Electroconvulsive therapy (ECT) is safe

There is no shortage of frightening images of electroconvulsive therapy (ECT) in movies – most notably in “One flew Over the Cuckoo’s Nest”, in which the main character Randle McMurphy (Jack Nicholson) is given electroconvulsive therapy (ECT) at a psychiatric hospital in Oregon, USA in the 1970s.

It has turned out to be difficult to move on from the associations between ECT and pain, the exercise of power and danger. Even though “One flew Over the Cuckoo’s Nest” is 43 years old, the negative image of ECT remains intact for many people. This is emphasised by the fact that every fifth respondent to a British survey expressed a fear of dying from ECT. This is an unfortunate statistic according to Associate Professor Søren D. Østergaard from Aarhus University Hospital - Risskov, which is part of the Department of Clinical Medicine at Aarhus University in Denmark.

"In the psychiatric field we have had a clear impression that the fear of dying due to ECT was unfounded, but we have lacked a large-scale study on the topic. We have therefore conducted a systematic review of the literature that contains information about so-called ECT-related deaths, that is deaths where ECT represents the most likely cause of death," explains Søren D. Østergaard.

Søren D. Østergaard is senior author of the article "The mortality rate of Electroconvulsive Therapy (ECT): A systematic review and pooled analysis”, which was recently published in the journal Acta Psychiatrica Scandinavica. The most significant result in the article is that only one ECT-related death has been reported for the 414.747 ECT treatments that are registered in studies published after 2001.

"The risk is very small and even many elderly patients with comorbid medical illnesses can be safely treated with ECT,” says Søren D. Østergaard.

Lower risk compared to surgery under general anaesthesia

The systematic review covered 15 studies with data from 32 countries published in the period from 1976 to 2014. For this entire period, the ECT-related mortality was estimated at 2.1 per 100,000 treatments. By comparison, the number of death caused by surgery under general anaesthesia was recently estimated at 3.4 per 100,000 surgeries.

"The idea of an electric current running through the head is unpleasant, and some patients find it difficult to forget the frightening portrayals of ECT from movies. But these have little resemblance with reality," says Søren D. Østergaard.

"One Flew Over the Cuckoo's Nest is a great movie, but it has been detrimental to psychiatry, because ECT was shown as being a form of punishment. That could hardly be farther from reality," explains Søren D. Østergaard.

ECT is still portrayed very negatively in movies. This was the main conclusion in the review “Based on a true story? The Portrayal of ECT in International Movies" from 2016. For instance, ECT is often portrayed as a treatment that is given without anaesthesia, despite the fact that ECT treatment is only carried out under general anaesthesia in developed countries and with the use of muscle relaxants, so that the convulsions are minimal.

ECT is a highly effective treatment

"These frightening images cause great harm because in addition to being a very safe procedure, ECT is a highly effective treatment for many patients suffering from severe psychosis, mania or depression," says Søren D. Østergaard. He describes how extremely tormented patients can – during the course of just 2-3 treatments over a week – go from being in the deepest depression, being unable to take care of themselves, to gradually become their old selves again. Most often 8-12 treatments are required before a patient gets well.

"Typically, you can see the improvement caused by ECT in the patient’s eyes, facial expression and posture already before talking to him or her about the mood. Prior to the treatment these individuals are often not able to eat or take a shower because they are so extremely ill, and then a couple of weeks later they sit in front of you with their chin up and a completely different intensity in their eyes. That leaves a great positive  impression on you," says Søren D. Østergaard.

ECT has side effects, but the alternative can be detrimental

As with most forms of treatments, ECT has side effects. Some of the most common are headache and nausea, but memory impairment is probably the most feared side effect of ECT.

"Memory impairment is a side effect for some patients, but for the majority the impairment is temporary. In addition, it is essential to weigh the side effects against the highly beneficial effects of ECT on the mental disorder being treated. Patients receiving ECT are often so ill that they do not want to live anymore. For these individuals, ECT can be life saving,” says Søren D. Østergaard.

"Close to 800,000 people die from suicide every year. I strongly believe that many of these suicides could have been prevented had these individuals received ECT in due time," says Søren D. Østergaard.

More information

• Study design: Systematic review and pooled analysis
• Authors: Nina Tørring (Psychosis Research Unit, Aarhus University Hospital - Risskov), Sohag N. Sanghani & Georgios Petrides (The Zucker Hillside Hospital, Northwell Health System, Glen Oaks, NY, USA), Charles H. Kellner (Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA) and Søren D. Østergaard (Psychosis Research Unit, Aarhus University Hospital - Risskov)
• The study is supported by a grant from the Lundbeck Foundation
• The article based on the study is published in Acta Psychiatrica Scandinavica: http://onlinelibrary.wiley.com/doi/10.1111/acps.12721/full

Contact

MD, PhD Associate Professor, Søren Dinesen Østergaard
Department of Clinical Medicine, Aarhus University and
Psychosis Research Unit, Aarhus University Hospital - Risskov
Phone: (+45) 6128 2753
Email: soeoes@rm.dk