electroconvulsive therapy

Illustration by Diego Sabogal

In 1990, life was good for Carol Kivler. At age 40, she was happily teaching business skills at a college near her home in Lawrence, New Jersey, raising three healthy tweens, and married to a loving husband. “I had a beautiful home and money in the bank,” she says.

And then, without warning or explanation, “depression brought me to my knees.”

Kivler couldn’t concentrate. She couldn’t sleep. She lost her appetite. “What do I have to be depressed about?” she kept asking herself.

Her doctor explained that a chemical imbalance in Kivler’s brain could be to blame and started her on antidepressants, cautioning that they could take up to six weeks to kick in. Kivler had only been on the medication a month before she started having psychotic symptoms.

“My depression was like a funnel and I had been hanging on by my fingernails,” she says. “At that point, I just let go. I lost touch with reality.”

Certain that the only way to escape her hopelessness was by taking her own life, Kivler attempted to convince her husband that he and their children should be in the car with her when she drove off a bridge.

By the following day, she was hospitalized in a locked-down psychiatric ward where she couldn’t hurt herself. But 24 days later, when Kivler was still no better despite trying various medications, her doctors suggested she try a different treatment: electroconvulsive therapy (ECT).

During the procedure, which would be performed under general anesthesia, electric currents would be passed through Kivler’s brain to trigger a small, controlled seizure. The hope was that the resulting changes to her brain chemistry could finally lift the symptoms of her depression.

Kivler recoiled at the idea. “My first reaction was, ‘You’re going to fry my brain?’” she recalls.

What would the dean of her college think? Would she ever be allowed back into the classroom to teach? If her neighbors found out, would they still let their kids come over and play with her children?

An empathetic nurse persuaded her to give the procedure a try.

“ECT was my silver bullet,” admits Kivler. “After the third treatment, my husband had tears streaming down his face. He said ‘I can see life in your eyes again.’”

“Mom!” her kids exclaimed. “You’re back.”

Carol Kivler, who was treated with electroconvulsive therapy, now works as a mental health advocate and author. Image by Carol Kivler

How ECT helps

It’s been estimated that worldwide, one million people undergo ECT each year. But if you’re feeling depressed and go see your doctor for help, it won’t be the first treatment they’ll suggest. Or even the second, or the third.

The procedure is most commonly used to alleviate what medical professionals refer to as “treatment-resistant depression” — depression which hasn’t responded to other forms of help such as medications.

ECT can help people with major depressive disorder or bipolar disorder. It’s also used to treat catatonia, a potentially life-threatening state in which people have trouble controlling their movements to the point where they stop eating or talking altogether.

During ECT, patients are put under general anesthesia and given a medicine that stills their muscles. Then, a doctor applies electrodes, each about the size of a silver dollar, directly to specific areas on the head. When a button is pushed, a low-voltage electrical pulse is delivered to the person’s brain.

The seizure that’s triggered generally lasts 30 to 45 seconds, and the total amount of time the patient spends asleep is 4 to 5 minutes, says Dr. Kala Bailey, a psychiatrist with UT Southwestern’s Peter O’Donnell Jr. Brain Institute. “It’s quite underwhelming,” she admits. “We have trainees who come in and say, ‘That was it?’”

A half hour later, some patients are ready to go home for the day.

“Most antidepressants can take six to eight weeks to work,” Bailey says. “When ECT works, we can start to see a difference in about a week or two. It can vary from a person subjectively feeling better and saying, ‘My mood is better,’ to their family noticing they’re engaging more, getting themselves dressed, eating, and wanting to get out of the house.”

Still, a full course of ECT can require as many as 20 treatments, administered as frequently as 3 times a week.

Although studies have shown that ECT has antidepressant, antipsychotic, antimanic, and anticonvulsive effects, how it works remains a bit of a mystery. There’s likely more than one reason.

Like antidepressants, ECT can trigger the production of important brain chemicals like serotonin, which regulates mood. It also boosts the output of dopamine, a neurotransmitter linked to the brain’s pleasure center. Other research points out that ECT reduces brain activity in the amygdala, the part of the brain that controls anxiety and fear.

“It’s pretty amazing,” says Bailey. “If we make good patient selections, at least 60 — if not 70 percent — will have a response to ECT. That’s saying a lot.”

The risks of ECT

It’s impossible to talk about ECT without referencing the 1975 movie, “One Flew Over the Cuckoo’s Nest” in which “shock therapy” is portrayed as a form of punishment for people with mental illness.

“ECT was once considered a barbaric form of therapy,” acknowledges Sal Raichbach, PsyD, LCSW, a licensed psychologist and chief of clinical compliance for Ambrosia Treatment Center. “Pictures illustrating patients strapped to a chair, with a device placed over their head and a wooden stick in their mouth to avoid biting their tongue is what many remember about ECT.”

“Thankfully,” he adds, “real electroconvulsive therapy looks a lot different.”

Still, although experts consider it safer, gentler, and more precise, it’s not without side effects.

Mild reactions like headaches, muscle aches, and nausea can often be controlled with over-the-counter medicines, but “the cognitive side effects are typically the greatest concern with ECT,” says Dr. Joseph J. Cooper, associate professor of clinical psychiatry at the University of Illinois at Chicago.

The most common issue people who receive ECT can experience is a lapse in short-term memory, although that appears to be temporary. “The ability to make new memories typically goes back to normal within one to two weeks of stopping ECT,” Cooper said.

People often worry that ECT will cause brain damage or drastically change their personality but “this has been studied and there’s no scientific evidence that supports these as risks,” said Cooper. “In fact, some evidence indicates that ECT may induce… new connections between brain cells in the hippocampus and this may be an important mechanism of ECT’s antidepressant effects.”

The process of ECT continues to be refined. Recent research published in The Journal of Clinical Psychiatry shows that identifying markers of brain inflammation may help pinpoint the people who will benefit most from having ECT.

Meanwhile, researchers at Duke University School of Medicine are working to create an electrical map of depression in the brain. Doing so could allow ECT providers to target specific areas of a patient’s brain that aren’t functioning correctly.

Still, “electroconvulsive therapies directly target the brain, the most delicate and intricate part of any human being,” reminds Raichbach. “Therefore, [it] should only be considered as an alternative to ‘traditional therapies’ if they haven’t yielded success.”

Anyone being considered for ECT should have both a medical and psychiatric exam. It’s also important, Raichbach says, “to gather information from the patient him or herself on the expectations and goals of their therapy.”

The reported relapse rate following ECT is 50 percent within the first 6 months. That may seem high, acknowledges Bailey, but if a patient’s symptoms return, “we have an opportunity to intervene again with ECT.”

And occasionally, she notes, “we have patients stay in remission 15 or 20 years, or never have to have it again.”

What happens after ECT

Four years after Kivler first had ECT, her mental health began to deteriorate once more. She had ECT again and her depression skulked away — only to rear its head twice more over the years. Yet after her last treatment in 1999, it took 5 more years to simply admit she had the procedure.

“I was fearful about being labeled. I didn’t want to be ‘damaged goods,’” Kivler says. “Mental health disorders have such a personal and professional stigma.”

ECT needs to lose the unfortunate nickname of “shock therapy” and be rebranded as a “defibrillator of the brain,” she said. “When your heart stops, they shock it,” she points out. “When they hit your brain with electricity, they’re rebooting it too. The word ‘shock’ — its connotation is frightening.”

“Coming out [about ECT] was part of my healing,” said Kivler, who has since become a mental health advocate and written a book about her experience: “Will I Ever Be the Same Again? Transforming the Face of Depression & Anxiety.” “I was harboring so much guilt and shame. That in itself was debilitating.”

Today, at age 67, Kivler hasn’t experienced depression in 18 years. She credits that not only to her experience with ECT, but the sweeping lifestyle changes she’s made.

“I went on a quest to get mentally healthy,” Kivler says.

These days, she does acupuncture. She exercises. She works with a nutritionist and takes herbal supplements. She meditates, does yoga, and partakes in both cognitive behavioral therapy and mindfulness.

“It’s hard work to stay well,” Kivler says. “We’re a quick-fix society, but I work on recovery, 7 days a week, 365 days a year.”