ECT: the blues and the electric avenue

Electroconvulsive therapy, ECT or electroshock therapy is the most controversial treatment in psychiatry, and it’s also the most misunderstood.

It’s impossible to discuss ECT without mentioning One Flew Over the Cuckoo’s Nest because the book, the play and the film have given us the most culturally salient image of the treatment.

Kesey depicts it as little more than tool of oppression to subjugate Randal P. McMurphy who is only in hospital because, as far as he can figure out, “I, uh, fight and fuck too much”.

This negative portrayal is almost standard in the film industry but captures little of the reality of the average ECT treatment, which is usually prescribed for depression of the most severe kind (it is sometimes used for psychosis and catatonia, but much less frequently).

ECT treatment involves passing about 800 milliamps of electricity through the brain. 800 milliamps is a bit more than your average mobile phone battery puts out, but is quite significant as far as the brain is concerned and is enough to cause a seizure.

The current can be applied to both sides of the brain (bilaterally, most common) or one side only (unilaterally, less common), and can take the form of a pulse (most common) or a sine-wave (less common). There is evidence to suggest that different versions have different benefits and side effects, but the choice may depend on national guidelines or clinic preference.

This effect on the brain is essentially the same as an epileptic seizure, but it looks quite different. This is because the patient is given a general anaesthetic, so they are unconscious, and a muscle relaxant, so there is barely any movement.

In terms of physical health risks, ECT is thought to be much safer than most drug treatments and is often prescribed to people in the most fragile state of health (e.g. pregnant women, the elderly) for exactly this reason.

The biggest risk to health is actually the anaesthetic and muscle relaxant drug, which is the main reason a heart and general medical check-up is given before treatment.

ECT is usually given in doses of 6-12 treatments over a similar number of weeks (psychiatrists seem to have a superstition about giving an odd number of treatments for some reason, and so it is usually given in ‘pairs’ of doses), although can be given as a ‘maintenance’ treatment, less frequently, over longer periods.

We still don’t know how ECT works, although effects on brain plasticity (physical change and adaptation) and neurochemistry are being investigated.

In terms of its effectiveness and impact, the whole business of ECT is a complicated issue, but here’s what the current evidence suggests.

At least in the short-term, it is one of the most rapid and effective treatments for severe depression.

It is associated with ongoing memory difficulties, even after the treatment has stopped.

Patients generally view it much less favourably than clinicians, and it is generally viewed negatively by the public and carries significant stigma.

Now here are the caveats: because ECT is typically given to the most severely depressed patients (who likely already have cognitive problems), it is difficult to do ideally balanced, gold standard randomised controlled trials that give a good matched measure of both benefit and side-effects. In fact, these sorts of studies have not been done.

This is why there is disagreement, even with the medical and scientific community, about its effects, both good and bad.

Furthermore, Dr Richard Abrams, one of the leaders in ECT research and author of the standard clinical textbook, has a financial interest in, and reportedly owns, Somatics, one the world’s biggest suppliers of ECT machines and equipment. This makes some people suspicious of his promotion of the treatment.

However, Dr Harold Sackheim, probably the other ‘big name’ in ECT research, has no financial interests in any ECT company and does not receive financial compensation for consultation with the ECT industry.

Importantly, there is considerable individual variation in how people respond to ECT, in terms of their symptoms, post-treatment cognitive impairment, their subjective experience, and their attitudes.

Some people find ECT ineffective and damaging, others feel their life has been saved and their illness properly treated for the first time.

There are many articulate and moving accounts of the treatment on the web. Journalist Liz Spikol found ECT largely unhelpful and suffered debilitating cognitive effects, while surgeon Sherwin Nuland found it was the only thing that helped him recover and return to work.

Perhaps the most controversial topic is involuntary or forced treatment.

The majority of ECT patients volunteer for the treatment (usually on the suggestion of their doctors) and sign a consent form for treatment.

In some countries, where law allows, a minority of patients are treated with ECT against their will, usually if they are deemed to be a danger to themselves or others, and where other treatments have failed.

In a nutshell, it seems to be the most effective treatment for severe depression, seems to impair memory, is disliked and stigmatised, and is difficult to research. Most notably, as a patient, your mileage may vary. Some people have no benefit, some have huge improvement; some have no side-effects, some have ongoing difficulties. Most have some of each.

It’s also really hard to have a sensible discussion about ECT because of the emotions it stirs up. Like any treatment that provokes such opposite reactions from both those that have had it, and those that haven’t, it’s worth learning more with a cool head and an open heart.

I’ve avoided giving my own opinions on the treatment, which, like the evidence are complex, but I hope you’ll learn more, decide for yourself and be able to consider both new scientific evidence and reaction from people you meet who have had, or are considering ECT.

Link to Wikipedia page on ECT.

7 thoughts on “ECT: the blues and the electric avenue”

  1. I am very disappointed in Mindhacks.
    Firstly you do not mention how and why ECT was invented.
    It was used alongside Insulin shock therapy derived from the belief that epileptic convulsions and mental illness were never present at the same time in one patient.
    Secondly you omit what precedes today’s modern ECT. The various antidepressants that exist are used first. With the drugs use perhaps it makes many patient worse, worse from the withdrawal effects that are not supposed to exist , worse from the idea that a depressed persons brain is chemically imbalanced that can be fixed by adding the correct chemicals.
    Thirdly you fail to use Occam’s razor and a history of evidence of how ECT works . Occam’s razor says the simplest reason is most likely, the method of ECT being damage and fear to cure mental illness.
    Mindhacks likes to compare the human mind with computers, and the analogy would be to erase the hard drive of a person. Was the hard drive defective or did psychiatry damage it with antidepressants first? Is erasing it the right thing to do?
    “The evidence assembled from the various fields of investigation in regards to shock therapy points definitely to damage to the brain. Perhaps the majority of authors tend to minimize the significance of this and attempt to find some explination more satisfying to their consciences.” Walter Freeman and James W. Watts “Physiological Psychology” Annual Review of Physiology 1944
    ECT works by fear “Terror acts powerfully upon the body, through the medium of the mind, and should be employed in the cure of madness.”Benjamin Rush.
    Anecdotal stories of the ECT treatment always mention fear. Fear when waking up, fear when forced to get another treatment.
    You could compare ECT to the medical success of setting a broken leg, everyone sees the person walking after treatment, if no one sees or hears the ECT patient negatively affected, do they exist or matter?
    Brain damage may be so severe that patients are unaware of their losses, but then who cares?

  2. Vaughn wrote: “In fact, these sorts of studies have not been done.” Actually, they have. By Harold Sackheim himself. In (Nature Group’s) Neuropsychopharmacology.

    Click to access 1301180a.pdf

    “This study provides the first evidence in a large, prospective sample that the adverse cognitive effects can persist for an extended period, and that they characterize routine treatment with ECT in community settings.”
    Welcome to reality. Sorry to disappoint.

  3. Hi Larry,
    The study you cite is certainly the best evidence for the negative impact of ECT on memory and is in fact already linked from the article (“It is associated with ongoing memory difficulties…”).
    However, this is not a ‘gold standard’ study and so I stand by my statement.
    As Abrams notes in his critique of the study (see PMID 17548971), the assignment to treatment group was not fully randomised, there was no untreated or drug-treated depressive control group (only an age-matched “comparison group” of never-ill normal patients) and the data collection was not done in a well-blinded manner.
    Although Sackheim and colleagues argued that their measurement methods mitigated some of these shortcomings (see PMID 17548970), it is still true at the time of writing that we lack “ideally balanced, gold standard randomised controlled trials that give a good matched measure of both benefit and side-effects”.
    Reality, it seems, is still to be fully researched.

  4. I am to a point where I don’t care if I have some memory loss if it stops the depression and anxiety. This is no way to live. Besides, I have much memory loss now due to, I think, the medication I’m taking.

    This article although may be lacking a bit, is easier to read and understand than many.

    Will let you know how it goes, what I think about ect after I have it done: if I remember.

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