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3 August 2022

We need reasoned debate on ECT, not polarisation

Media coverage pits those who want to ban electroconvulsive therapy against those who advocate for it.

By Rebecca Lawrence and Stephen Lawrie

Electroconvulsive therapy, a treatment for mental illness, has been in the news of late. A number of articles have highlighted the plight of people who have had ECT and experienced problems with memory and cognition, without the reports acknowledging any benefits of the treatment. Unfortunately, this can only lead to further polarisation among those who disagree about its use.

We are two consultant psychiatrists. Stephen is a senior academic and clinician, and Rebecca is a senior clinician and patient with a recurrent mood disorder who has received around 70 electroconvulsive therapy (ECT) treatments over the last 30 years. We cannot comment on stories that have appeared in the media without knowing the complex history of each individual. It is reasonable, however, to say that many medical interventions can have life-changing consequences.

Severe depression is a hideous illness, something we both know from different perspectives, and people don’t always get better on antidepressants. It is quite different to everyday sadness. It is defined as low mood most of the time for at least two weeks, with at least four other symptoms including sleep and appetite disturbance, impaired memory and concentration, and suicidal thoughts. At worst, people see no point in living, and may hear voices or hold delusional beliefs that they have committed terrible acts. If this affects someone who has just given birth, both mother and child are at risk.

This is awful to see, and unbearable to experience. No one would choose ECT, but when you are faced with a patient who doesn’t eat or drink and can barely speak, your options are limited. It is not the moment for psychological therapy – although psychological support is always valuable. ECT does not cure depression, but it relieves it – usually faster than antidepressants. What it does is induce a wide range of changes in neurotransmitter and neurohormonal levels in the brain, stimulates nerve cell growth and normalises connectivity between different regions, which leads to improvement in certain conditions. Once established, that improvement needs to be maintained, often with both medication and therapy.

ECT’s reputation is undeserved, and has been fed by literature, films and the media. When first used, it was brutal – often given on a daily basis without anaesthetic or muscle relaxant. This caused terrible harm and broken bones were common.

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But now there is no pain, and any anguish experienced is due to the underlying depression. A patient is given an injection of anaesthetic and muscle relaxant, before an electric current is briefly passed through their skull. They then have a controlled seizure for 20-30 seconds, and then wake. Inevitably, they feel a bit “woozy” afterwards, and 10-20 per cent will have headaches or confusion for hours or days.

There are worse experiences in medicine, many desperate attempts to save lives that hurt more, but are thought worthwhile. We say ECT can also be worth it to treat severe depression, a disabling condition with a high mortality and much suffering.

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The best evidence for the efficacy of ECT comes from clinical trials done between the sixties and eighties, where “real” ECT was compared to “sham” or simulated ECT, in which clinically depressed people got the anaesthetic without the electric current. The Lancet published a review of these trials in 2003, showing not only large effects for ECT, but also that ECT was much more effective than antidepressants in these patients.

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Subsequent research has rightly focused on comparing different ways of giving ECT or other “physical” interventions for depression to maximise benefits and minimise adverse effects. Thus, it is hard to see the benefits in picking over the deficiencies of old trials, which is unlikely in any other area of medicine.

There is compelling evidence that ECT is effective in everyday practice. The electroconvulsive therapy accreditation service (ECTAS), a voluntary network, provides standards and accreditation for services in England, and there has been an audit of practice and outcomes for many years in Scotland, where we live and work. Some of the most common reasons for treatment are a lack of response to medication, previous good response to ECT, or patient preference, and most of the several hundred people each year in Scotland will complete a typical ten sessions of ECT and get better.

Few treatments for serious illness come without side-effects. The memory problems linked to ECT have been underestimated and understated, with little support provided. A review of patients’ views found that subjective memory complaints were common, and that the “neuropsychological tests to assess memory do not address the types of memory loss reported by patients”.

Regrettably, this remains true. Having ECT is frankly discombobulating – during the course of treatment you can feel bewildered and, afterwards, many people will have memory holes for that period – or even for previous memories. But most will recover the ability to form new memories within a month of their last treatment and, if they recover fully from their illness, will be able to return to their previous lives.

Consent for ECT should ideally take place with a relative, and be repeated and re-explained throughout – otherwise how can patients remember giving it? As most patients are very ill, some cannot give informed consent, and a second opinion should be sought for their protection. Getting consent from a close relative or carer is also good practice.

After the course, patients should be offered opportunities to discuss their treatment; any concerns about cognition or memory should be monitored or further assessed. A subsequent visit to the ECT suite could brush away clinging fears, and peer support, which one of us has given informally, can help. Above all, people should be taken seriously.

Perhaps the worst aspect of the current press coverage of ECT is the polarisation of the debate between clinicians and patients who advocate for it, and critics who seek to have it banned. Balanced coverage, acknowledging the pros and cons, as well as better routine practice provided by dedicated ECT specialists using standardised outcome measures in better-funded services is what is needed, not divisive discourse.

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