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Continuation treatments for melancholic depression

Max Fink   (31 December 2008)

Electroconvulsive therapy: one of the most audit treatments in Medicine

Antonio E Nardi   (2 January 2009)

ECT- the best choice for depression

Om Prakash   (2 January 2009)

A UK-Based Psychiatrist's Perspective on Maintenance ECT

Nitin Gupta   (4 January 2009)

Psychotherapy should be made available to her

Andrew S Horne   (9 January 2009)

The Portrayal of ECT in the Media: Realistic or Deceptive?

David T Healy, Bruce Charlton   (9 January 2009)

Feeling distress for patient during ECT

Sebastien TASSY, Michel CERMOLACCE   (13 January 2009)

A positive recommendation for ECT

Abimbola. O Fadipe   (18 January 2009)

Denial and deceit

Richard J Winkel   (19 January 2009)

Re: ECTmasquerading as a treatment

Margaret A Parry   (19 January 2009)

ECT: an increasing evidence base and positive profile

Bradley Ng   (20 January 2009)

MHA 2007 amendments - ECT a "Special case"

Sarah A Ashurst-Williams   (20 January 2009)

Doctors personal perspective on ECT

K.D White, Ninewells Hospital, Dundee, DD1 9SY   (24 January 2009)

ECT Contraindications

Richard J Winkel   (26 January 2009)

Patient's experience of ECT

Harold Bourne   (27 January 2009)

Continuation treatments for melancholic depression 31 December 2008
Max Fink, Professor of Psychiatry Emeritus Stony Brook University, PO Box 457, St James NY 11780 Send response to journal: Re: Continuation treatments for melancholic depression	Matthew Webber's successful experience with the treatment of a patient suffering postpartum depressive illness (best characterized as melancholia or melancholic depression) is quite common and his patient is fortunate in having electroconvulsive therapy (ECT) available. Effective treatment for this illness is well demonstrated today as either tricyclic antidepressants at as high doses that are just tolerable or ECT. The common assumption that ECT is best administered for the fewest treatments that elicit an immediate benefit suggests that the treatment is viewed like an antibiotic for an acute infection. That view is not correct. ECT is best viewed as comparable to insulin treatment for diabetes, the immediate effects must be sustained by continued insulin administration (or equivalents). Continuation ECT for periods of six months has been demonstrated to be effective in sustaining remission. The only other continuation treatment with demonstrated equivalent efficacy is the combination of lithium and nortriptyline, both monitored for effective serum levels (1). Continuation with other antidepressant medications or psychotherapy is not demonstrated to be effective. Since 1993 the US government's National Institute of Mental Health has supported two large multi-site collaborative studies to assess effective continuation treatments after ECT in depressive illness. A summary of the findings is published (2). Max Fink, M.D. 1. Kellner CH et al. Arch Gen Psychiatry 2006; 63:1337-44. 2. Fink M, Taylor MA. JAMA 2007; 298:330-332 Competing interests: None declared
Electroconvulsive therapy: one of the most audit treatments in Medicine 2 January 2009
Antonio E Nardi, Associate Professor Institute of Psychiatry. Federal University of Rio de Janeiro. RJ. 22410-003. Brazil Send response to journal: Re: Electroconvulsive therapy: one of the most audit treatments in Medicine	Webber M (1) described the frequent fears and questions of people who are involved in an electroconvulsive therapy (ECT) as patient, family member or even as a physician. When we search the medical literature it is easy to observe that ECT is a well established psychiatry treatment (2) and many audits have been conducted in different countries and hospitals to review all aspects of ethical and technical administration of ECT (3- 5). Sienaert et al. (3) described that in 2003 ECT was widely available in Belgium. ECT hospitals are equally spread over the country with a significant difference in its utilization rate but no differences in its practice. The major indication for ECT was depression (89.7%). Bitemporal electrode placement was the preferred option in 65.6%, and 37.0% of these used the combination of bitemporal electrode placement and a fixed high stimulus dose. Continuation ECT and outpatient ECT were rarely used. Some clinical audits have also been conducted. Fisher et al. (4) compared cognitive and other outcomes of 2 groups of mood disorder patients, those who received ECT and those who did not, from two private South Australian hospitals. They found that a positive response to either ECT or non-ECT. Despite the ECT group being significantly more depressed at admission there was no difference upon discharge. They observed that ECT treatment of depression was not associated with a deterioration of cognitive functioning. There are also some places with regular audits. Fergusson et al. (5) described a 3-year study between 1997 and 1999 consisted of a series of audit cycles to systematically answer questions about ECT demographics and outcome across Scotland. Facilities and equipment at ECT centers were up to date and generally of a high standard. ECT was given at a rate of 142 treatments per 100,000, mainly to depressive disorder with a definite clinical improvement with treatment in 71%. ECT given in routine clinical settings across Scotland meets Royal College of Psychiatrists standards (2) and is an effective treatment of the majority of patients (5). The prescripition of ECT is for severe depression which has not responded to other treatment, severe psychotic maniac episode, catatonia, and some other rare indications. It is usualy prescribed in a course of 6- 12 treatments administered 2 or 3 times a week. Electroconvulsive therapy can differ in electrode placement, length of time that the stimulus is given, and the property of the stimulus. There is still a wide variation in ECT use between countries and hospitals. The variance of these forms of application have differences in both adverse side effects and outcomes. The use of inform consent, anesthesia, and muscle relaxant are universally recommended. The non uniform application of ECT procedures may keep the ECT a controversial procedure. 1.Webber M. Electroconvulsive therapy. BMJ 2008; 337: a2998. 2.The Royal College of Psychiatrists' Memorandum on the use of Electroconvulsive Therapy. Part 1-Effectiveness of ECT-a review of the evidence. Br J Psychiatry1977; 131: 261-268. 3.Sienaert P, Dierick M, Degraeve G, Peuskens J. Electroconvulsive therapy in Belgium: a nationwide survey on the practice of electroconvulsive therapy. J Affect Disord 2006; 90: 67-71. 4.Fisher LJ, Goldney RD, Furze PF, Williams JL, Mattner J, McCleave DJ. Electroconvulsive therapy, depression, and cognitive outcomes: an Australian audit. J ECT 2004; 20:174-8. 5.Fergusson GM, Cullen LA, Freeman CP, Hendry JD. Electroconvulsive therapy in Scottish clinical practice: a national audit of demographics, standards, and outcome. J ECT 2004; 20:166-73. Competing interests: None declared
ECT- the best choice for depression 2 January 2009
Om Prakash, Assistant Professor of Psychiatry Geriatric Clinic & Services, National Institute of Mental Health & Neurosciences, Bangalore, INDIA Send response to journal: Re: ECT- the best choice for depression	I want to congratulate BMJ for publishing Matthew Webber's successful experience (1) with the treatment of a patient suffering postpartum depressive illness with electroconvulsive therapy (ECT). In spite of recent developments in the pharmacotherapy of depressive disorders, ECT is a non-pharmacologic biological treatment and a highly effective treatment option, predominantly for depression. The safety and tolerability of ECT have been enhanced by the use of modified stimulation techniques and by progress in modern anesthesia (2). Continuation and maintenance ECT is used to prevent relapse and recurrence of depressive episodes in those patients who have failed previous continuation and/or maintenance pharmacotherapy and who have also responded to an acute course of ECT (3). ECT still represents an important option for treatment- resistant psychiatric disorders after medication treatment failures. Earlier consideration of ECT may reduce the rate of chronic and difficult- to-treat psychiatric disorders. This article definitely clears myth and misconceptions about ECT among medical fraternity. References: 1.Matthew Webber. Electroconvulsive therapy. BMJ 2008;337: a2998. 2.Baghai TC, Möller HJ. Electroconvulsive therapy and its different indications. Dialogues Clin Neurosci. 2008;10 (1):105-17. 3.Frederikse M, Petrides G, Kellner C. Continuation and maintenance electroconvulsive therapy for the treatment of depressive illness: a response to the National Institute for Clinical Excellence report. J ECT. 2006 Mar;22(1):13-7. Competing interests: None declared
A UK-Based Psychiatrist's Perspective on Maintenance ECT 4 January 2009
Nitin Gupta, Consultant Psychiatrist-South Staffordshire and Shropshire Healthcare NHS Foundation Trust Margaret Stanhope Centre, Belvedere Road, Burton upon Trent, DE13 0RB, Staffordshire, U.K. Send response to journal: Re: A UK-Based Psychiatrist's Perspective on Maintenance ECT	This is an informative and enlightening article which hopefully should help in mitigating the stigma and negative attitudes that surround an effective treatment like ECT. Of particular interest is highlighting of the effective use of ‘maintenance ECT’. I would like to use this opportunity to discuss some broader, clinically relevant issues; particularly related to the use of ECT in the UK. A very important issue is mentioned in the article i.e. patients who are unable to consent (1). This is also relevant for patients detained under the Mental Health Act (2007)who do not have the capacity to consent. Inherent safeguards are built in for such detained patients, in that it is mandatory to have a second opinion psychiatrist (appointed by the Mental Health Act Commission) to agree with the ECT treatment so proposed by the treating psychiatrist (responsible medical officer). But, what about patients who are not detained but are unable to consent and/or lack capacity? Best Practice Guidelines advise seeking a second opinion from a consultant colleague; though this position possibly has questionable legality for a course of maintenance ECT (2). However, the real ‘potentially thorny’ and debatable issue arising out of this account is the use of ECT as maintenance treatment in depression. Maintenance ECT has some body of evidence to support its use (3). However, in the UK, NICE guidance does not recommend the use of maintenance ECT; a position maintained in their most recent update in January 2008 (4). A more balanced guidance has been provided by The Royal College of Psychiatrists which helps practitioners to accommodate the NICE guidance in clinical practice (2). This issue is important as [a] use of maintenance ECT is deemed as being divergent from NICE guidance, and [b] there is a perception and implication that NICE guidelines are meant to be followed implicitly by clinicians; this view being held more inflexibly by managers and commissioners (in NHS Trusts and Primary Care Trusts respectively) than by patients & carers. Though NICE guidance on ECT has no legal jurisdiction, yet it is extremely important for the treating clinicians to ensure that maintenance ECT is used after a thorough clinical cum risk-benefit assessment with patient choice being an essential component of the final decision (2). Any treatment modality is open to abuse/improper use, and ECT probably ranks high on the list. With Ana, all the proper guidelines (as outlined by NICE and The Royal College of Psychiatrists) appear to have been followed. It is hoped that such clinical situations, positive patient and carer experiences, and robust research data (3) shall help in mitigating the stigma associated with ECT and hopefully facilitate incorporation of ‘clinically nice’ recommendations into the forthcoming NICE guidance update for ‘ECT in Depression’ in the summer of 2009. REFERENCES [1] Webber M. A Patient’s Journey: Electroconvulsive Therapy. BMJ 2008; 337: a2998. [2] The Royal College of Psychiatrists. The ECT Handbook-second edition: Council Report CR128. The Royal College of Psychiatrists, London, 2005. [3] Fink M, Taylor MA. Electroconvulsive Therapy: Evidence and Challenges. JAMA 2007; 298: 330-332. [4] www.nice.org.uk/guidance/TA059 (last accessed 2 January 2009) Competing interests: None declared
Psychotherapy should be made available to her 9 January 2009
Andrew S Horne, Consultant Forenesic Psychiatrist Broadmoor Hospital, Crowthorne, Berks RG41 5UR Send response to journal: Re: Psychotherapy should be made available to her	I read Matthew Webber's very moving description of his wife's experience of severe depression and ECT with great interest. But I was shocked to read that as she was not well enough for psychotherapy when she reached the top of the waiting list she was immediately placed at the bottom of it, to wait for another 18 months. People who are, for whatever reason, unable to start their treatment when they reach the top of the list should be kept at the top of the list and given the treatment as soon as they are ready. He and his wife should complain as vigorously as necessary to get this system corrected. Secondly, it sounds from the paper as if they have given up the idea of psychotherapy. If so, that is a pity. The treatment of choice would be cognitive-behavioural therapy which has a very sound evidence base in depression, both for getting the patient well again and for preventing future relapse. I would have thought that Ana should be receiving it along side the maintenance ECT, and I would expect the effect of it to be complementary to that of the ECT. Competing interests: None declared
The Portrayal of ECT in the Media: Realistic or Deceptive? 9 January 2009
David T Healy, Professor of Psychiatry Wales LL57 2PW, Bruce Charlton Send response to journal: Re: The Portrayal of ECT in the Media: Realistic or Deceptive?	Dear Sir M Webber's letter on the benefits of electroconvulsive therapy (ECT/Shock Therapy) was one of the few positive accounts of this treatment to appear in recent years [1]. The value of such accounts should not be underestimated, given a backdrop of continuing adverse portrayals of ECT. The Oscar nominated movie, The Changeling, for instance centres on police deception of a mother about her missing son including their introduction of a changeling. The opening sequence claims this is a true story, rather than just based on one. In the movie, ECT symbolises the capacity of mental health systems to punish people. But curiously the story and supposed administration of ECT happen 10 years before the treatment was invented; the story in this sense is profoundly untrue [2]. The best known portrayal of ECT appears in One Flew over the Cuckoo’s Nest [3]. Here again, the administration of an older unmodified ECT given punitively, is used as a device to move the plot along rather than as a treatment. Kesey’s own views of ECT may have been at odds with this use of the treatment, in that he appears to have set up a home treatment device probably to explore whether it might have a consciousness expanding effect [2]. ECT also features in Robert Pirsig's novel [4] Zen and the Art of Motorcycle Maintenance. This has sold more than five million copies; making Pirsig perhaps the most widely read philosopher alive. The book is apparently autobiographical, and describes the author suffering a psychotic breakdown treated by ECT, which supposedly annihilated all memories of the author’s earlier self, producing a lost personality called Phaedrus. However recently published biographical information on Pirsig [5] documents that the role of ECT in Zen is also as a 'literary device', added at a late stage in drafting the book. Robert Pirsig had no long- term memory problems. The term changeling implies a deception capable of wreaking mischief. In the case of the ECT, in fiction and movies, we are faced with a changeling; artists it seems are uniformly deceptive, replacing a real treatment with a fantasy of punishment. Against this backdrop, realistic accounts of this treatment in prominent journals are extremely valuable. References 1. Webber M. A patient’s journey. Elecontroconvulsive therapy. BMJ 2008;337:a2998 2. Shorter E, Healy D. Electroshock: A History of Electroconvulsive Treatment in Mental Illness. New Jersey, USA: Rutgers University Press, 2007. 3. Kesey K. One Flew Over the Cuckoo's Nest. NY: Viking Press, 1962 4. Robert M Pirsig. Zen and the Art of Motorcycle Maintenance. London: Corgi, 1976. 5. Mark Richardson. Zen and now: on the trail of Robert Pirsig and the art of motorcycle maintenance. New York: Knopf, 2008. Competing interests: None declared
Feeling distress for patient during ECT 13 January 2009
Sebastien TASSY, Geriatric Psychiatrist Sce de Psychiatrie, Pr Azorin, CHU Ste Marguerite, Marseille, FRANCE, Michel CERMOLACCE Send response to journal: Re: Feeling distress for patient during ECT	Dear Editors, We read with great interest Dr Weber's view on electroconvulsive therapy (ECT) as he experienced it as a patient’s close relative(1). We felt he perfectly expressed the difficulty one may have to accept such a stigmatised therapy. While in severe or resistant depressive disorders, efficiency of ECT is well established, with relatively low side effects when compared to high doses of antidepressants (2), ECT still remains one of the most controversial therapeutic practices in current psychiatry. Several factors contribute to this reluctance among patients and their family, mainly in terms of social representations. Another aspect which might also be involved is the disinclination from clinicians themselves. In addition with limitations in technical requirements or lack of neurobiological understanding we also would like to point out another hypothesis drawn from current neurocognitive findings about empathy. In our view, bodily and emotional attunement with the patient during ECT sessions are very powerful. It is now well established that we do share other emotions and pains through body language. Wicker and his colleagues showed that observing an emotion activates the neural representation of that emotion in the brain of the spectator (3). Moreover, Singer found that the same mechanism is effective for pain representation. Observing someone suffering activates the affective (but not sensory) neural representation of pain (4).This finding provides a unifying mechanism for understanding the distress of others. As long as patient’s bodies and faces are twisted by seizure during ECT, embodying negative emotions and pain, it must strongly affect neural representations of the physician watching it. Although clinicians do rationally know that the patient is totally unconscious, he can hardly avoid being touched by the negative expression of the patient's body distress. We feel this should partly explain why some psychiatrists are so reluctant with regards to ECT, inspite of objective evidence of its efficiency. (1) Webber M. Electroconvulsive therapy. BMJ 2008; 337: a2998 (2) Baghai TC, Möller HJ. Electroconvulsive therapy and its different indications. Dialogues Clin Neurosci. 2008;10:105-17. (3) Wicker B, Keysers C, Plailly J, Royet JP, Gallese V, Rizzolatti G. Both of us disgusted in My insula: the common neural basis of seeing and feeling disgust. Neuron. 2003;40:655-64. (4) Singer T, Seymour B, O'Doherty J, Kaube H, Dolan RJ, Frith CD. Empathy for pain involves the affective but not sensory components of pain. Science. 2004 ;303:1157-62. Competing interests: None declared
A positive recommendation for ECT 18 January 2009
Abimbola. O Fadipe, Specialist Registrar, in Old age and General Adult Psychiatry Grovelands Day Hospital RM6 4XH Send response to journal: Re: A positive recommendation for ECT	Considering the negative perception of the public towards Electroconvulsive therapy(ECT), it was refereshing to read a positive recommendation regarding the procedure and its effectiveness. The NICE guidelines and the Mental health Act 2007, have made it diffcult for ECT to be used with the consent of the patient. Even though clinicians mayb eaware that this is what is required at times to relieve patients from the crippling effects of severe depression. I wish the author and his wife all the best in their journey towards recovery. I can only hope that their story will cause other people to view ECT in a positive light Competing interests: None declared
Denial and deceit 19 January 2009
Richard J Winkel, Computer programmer University of Missouri, 65211 Send response to journal: Re: Denial and deceit	It seems psychiatrists never tire of rationalizing ECT based on ancedotal reports of its short term efficacy. It should not be necessary to point out that safety must also be a consideration. Not just neurological and physical safety, but psychological safety: the avoidance of psychological trauma and subsequent iatrogenic post traumatic stress and depression. Given that pro-shock ancedotes can be readily countered with anti-shock horror stories of broken lives, including the lives of innocent and sane children whose family situations led to their psychiatric pathologization and stigmatization, and that psychiatry is still unable to predict whether ECT will help or harm a patient in the long run, one must question psychiatrists' motivations in continuing to push this admittedly and demonstrably brain-damaging quackery on unsuspecting patients and parents. It's ironic how often psychiatry manifests psychopathology at an institutional level. Compulsive "helpers" should be advised that we have an institutional remedy analogous to shock treatment for such refractory dysfunction: class-action lawsuits. Given the incriminating admissions already published in psychiatric journals, it's only a matter of time. Competing interests: None declared
Re: ECTmasquerading as a treatment 19 January 2009
Margaret A Parry, semi retired Hamilton New Zealand 3200 Send response to journal: Re: Re: ECTmasquerading as a treatment	I think these letters written by psychiatrists etc. are the most disgusting comments I have ever read. How would these so called "doctors" like to have ECT themselves? None I bet. I have never heard of any takers on that Electro Convulsive Shock is not a treatment but a torture masquerading as a treatment for the benifit of those in control of poor unfortunate people's lives From one who knows Competing interests: None declared
ECT: an increasing evidence base and positive profile 20 January 2009
Bradley Ng, Old Age Psychiatrist Robina Hospital, QLD 4226, Australia Send response to journal: Re: ECT: an increasing evidence base and positive profile	Dear Editor Matthew Webber’s article (1) of his wife’s, Ana, experience with electroconvulsive therapy (ECT) adds to an increasing body of positive and balanced accounts of this controversial treatment, in both the scientific literature (2) and popular press (3). In Ana’s account, cognitive side effects are minimal and short lived, which is representative of the majority of patients’ experiences with ECT despite the increasing recognition of subjective memory problems after treatment (4). The account is particularly important as it highlights the use of continuation/maintenance ECT on a weekly to monthly basis after the acute treatment episode to prevent the relapse of major depression. Continuation treatment is arbitrarily defined as treatments administered up to six months after an acute episode and maintenance treatment is defined as treatments given after six months. There is emerging evidence for the use of continuation/maintenance ECT in depressive disorders. In the multi-site CORE collaboration (5), continuation ECT was compared to pharmacotherapy of nortriptyline and lithium for six months in 201 patients with unipolar depression that had remitted with an acute course of ECT. In this randomized control trial, the relapse rates for both treatment arms were similar but significantly superior to a historical placebo control. Whilst both treatments had limited efficacy and a high number of drop outs, the use of continuation ECT, rather than antidepressant medication, to keep a patient well after an acute course of ECT was raised as a therapeutic option. This may be particularly pertinent for patients unable to tolerate or who had failed to respond to antidepressant medications. A recent single blind trial of 33 elderly patients with late life psychotic depression compared maintenance ECT and nortriptyline to nortriptyline alone (6). Over two years, the mean survival time was significantly longer in the group receiving ECT and nortriptyline and the medication arm alone also had a higher rate of relapse. All treatments appeared to be well tolerated. ECT remains a much maligned treatment, with some people perceiving it similar to torture. It is not. Positive patient accounts of ECT are needed in a wide variety of publications and media, for both health professionals and the community. Such accounts must highlight the pros and cons of ECT, including the possibility of side effects. However, they also must not shy away from the complexities and emotions faced by patients and their families when considering ECT. Finally, discussions of continuation/maintenance ECT can only help increase the profile of this therapeutic option in the treatment of severe and relapsing depression. References: 1. Weber M. Electroconvulsive therapy. BMJ 2008; 337: a2998. 2. Hensley MA. The meaning of electroconvulsive therapy: a patient’s perspective. J ECT 2008; 24: 112-3. 3. Dukakis K & Tye L. Shock. The healing power of electroconvulsive therapy. New York: Avery, 2006. 4. Rose D, Wykes T, Leese M, et al. Patients’ perspectives on electroconvulsive therapy: systematic review. BMJ 2003; 326: 1363. 5. Kellner CH, Knapp RG, Petrides G, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry 2006; 63: 1337–44. 6. Navarro V, Gasto C, Torres X et al. Continuation/maintenance treatment with nortriptyline versus combined nortriptyline and ECT in late -life psychotic depression: a two year randomized study. Am J Geriatr Psychiatry 2008; 16: 498-505. Competing interests: None declared
MHA 2007 amendments - ECT a "Special case" 20 January 2009
Sarah A Ashurst-Williams, F1 in Cardiology St Helier Hospital, Surrey, SM4 1AA. Send response to journal: Re: MHA 2007 amendments - ECT a "Special case"	It was not clear in this interesting account as to whether the initial course of ECT was given with the patient's consent. The 2007 amendments to the Mental Health Act mean that ECT can no longer be given without consent to patients with capacity in non-emergency situations. Previously this was possible with the agreement of two independent consultant psychiatrists. This further increases the legal differentiation of ECT when compared with pharmacological treatments under the Mental Health Act. The public preception of ECT, particularly against the patient's wishes, is a largely negative one. This fact was, in my limited experience, taken into account when making the decision to apply for a second opinion for ECT against consent under the previous Act. This is important in the protection of the doctor-patient relationship and in the broader context of the relationship between mental health services and the general public. However, given that ECT is in fact a treatment with a safety profile comparable to its pharmacological counterparts, which can succeed (as in the article above) where other treatments have failed, it is unfortunate that now some patients may have to be allowed to deteriorate to the point of requiring "emergency" treatment before they are given ECT. Mental Health Act 2007 http://www.opsi.gov.uk/acts/acts2007/ukpga_20070012_en_1#Legislation- Preamble Competing interests: None declared
Doctors personal perspective on ECT 24 January 2009
K.D White, Consultant Neurologist Department of Neurology,, Ninewells Hospital, Dundee, DD1 9SY Send response to journal: Re: Doctors personal perspective on ECT	This is a very accurate and appreciated account of ECT and depression by a carer. As a recipent I had intended to write an account of what ECT has done for me personally, but perhaps the stigma of the illness more than the treatment intervened. I was first hospitalised with depression as a senior registrar in 1997;it wasn't my first episode of depression. After being off work for months and still attending a day unit, my wonderful psychiatrist suggested ECT to myself and my husband. We were a little anxious, but I had had different antidepressants,CBT and still couldn't function as a wife or mother ;returning to my SR post was out of the question. After my first treatment I felt fabulous and alive again. Lights and colours were brighter, my husband saw the 'old me' briefly. That sensation dwindled over 24 hours. I completed a course of 13 treatments. I got back to work, finished my training, looked after my small children, completed a perfomance certificate in singing. I got my life back. Living with depression is existing as the walking dead;anything is better than that. Even being dead or the possibility of death is a slight comfort, when you are at your worst. As for my memory; around the time of the treatment I was more forgetful, but that resolved. I lost some personal memories. It did not affect my memory or capability at work. No one at work noticed anything unususal. We moved house in 2000.I was appointed as a full-time consultant in 2002. I became noticeably more unwell in early 2004. My husband and I had asked my then psychiatrist about ECT 5 months previously but were informed that 'it was not used now and that they had no experience of it'. They watched me continue to deteriorate and accumulate side-effects, before referring me to the Treatment Resistant Depression clinic (the best thing they did for me).I was admitted to hospital 2 days after I eventually had to stop work. I didn't get the powerful, energising sensation of returning from the dead with my first dose, but it built up.The improvement was clear immediately. I became more mobile. I completed 13 treatments, later ones from home as an outpatient.I spent 6 weeks in hospital. Eventually I was able to start working with an excellent clinical psychologist. ECT is a life saver and I would have it again, if necessary. I had memory problems mainly around the time of the treatment( which were more of a curiosity than concern).I have lost personal memories from the previous year. Whether this was due to the treatment or the cognitive affects of the Depression is open to debate. Personally I feel the ECT cognitive impairment was temporary. That of severe depression is underestimated, more subtle and longer lasting. As a consequence of my last severe episode I have learnt more about the illness, stigma and am more aware of trying to manage it as a chronic condition. I have also learnt more neuropsychology, clinical psychology and psychiatry. Although I wish I had never had it, life might have been so much easier, I manage to work full-time in a teaching hospital. I have a surgeon husband and two teenage children who would be alot worse off, if I had not had both ECT and experienced psychiatrists, who knew the time and place for this vital treatment. ECT is unjustly stigmatised by those who fail to understand the impact of severe depression, the indications and benefits of ECT and those who use it indescriminately. Competing interests: None declared
ECT Contraindications 26 January 2009
Richard J Winkel, Programmer 65256 Send response to journal: Re: ECT Contraindications	Apparently mainstream psychiatry has determined that the well- documented brain damage caused by ECT [1], the resultant memory and cognitive dysfunction [2], and the psychological trauma of coming to the realization that one's ability to experience and enjoy life has been compromised on a neurological level [3] are of no long-term consequence to depressed and often already-traumatized patients, despite consistent patient feedback to the contrary [4]. My only question is: Why? [1] http://retina.anatomy.upenn.edu/pdfiles/Oct2002NYC.pdf [2] http://www.nature.com/npp/journal/v32/n1/full/1301180a.html [3] http://www.bmj.com/cgi/content/full/316/7138/1160 [4] http://www.bmj.com/cgi/content/full/326/7403/1363 Competing interests: None declared
Patient's experience of ECT 27 January 2009
Harold Bourne, Emeritus Consultant Psychiatrist Via P.de Cristofaro 40 Rome Italy Send response to journal: Re: Patient's experience of ECT	Webber's paper about his wife's experience of Electoconvulsive therapy is remarkable in at least one respect. It contains the only account of convulsion dependence in the medical literature since I described it in the 1950s. I denoted an initial dynamic phase of ECT, followed by a convulsion-dependent phase with brief, protracted, and chronic forms, along with different management of these two phases. As this has never been recognised and taught in psychiatric training, ECT is commonly a waste of time producing temporary or no benefits. In ignorance of convulsion dependence, ECT is given in a fixed schedule, twice or thrice weekly, according to the hospital's habit, for 2-4 weeks. I have never understood why convulsion therapy is given in this way in an age of tailor made therapy, individual monitoring, and precise doseage adjustments. Were antibiotics always given in one rather limited doseage, for the same length of time, for every patient and all infections, they too would be found to have some advantage at first which was soon lost. For that matter, the same would apply to psychotropic drugs. Why don't psychiatrists give them in one set dose, for one month only, to every patient regardless? After all, they take it for granted that this curious method is the way to give ECT, as if there were no very different schedules advocated over the years here and there in the literature. 1) Bourne H - Lancet 1954. (ii) 1193 2) Bourne H - NZ Med. J. 1955 : 54.697 Competing interests: None declared