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When should ECT be used on a bipolar patient?

Asked by Yaba, Virginia

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At what point in a bipolar patient should ECT (electroconvulsive therapy) be tried?

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer:

Dear Yaba,

Forgive me for the complicated answer I am going to give to such a straightforward question. What makes any good answer complicated is that when someone turns to ECT depends on many factors above and beyond how well ECT works. These factors include whether ECT is available in your area, whether your insurance covers the procedure and how you feel about it as a treatment.

As most people know, ECT stands for electroconvulsive therapy, a name that reflects the treatment itself, which involves passing a small amount of electricity through the brain to generate a seizure. It is the seizure, not the electricity itself, that has the antidepressant effect. And what an effect it has.

Study after study has shown that it is the most powerful antidepressant treatment we have and that it provides relief -- although sometimes short-lived -- to about 90 percent of people who have failed all other treatments. I have seen people at death's doorstep from their depression recover completely after just a couple of treatments.

I remember one woman who had been stiff as a board and hadn't spoken for years who woke up after her first treatment and said, "Where am I, and how did I get here?" She went on to a full recovery.

Those of us who work in the field and have seen the potentially lifesaving power of ECT are big believers. But of all psychiatric treatments, ECT is by far the most infamous and the most hated, and the one around which swirls the most misconceptions. It is often described as inhuman, barbaric or dangerous.

In fact, today's ECT is painless and at least as safe as medications. But I have empathy for people who have very strong feelings against it, because our culture is alive with images -- most famously from "One Flew Over the Cuckoo's Nest" -- of ECT from the first half of the 20th century, when it was delivered without the benefits of anesthesia or bodily paralysis that confine the seizure to the brain alone. Early in my psychiatric career, I met patients who'd received ECT while wide awake, and they had a profound, and fully understandable, terror regarding the procedure.

Let's simplify things by assuming that your insurance covers ECT, that it is available in your area and that you have no reservations about trying it. In that case, we generally say that people should consider ECT after having failed two adequate trials of different antidepressants. I'd probably also suggest a trial of psychotherapy before trying ECT. Two trials of antidepressants aren't many, but it points to the fact that if someone fails two adequate trials (full doses for at least eight weeks), their chances of responding in any lasting way to a third antidepressant are fairly small.

The good things about ECT are that it is highly effective, that it works right away and (in your case) is as effective for treating mania as it is for treating depression. The most important downsides of ECT are that its effects do not always last, that it requires anesthesia and that it causes time-limited memory problems fairly regularly and may decrease memory chronically in rare cases (although this is still debated).

As one who has seen hundreds of people get their lives back as a result of ECT, I hope that you will indeed consider it if you have tried multiple medications without good effect.

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