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Information on ECT
This leaflet is for anyone who wants to
know more about ECT (Electro-convulsive therapy). It discusses how
it works, why it is used, its effects and side-effects, and
ECT remains a controversial treatment and
some of the conflicting views about it are described. If your
questions are not answered in this leaflet, there are some sources
of further information at the end of the leaflet.
Where there are areas of uncertainty, we have listed other
sources of information that you can use. Important concerns are the
effectiveness and side-effects of ECT and how it compares with
other treatments. At the time of writing, these references
are available free and in full on the Internet.
What is ECT?
ECT is a treatment for a small number of
severe mental illnesses. It was originally developed in the 1930s
and was used widely during the 1950s and 1960s for a variety of
conditions. It is now clear that ECT should only be used in a
smaller number of more serious conditions.
ECT consists of passing an electrical
current through the brain to produce an epileptic fit – hence the
name, electro-convulsive. On the face of it, this sounds bizarre.
Why should anyone ever have thought that this was a sensible way to
treat a mental disorder? The idea developed from the observation
that, in the days before there was any kind of effective
medication, some people with depression or schizophrenia, and who
also had epilepsy, seemed to feel better after having a fit.
Research suggests that the effect is due to the fit rather than the
Q How often is it
It is now used less often. Between 1985 and
2002 its use in England more than halved, possibly because of
better psychological and drug treatments for depression.
Q How does ECT
No-one is certain how ECT works, and there are
a number of theories.
It can change patterns of blood flow
through the brain. It can change the metabolism of areas of the
brain which may be affected by depression. Many doctors believe
that severe depression is caused by problems with certain brain
chemicals. It is thought that ECT causes the release of these
chemicals and, probably more importantly, makes the chemicals more
likely to work and so help recovery.
Recent research has suggested that ECT
can stimulate the growth of new cells and nerve pathways in certain
areas of the brain.
Q Does ECT really
It has been suggested that ECT works not because of the fit, but
because of all the other things – like the extra attention and
support and the anaesthetic – that happen to someone having it.
Several studies have compared standard ECT with "sham" or
placebo ECT. In placebo ECT, the patient has exactly the same
things done to them – including going to the ECT rooms and having
the anaesthetic and muscle relaxant – but no electrical current is
passed and there is no fit. In these studies, those patients who
had standard ECT were much more likely to recover, and did so more
quickly than those who had the placebo treatment. Those who didn't
have adequate fits did less well than those who did.
Interestingly, a number of the patients having "sham" treatment
recovered too, even though they were very unwell; it's clear that
the extra support does have a benefit as might be expected.
However, ECT has been shown to have an extra effect in severe
depression – it seems, in the short term, to be more helpful than
Pros & Cons of
Q Who is ECT likely to
The National Institute of Health and
Clinical Excellence (NICE) have looked in detail at the use of ECT
and have said that it should be used only
in depression, resistant mania or catatonia.
They say ECT should be considered
for acute treatment of severe depression that is life-threatening
and when a rapid response is required, or when other treatments
It should not be used routinely in
moderate depression, but should be considered for people with
moderate depression if their depression has not responded to
multiple drug treatments and psychological treatment.
Q Who is ECT unlikely to
ECT is unlikely to help those with mild to
moderate depression or most other psychiatric conditions. It has no
role in the general treatment of schizophrenia.
Q Why is it given when there
are other treatments available?
ECT has been shown to be the most effective
treatment for severe depression. It would normally be offered
- several different medications have been tried
but have not helped
- the side-effects of antidepressants are too
- you have found ECT helpful in the past
- your life is in danger because you are not
eating or drinking enough
- you are seriously considering suicide.
Q What are the side effects of
ECT is a major procedure involving, over a few
weeks, several epileptic seizures and several anaesthetics.
It is used for people with severe illness who are very unwell and
whose life may be in danger. As with any treatment, ECT can
cause a number of side-effects. Some of these are mild and some are
Many people complain of a headache immediately
after ECT and of aching in their muscles. They may feel
muzzy-headed and generally out of sorts, or even a bit sick. Some
become distressed after the treatment and may be tearful or
frightened during recovery. For most people, however, these
effects settle within a few hours, particularly with help and
support from nursing staff, simple pain killers and some light
There may be some temporary loss of memory for
the time immediately before and after the ECT.
Older people may be quite confused for two or
three hours after a treatment. This can be reduced by changing
the way the ECT is given (such as passing the current over only one
side of the brain rather than across the whole brain).
There is a small physical risk from having a
general anaesthetic – death or serious injury occurs in about 1 in
80,000 treatments, around the same level of risk in dental
anaesthesia. However, as ECT is given in a course of treatments,
the risk per course of treatment will be around 1 in 10 000.
The greater concern is that of the long-term
side effects, particularly memory problems. Surveys conducted by
doctors and clinical staff usually find a low level of severe
side-effects, maybe around 1 in 10. Service user-led surveys
have found much more, maybe in half of those having ECT. Some
surveys conducted by those strongly against ECT say there are
severe side-effects in everyone.
Some difficulties with memory are probably
present in everyone receiving ECT. Most people find these
memories return when the course of ECT has finished and a few weeks
have passed. However, some people do complain that their memory has
been permanently affected, that their memories never come back. It
is not clear how much of this is due to the ECT and how much is due
to the depressive illness or other factors.
Some people have complained of more
distressing experiences, such as feeling that their personalities
have changed, that they have lost skills or that they are no longer
the person they were before ECT. They say that they have never got
over the experience and feel permanently harmed.
What seems to be generally agreed is that the
more ECT someone is given, the more it is likely to affect their
Q What if ECT is not
- You may take longer to recover.
- If you are very depressed and are not eating
or drinking enough, you may become physically ill or die.
- There is an increased risk of suicide if your
depression is severe and has not been helped by other
Q What are the
If someone with severe depression declines
ECT, there are a number of possibilities. The medication may
be changed, new medication added or intensive psychotherapy
offered, although this should already have been tried. Given time,
some episodes of severe depression will get better on their own,
although being severely depressed carries a significant risk of
Deciding to have (or not to have) ECT
Q Giving consent to having
Like any significant treatments in
medicine or surgery, you will be asked to give consent, or
permission for the ECT to be done.
The ECT treatment, the reasons for
doing it and the possible benefits and side-effects should be
explained in a way that you can understand. If you decide to go
ahead, you then sign a consent form. It is a record that ECT has
been explained to you, that you understand what is going to happen,
and that you give your consent to it. However, you can withdraw
your consent at any point, even before the first treatment.
Q What if I really don’t want ECT?
If you have very strong feelings about ECT,
you should make them known to the doctors and nurses caring for
you, but also friends, family or an advocate who can speak for
Doctors must consider these views when they
think about what to do.
If you have made it very clear that you do not
wish to have ECT, then you should not receive it. You could write
an 'advance decision to refuse ECT' to make clear how you want to
be treated if you become unwell again. Alternatively you could
appoint someone to be your Health and Welfare Attorney to make
decisions on your behalf when you are not able to decide for
Q Can ECT be given to me
without my permission?
Most ECT treatments are given to people who
have agreed to it. This means that they have had:
- a full discussion of what ECT involves
- why it is being considered in their case
- the advantages and disadvantages
- a discussion of side-effects.
You cannot be given ECT against your wishes,
even if you are sectioned under the
Mental Health Act. It is the responsibility of the doctors and
nurses involved to make sure that this discussion has been had –
and to document it.
Sometimes, however, people become so unwell
that they are unable to take on board all of the issues – perhaps
because they are severely withdrawn or have ideas about themselves
that stop them fully understanding their position (e.g they believe
their illness is a punishment they deserve).
In these circumstances, it may be impossible
for them to give proper agreement or consent. When this
happens, it is still possible to give ECT. The legal provisions for
this differ from country to country, even within the United
In England and Wales, ECT can be given
under the Mental
Health Act which requires the agreement of two
doctors and another professional who is usually a social
worker. There must then be a second opinion from an
independent specialist who is not directly involved in their care.
The clinical team should also speak to family and other carers, to
consider their views and any views the patient may have expressed
Sometimes - if a person doesn't have the capacity to give an
informed consent - the team may decide the ECT can be given under
Capacity Act. This is unusual, as in most cases, the Mental
Health Act provides the most appropriate protection for a patient's
rights. The Mental Capacity Act can only be used if the
patient lacks capacity and a "decision maker" (usually the
consultant in charge of their care) decides that ECT is in the
patient's "best interests".
It is expected the decision maker will consult with other people
to try to find out what the person's views would have been. This
would usually include family members and other people close to
them. The decision maker should also make "all reasonable attempts"
to help the patient to regain capacity to consent (if this is
possible). An independent specialist is not needed, though the
clinical team may request a second opinion from another
Whether ECT is given under the Mental Health Act or the Mental
Capacity Act, regular assessments of the patient's ability to
understand their treatment must be made. Once they are able to give
consent, the treatment can only continue if they do consent and
must stop if they refuse.
In scotland, the principles above are the same, although the
laws involved are the Mental Heath
(Care and Treatment) (Scotland) Act 2003 and the Adults
With Capacity Act (Scotland) 2000.
How is ECT
ECT is generally used to treat severe
illnesses, so the person having it will often be in
hospital. If you do not need to be an in-patient, it
should be possible for you to attend as a day patient to have
ECT. You may need to check if this is available to you from
your local service.
The seizure is made to happen by passing an
electrical current across the person’s brain in a carefully
controlled way from a special ECT machine.
An anaesthetic and muscle relaxant are given
- the patient is not conscious when the ECT is
- the muscle spasms that would normally be part
of a fit – and which could produce serious injuries - are reduced
to small, rhythmic movements in the arms, legs and body.
By adjusting the dose of electricity, the ECT
team will try to produce a seizure lasting between 20 and
Q Is there any
In the days before a course of ECT is started,
your doctor will arrange for you to have some tests to make sure it
is safe for you to have a general anaesthetic. These may
- a chest X-ray
- a tracing of your heart working
- blood tests
You will be asked not to have anything to eat
or drink for 6 hours before the ECT. This is so that that the
anaesthetic can be given safely.
Q Where is ECT
ECT should always be done in a special set of
rooms that are not used for any other purpose, usually called the
“ECT suite”. There should be separate rooms for people to
wait, have their treatment, wake up fully from the anaesthetic and
then recover properly before leaving.
There should be enough qualified staff to look
after the person all the time they are there so that any confusion
or distress can be helped.
Q What happens during
- You should arrive at the ECT suite with an
experienced nurse who you know and who is able to explain what is
happening. Many ECT suites are happy for family members to be
there, so you may wish to check with your local team that this is
possible, if it is reassuring for you. You should be met by a
member of the ECT staff who will do routine physical checks if they
have not already been done. The staff member will check that
you are still willing to have ECT and if you have any further
- When you are ready you will be accompanied
into the treatment area and be helped onto a trolley.
- The ECT team will connect monitoring equipment to check your
heart rate, blood pressure, oxygen levels, ECG and EEG during the
- A needle will then be put into your hand,
through which the anaesthetist will give the anaesthetic drug and,
once you are asleep, a muscle relaxant. While you are going
off to sleep, the anaesthetist will also give you oxygen to
- Once you are asleep and fully relaxed a
doctor will give the ECT treatment; your fit will last between
around 20 to 50 seconds. The muscle relaxant wears off quickly
(within a couple of minutes) and, as soon as the anaesthetist is
happy that you are waking up, you will be taken through to the
recovery area where an experienced nurse will monitor you until you
are fully awake.
- When you wake up, you will be in the recovery
room with a nurse. He or she will take your blood pressure and ask
you simple questions to check on how awake you are. There will be a
small monitor on your finger to measure the oxygen in your blood
and you may wake up with an oxygen mask. You will probably take a
while to wake up and may not know quite where you are at first. You
may feel a bit sick. After half an hour or so, these effects should
have worn off.
- Most ECT units have a second area for light
refreshments. You will be free to leave the suite when the staff
are happy that your physical state is stable and you feel
ready to do so.
- The whole process usually takes around half
Q. What are bilateral and
In bilateral ECT, the electrical current is passed across the
whole brain; in unilateral ECT, it is just passed across one side.
Both of them cause a seizure in the whole of the brain.
Bilateral ECT seems to work more quickly and
effectively and it's probably the most widely used in Britain;
however, there has been concern that it may cause more
Unilateral ECT is now used less. It had been
thought to cause less memory loss, but recent research has shown
that it is necessary to use much larger doses of electricity to
make unilateral ECT as effective as bilateral ECT. If the dose of
electricity is increased to make it equally effective,
the risks of memory loss are as great as with bilateral
Sometimes ECT clinics will start a course of treatment with
bilateral ECT and switch to unilateral if the patient experiences
side-effects. Alternatively, they may start with unilateral and
switch to bilateral if the person isn't getting better.
You may wish to speak to the doctor who is suggesting ECT for
you to decide whether unilateral or bilateral ECT is best for
Q How often and
many times is ECT given?
Most units give ECT twice per week, often on a
Monday and Thursday, or Tuesday and Friday. It is impossible to
predict how many treatments someone will need. However, in general,
it will take 2 or 3 treatments before you see any difference, and 4
to 5 treatments for noticeable improvement.
A course will on average be 6 to 8
treatments, although as many as 12 may be needed, particularly if
you have been depressed for a long time. If after 12
treatments you feel no better, it is unlikely that ECT is
going to help and the course would usually stop. A member of the
mental health team should see you after each treatment to see how
your are responding to treatment and check that you are not
experiencing any serious side-effects. Your consultant should
see you after every two. ECT should be stopped as soon as you have
made a recovery, or if you say you don't want to have it
Q What happens after a course
Even when someone finds it effective, ECT is
only a part of recovering from depression. Like antidepressants, it can help to ease
problems so you are able to look at why you became unwell.
Hopefully you can then take steps to continue your recovery
and perhaps find ways to make sure the situation doesn’t happen
again. Psychotherapy and
counselling can help and many people find their own ways to help
themselves. Certainly people who have ECT, and then do not have
other forms of help, are likely to quickly become unwell again.
There are many areas in which people disagree
over ECT, including whether it should even be done at all. People
tend to have very strong feelings about ECT, often based on their
own experiences. The main areas of disagreement are over whether it
works, how it works and what the side-effects are.
Q Why is ECT still
ECT is now used much less and is mostly a treatment for severe
depression. This is almost certainly because modern treatments for
depression, like psychotherapy (talking treatments),
antidepressants and other psychological and social supports are
much more effective than they were in the past.
Even so, depression can for some people still be very severe and
life-threatening, with extreme withdrawal and reluctance, or
inability to eat, drink or communicate properly. Occasionally
people may also develop strange ideas (delusions) about themselves
or others. If other treatments have not have worked, it may be
worth considering ECT.
Q What do patients think of
In 2003 researchers analysed all the work
which had been done on patients' experiences of ECT.
They found that the proportion of people who had had ECT and
found it helpful ranged from 30% to 80%. The researchers
commented that studies reporting lower satisfaction tended to have
been conducted by patients and those reporting higher
satisfaction were carried out by doctors. Between 30% and 50% of
patients complained of difficulties with memory after ECT.
Q What do those in favour of
Many doctors and nurses will say that
they have seen ECT relieve very severe depressive illnesses when
other treatments have failed. Bearing in mind that 15% of people
with severe depression will kill themselves, they feel that ECT has
saved patients' lives, and therefore the overall benefits are
greater than the risks. Some people who have had ECT will agree and
may even ask for it if they find themselves becoming depressed
Q What do those against ECT
There are many different views and many
different reasons why people object to ECT. Some say that ECT is an
inhumane and degrading treatment, which belongs to the past.
They say that the side-effects are severe and that psychiatrists
have either accidentally or deliberately ignored how severe they
can be. They say that ECT permanently damages both the brain
and the mind, and if it does work at all, does so in a way that is
ultimately harmful for the patient. Many would want to see it
Q What happens in other
At the moment, ECT is part of standard
psychiatric practice in Britain and the majority of countries
worldwide. Some countries (and some states in America also) have
restricted its use more than in the UK, though only a small number
have prohibited its use.
Q How do I know if ECT is done
The Royal College of Psychiatrists has set up
ECT Accreditation Service (ECTAS) to provide an independent
assessment of the quality of ECT services. ECTAS sets very
high standards for ECT, and visits all the ECT units who have
registered with it. The visiting team involves psychiatrists,
anaesthetists, and nurses. It publishes the results of its
findings and also provides a forum for sharing best clinical
practice. Membership of ECTAS is not compulsory, but every
ECT unit should be able to tell you:
- if they have signed up to
- the result of their most recent
- who to speak to if you are concerned
that your local unit has not been assessed.
A list of accredited site is available on the
Royal College of Psychiatrists' website.
Q Where can I get more
Many ECT suites provide their own information
packs and they should be able to give written information to
patients or their family/carers before a course starts. The
information in these packs is often strongly in favour of ECT.
The Internet has many sites discussing ECT
that are produced by professionals, organisations, people who have
had ECT, or others with particular opinions. There are more
negative than positive websites.
National Institute for Health and
Clinical Excellence (NICE)
Scottish ECT Accreditation Network (SEAN): A site
designed to complement the work of SEAN, by enabling communication
of the latest information on ECT in Scotland.
Electroconvulsive Therapy Accreditation Services
(ECTAS): Launched in May 2003, ECTAS aims to assure
and improve the quality of the administration of ECT; awards an
accreditation rating to clinics that meet essential standard.
Ebmeier, K. et al (2006) Recent development
and current controversies in depression. Lancet, 367,153-167
Eranti,S. V. & McLoughlin, D.M (2003)
Electroconvulsive therapy - state of the art. the British Journal
of Psychiatry 182: 8-9
Rose, D., Fleischmann, P., Wykes, T., Leese,
M. & Bindman, J. (2003) Patients' perspectives on
electroconvulsive therapy: systematic review
Scott A.I.F. (2004) The ECT Handbook (Second
edition): The Third Report of the Royal College of Psychiatrists’
Special Committee on ECT. Royal College of Psychiatrists:
UK ECT Review Group. (2003)
Efficacy and safety of electroconvulsive therapy in depressive
disorders: a systematic review and meta-analysis. Lancet 361:
Department of Health Statistical survey (2007) Electro Convulsive
Therapy: Survey covering the period from January 2002 to March
2002, England. DH: London
This leaflet was produced by the Royal College of
Psychiatrists' Public Education Editorial Board.
Original author: Dr Richard Barnes
With input from the Royal College of
Psychiatrists' Special Committee on ECT and related
This leaflet reflects the best available evidence available at
the time of writing.
© December 2012. Due for review: December 2014. Royal College of
Psychiatrists and the Mersey Care NHS Trust. This leaflet
may be downloaded, printed out, photocopied and distributed free of
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