page_title: Electroconvulsive therapy
section_title: Technique
hierarchical_section_title: Electroconvulsive therapy / Technique
caption_attribution_description: English: Electroconvulsive therapy machine on display at Glenside Museum
context_page_description: Electroconvulsive therapy, formerly known as electroshock therapy, is a psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders. Typically, 70 to 120 volts are applied externally to the patient's head resulting in approximately 800 milliamperes of direct current passed through the brain, for 100 milliseconds to 6 seconds duration, either from temple to temple or from front to back of one side of the head.
  The ECT procedure was first conducted in 1938 by Italian psychiatrist Ugo Cerletti and rapidly replaced less safe and effective forms of biological treatments in use at the time. ECT is often used with informed consent as a safe and effective intervention for major depressive disorder, mania, and catatonia. ECT machines were originally placed in the Class III category by the United States Food and Drug Administration in 1976. They were re-classified as Class II devices, for treatment of catatonia, major depressive disorder, and bipolar disorder, in 2018.
  A course of ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or bipolar.
context_section_description: ECT requires the informed consent of the patient.
  Whether psychiatric medications are terminated prior to treatment or maintained, varies.  However, drugs that are known to cause toxicity in combination with ECT, such as lithium, are discontinued, and benzodiazepines, which increase the seizure threshold, are either discontinued, a benzodiazepine antagonist is administered at each ECT session, or the ECT treatment is adjusted accordingly.
  In the US, the medical team performing the procedure typically consists of a psychiatrist, an anesthetist, an ECT treatment nurse or qualified assistant, and one or more recovery nurses. Medical trainees may assist, but only under the direct supervision of credentialed attending physicians and staff. The placement of electrodes, as well as the dose and duration of the stimulation is determined on a per-patient basis.
  In unilateral ECT, both electrodes are placed on the same side of the patient's head. Unilateral ECT may be used first to minimize side effects such as memory loss.
  In bilateral ECT, the two electrodes are placed on opposite sides of the head. Usually bitemporal placement is used, whereby the electrodes are placed on the temples. Uncommonly bifrontal placement is used; this involves positioning the electrodes on the patient's forehead, roughly above each eye.
  Unilateral ECT is thought to cause fewer cognitive effects than bilateral treatment, but is less effective unless administered at higher doses. Most patients in the US and almost all in the UK receive bilateral ECT.
  The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT.  Below these levels treatment may not be effective in spite of a seizure, while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe cognitive impairment without additional therapeutic gains. Seizure threshold is determined by trial and error ("dose titration"). Some psychiatrists use dose titration, some still use "fixed dose" (that is, all patients are given the same dose) and others compromise by roughly estimating a patient's threshold according to age and sex. Older men tend to have higher thresholds than younger women, but it is not a hard and fast rule, and other factors, for example drugs, affect seizure threshold.
  Immediately prior to treatment, a patient is given a short-acting anesthetic such as methohexital, etomidate, or thiopental, a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation.   In a minority of countries such as Japan, India, and Nigeria, ECT may be used without anesthesia. The Union Health Ministry of India recommended a ban on ECT without anesthesia in India's Mental Health Care Bill of 2010 and the Mental Health Care Bill of 2013.  The practice was abolished in Turkey's largest psychiatric hospital in 2008.
  The patient's EEG, ECG, and blood oxygen levels are monitored during treatment.
  ECT is usually administered three times a week, on alternate days, over a course of two to four weeks.
caption: Electroconvulsive therapy machine on display at Glenside Museum in Bristol, England
exif: {"Image Make": "Canon", "Image Model": "Canon EOS 500D", "Image Orientation": "Horizontal (normal)", "Image XResolution": "72", "Image YResolution": "72", "Image ResolutionUnit": "Pixels/Inch", "Image DateTime": "2014:07:21 13:44:35", "Image Artist": "", "Image YCbCrPositioning": "Co-sited", "Image Copyright": "", "Image ExifOffset": "360", "GPS GPSVersionID": "[2, 2, 0, 0]", "Image GPSInfo": "8426", "Thumbnail Compression": "JPEG (old-style)", "Thumbnail XResolution": "72", "Thumbnail YResolution": "72", "Thumbnail ResolutionUnit": "Pixels/Inch", "Thumbnail JPEGInterchangeFormat": "10316", "Thumbnail JPEGInterchangeFormatLength": "14218", "EXIF ExposureTime": "1/15", "EXIF FNumber": "4", "EXIF ExposureProgram": "Unidentified", "EXIF ISOSpeedRatings": "1600", "EXIF ExifVersion": "0221", "EXIF DateTimeOriginal": "2014:07:21 13:44:35", "EXIF DateTimeDigitized": "2014:07:21 13:44:35", "EXIF ComponentsConfiguration": "YCbCr", "EXIF ShutterSpeedValue": "4", "EXIF ApertureValue": "4", "EXIF ExposureBiasValue": "0", "EXIF MeteringMode": "Pattern", "EXIF Flash": "Flash did not fire, compulsory flash mode", "EXIF FocalLength": "25", "EXIF SubSecTime": "00", "EXIF SubSecTimeOriginal": "00", "EXIF SubSecTimeDigitized": "00", "EXIF FlashPixVersion": "0100", "EXIF ColorSpace": "sRGB", "EXIF ExifImageWidth": "3456", "EXIF ExifImageLength": "2304", "Interoperability InteroperabilityIndex": "R98", "Interoperability InteroperabilityVersion": "[48, 49, 48, 48]", "EXIF InteroperabilityOffset": "8380", "EXIF FocalPlaneXResolution": "576000/149", "EXIF FocalPlaneYResolution": "2304000/593", "EXIF FocalPlaneResolutionUnit": "2", "EXIF CustomRendered": "Normal", "EXIF ExposureMode": "Auto Exposure", "EXIF WhiteBalance": "Auto", "EXIF SceneCaptureType": "Standard"}