Electroconvulsive therapyBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2998 (Published 30 December 2008) Cite this as: BMJ 2008;337:a2998
- Matthew Webber, carer1
- Correspondence to: C Thompson, Specialist Registrar in Liaison Psychiatry, Harplands Hospital, Hilton Road, Stoke on Trent ST4 6TH
- Accepted 3 November 2008
When my wife, Ana, suffered a depressive episode in 2001 after the birth of our daughter, we took it seriously but at first we weren’t excessively worried. Ana was no stranger to depression, having been diagnosed with it in 1990. The illness had always responded to medication, and we were both confident it would again. But something in the equation had changed. Drug after drug was tried. We tried to identify what in our lives might be dragging her down, but we couldn’t find anything. Our relationship was great, the children were doing well at school, money wasn’t a problem—we should have both been very happy. I watched as Ana, one of the most incredibly active people I’d ever met, shut down by degrees. We stopped going out for walks, shopping, and even just chatting to the neighbours. The situation worsened rapidly until Ana was admitted to hospital in March 2003 in such a dire state that she was immediately placed on 15 minute suicide observation. The doctors decided then to put Ana on a programme of electroconvulsive therapy (ECT) to lift her mood. The improvement was rapid and quite profound.
It is worth relating what really severe depression is like to live with. Formal medical jargon is specifically designed to be objective and deliberately strips emotive descriptions away to leave a clear picture for the practitioner. But depression affects the emotions; indeed it’s all about emotion. To people with depression and their carers, phrases such as “low motivation,” “poor self esteem,” and “persistent low mood” are all miracles of understatement. To me as a carer, it feels as if some malign, intangible entity has attached itself to my wife, constantly attacking her. Ana and I are very close: I can feel her mood as soon as I enter the same room as her, and when things are bad, the depression is like an oppressive weight that lies on us both. It sucks the colour out of life.
I’ve never seen mentioned in any medical text just how truly terrifying depression is. It’s very, very scary, watching the one you love withdraw from life and turn into an inert stranger—and you can never, ever, relax, because you know that the spectre of suicide is always hanging over all your lives.
ECT was like a magic wand. Very rapidly Ana picked up before my eyes. Her interest in life was renewed and she began to smile and laugh again. It became safe to speculate about the future. Optimism was reborn and Ana was discharged from hospital.
Sadly, the effects of ECT are not permanent. In Ana’s case, although we continued to try different drugs, antidepressant medicine just wasn’t helping. Psychotherapy carried an 18 month waiting list, and when she reached the top of that list, Ana was told she had not yet achieved sufficient improvement to be able to cope with the therapy and so she promptly returned to the bottom of the list. We struggled through five very long years—a testament to Ana’s willpower, despite the weight of her illness. It wasn’t all bad. Two or three medications produced an improvement that would last three or four months, and when things got really bad, Ana returned for more ECT. The staff in the ECT suite do a wonderful job of reassuring new patients and worried carers, because after all, what is this therapy? The process is stigmatised with misunderstanding and scaremongering. My early misconceptions of physical restraints and bulky electric shock pads were soon brushed away. The patient receives a general anaesthetic and a muscle relaxant to mitigate any physical convulsion. The shock itself is administered through small self adhesive electrodes not dissimilar to those used for pocket TENS (transcutaneous electrical nerve stimulation) machines. After a treatment Ana might forget the way to the local shops or when my birthday is, but she remembers again in most cases before the end of the day. To date, she has never failed to remember who she is or who I am. And that’s all there is to it. Ana has far more reticence about visiting the dentist than the ECT suite.
Last year we hit another trough. Ana was recommended for ECT again. It worked, as it always had before, and we—Ana, I, her consultant, and the consultant in charge of ECT—wondered where to go next. I don’t think anyone believed that the “right medicine” was still waiting to be found, and psychotherapy still looked like a distant proposition. In Ana’s words, she wasn’t after perfect recovery, just something she could, quite literally, live with.
It was at this point that the idea of maintenance ECT was suggested. If ECT was the only treatment that consistently worked, why not continue receiving it on an ongoing basis? Initially, treatments might be as frequent as once a fortnight, but over time the frequency is reduced so that the patient receives the minimum number to maintain their mood. Treatment is continued over an extended period—12 months or more. Many of the patients who have undergone this have discovered that in time their better mood seems to persist, as if the brain learns to sustain the effect. The mechanism by which this happens isn’t clearly understood but the results are undeniable.
Ana was eager to try maintenance ECT and began it at once. With bated breath, we began to count the weeks as they went by and Ana’s mood remained good. Not perfect—the ECT did not effect a complete cure with no sign of depression at all, but it certainly worked well enough for Ana to live life again.
It is now 12 months since Ana started maintenance ECT. It is impossible to convey to anyone who hasn’t experienced living with severe depression, just how profound the improvement in our quality of living has been. Not just for Ana, but for the children and me too. We go out as a family now, cautiously maybe, and always with an escape plan so that Ana can retreat any time she wishes. So far she hasn’t once done this. The horrible sick feeling I’ve learnt to live with over the past seven years at seeing my wife in such a dire state has receded. Problems still arise, of course, but I no longer have the constant gut wrenching fear that next time my back is turned Ana will seek to take her own life. That’s one hell of an improvement.
And the price? A very acceptable one as far as Ana and I are concerned. We’ve talked about it a lot. The side effects of ECT are minor and have not constituted any kind of life altering problem. Disorientation and short term memory loss are usually over and done with in a couple of hours. We accept that for slightly more than a day, once every three weeks, we won’t be going out anywhere or doing very much—the anaesthetic leaves Ana very sleepy for the day of the therapy, and sometimes the day after. The biggest issue for us is how desirable is it to have a general anaesthetic every three weeks? Ana has had more than 60 treatments in total now. What if the worst did happen? Supposing something went wrong and she died during the procedure?
It’s a risk we are both willing to take. The alternative is the almost certain deterioration of her mood until Ana can’t fight any more and takes her own life. Instead we accept the slight risk in exchange for living life again—a good quality life—and knowing there is something to live for.
A doctor’s perspective on electroconvulsive therapy
Administering ECT is a training requirement for all psychiatric trainees. From my experience it is not always easy—technically or emotionally.
My anxiety levels were high when I administered my first ECT. On the day, I was left without supervision to muddle my way through the procedure. The patient was offered little explanation of events—I wondered if I was responsible for explaining things but was far too preoccupied with how to work the archaic machine. The anaesthetist and nurse in charge were grumpy at my lack of knowledge, and seven years later I find it difficult to believe that this procedure was left to a junior trainee without adequate training or supervision.
The Royal College of Psychiatrists now has guidelines on how ECT training should be undertaken by trusts, and my current trust follows the guidelines impeccably. I hope I am not naive in the belief that juniors no longer experience what I have described above.
The evidence base suggests that ECT is a valuable and effective treatment. However, there remains something disturbing to me about being responsible for inducing a seizure in someone who may not be capable of consenting. Patients having ECT deserve dignity in the approach to their treatment, particularly when it is performed without their consent. If the guidelines are followed with regular audit of protocols then I believe dignity and humane treatment can be achieved. The repeated experience of seeing the beneficial effects that ECT can have in patients such as Ana where other treatments have failed, help me to continue administering and advocating ECT.
Indications and administration
The guidance from the National Institute for Health and Clinical Excellence (NICE) recommends that ECT is used to achieve rapid and short term improvement of severe symptoms in individuals with severe depressive illness, catatonia, and a prolonged or severe manic episode. It recommends consideration only after an adequate trial of other treatment options has proved ineffective and/or when the condition is considered to be potentially life threatening (www.nice.org.uk/nicemedia/pdf/59ectfullguidance.pdf)
The Royal College of Psychiatrists also recognises that maintenance ECT ( defined as a prophylactic treatment over the first six months of remission) is a treatment option in certain cases (www.rcpsych.ac.uk/publications/collegereports/cr/cr128.aspx).
Prescription of ECT requires an assessment of potential risks and benefits of treatment, for which valid consent has been obtained where possible. Risks include those associated with a general anaesthetic, current comorbidities, and anticipated side effects, particularly cognitive impairment. Anterograde and retrograde amnesia surrounding the procedure is a recognised side effect, as is retrograde amnesia affecting longer term memory in some cases. The benefits of the treatment are the improvement or prevention of further deterioration in symptoms and reduction of associated life threatening risks.
ECT in the United Kingdom is administered under a general anaesthetic and with a muscle relaxant. Once the patient is anaesthetised, an electrical current is delivered across the brain via placement of electrodes on the skull either unilaterally or bilaterally. A generalised tonic-clonic seizure is induced, which is usually monitored by the use of electroencephalography and electromyography. A typical course would be 6-10 sessions, with two sessions a week.
Catherine Thompson, specialist registrar in liaison psychiatry, Harplands Hospital, Stoke on Trent ST4 6TH
www.rcpsych.ac.uk/mentalhealthinformation.aspx—The Royal College of Psychiatrists has useful patient information leaflets on depression and treatments for depression including a leaflet on ECT
www.rcpsych.ac.uk/publications/collegereports/cr/cr128.aspx—The Royal College of Psychiatrists’ The ECT Handbook provides clinical guidelines for psychiatrists who prescribe ECT and practitioners who administer it. It clarifies the place of the therapy in modern practice and reviews the evidence for its efficacy
www.mind.org.uk—MIND is a major UK mental health charity, and the website includes factsheets and details of local branches and support networks
Cite this as: BMJ 2008;337:a2998
This is one of a series of occasional articles by patients about their experiences that offer lessons to doctors. The BMJ welcomes contributions to the series. Please contact Peter Lapsley (email@example.com) for guidance.
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.
Patient consent obtained.