MEDICAL MATTERS:The treatment can work when all else fails, writes MUIRIS HOUSTON
FOR MANY OF us, our first experience of electroconvulsive treatment (ECT) was watching the film One Flew over the Cuckoo’s Nest. Portraying the use of ECT as punishment, the film is not a good advertisement for the procedure.
My first clinical experience of ECT was as a fourth year medical student during my rotation in psychiatry. I found the procedure distasteful: despite the use of a general anaesthetic, seeing a patient jerk violently as the electric shock passed through pads on either side of their head had a distinctly medieval feel.
And yet, I will always remember how the treatment worked in one older man. He was one of the people I followed for the two-month attachment and was the subject of a case study which formed part of my assessment.
“Jim” was 76 and had suffered from depression earlier in his life. However, his current admission was due to a severe episode of psychotic depression, in which he suffered delusions of persecution. One of these centred around his food being “poisoned”, so he was notably emaciated from anorexia.
Several attempts at drug treatment failed: he was diagnosed with involutional melancholia, a particular form of severe depression encountered in older people.
ECT was administered twice a week for about three weeks. Gradually Jim perked up, rediscovering an interest in food and beginning to emerge from his shell. I have no doubt the ECT saved his life.
But my distaste of ECT has persisted; I can fully understand the feelings of its opponents who regard it as a barbaric treatment. Many would like it banned forthwith, which is where I part company with the anti-ECT lobby.
If even a small minority of lives can be saved with the treatment, then access to ECT must be maintained. And if it helps others for whom medication and therapy leave them still feeling as if living with depression is akin to “existing as the walking dead”, then an outright ban must be resisted. As long as, where possible, the patient gives valid, fully informed consent, which includes a discussion of ECT’s side effects and risks, then the treatment must remain available.
Guidelines for its use certainly need continual review: at present it may be used in people with severe depressive illness, catatonia or prolonged mania. In the UK, official guidance suggests ECT be considered “only after an adequate trial of other treatment options has proved ineffective and/or when the condition is considered to be potentially life threatening”.
Patients must be told that ECT induces amnesia in some people, with long-term memory a casualty for some recipients. It can also cause temporary confusion, low blood pressure and a fast heartbeat. And we have no firm understanding of how it works.
There is no doubt that ECT’s reputation suffers because of a lack of robust, randomised controlled trials into its efficacy. Because it is not a drug and the manufacturers of ECT machines are by and large small-time operators, sourcing research funding will always be an issue. The US government funded a 2007 study by researchers from the New York Psychiatric Institute, the first large-scale, prospective study of objective cognitive outcomes of patients treated with ECT.
The study of some 347 patients found that delivering the shock to both sides of a person’s head resulted in more severe and persisting retrograde amnesia than giving the ECT unilaterally to one side of the head. And older people and women had greater cognitive deficits than other groups, including an impaired ability to recall newly learned information after the therapy.
ECT is now under investigation by the Food and Drugs Administration in the US. An advisory panel has been asked to decide if the technique is high risk or can be classified as medium to low risk. If its decision falls in favour of high risk, that will mean ECT has to undergo a stringent approval process, which device manufacturers may not be able to afford. More than 80 per cent of submissions to the panel were in favour of greater regulation.
But calls for an outright ban would be a mistake.