Mental health Sunnybrook Magazine Sunnybrook Magazine - Fall 2019

How virtual reality is helping patients undergoing electroconvulsive therapy (ECT)

Patient uses VR before ECT

For decades, electroconvulsive therapy (ECT) has been viewed in a harsh light. But a virtual reality simulation is helping patients become more comfortable with this safe and effective treatment.

(Photography by Doug Nicholson)


Major depression affects nearly 5 per cent of the Canadian population, and when medications aren’t helping – which happens frequently – many people struggle to do their jobs, take care of their families and have healthy relationships. Some may even develop what’s called catatonic depression, which robs them of their ability to move or speak.

There is a well-known procedure, however, that can have a dramatic impact on patients with major depression. It’s called electroconvulsive therapy (ECT) and it helps as many as 80 per cent of patients with the disorder, with 65 per cent experiencing a full remission.

“It’s life-saving in some situations,” says Dr. Peter Giacobbe, psychiatrist and associate scientist at Sunnybrook.

He’s seen people’s lives transformed by this straightforward, humane and painless treatment. But the stigma associated with ECT could make the decision to use it difficult for some patients and doctors.

“They’re so vulnerable at this moment. Their anxiety levels and their stress levels are very high,” says Dr. Fahad Alam, anesthesiologist and associate scientist at Sunnybrook.

To help patients cope with anxiety and get a sense of the procedure, Sunnybrook has developed a seven-minute virtual reality (VR) simulation video. It was filmed in 360 degrees and patients view it through a VR headset.

A calming journey

The video begins with the patient on a stretcher in the pre-procedure area. They can see the foot of the stretcher as if it was their own body lying in it. A nurse tells them what to expect when being prepped for the procedure, including getting an IV and an oxygen mask.

Next, Dr. Giacobbe appears, explaining the benefits and risks of ECT. He then wheels the bed into the procedure room. The nurse explains the equipment in this new room, and the viewer can pan around to get a closer look. Dr. Alam enters the scene to talk about the anesthetic and how it will keep the patient comfortable. The video simulates the oxygen mask coming down on the patient’s face and things fading out. Then, the video jumps ahead, showing the patient on the stretcher in the recovery room. The nurse enters again to talk about what the patient will feel like when the treatment is completed.

“[The video] reduces anxiety and stress, but also educates [patients] on the procedure,” says Dr. Alam. Ensuring that patients understand the procedure and fully consent to having it done are critical steps, he adds. The VR experience can help reinforce the information discussed by the patient and the clinical team.

Dr. Alam and Dr. Giacobbe are leading a study of 150 patients at Sunnybrook to test the technology’s effectiveness in helping people feel prepared for ECT. They want to know if VR will help people worry less about the procedure, and determine the optimal manner in which to view it. These patients will answer survey questions, report anxiety scores and also undergo tests, such as blood pressure assessments.  If the study goes well, it will become a standard offering at Sunnybrook for anyone getting the procedure.

“We know that ECT is under-utilized. Stigma and fear might be factors,” says Dr. Giacobbe. Using VR to make the therapy more palatable and dispel myths about the treatment may also inspire other centres to offer it more often.

Combatting stigma

Some of the roots of ECT’s bad rap can be traced back to pop culture. Films such as One Flew Over the Cuckoo’s Nest portray it as cruel, painful and personality-changing.

But the actual treatment is very different. For an ECT procedure, the patient is put under general anesthetic and then given a muscle relaxant. Electrodes are placed on the patient’s scalp and the brain is stimulated with brief electrical pulses, resulting in tiny seizures – a process that takes less than 10 minutes. While some people experience headaches or disorientation, others don’t need much recovery time at all.

Dr. Giacobbe recalls a patient having ECT and returning to work a few hours after the procedure.

Dr. Peter Giacobbe (left) and Dr. Fahad Alam

Dr. Peter Giacobbe (left) and Dr. Fahad Alam (Photography by Doug Nicholson)

Dr. Alam and Dr. Giacobbe created the content of the video with patient input last spring. “It’s based on what patients told us scared them,” says Dr. Alam.

The doctors then did a small pilot study, to make sure the video didn’t make anyone feel dizzy or nauseous, common side effects associated with VR technology.

A 2017 review study found that as many as 75 per cent of people come to ECT with anxiety about the procedure, concerned that it would cause memory impairment or brain damage. Meanwhile, Dr. Alam notes that simply being in a health-care environment causes stress. “Across the board, if anyone walks into a hospital, 90 per cent of them have some form of anxiety or stress, and up to 60 per cent have severe anxiety or stress.”

Being stressed out before a procedure causes problems. With more invasive surgeries, Dr. Alam says anxiety before being given an anesthetic is associated with higher blood pressure during surgery, the need for more medication, higher rates of infection and slower recovery times. This is likely because of stress hormones like cortisol spiking and interfering with the body’s ability to calm down and heal itself.

Teams at Sunnybrook have studied VR videos and their effectiveness for people getting general surgery. They found that viewing these short simulations reduced anxiety and gave patients extra information on the procedure and that the videos worked best if viewed just before surgery.

ECT is a non-invasive surgery, so the risk for wound infection or death are very low. But this is a vulnerable population, Dr. Alam says, because many people with depression also have anxiety.

“They have severe depression and are facing a treatment that carries a lot of stigma. It can be scary,” he says.

Sending a positive message

ECT is an outpatient procedure that is administered as a series of treatments. As many as 20 treatments may be needed, one every few days. Patients won’t feel better right away, so it’s important to reassure patients that time is needed.

The hope is this short VR video will help patients at Sunnybrook feel more relaxed and informed about their procedure before they head into their first ECT treatment, and to view machines and health-care staff as a comfort, not something to fear. It could also help send out a wider, more positive message about ECT to the health-care community, says Dr. Giacobbe, and have an impact on depression rates.

“People have an [outdated] impression of this treatment that isn’t keeping up. Our goal is to change that,” he says.

About the author

Diane Peters