Electroconvulsive Therapy

chrisb said:
Some might regard the reference to "scared laymen" as potentially pejorative. Not to mention "cavalier".
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You may be right.
But it doesn't change the fact.
It can not be known with the required certainty.
 
Since the article at the start of this thread did not refer to any research articles, I've tried a Google search and found this article:
Neuropsychiatry(London) 2014
Current electroconvulsive therapy practice and research in the geriatric population
Nancy Kerner*,1 and Joan Prudic1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4000084/

Summary
Electroconvulsive therapy (ECT) is utilized worldwide for various severe and treatment-resistant psychiatric disorders.

Research studies have shown that ECT is the most effective and rapid treatment available for elderly patients with depression, bipolar disorder and psychosis. For patients who suffer from intractable catatonia and neuroleptic malignant syndrome, ECT can be life saving.

For elderly patients who cannot tolerate or respond poorly to medications and who are at a high risk for drug-induced toxicity or toxic drug interactions, ECT is the safest treatment option.

Organic causes are frequently associated with late-life onset of neuropsychiatric conditions, such as parkinsonism, dementia and stroke. ECT has proven to be efficacious even when these conditions are present.

During the next decade, research studies should focus on the use of ECT as a synergistic therapy, to enhance other biological and psychological treatments, and prevent symptom relapse and recurrence.
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My doubts about the treatment of mental health problems are because I don't think doctors do a thorough job in checking for physical health issues that could be causing the mental health problems, before they label the patient, dose them up to the eyeballs on something to keep them quiet, and then dismiss them as not worthy of any more consideration. Any physical complaints are assumed to be a result of the mental health problems, not the other way around. And once someone has a mental health diagnosis they are apparently superman or superwoman - after all they can never be physically ill again according to current medical practice. There is, apparently, no point in "wasting" time and money investigating "mad" people, so their physical problems are often never found or believed.

Another issue is that current medical practice virtually dismisses nutrient problems as being minor and of little consequence, and certainly there is no acceptance that low nutrients can cause depression. As long as (for example) ferritin is just within the reference range, or vitamin B12 matches the bottom of the reference range, then some patients are told that to treat these low levels is "unethical" because their results are in range.

The issues with thyroid treatment are huge for people of all ages. Current medical practice is massively reducing thyroid hormone treatment (or refusing to supply it at all) once patients get to about 50+, because a TSH of 10 is apparently wonderful once you get older. The fact that Free T4 and Free T3 are bottom of range or below range is fine too, so we are told, because the TSH is around 10 and that's normal for old people. But it isn't. Modern endocrinology doesn't care about symptoms, only blood tests - and I didn't make that phrase up, several endocrinologists have told thyroid patients that.

But it would appear that nutrient and thyroid problems are too expensive to treat, and too much like hard work. Just give the patient a prescription for anti-depressants. If the patient doesn't get better or refuses to take them then shrug your shoulders, label them as non-compliant, and dismiss them as not worth the effort.

If the patients decide to treat themselves then they discover that they feel a lot better with iron levels which are mid range, or B12 levels which are top of range, and thyroid hormone levels which are in the upper half of the range. Depression may disappear , but unfortunately what happens is that you end up with lots of angry people who were allowed to rot for decades being told that they were fine, they only needed an anti-depressant.
 
adambeyoncelowe said:
I'm skeptical. What's the evidence and how much of it is the same-old for psychological treatments?
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There is no comparison. Everyone who has ECT in the U.K. Has to have it approved by an independent physician and formally recorded. Based on this long term studies have been done. The fact that there is an established optimum dose means that there are reliable measurements of benefit that are not subject to the biases of psychological therapies. Nobody has a vested interest in using ECT. It is expensive and requires highly trained staff an nobody makes a profit.

The effect is also extremely characteristic in time course. You can even predict the changes in thinking day by day and for times of day. It is a bit like trying to find the best places hang a radio aerial - as you move from time to time rather than place to place the mind seems to retune to normality rather than paranoid delusions.
 
Barry said:
I can understand that it is a pity, but that is always with hindsight surely, when it only later becomes evident there is likelihood of benefit unachievable any other way. If used earlier there would presumably be excessive risk of using a heavy duty tool on those who might yet benefit from lighter interventions. Medicine must be full of such tricky balancing acts.
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I don't think it is necessarily a matter of hindsight. My understanding is that the rules have been skewed by lay pressure. My wife's psychiatrist knew that ECT was likely to be the best option long before things got bad enough for it to be allowed. If she had had it three months earlier sh.e might only have needed one course instead of three. The problem appears to be simple prejudice/politics. And the availability of a dozen drugs to try first has lengthened the delay.
 
Jonathan Edwards said:
The effect is also extremely characteristic in time course. You can even predict the changes in thinking day by day and for times of day. It is a bit like trying to find the best places hang a radio aerial - as you move from time to time rather than place to place the mind seems to retune to normality rather than paranoid delusions.
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Was this all pretty much well understood in the 1950's and 60's, or is this level of understanding since then?
 
FWIW- I had 2 individual doses of ECT in the 60s. I was 17. I had no memory loss: took my A levels 6 months later and achieved v good grades, straight to uni. No further psych treatment other than GP antidepressants.

My mother had ECT when she was 80 as an inpatient. It relieved her of a desperate depression. Terrible suffering.

ETA: I am now 71 ( reverse numbers)
 
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@arewenearlythereyet, I take the point about being worried about who is prescribing ECT. However, my own experience was reassuring. In order for ECT to be prescribed an independent physician specifically assigned the job of assessing the right indications has to be called in. In my wife's case this was an Indian guy in his late fifties who was clearly used to spending one or more days a week simply fulfilling this task. He was impressively knowledgeable about the evidence and spent rather more than an hour assessing my wife.

His job included explaining his decision to me since my wife was under section and rightly so because she did not actually exist as a person at this point. The problem was not sadness it was sheer insanity. The guy was brutally frank but in a compassionate way. He was obviously used to this job. He explained that without ECT the likelihood was that the person I knew would never return and the body would require long term institutional care. But with ECT there was a reasonable chance that could be avoided - and he was right.

The guy who did the ECT was also interesting. He spent much of his time doing this as a specialist skill. He had a comfoRtable friendly room with a couch. He started by asking the patient what music they liked and selected something suitable. My wife likes opera and he said he did too so they talked about that for a while. After the first session my wife looked forward to her sessions so that she could chat about music. She was sedated so that she knew nothing about the procedure. Afterwards she was amnesiac but remembered that the sessions were much more pleasant than the rest of her inpatient routine. The first spark of wanting to be here tomorrow emerged.

These people reminded me of colleagues in leukaemia oncology or transplantation medicine where the job is to somehow avoid tragedy on a daily basis. They beaR no relation to people who talk of 'biopsychosocial models'.
 
Interesting. I actually posted my previous post before reading the third page of comments (brain fog), so hadn't realised the question had sort of already been answered. Thanks for the links and additional clarification, though!

It does sound like it would help some people. My wariness of psychologists and psychiatrists remains, because I don't necessarily trust anyone with that kind of power, but I'm pleased to hear it can be very effective.

I'm reminded of June Whitfield in Ab Fab talking about how pleasurable (and in her case addictive, because it's a comedy after all) the treatment was. It does sound like it might be a positive experience.
 
Jonathan Edwards said:
@arewenearlythereyet, I take the point about being worried about who is prescribing ECT. However, my own experience was reassuring. In order for ECT to be prescribed an independent physician specifically assigned the job of assessing the right indications has to be called in. In my wife's case this was an Indian guy in his late fifties who was clearly used to spending one or more days a week simply fulfilling this task. He was impressively knowledgeable about the evidence and spent rather more than an hour assessing my wife.

His job included explaining his decision to me since my wife was under section and rightly so because she did not actually exist as a person at this point. The problem was not sadness it was sheer insanity. The guy was brutally frank but in a compassionate way. He was obviously used to this job. He explained that without ECT the likelihood was that the person I knew would never return and the body would require long term institutional care. But with ECT there was a reasonable chance that could be avoided - and he was right.

The guy who did the ECT was also interesting. He spent much of his time doing this as a specialist skill. He had a comfoRtable friendly room with a couch. He started by asking the patient what music they liked and selected something suitable. My wife likes opera and he said he did too so they talked about that for a while. After the first session my wife looked forward to her sessions so that she could chat about music. She was sedated so that she knew nothing about the procedure. Afterwards she was amnesiac but remembered that the sessions were much more pleasant than the rest of her inpatient routine. The first spark of wanting to be here tomorrow emerged.

These people reminded me of colleagues in leukaemia oncology or transplantation medicine where the job is to somehow avoid tragedy on a daily basis. They beaR no relation to people who talk of 'biopsychosocial models'.
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Thank you @Jonathan Edwards for sharing your story, it sounds a truly awful experience that you have both been through and quite a difficult subject to share so openly. It is quite an inspiring story and does certainly make me feel grateful to all those involved that led to such a positive outcome for you and your wife. It’s also reassuring to hear detail about the rules in place before prescription/treatment.

I have never had ECT, nor had depression or really reviewed all the evidence to form an opinion of its effectiveness and my mind remains open as to whether it’s a good treatment or not for certain conditions. In fact my cousin had ECT as a teenager following a very traumatic life event that triggered her depression ...but since the event was so awful I’m not sure what good it has done ...this was carried out despite the objections of her parents. She was 14.

I am experienced with neurologists in the NHS and sadly psychiatrists (despite never having a mental health condition) since the age of around 6 years. My experience of effective diagnosis and treatment is certainly not what you would call favourable. I suppose I am a biased layman.

I have also lived through around 2-3 years of my wife having severe depression following several miscarriages (not at all the same I realise but at points she was quite severe). Your story resonates with me since these were truly awful times for us, so I can only imagine how awful it was for you.

For us, luck rather than anything else led to us discovering that the depression and miscarriages were down to her undiagnosed hypothyroidism which meant she could come off the antidepressants that were initially prescribed. It was the practice nurse that had gone through a similar experience that spotted this not her GP who looked no further. The antidepressants didn’t work but the thyroid treatment did and we did manage to have a child (albeit a little later than planned). My wife is fine now...this was quite a transformation.

I am reassured by your experience of how this works in the NHS currently and if it works for certain conditions then a careful considered prescription and treatment with good predicted outcomes seems all fine and dandy to me.

However this does lead me to wonder though, what would happen if ECT does become more widely accepted as an early intervention treatment? I’m wondering what would have happened to my wife had the nurse not happened to have noticed that she had been dumped in the depression dust bin? What if this was someone who had no friends or family to look out for them?

The mental healthcare provision is being looked at by the current government without considering improving diagnosis of alternatives (whether treatable or not). This is worrying.

Losing ones memory when you have no support at home and you don’t actually have depression still seems a bit scary.

Best wishes though I’m so glad it worked out well for your wife :)
 
MPs call for ban on electroconvulsive therapy for women in mental health care
MPs from across the political spectrum have called for a ban on electroconvulsive therapy (ECT) as a treatment for mental illness in England, and want the practice to be subject to an urgent inquiry.

MPs told The Independent they have serious concerns that women are disproportionally given electroconvulsive therapy, and argued that patients are not properly notified of the treatment’s potential side effects. Some patients have also reported that they weren’t asked to provide consent before it was administered.

Dr Pallavi Devulapalli, a GP, called for the government to undertake an “urgent and comprehensive review” of the treatment as she warned that patients’ wellbeing was “at stake”.

Dr Devulapalli, who is health, social care and public health spokesperson for the Green Party, said she has concerns that no new robust research has been carried out into ECT since 1985 despite there having been “multiple anecdotal reports of harm and distress, such as memory loss and fatigue” in those who have undergone the treatment.

Some patients say electroconvulsive therapy has helped their condition, while psychiatrists and the Department of Health and Social Care say the treatment is closely regulated and can help those for whom other therapies have failed.

The calls come after The Independent previously reported that thousands of women were being given ECT despite concerns that it can cause irreversible brain damage.
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MPs call for ban on electroconvulsive therapy for women in mental health care (msn.com)
 
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Sly Saint said:
MPs call for ban on electroconvulsive therapy for women in mental health care
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This is worrying. I hope it is not an indication that ill-informed MPs are now in charge of detailed healthcare decisions.

Very simply my wife would be dead without ECT. And so would tens of thousands of others.
Maybe the fact that more women get ECT means they are lucky - getting better treatment.
Has anybody thought of that possibility?
 
I found this article interesting:
https://www.rnz.co.nz/programmes/in...ade-of-over-300-ect-treatment-she-didn-t-need

I thought the reporter did a good job - Anusha Bradley. She might be interested in writing a story about e.g. the Lightning Process.

The woman at the centre of the story underwent over 300 ECTs for depression, it seems that she was not properly informed of the risks. In her case, it has caused permanent and extensive memory loss. It was later found that she had a brain tumour that causes depressive symptoms; removal of the tumour resolved the depression.

Even from a purely economic point of view: 300 ECTs is an extraordinarily expensive approach, especially when the approach is not giving lasting relief. Surely there should be some requirement to do brain imaging at some point. Perhaps tumours are rare, but you would not have to find many treatable ones in order to justify the expense of a screening protocol. We often see this (unreasonable) rationing of imaging that could inform medical care.

There's discussion of the evidence base for ECTs - unsurprisingly, it is less robust than might be hoped.

Edit - the short interview video is worth watching
 
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The article looks fairly poorly researched. A colloid cyst is not a tumour. If it was capable of causing severe depression it was probably capable of causing severe memory loss - as might the surgery have been. 300 ECT sessions is a huge number so it isn't representative of the usual situation. At least in the UK an MRI is done as a routine first. So it all seems a bit garbled. And you will always find some academic in a minor college who says something is bad, without balance.
 
300 ECT's would definitely have been an extra-ordinary figure in the 90's onwards when I was doing my registrar training and then as a consultant in NZ. The article does note she had severe, likely melancholic depression (which ECT gives the best result for), and was committed many times with suicidality. (this means she was at very high risk of killing herself and I note there is no mention of suicide attempts but she may have had some). ECT is life-saving but is only used when medication (several trials) is ineffective, the person can't tolerate medication due to medical condition, or if the person has shown a good response to ECT in the past. People have full medical work-ups prior to ECT, with imaging if indicated. This person appears to have developed frontal lobe symptoms many years later, which is not a side effect of ECT.

It is only under very specific circumstances when ECT is given without consent. In my area, there was a designated ECT consultant who would assess the suitability for ECT. If I recall correctly, the treating psychiatrist (known as the Responsible Clinician for the purposes of the Mental Health Act) would also seek a second, independent opinion. Usually the ECT consultant and the treating psychiatrist would do pre-ECT cognitive testing and after the ECT course (normally 6 sessions but for recurring major depression of melancholic type, but if the person shows a response after one, only one is given). Post ECT cognition was tested over some months. Repeat courses in my experience were only given once.

ECT has changed over time due to the known effect of memory loss. All my patients were warned of this, and they had a right to refuse treatment. I gave unilateral ECT right through the 90's and 00's as a registrar which has shown to cause less memory loss but often bilateral ECT is more effective. I do think this should be compensated for by ACC. It is a very severe and life changing side effect. I know people who had ECT in the 60's and 70's who had severe memory loss and it was very sad to hear how it had affected them and always a reminder that ECT has severe side effects and it's use must be weighed up carefully against the threat to life by suicide.

Catatonia not treatable with medication would often be treated with ECT. I saw people have a positive response to ECT.

Coercion is a difficult problem. I would tell people the likely outcome/effect of the treatments (ECT, medication, therapy etc) I had available, based on current evidence. They could also discuss it with the ECT consultant. They would be told that unless their symptoms improved and their suicide risk changes they would likely to stay under the MHA and in hospital. This often feels like coercion as they are under the Mental Health Act. The effects of their mental illness can also have impacts on their memory and their ability to consent eg. catatonia. Then their family is consulted and they decide.

Some people requested ECT after researching their depressive illness, often because medication had been ineffective. They would have to have melancholic features and moderate to severe Major Depression for me to consider it due to the side effect of memory loss (which is not "rare"...)
 
According to the article, the patient commenced ECT in 1994.

She first became unwell in 1993 with stomach problems. When her doctors couldn’t find anything physically wrong, they referred her to mental health services, where she received numerous diagnoses including anorexia, a personality disorder and, finally, major depressive disorder.

Medication didn’t work and Hodgson became suicidal. She had her first course of ECT at North Shore Hospital’s Taharoto acute mental health service in March 1994.
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As I recall, at that time in NZ there was one MRI scanner. Patients with major mental health diagnoses might be referred for neuro-imaging but this wasn't routine and consisted of non-contrast CT, and only if there were "organic features" to justify it. So she may not have even had a CT. Third ventricular colloid cysts are usually hyperdense (mucin) and easily seen on CT, but can be isodense and so invisible if not causing ventricular dilation. Depending on their location in relation to the foramina of Munro they have a well-described propensity to cause acute CSF obstructive symptoms that are relieved on lying down (which is also how patients are scanned).

As far as I know, neurosurgeons do classify them as benign primary intraventricular tumours, though they're probably some embryological remnant rather than a neoplasm. It's a tumour inasmuch as it's a lump.

Natural history of colloid cysts of the third ventricle (2016, Journal of Neurosurgery, Sci-Hub)
 
Hutan said:
I found this article interesting:
https://www.rnz.co.nz/programmes/in...ade-of-over-300-ect-treatment-she-didn-t-need

I thought the reporter did a good job - Anusha Bradley. She might be interested in writing a story about e.g. the Lightning Process.

The woman at the centre of the story underwent over 300 ECTs for depression, it seems that she was not properly informed of the risks. In her case, it has caused permanent and extensive memory loss. It was later found that she had a brain tumour that causes depressive symptoms; removal of the tumour resolved the depression.

Even from a purely economic point of view: 300 ECTs is an extraordinarily expensive approach, especially when the approach is not giving lasting relief. Surely there should be some requirement to do brain imaging at some point. Perhaps tumours are rare, but you would not have to find many treatable ones in order to justify the expense of a screening protocol. We often see this (unreasonable) rationing of imaging that could inform medical care.

There's discussion of the evidence base for ECTs - unsurprisingly, it is less robust than might be hoped.

Edit - the short interview video is worth watching
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"Between September 20, 2002 until her last ECT shock on September 29, 2004, there were only three weeks during which she did not undergo a procedure." from the article

This seems such a strange thing to do because people really tend to not fully recover from the last one for about 2 weeks. It is perhaps one thing if there is a series of only 10 being given 'just days apart' and the person not fully recovering in between. Just thinking about the whole body and there only being 3 individual weeks in 2 years 'off'. I mean it must accumulate surely because it must take it out of people having eg 70 sessions only a few days apart.

So at what point did they think they were measuring or monitoring 'results' during this (to see if she needed more), if someone is still probably not fully had the chance to even physically get past and recover from the sessions?
 
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