Electroconvulsive therapy
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2998 (Published 30 December 2008) Cite this as: BMJ 2008;337:a2998
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests