April 29, 2021
By Michael Gordon, MD, MSc, FRCPC
Electroconvulsive therapy (ECT) sounds brutal, right? It’s an electro current through the brain, usually associated with at least one, if not more, major seizures. With the introduction of potent antidepressants, it was hoped and expected that ECT would see its last days. With the Hollywood hit film, “One Flew Over the Cuckoo’s Nest,” it seemed that ECT would disappear from the repertoire of medical treatments for severe depression.
While I was a medical student in Dundee Scotland, ECT was still being used on patients with severe depression who were resistant to the standard medications, which at that time were tricyclic anti-depressants. Some patients did not respond to those often seemingly miraculous drugs, but for others, the effect was limited and often ephemeral.
The psychiatry in-patient department was housed in a large 19th century-built edifice. As students, we would visit there once or twice a week for in-patient rounds and once a week for an ambulatory clinic. One day, I saw a notice pinned to the student bulletin board. It was for students that wanted to spend three months on the psych ward, receiving room and board in exchange for assistance at ECT sessions with a schedule that allowed for attendance to regular medical school activities. The expectation was a return in the evening for a provided supper (as was called tea) and admission notes and orders for newly admitted patient and follow-up patients. It seemed like a very attractive arrangement since the cost of room and board was a good chunk of the costs of medical school. A fellow classmate and I volunteered and were told our start date a week after the notice was posted.
The protocol was simple; patients who were deemed suitable for ECT were fasting in the morning and wheeled on a gurney to the treatment room. The anesthetist and psychiatrist prepped the patient while either I or the other student made sure all the relevant information was reviewed from the chart. The paddles were placed on both sides of the head, although a number of patients received unilateral shocks as part of study of recovery time comparing unilateral and bilateral application of shocks. The students recorded the result of the shocks and accompanied the patient into a recovery room and from there back to their rooms. After 3 or 4 patients, the session was over and when the patients had recovered the students were free to leave to the medical school. In the evening we visited the patients from the morning and examined them and wrote in chart. Some patients seemed to respond very dramatically to the treatments and others not as much.
Later in in my career I had an experience where my stint doing ECT was helpful. I saw a patient in consultation after having been admitted for and treated for pneumonia. After she recovered from her infection, I was asked to see her again as she did not recover and lost her willingness to eat or drink and “curled” herself into what could be called fetal position with no interest in what was going on around her. Her daughter was frantic and claimed that before she was ill, she was “fine”. I could not find a clinical explanation for her condition and postulated that she was in a depressive state. Despite attempts at antidepressant treatment she did not recover. I suggested ECT therapy to the daughter who agreed. To my surprise the psychiatrist disagreed with me and attributed her state as that of dementia and did not agree to the use of ECT. I literally begged the psychiatrist and said I would take responsibility, but I did not have access to the ECT machine. He reluctantly agreed and we performed 2 ECT treatments.
On the third day I came to the ward to find the patient sitting up and eating a cheese sandwich from which she offered me a bite to eat. Three treatments later she was fully recovered and soon after was discharged home. A couple of years later I met the daughter and she told me that her mother had another episode of withdrawal while at another hospital and explained that the doctors there would not agree to treat her with ECT. They diagnosed her with late-stage dementia.
As my career progressed into being a staff geriatrician, the circle turned so that ECT became more acceptable as treatment for severe depression in older patients. I ended up working at an academic geriatric centre that had in addition to geriatricians on staff, geriatric psychiatrists. Part of the repertoire for the treatment of depression was ECT without the resistance I had witnessed previously. Some of my psychiatric colleagues suggested ECT even prior to antidepressants in order to avoid the potentially serious side-effects of the medications. Like so many things in medicine, the balance has shifted much to the benefit of severely depressed older patients.
Dr Gordon is a geriatrician and ethicist; formally medical director and head of geriatric medicine at the Baycrest Health Science Centre in Toronto. He trained in medicine at the University of St. Andrews in Scotland and in medical ethics at the University of Toronto. He has traveled and lectured widely and is a medical writer having published a number of books the most recent ones being Parenting your Parents: Straight talk about Aging in the Family—co-authored with Bart Mindzenthy.
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