MH@H Depression

This One Flew Over the Cuckoo’s Nest: ECT in Real Life

This one flew over the cuckoo's nest: electroconvulsive therapy (ECT) in real life

Ask anyone of a certain age what comes to mind first when they hear the term electroconvulsive therapy (aka ECT, or electroshock therapy as it was called back in the day), 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, a lot of people view ECT as dangerous, barbaric, and obsolete. 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 treating mania and psychosis. One of the biggest benefits is that it works fast—far faster than antidepressants. That’s at least in part why I first received ECT; it was my first hospitalization, I’d attempted suicide before admission as well as further attempts on the ward, and the treatment team just wasn’t prepared to wait the weeks it would take to see if I would respond to an antidepressant. 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 ECT was a good idea.

The process of real life ECT is fairly simple, and very different from One Flew Over the Cuckoo’s Nest. In the movie, they applied the shock with no anaesthetic, and he began wildly thrashing about. None of that is representative of modern ECT practice. Another practice of days gone by was to induce seizures by administering a whack of insulin, which was kind of like bashing your head with a sledgehammer to hit the fly sitting on your forehead; the film A Beautiful Mind portrays this.

The ECT process

In the present day, they prep the patient by applying electrocardiogram (ECG) and electroencephalogram (EEG) leads to monitor the heart and electrical activity in the brain. They establish intravenous (IV) access and give you oxygen by face mask, as good oxygenation reduces the risk of any complications during the procedure.

Then they put you out cold with an anaesthetic (typically propofol, which is a common induction agent for general anaesthesia) and also give you a muscle relaxant (succinylcholine). They give these by IV, and the propofol knocks you out within seconds. I had the odd experience of getting a yummy smoky sort of smell after they injected the anaesthetic, even though the only thing coming through the mask on my face was oxygen. One of the reasons I like ECT, beside the fact that it helps, is because I love that smell. This isn’t something I’ve heard anyone else report, but I experienced it every single time.

Once you’re knocked out, 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. Typically, a blood pressure cuff is inflated around one ankle before the muscle relaxant is injected. That way, the muscle relaxant doesn’t reach that foot and seizure activity can be observed.

Diagram of patient receiving electroconvulsive therapy
Adapted from Gouvernement du Québec, Ministère de la Santé et des Services Sociaux

You wake up feeling anywhere from foggy to fairly clear-headed (at least in relation to how you were feeling beforehand). I always woke up pretty alert; sometimes I thought the ECT hadn’t even happened yet.

“ECT”, stigma-style

I came across this electroconvulsive therapy (ECT) video that made me angry. It’s a simulation (aka not a real patient – he’s a doctor playing a patient, not actual ECT) and it’s “made with the support of St George’s, University of London & South West London & St George’s Mental Health NHS Trust.” In case you were curious, no, people don’t wear street clothes when they’re getting ECT. The video shows bitemporal (i.e. on both temples) electrode placement. Often unilateral (one-sided) electrode placement is used, or at least tried at first, to reduce cognitive side effects.

Those minor details aside, what’s boneheaded and stigma-reinforcing is that Dr. Stigma who’s playing the patient does his best Jack Nicholson impression of a seizure. It doesn’t work that way; the muscle relaxant makes sure of that. The hospital that made this should be ashamed of themselves, and Dr. Stigma should be fired.

There’s enough stigma around ECT without this kind of nonsense from people who should have half a brain.

Unfortunately, this is not an isolated instance. An article published in the Canadian Medical Association Journal in 2011 used a stock photo of a man with an intense red face and bulging eyes with bright red blood vessels, along with some type of mock electrodes taped to his forehead. Yikes.

Variations in ECT administration

You can get ECT on an inpatient or outpatient basis. Inpatient treatments can be done up to three times a week. Outpatient maintenance treatment is typically done once a week or less often.

Various parameters can be adjusted in the delivery of ECT, including the electrode placement that deliver the electric stimulus. Unilateral ECT involves both electrodes placed on the same side of the head; it’s less likely to cause side effects. Bilateral ECT involves one electrode on each side of the head (this can be on either the temples, i.e. bitemporal, or forehead, i.e. bifrontal). Bilateral is more effective, but at the same time, it’s also more likely to cause side effects. Someone receiving ECT for the first time would get unilateral.  

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-ish given in an inpatient course of treatment, I’ve needed 15+ during a couple of my hospitalizations.

Effects on memory

I am one of those (now former) mental health professionals who tells clients that for most people, ECT doesn’t have significant effects on memory. That’s not to say some people don’t have significant memory loss (and I had quite a bit), but there are a lot of people who don’t. Online, you’re always more likely to find bad news reports than good news. You might think from what you read on line that everyone has horrendous withdrawals coming off of antidepressants or benzodiazepines, but it’s a skewed perspective because you’re not hearing from all of the people who have no or minimal problems.

I’ve experienced a fair bit of memory loss from ECT, although it didn’t impact my ability to form new memories after completing treatment. Mostly, it affected short-term memory, 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 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.

My family tended to notice the short-term memory loss the most, as I’d 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 what seemed like brand new clothes/shoes/household items that I had no memory of purchasing.

Sign me up!

Despite the ECT-induced memory loss, I would gladly do it again. But to do that, I would need to a) do inpatient, or b) have someone available to babysit me on treatment days, which is required because you’ve been under anaesthetic. Both are possible, but not in a way that I would consider acceptable, so it’s off the table for now.

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.

A Quick Overview of ECT

  1. What does ECT do?

    Electroconvulsive therapy involves the application of energy to the brain to produce a seizure. The exact mechanism of how this works is unclear, although it does impact neural activity and increases the production of BDNF (brain-derived neurotrophic factor), which supports brain health.

  2. What is ECT used for?

    It's used primarily, but not exclusively, for the treatment of depression. It's the most effective treatment for depression that's currently available. It also works significantly faster than antidepressants do, so it's a particularly good choice for people who remain actively suicidal once hospitalized.

  3. Is it barbaric?

    No. Many people's idea of ECT comes straight from One Flew Over the Cuckoo's Nest, which doesn't represent modern reality. ECT is performed under aneasthesia (typically propofol), along with a muscle relaxant (succinylcholine) that prevents visible seizure activity from occurring. Seizure activity is monitored via EEG, and the dose of the electrical stimulus is adjusted to provide the minimum amount needed to produce adequate seizure activity.

  4. Does it erase people's memory?

    No. However, memory loss is a well-recognized side effect. In the majority of people, memory loss is temporary and is limited to the time period when they received ECT. In some cases, memory loss goes further back, and some, but not necessarily all, of this may come back once the course of ECT is finished.

    Memory-related side effects are affected by the specific parameters of an individual's treatment, including the number of treatments administered and the electrode placement. Unilateral ECT, with both electrodes placed on the same side of the head, causes less memory loss, but is also less effective, than bilateral (bitemporal or bifrontal) electrode placements.

    It's also important to keep in mind that depression itself can cause memory impairment, especially when people are most unwell, and therefore most likely to be getting ECT.

  5. Is ECT a cure?

    No. Just like other forms of treatment for depression, if you stop treatment, there's a risk of relapse. What ECT may be able to do is get someone well enough that other forms of treatment, such as medication, will be adequate for maintenance, even if those other forms of treatment weren't enough, on their own, to treat an acute episode.

book cover: Managing the Depression Puzzle, Second Edition, by Ashley L. Peterson

Managing the Depression Puzzle takes a holistic look at the different potential pieces that might fit into your unique depression puzzle. The revised and expanded 2nd edition is now available on Amazon.

For other books by Ashley L. Peterson, visit the Mental Health @ Home Books page.

30 thoughts on “This One Flew Over the Cuckoo’s Nest: ECT in Real Life”

  1. Toward the end – “both are possible, but not in a way I would consider acceptable”. What would you consider acceptable? What would you require in order to make this happen?
    Curious on that. Your articles on this topic are very informative and eye opening. I am glad to hear that something can and does help.

    1. I would have to be totally unable to look after myself for inpatient to be an acceptable option. To do outpatient, I would have to ask my mom to come stay with me, and for me to tolerate her for more than a day or two I’d have to be more fully out to lunch than I am now.

      1. I can understand that, my own mom is a bit difficult. Sounds like you could use an in-person friend or two. Like, close ones. Not casual fair-weather people. That may be challenging given many aspects of your condition. And how you hate people. But I think it’s possible. Gosh, if people knew how much good you do here on this blog.

          1. It appears there would be some big benefits to finding a way to work through that. Although I am sure I cannot understand how tall that mountain is for you. And I can see how your reaction to this might be “no shit, sherlock.” 🙂. Still. You’ve done great things and some of us wish the best for you and hope for you to get the therapies you need, when you need them. Despite major challenges.

  2. I think this is a great blog post and you’re preaching an important message, because the misconceptions and false portrayals are beyond idiotic and unprofessional. You’ve made a believer out of me, for one thing, and more people need to realize that pop culture does electroshock therapy a grave disservice. I scrolled up to find more things to note, and he’s having a seizure now… [massive eyeroll] … that video is beyond uncool. ECT needs to be more readily available for a variety of reasons: hospitalizations, the reality of antidepressant side effects, etc., etc. I hope you can help get the word out that it’s a valid and legit treatment!

  3. Ashley, it is quite astounding that you wrote this post on ‘ECT’ today. I bought your book the other day and it arrived today. I just finished the chapter on “ECT”. So far I can grip what you are writing about.
    I would like to write a review of your book when I finish it. It is the second edition. Will keep you in the loop going forward.
    I love how you close each chapter with “Potential Puzzle Pieces”.

  4. Despite some patients reporting (and being observed) feeling ‘foggy’ with some memory loss, I haven’t ever had any of them complaining about the ECT. They’ve all found it beneficial and one or two have requested it.

  5. A quick P.S., dear Ashley—after I wrote about my positive experience with ECT in HuffPost,

    I had some militant anti-ECT folk cyber-bully and cyber-slandering me. One of them really went over the top to the point where I informed her I had hired my (furry) lawyer, Lucy Harwood J.D. 😉 so her slandering and harassment would cease. That worked.

    Anyway, my main point is it’s refreshing to read these replies from kind, intelligent people!

    1. Yes, the anti-ECT folk do like to come crawling out of the woodwork, and I can image HuffPost would be a magnet for that kind of thing. Go Dr. Lucy!

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