ECT Isn't What You Think: A Century of Drift from the Shadows to Standard Care
Modern ECT is a procedure performed under anesthesia and muscle relaxants, with significant efficacy, but the evidence on memory loss side effects remains incomplete, and societal misunderstanding has led to excessive stigmatization.
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The actual ECT procedure
If you or I were to undergo ECT, here's what would happen: first, a risk assessment and informed consent, then a physical exam, and fasting overnight. The next morning, at the hospital or outpatient clinic, an IV line and two blood pressure cuffs (on the arm and right leg) are placed, and EKG, EEG, and EMG are connected. The anesthesiologist puts you to sleep, then inflates the leg cuff to restrict blood flow to the right foot, and administers a muscle relaxant (such as succinylcholine). Once the muscles are fully relaxed, a bite block is inserted, and a brief electrical current (lasting a few seconds or even half a second) is delivered through electrodes. The goal is not to make your whole body convulse, but to induce a generalized seizure, typically lasting 25-70 seconds. Because the muscles are relaxed, you see almost no external movement—the entire process is visible on the EEG.
— Erin Allman-UpdikeElectrode placement: why right side is chosen
There are several electrode placements: bilateral temporal (like in the movies), bifrontal, and the most common 'right unilateral'—one electrode on the right temple and another on the top right of the head. Right unilateral is used for most people because it has fewer cognitive side effects. Why consider the right side first? Because for about 98% of right-handed people and 70%-90% of left-handed people, language function is in the left temporal lobe. Avoiding left-side stimulation theoretically reduces language-related memory problems. But right unilateral is slightly less effective than bilateral. During treatment, doctors may switch based on side effects and efficacy: if bilateral causes severe side effects, they switch to right unilateral; if right unilateral is ineffective, they switch to bilateral.
— Erin Allman-UpdikeSeizure threshold and effective dose
The seizure threshold is the minimum electrical current that can induce a seizure. There is no precise measuring device; doctors estimate a starting point based on age, then titrate upward in small increments until a seizure occurs. But treatment does not merely aim to reach the threshold—the effective dose is usually 2.5 to 5 times the threshold. For bilateral, 2.5 times is sufficient, while right unilateral requires 5 times, because unilateral stimulation is less effective at achieving the same result. This dose varies from person to person and must be adjusted through trial and error. If a patient does not have a seizure or the seizure is too short (less than 25 seconds) during a session, the doctor may increase the dose and try again. Treatment is typically three times a week, with a total course of 6 to 18 sessions, or even longer.
— Erin Allman-UpdikeWe still don't know exactly how ECT works
Why does giving the brain an electric shock treat depression and catatonia? Frankly, we still don't fully understand. There are several main hypotheses. One is neurotransmitter changes: after ECT, serotonin, dopamine, and GABA (an inhibitory neurotransmitter) all show significant alterations. The increase in GABA itself is anticonvulsant, which may explain why the seizure threshold rises and seizures shorten over consecutive treatments. Another is that large fluctuations in hormones such as ACTH, prolactin, and TSH are seen in the hypothalamus and pituitary. A third is that ECT promotes neurogenesis, with the key molecule being BDNF (brain-derived neurotrophic factor). But how these changes directly relieve symptoms still lacks a one-to-one mechanism. Different diseases (depression, schizophrenia, catatonia) may involve different mechanisms, and research continues.
— Erin Allman-UpdikeDepression data: far better than first-line antidepressants
For treating major depression, ECT's key data are quite strong: most studies report remission rates (complete symptom resolution) of 50%-60% and response rates (significant symptom improvement) of 60%-90%. In comparison, the maximum remission rate for SSRI antidepressants is only about 40%. ECT also has a rare benefit—it can reduce the 30-day readmission rate by about half. This is not to say it should be a first-line treatment, nor that it is without risks (relapse or symptom recurrence within 6-12 months is not uncommon); but in patients with treatment-resistant depression and severe suicide risk, these efficacy advantages are hard to ignore.
— Erin WelshMemory issues are the most concerning side effect
ECT's most troublesome side effects center on cognition and memory. Immediately after the procedure, there is confusion lasting from a few seconds to half an hour, and attention and executive function may decline for weeks. Interestingly, most cognitive functions actually improve in the long term—possibly due to improvement in depression. The real problem is memory. Anterograde amnesia (difficulty forming new memories) usually resolves within weeks after the course, so many people are restricted from driving or making major decisions during treatment. Retrograde amnesia (loss of past memories) is more concerning to patients: it typically affects memories from the recent months to years before treatment, and while it often recovers, it can be permanent in some cases. Bilateral treatment is more likely to cause this problem than right unilateral.
— Erin Allman-UpdikeCatatonia: a deadly syndrome often misdiagnosed
Catatonia is often simplistically classified as a subtype of schizophrenia, but it is actually a psychomotor syndrome that can be triggered by any psychiatric or neurological illness. Patients appear awake, with eyes open, yet are almost completely immobile and mute, and may exhibit stupor, waxy flexibility (arm stays in a posed position without falling). Because they cannot eat or drink and are immobile for long periods, they are prone to malnutrition, pressure ulcers, muscle contractures, and even death. Untreated catatonia has a mortality rate as high as 20%! The most common treatment is benzodiazepines, but ECT is highly effective for catatonia from various causes. The previously mentioned girl with anti-NMDA receptor encephalitis (the 'Fire in the Brain' case) developed catatonia; immunotherapy and lorazepam were ineffective, and she eventually recovered with ECT.
— Erin Allman-UpdikeThe biggest bottleneck is not efficacy but access
Dr. Lopez believes the biggest obstacle ECT faces today is the difficulty in finding treatment centers. His hospital performs over 6,000 treatments annually across two campuses, averaging about 10-12 sessions per patient. But ECT is not widely available nationwide; many adult and pediatric patients travel across states for treatment, especially in cases of catatonia due to autoimmune encephalitis in infants, toddlers, and adolescents, where finding an experienced treatment team is extremely difficult. Therefore, improving access is his greatest hope. Additionally, physicians in other specialties—internal medicine, pediatrics, critical care—often do not recognize catatonia and are hesitant or fail to consider consulting ECT; thus, 'evangelizing' to non-psychiatric colleagues is part of his daily work.
— Leonardo LopezIn their own words · checked verbatim
The short answer to how does this work is that we still don't really know.
Erin Allman-Updike20:22
When we compare this to SSRIs, which we talked about in a prior episode, they have a remission rate at best of around 40 percent.
Erin Welsh24:24
The most common indication is for treatment-resistant depression, patients who have depression and have received medication for depression therapy and have not responded and remain ill.
Leonardo Lopez42:29
We use it in catatonia, which is a neuropsychiatric condition characterized by changes in speech and motor behavior that sort of spans a number of diagnoses.
Leonardo Lopez43:31
The more that we're able to show our colleagues in other fields the value of this treatment, the more they support it. I think that's been a big reason why we have tried at my hospital to sort of be very forward-facing with other departments.
Leonardo Lopez47:35
I think the biggest limitation is access to treatment without question.
Leonardo Lopez48:36
Figures
| Mortality rate of untreated catatonia | up to 20% | 36:58 |
| Remission rate of ECT for major depression | 50%-60% | 24:24 |
| Response rate of ECT for major depression | 60%-90% | 24:24 |
| Best remission rate for SSRI antidepressants | about 40% | 24:24 |
| Reduction in 30-day readmission rate with ECT | about half | 25:00 |
| Percentage of right-handed people with language in left temporal lobe | about 98% | 15:17 |
| Percentage of left-handed people with language in left temporal lobe | 70%-90% | 15:17 |
| Typical ECT seizure duration | 25-70 seconds | 12:15 |
| Annual ECT treatments at Lopez's two campuses | over 6,000 | 45:33 |
| Average number of ECT sessions per patient | 10-12 | 44:31 |
Glossary
- Catatonia
- A syndrome characterized by marked abnormalities in movement, speech, and behavior, triggered by various psychiatric or neurological conditions, and life-threatening in severe cases.
- Anti-NMDA receptor encephalitis
- An autoimmune encephalitis often presenting with seizures, psychiatric symptoms, and catatonia, requiring immunotherapy.
- Succinylcholine
- A muscle relaxant used in ECT to block neuromuscular transmission and prevent strong full-body convulsions during the shock.
- Retrograde amnesia
- Loss of memories formed before the event, often affecting events from months to years prior to ECT.
- Transcranial magnetic stimulation (TMS)
- A treatment using magnetic pulses to induce weaker currents in the brain without causing seizures; fewer side effects but generally less effective than ECT.
How to listen
Clinicians, psychiatric and pediatric medical staff, medical students, and anyone with doubts about ECT or wanting to understand first-line treatment evidence.
The historical background in the first half can be skimmed; but the treatment process and case examples are crucial.