Electroconvulsive therapy, commonly known as ECT, has been a “scary” treatment for pharmacoresistant psychiatric illnesses since its conception in the 1930s. Efforts to make ECT less fearsome, however, have been a work in progress. The history of ECT can be traced back to several important physicians. Hungarian psychiatrist Lasidlas Meduna induced seizures using the chemical camphor – a frightening method that left patients consciously waiting for their seizures to arrive. Italian neurologist Ugo Cerletti and psychiatrist Lucio Bini were the first to utilize electrical stimuli to initiate seizures, albeit without any anesthesia or muscle relaxants to prevent violent convulsions. Furthermore, negative attitudes towards ECT have stemmed from events including its use as torture during the Nazi genocide as well as its barbaric portrayal in films such as One Flew Over the Cuckoo’s Nest. 

It may be an understatement to say that my impression of ECT after volunteering in Psychiatric Hospital X was the antithesis to what I had learned about it through the media. During my time there, I had come to learn that the majority of patients were being treated for major depressive disorder (MDD) and suicidality, yet paradoxically most seemed content to be at the clinic – one patient would even consistently arrive for her appointment over an hour early! After each new patient took a seat on a gurney (that I meticulously cleaned off and put sheets on), a nurse or one of the attending psychiatrists would make small talk centered around the patient’s family or work life – a behavior that always impressed me considering the multitude of people who would visit the clinic in a given day. The mere act of conversing with healthcare professionals who took the time to know (at least superficially) the patients seemed to put them at ease before deeper questions were asked: What is your anxiety on a scale of 1 to 10? How is your depression? Have you had any suicidal thoughts? Any hearing or seeing things?

Most patients that I encountered at the ECT clinic were regulars, while I had witnessed interactions involving first-timers: in these cases the psychiatrist or nurse would take extra time to explain the intricacies of the treatment and answer any questions. I also observed multiple instances of such informed consent when the attending psychiatrist would discuss with an MDD patient whether to proceed with a unilateral or bilateral (bitemporal) ECT treatment: the former is associated with less cognitive side effects, while the latter provides more immediate symptom relief early in treatment. Nevertheless, some research suggests that high-dose unilateral ECT provides antidepressant efficacy comparable to moderate-dose bilateral ECT with less autobiographical memory loss. 

In addition to cognitive problems, there is a whole litany of side effects and what-could-go-wrongs that may trigger one’s pre-existing nosocomephobia or tomophobia. While muscle aches, headaches, and jaw pain are the most common short-term physical effects, cardiovascular changes are possible, and in exceedingly rare cases so is death. Despite the uncertainty over one’s state after ECT treatment, I had never witnessed anyone try to back out of it. If I were to speculate as to the factors contributing to the patients’ willingness to accept ECT, I would first consider the overall positive and inspirational ambience of the clinic. As a treatment known for its high success rate, the regulars at the clinic seldom report being 10/10 for depression or anxiety and more often than not are affable when conversed with. I found some of the most inspiring cases to be of nonverbal, non-ambulatory patients with catatonia who regained the ability to speak and walk after several treatments. Being surrounded by innumerable success stories may contribute to improved patient attitudes toward ECT. One study found that a patient’s mindset about a treatment can influence their physiological response to it, and that positive expectations can improve treatment effectiveness. 

Positive expectations may be fostered not only by the outcomes of surrounding patients, but by the overall welcoming atmosphere of the clinic that makes ECT feel less scary. The treatment room abutted the small bay area and was separated by only half a wall and a curtain, giving the space a close-knit feel – so close-knit that the attending psychiatrist could easily pop over to the bay area if there was an emergency, as evidenced by the one time a schizophrenic patient was resisting a nurse. Even the presence of volunteers (including myself) to greet the patients and bring them drinks and snacks after treatment seemed to remove intimidating qualities from the clinic; it is important to note that the post-ECT selection included a plethora of juices as well saltines, granola bars, and shortbread cookies (a favorite at the clinic). Perhaps the most appealing aspect was the music played on a speaker in the background; this drowned out any sounds coming from medical equipment, and I’m sure this greatly benefitted the patients as well, especially those in the treatment room who had just received muscle relaxants to start the procedure. Research has shown that most patients enjoy listening to music in a preprocedural setting: music is a low-cost intervention without any adverse side effects that may reduce pre-ECT anxiety. It is evident that patient-centered care – whether it be through clinic geography, personnel, snack/drink choices, and music – is at the heart of the ECT clinic’s functioning.

Now do I think ECT is actually scary? ECT has evolved greatly over the past century, and thus it did not appear particularly frightening to me from an observational standpoint. However, I do not have firsthand experience of the preprocedural anxiety and fear that may grip patients before being wheeled into the treatment room, nor have I experienced the trepidation over what physical discomfort may happen in the aftermath. Nonetheless, without my volunteer experience at the ECT clinic, I would have never gained an understanding of the multifaceted patient-centered care at the clinic that seems to prevail over fear.