by Robert Roca, M.D.
For many patients who have not responded to medications or psychotherapy, ECT may provide dramatic relief of symptoms. It is the single most effective treatment for serious mood disorders and may be helpful in other conditions as well. Mrs. A is a 79-year-old woman who was referred to the Geriatric Inpatient Unit for the evaluation and treatment of profound depression accompanied by anorexia, fatigue, hopelessness, and delusional guilt. She was brought to psychiatric attention by her daughter, who felt that the patient's primary physician was misattributing her symptoms to old age rather than to treatable illness. We confirmed the presence of major depression with psychotic features and embarked upon a medication trial.
After almost two weeks of treatment with antidepressant and antipsychotic medications she was not showing signs of improvement, continuing to exhibit fretfulness, anorexia and the delusion that she was inadvertently injuring people all around her. Because of the severity of her symptoms and the absence of apparent benefit from antidepressant medications, we discussed ECT. She and her family decided to proceed, and the patient signed the consent form. In preparation for ECT, an internist performed careful general physical and neurological examinations. The results of an electrocardiogram, chest X-ray and blood tests were reviewed. A CT scan of the brain was performed. Her antidepressant medication was discontinued, and the dosage of her antipsychotic medication was reduced. At this point she was designated "medically cleared" for ECT.
On the morning of her first treatment, she went to the specially-designed ECT suite and met the nurses and medical staff who would be caring for her during the procedure. The anesthesiologist placed an intravenous line in one arm and a blood pressure cuff on the other. The psychiatrist secured the treatment electrodes in the unilateral position on her forehead. A soft rubber bite guard was inserted into her mouth to protect her teeth. She was then given an intravenous dose of a short-acting general anesthetic to put her to sleep for the treatment. She was also given a powerful muscle relaxant to prevent a generalized convulsion. A brief electrical current was then passed between the electrodes. This induced a one-minute electrical seizure in her brain that was recorded on the electroencephalogram (brain wave recorder); the only physical manifestation of the seizure was a gentle rhythmic movement of her right foot. She was given concentrated oxygen to breathe as she gradually awakened over the next five minutes. She recovered uneventfully in the ECT suite over the next 30 minutes under the watchful eye of her nurse. Upon returning to her room she ate breakfast and was given a dose of acetaminophen for a mild headache. Later that day she appeared brighter and less distraught than she had at any time during her hospital stay; however, the following morning she was again fretful and distraught.
She went on to have a total of six treatments over the next two weeks (6-12 treatments is the usual range). By the end of that time she was much brighter, more talkative, was able to eat with appetite. She showed no trace of fretfulness, and guilt and self-reproach had completely disappeared. Her family said that she was "herself again." An antidepressant medication was ordered to help prevent relapse of her depressive symptoms, and the antipsychotic medication was discontinued. She returned to the home she shares with her daughter and son-in-law and is in regular follow-up care with her psychiatrist. She has been well ever since.