel) certainly contributes significantly to this security.

What side effects can occur?

Shortly after waking up after ECT, it may take a certain amount of time (minutes) to regain consciousness. The memory of recent events or of certain facts (e.g. different dates, names of acquaintances, public events, addresses or telephone numbers) can be temporarily impaired, which can be extremely irritating. For most patients, memory disturbances are transient, they only last a few days. Occasionally and in a milder form they last a few months, and very rarely longer. In this context, however, it must be taken into account that severe depression and other psychoses also lead to significant memory disorders independently of ECT. Fortunately, with modern stimulation techniques, memory disorders have become much rarer.

Can ECT cause permanent memory damage?

This is certainly not the case for the majority of patients. A few patients report that some events appear to be permanently erased. In this context, it should be noted that severe depression can occur as an early symptom of another brain disease, which itself later leads to memory disorders, which then become apparent earlier because of the ECT. Overall, it is important to know that the ability to memorize, that means learning is not affected in any way by ECT, in fact it usually improves. In any case the treating physicians make sure that the treatment is as gentle as possible in order to avoid memory disorders.

Must I be afraid of ECT?

It is absolutely normal if there is a certain bias before the therapy. However, the reality of a treatment has nothing to do with the completely exaggerated and dramatic depictions in movies and other media. There, ECT is often presented as an instrument of punishment or torment. Most patients rate their ECT as not worse than going to the dentist.

How does ECT work?

This question is still largely unanswered. The brief stimulation leads to a strong activation and subsequent inhibition of brain activity, from which the brain finds a new balance in its function. Countless electrical and chemical processes occur between treatments that ultimately lead to recovery. Current research shows, that there are many and above all different starting points for the effect of ECT, ultimately ECT makes use of the brain’s natural ability, namely to work electrically.

Can ECT be performed without consent?

Every patient has to consent to the treatment after the patient information has taken place. In this respect, ECT is no different from other medical interventions. As a rule, the patient is informed about the advantages and risks as well as alternatives before the consent is obtained in writing. The consent can be withdrawn at any time without giving reasons. Patients who are unable to give consent can only be treated in life-threatening emergency situations, otherwise legal representatives must be involved in the decision-making process.

Why does ECT have such a negative press?

It is apparently an unavoidable part of reality that mental illnesses and their therapy are defamed as disturbing and sometimes inhuman. The sober reality, on the other hand, is mostly unspectacular. This also applies to ECT. However, it must also be stated that at the beginning of its introduction it was sometimes used uncritically and too often, which contributed to a negative impression. The influence of movies, which often rely on dramatization, is probably also considerable. ECT certainly has this bad reputation wrongly. ECT has helped countless patients, although they often and quite understandably do not want to openly admit to the illness and treatment and therefore the other negative representations lack a real counterweight. It can be expected, that it will probably not be completely avoidable in the future, that ECT will be deliberately misrepresented and presented in way that arouses fear. Fortunately, this is not a big problem for almost all patients who undergo this treatment.

Electroconvulsive therapy (ECT) Downloads

Download PDF brochure ECT in 24 questions

The DGPPN brochure can be downloaded here to find out more about the topic.

Download PDF Thymatron ECT in german

Here you can download our brochure for the Thymatron, our ECT device.

Download PDF Thymatron EKT english

Here you can download our brochure for the Thymatron, our ECT device.

Download PDF Thymatron ECT in russian

Here you can download our brochure for the Thymatron, our ECT device.

Download PDF Thymatron ECT in italian

Here you can download our brochure for the Thymatron, our ECT device.

Download PDF Thymatron ECT in swedish

Here you can download our brochure for the Thymatron, our ECT device.

Download PDF DGPPN statement on ECT

Here you can download the statement of the DGPPN to learn more about the topic.

How to use our ECT devices

Connection Scheme 1

Connection Scheme 2

Connection Scheme 3

Connection Scheme 4

Connection Scheme 5

Position of the stimulation electrodes

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