A cure for depression?

“Often I would wake up and find myself crying. I didn’t know
where I was. Sometimes I found myself sitting with a cup of tea and
someone would have to remind me why I was there,” says Margaret
Walker about her spell in hospital being treated for depression in
1996.

Her disorientation was not caused by her illness but by the
medical treatment she was receiving to make her better. Twice a
week, for a short period, she received electroconvulsive therapy
(ECT), one of the most controversial psychiatric treatments
available.

During ECT, electrodes are placed on the patient’s head and an
electric current is passed through the brain, causing a fit. The
procedure is carried out under general anaesthetic with a muscle
relaxant to stop body spasms. Exactly why ECT works is unclear but
in Walker’s case, after just four sessions she started to feel more
alert and interested in life. “It just lifts your mood. You feel
more energetic again, you’re able to think and concentrate and you
want to eat,” she says. Before receiving ECT she was so depressed
that she just lay in bed, hardly eating and feeling suicidal.

A recent study published in the British Journal of Psychiatry(1)
supports the use of ECT. Researchers found that just two weeks
after treatment, depressed patients’ mood, cognition, and quality
of life had improved. They concluded that “a restrictive attitude”
towards ECT was not justified.

Yet last year the National Institute for Clinical Excellence
recommended limiting the use of ECT.(2) It published guidance
stating that ECT should only be used to treat severe depression
after other treatments have failed, or when the condition is
considered to be potentially life threatening. The Royal College of
Psychiatrists, however, disagrees with these recommendations.

Between January and March 2002, 2,300 people received ECT. While
it is most often used to treat severe depression (including
postnatal depression), it can also be used to treat catatonia,
(characterised by abnormal movement or posture) and mania.

Some people, like Margaret Walker, find the treatment
beneficial, but many do not. Unwanted side-effects are prevalent –
a survey by mental health charity Mind found that more than eight
in 10 people experienced side-effects such as headaches and sexual
difficulties. The most common problem cited was memory loss, which
can be permanent and the effects variable. Some patients are unable
to recognise people while others cannot remember things they used
to do before they received ECT.

Deciding whether to use ECT comes down to a risk-benefit
assessment. Roger Hargreaves, chair of the British Association of
Social Workers’ mental health special interest group, says that
often the choice is between anti-depressants and ECT. Given that
nearly half the people who receive ECT are over 65, this can be a
significant factor.

“We know there are risks attached to anti-depressants,
particularly for older people who are often on a cocktail of
medication. You have to balance the risk of yet another tablet
against the risks inherent in ECT,” he says.

ECT is often preferable because anti-depressants take a while to
kick in, he says. However, a new generation of anti-depressants
could change that. “ECT works much faster and so if you need to get
someone improving quickly it has a big advantage. However, if there
are new drugs that work as fast then maybe ECT will be less
needed,” he says.

BASW does not have a policy on the use of ECT, but social
workers working in older people’s mental health services tend to
support its use, Hargreaves adds.

Of course, not everyone agrees. Lucy Johnstone, a practising
clinical psychologist and academic at Bristol University, would
like to see ECT banned.

“If you accept the view that ECT is in essence a
doctor-inflicted head injury then there are ethical questions about
whether it can be justified. I don’t think it’s ever a good idea,”
she says.

Many studies have shown improvements that last for four weeks,
but none have demonstrated improvements that last for longer, she
says. It is her view that “almost anything else” is preferable to
ECT, but she acknowledges that alternatives such as counselling are
often more time-consuming and expensive in the short term. She says
that long-term intensive nursing care has even been found to
achieve as good an outcome as ECT. “We use ECT more than other
countries but people do manage to get by without it,” she says.

In addition to physical symptoms, many people who have had ECT
also experience adverse psychological effects – they may feel
punished and insulted, or as if they have been abused. Johnstone
says:”You have to look at the meaning of treatments for people as
well as the cognitive effects. You must ask not only whether it
harms them but what does ECT mean for the patient and how they view
themselves?”

This is an area that Una Parker is all too familiar with. She
was affected emotionally after being given 15 sessions of ECT back
in the 1970s. “It undermined my confidence. I felt like an empty
shell after it,” she says.

Despite not wanting the treatment, Parker remembers feeling
pressurised by her psychiatrist who kept telling her she needed it.
She doesn’t think it helped her mental health problems – she had
two more psychotic episodes but recovered without going into
hospital or receiving ECT.

Parker now works for ECT Anonymous, which wants to see the use
of ECT restricted to those who ask for it. She says that vital
information is still being withheld and that patients are still
being persuaded to agree to treatment.

“It has been known and is still known that people are told they
could be sectioned if they don’t agree,” she says. This is despite
Nice guidance stating that consent should be obtained “without
pressure or coercion”.

It may be that the issue of consent will be improved by
proposals within the revised draft mental health bill, which will
allow patients over 16 to refuse as well as consent to ECT,
providing they have capacity.

ECT has been around since the 1930s, but if the number of
patients undergoing treatment continues to fall, it could be
extinct as early as 2012. Many of those who have benefited from ECT
feel this would be a shame. After all, shouldn’t patients have a
choice about how they are treated?

• More information at www.depressionalliance.org
  tel: 0845 1232320

(1) “Quality of life and function after electroconvulsive
therapy”, British Journal of Psychiatry, 2004

(2) Guidance on the Use of Electroconvulsive Therapy, National
Institute for Clinical Excellence, 2003

Users’ views on ECT

 “ECT was done ‘to’ me, not done ‘for’ me. It paralleled sexual
abuse, which I experienced as a child. Someone doing something to
my body against my will.”

“I know ECT works well for me when I am severely depressed. I have
a right to choose to have it. If I don’t have it I am unable to do
anything for about six months – with ECT it is over in a few
weeks.”

“It was an absolutely dreadful experience. It was like
torture.”

“The effect of the treatment was amazing. I honestly believe that
had I not received ECT I would not be living the full, happy and
healthy life that I am living today.”

“This barbaric invasion of a person’s delicate make up in my
opinion should be illegal.”

“I feel that it should be a personal choice. I have no doubts that
I would have committed suicide had I not had ECT.”

Source: Shock Treatment: A survey of people’s experiences
of electroconvulsive therapy, Mind 2001