"You Want to Zap My WHAT!?" Electroconvulsive Therapy, Transcranial Magnetic Stimulation and Memory

Monday, April 27, 2015 by Meg   •   Filed under Treatment Techniques

When people think of Electroconvulsive Therapy (ECT), they usually envision something pretty archaic. A One Flew Over the Cuckoo’s Nest style lab complete with sadistic doctors in lab coats and patients strapped to tables prepared to have their brains scrambled. Or they picture that whole lobotomy thing with ice picks up the nose. 

Except…that’s not at all what it is, though there are probably those who would embrace lobotomy treatments if it meant the depression would cease altogether. (For a great insight into ECT and recovery check out Will I Ever Be the Same Again? Transforming the face of ECT.)

So let’s get into this. 

Disclaimer: I have never been involved in administering ECT, though I have worked with a few outpatient and inpatient clients who have undergone this procedure. I’m a smart girl, but treating a handful of people who have undergone ECT does not make me a expert on this particular treatment. 

I wish it did. I’d be an expert on Every Damn Thing. 

What I can offer you is what I saw, answer the questions that my patients had, give you some background on what ECT is and what it isn’t and tell you about another less invasive treatment using magnets.

Uh...magnets?

That's right folks. Prepare to be fucking amazed.

What Is Electroconvulsive Therapy (ECT)? 

In ECT, electrodes are placed on the scalp and send electrical signals through the brain, which causes a brief seizure. You don’t feel it; patients are put under anesthesia and given a muscle relaxant (to avoid the thrashing and jaw clenching of times past). I know it sounds like scary shit, but the seizures are well controlled for maximum benefit with the least amount of damage. 

With bilateral treatments, electrodes are put on the forehead and on each temple. This is the one usually used for psychosis or severe issues that need fast relief, such as in cases where patients are actively suicidal. 

For right unilateral treatment, the electrodes will go on the forehead and the right temple. It may take a few extra sessions to get the same effect as bilateral treatments but it usually has fewer memory side effects. If right unilateral treatments don’t work for you, they may switch you to bilateral treatments. 

After the procedure, people often feel dizzy, loopy or generally out of it, like they've just spent all night at a rave, or as one client put it, "Like I spent the night as a Motley Crue groupie." You might vomit or have jaw pain, muscle pain, or muscle spasms. And some people have confusion that lasts for hours or days. The muscle relaxants and anesthesia may be partly to blame and can cause more severe issues if you have certain underlying conditions. For example, those with B vitamin deficiencies sometimes respond strongly with illness or confusion to specific types of anesthesia like nitrous oxide because the brain has trouble protecting itself from damage without the B to process the chemicals1. This is not the type of anesthesia normally used in ECT, but it seemed worth mentioning to illustrate that the whole process can be kinda complicated. Or maybe I just thought it was a random fun fact that I never got to tell you guys before. Either way, you’ll get a full physical before treatment and the anesthesia used is matched to your physical condition. 

Commonly, people undergo ECT three times a week for two to four weeks, but this may be different depending on your particular condition and your response to the treatment. It usually takes six or so treatments to see results. If side effects are too severe, ECT may be stopped or postponed. 

Why Use Electroconvulsive Therapy (ECT)? 

ECT is usually used to treat patients who need immediate results, such as those who are a high risk for suicide, those who are pregnant with severe symptoms such as depression with postpartum psychosis or for depression with psychosis (a break with realty that might include seeing or hearing things that aren’t there). It is also used to treat major depression without psychosis, mania, bipolar conditions, schizophrenia and catatonia. 

Now, I know what you’re really wondering: Does it actually help?

For many, the answer is a resounding, “Yes.”

But why the fuck would zapping electricity into your head make you less depressed? 

There are a few theories about why this is. Some think that seizures cause the neurotransmitters in the brain to change suddenly and reorganize. Others think that ECT changes the way stress hormones such as cortisol are regulated, which in turn triggers change in other areas, including neurotransmitter function. Either way, it does seem effective in changing the chemical makeup of the brain. But we don’t know precisely why, which makes me feel all twitchy. I WANT TO KNOW, PEOPLE! Especially because this not knowing may lead to additional problems in the form of side effects we can't protect against. 

Electroconvulsive Therapy (ECT) and Memory

Most studies done on ECT are narrow in scope, with fewer patients or only those with certain disorders, making it hard to tell exactly who will have more severe or long-lasting memory side effects2. A bigger issue is that most don’t take into account more general knowledge about memory because we don’t understand exactly how it works2. And because doctors often have no idea how it will effect your memory, or at least to what extent, this causes some ethical issues with informed consent3. It’s not about stoking fear here; as with anything, just read the consent forms over carefully and know that if your doctor is recommending this treatment there is probably a good chance that the benefits outweigh the risks. 

My clients had been properly informed about the issues at hand, and were made aware of the risks before they underwent the procedure. And most said that they would have done it again, even with the memory issues, because it improved their symptoms to something they could live with and work through. 

However, a few did have concerns about their memories. One feared that she would not be able to figure out how to do things, such as putting together toys for her kids. We tested this by actually buying a toy and it ended up being a moot point. For most, this type of memory is not the one affected by ECT.  

So what are the biggest issues with memory? 

After ECT, immediate memory, or working memory is usually okay4. That’s what we recall for a few seconds at a time, say, remembering the spoon in the sink while you’re doing dishes until you can put it in the dishwasher. So in most cases, you can still function properly.

Declarative memory, or explicit memory is the one we use to consciously recall facts and information. This is the one that is impaired after ECT4. Not only do people tend to have issues remembering things form the past, but they may have problems transferring things from that three second working memory into longer term memories. So if you didn’t wash the spoon and went to make a phone call, you might forget entirely that it was ever there. This makes things like finding car keys even more of a pain in the ass than it was already. And rest assured, even those without an ECT history lose things. Especially those damn car keys. And renegade socks in the dryer.   

Researchers think the memory issues probably have to do with the way neurotransmitters and synapses work after ECT; that certain chemical messages that we need to form memories are not received or transmitted the right way4. And while memory usually improves over time following ECT, some people have severe memory issues in the long term. 

So what if you’re worried about that memory stuff, think ECT just sounds too scary and have a condition that isn’t so severe it needs six session seizure-induced brain changes? 

A Gentler Alternative: Transcranial Magnetic Stimulation (TMS)

Aside from the standard treatments for depression, (some discussed here in Depression and Brain Changes) there are also ECT-like treatments that are gentler on the brain. But keep in mind that gentleness also means that it might not work as well for those who have more severe depression or other issues.  

Transcranial Magnetic Stimulation (TMS) has been approved for the treatment of Major Depression since 2008. Instead of electrodes, this treatment uses a magnetic field to create an electrical current in the brain, but a much smaller one than in ECT. This one doesn’t cause seizures or a loss of consciousness. It doesn’t even require sedation and is done on an outpatient basis. 

TMS is usually used for those who have tried one antidepressant but didn’t show progress. Those who have tried multiple treatments without success are less likely to benefit from TMS because the treatment is not generally strong enough. 

Electrodes and magnets can all sounds a little out of this world, but depression is a sneaky bitch. Sometimes it takes new avenues of exploration to figure out what works and what doesn’t. In the future, more research should help us to figure out why this works and discover less invasive ways to go about treating depression and other stubborn conditions. For now, it beats the hell out of a lobotomy (and depression). 

Related Posts: 

Citations
  1. http://www.ncbi.nlm.nih.gov/pubmed/8250714
  2. http://www.ncbi.nlm.nih.gov/pubmed/10868323
  3. http://retina.anatomy.upenn.edu/pdfiles/5524.pdf
  4. http://journals.lww.com/ectjournal/Abstract/2001/06000/Subtypes_of_Memory_Dysfunction_Associated_with.8.aspx



Topic-Relevant Resources

Will I Ever Be the Same Again? Transforming the Face of ECT (Shock Therapy)
Beautiful memoir of clinical depression, and the fight to regain control using ECT. A must read.

Against Depression
Detailed explanations of the systems involved in depression along with personal stories of success from psychiatrist Peter Kramer.



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