Ask anyone of a certain age what comes to mind first when they hear the term electroconvulsive therapy (aka ECT, aka electroshock therapy, aka shock therapy), and chances are they will mention the film One Flew Over the Cuckoo’s Nest starring Jack Nicholson. Given the lack of more realistic portrayals of this treatment, ECT may be viewed as a dangerous, obsolete treatment. Except it’s not; ECT in real life is a very different creature.
ECT is a highly effective treatment option for depression, and can also play a role in mania and psychosis. One of the biggest benefits is that it works fast, much faster than antidepressants could be expected to start working. That’s why I first received ECT; it was my first hospitalization, I was highly suicidal, and the treatment team just wasn’t prepared to wait the weeks it would take to see if I would respond to the antidepressant that had been started. I was too ill to be able to remember any of those first few weeks, and I was being treated on an involuntary basis, but being a mental health nurse I probably knew at least on some level that this was a good idea.
The ECT process
The process of ECT in real life is fairly simple, and very different from Jack Nicholson’s ECT scene in One Flew Over the Cuckoo’s Nest. In the movie a bite block was roughly shoved in his mouth, a shock was applied with no anaesthetic, and he began wildly thrashing about. None of this is representative of current ECT practice.
As a patient, they put you out cold with a general anaesthetic (such as propofol) and a muscle relaxant (succinylcholine). These are given by IV and knock you out within seconds. I had the odd experience of getting a yummy smoky sort of smell after they injected the meds, even though the only thing coming through the mask on my face was oxygen. One of the reasons I like ECT is because I love that smell. This is not something I’ve heard anyone else report, but I experienced it every single time.
Once you’re anaesthetized, they fit the rubber bite guard into your mouth to protect your teeth and tongue. The shock is delivered via two electrodes placed on the head. The muscle relaxant means there is not a visible seizure; instead, the intensity of the seizure is measured via EEG (electroencephalogram). You wake up feeling fairly clear-headed (at least in relation to how you were feeling beforehand); sometimes I haven’t even realized the ECT had already been done.
There are various parameters that can be adjusted in the delivery of ECT, one of which is the electrode placement. Unilateral ECT, which involves both electrodes being placed on the same side of the head, is less likely to cause side effects. Bilateral ECT, which involves one electrode on each side of the head (on either the temples or forehead), is more effective but also more likely to cause side effects.
Unilateral didn’t work very well for me, so after my first few treatments I’ve always had bilateral ECT. I’ve also required relatively long courses of ECT; instead of the typical 8, I’ve needed 15+ during a couple of my hospitalizations.
Effects on memory
I am one of those mental health professionals who tells clients that ECT usually doesn’t have significant effects on memory. That’s absolutely true, but my experience was not typical, and I’m not alone in that atypicality.
I’ve experienced a lot of memory loss from ECT, although it hasn’t impacted my ability to form new memories after completing treatment. Mostly it was short-term memory that was affected, but some of the memory loss has gone farther back. There have been substantial chunks of time that have gone missing from the months leading up to my first hospitalization. Some of these eventually did return, but others didn’t.
It was truly bizarre to have people tell me things that I did or even show me photographs taken of me, and I would have sworn that these events never occurred. I feel absolutely certain I’ve never been snow-tubing, yet there’s a photo of me doing exactly that at a local ski hill.
My family tends to notice the memory loss the most, as I say the same things and ask the same questions over and over. On a lighter note, after each discharge from hospital after a course of ECT, it was kind of fun to return home to an assortment of what seemed like brand new clothes/shoes/household items that I had no memory of purchasing.
Despite the disruptive effects of the ECT-induced amnesia, it remains very much on the table as a treatment option for me. I would probably ask for outpatient ECT right now if it weren’t for the requirement that someone be available to take you home after treatments and keep an eye on you (a safety precaution because of the use of general anaesthetic). This is just not feasible in my circumstances right now, and it bothers me that this restriction limits my access to effective treatment.
So, that’s my journey over the cuckoo’s nest receiving ECT in real life. A lot less movie-worthy than Jack Nicholson’s, but a lot more real.
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