UNDER THE MICROSCOPE / Prof William Reville: A recent study of mental health services in Galway recommended further research into electroconvulsive therapy (ECT) to justify its continued use in psychiatric hospitals (reported in the Irish Examiner May 27th). ECT is used to treat patients suffering from a number of serious psychiatric disorders, most notably severe depression.
ECT has always been a controversial therapy. Psychiatry regards ECT as a useful treatment, but there is a minority opinion that questions the treatment on medical and ethical grounds. This whole area has been reviewed by clinical psychologist Lucy Johnstone in the May edition of the Psychologist.
ECT was administered to 11,340 patients in England in 1999, which compares with a peak of 28,000 in 1985. Two-thirds of the recipients of ECT were women and 41 per cent were over the age of 65. ECT is now rarely used in Italy, Germany, the Netherlands and Austria and is used much less in many other European countries than in the UK, according to Johnstone. The Inspectorate of Mental Hospitals reported that in 2001, 1,024 patients received ECT in Ireland.
ECT consists of four to 12 treatments in which an epileptic-type seizure is induced in the anaesthetised patient by the passage of electric current through the brain. ECT was introduced in the 1930s to treat schizophrenia on the basis of a belief, incorrect according to Johnstone, that epilepsy and schizophrenia are mutually incompatible conditions and that, therefore, inducing a seizure might cure the condition. Psychiatrists report that ECT works rapidly and effectively in certain disorders. ECT is particularly indicated when drug treatment will not work fast enough, or when the condition is resistant to medication.
The medical model assumes that mental illnesses have underlying biochemical causes in the brain. Johnstone claims that, in the case of depression, there is no hard evidence for primary causal biochemical factors. However, some researchers would dispute this. Many biological mechanisms for the action of ECT have been proposed but Johnstone claims that none of these has been reliably established. She therefore concludes that the 1997 statement by the Royal College of Psychiatrists - "Repeated treatments alter chemical messages in the brain and bring them back to normal" - is purely speculative.
Many psychiatrists report from their clinical experiences that ECT is effective, and in some cases even life-saving, especially when used to treat severe depression. Johnstone claims that the research evidence to back up this claim is mostly lacking.
She quotes one careful study by Buchan and others published in the British Journal of Psychiatry, Vol. 160, p. 355 (1992), which concluded that ECT has beneficial effects, but only in patients whose depression is accompanied by physical retardation or delusions. This paper also reported that the benefit of ECT was apparent four weeks after treatment but not after six months.
ECT causes short-term memory loss in patients but the official psychiatric position is that repeated studies have failed to detect memory loss beyond the first few weeks. The Royal College of Psychiatrists states that ECT is "among the safest medical treatments given under general anaesthesia and, as far as we know, ECT does not have any long-term effects on memory or intelligence". Johnstone, on the other hand, quotes evidence to the effect that general mental and emotional dysfunction, and not just memory loss, is a consequence of ECT.
What do patients who have received ECT say about their experience? Surveys have shown that about 40 per cent of patients find ECT helpful. However, up to one-third of people who receive ECT report that it is a distressing experience. The recent survey in Galway found that 67 per cent of people who received ECT felt pressured into having it, 43 per cent said they didn't experience any long-term benefits and 57 per cent said they suffered side-effects.
ECT traditionally had a poor public image because of the physical nature of the treatment. In the early days of ECT, the patient was strapped to a table and sent into repeated agonising-looking convulsions by the application of electricity to the head. Popular films such as One Flew Over the Cuckoo's Nest lingered on such images. Nowadays the patient is under general anaesthesia and muscle relaxant when the procedure is carried out and shows very little physical reaction during treatment.
It is clear from Johnstone's paper that much remains to be discovered about the biochemical basis of mental illness, about the biological mechanism through which ECT causes its effects, and finally about the extent of the beneficial effects that result from ECT. Johnstone's position is that ECT damages the brain and that it should not be offered as a treatment by the medical profession on ethical grounds.
I would not agree with all of Johnstone's conclusions about ECT. I would not lightly dismiss the clinical experience of so many psychiatrists who report that ECT is helpful as a last resort in the treatment of severe depression. I think it would be premature to abolish ECT as an option at the present time. If drugs or psychological treatments are developed that can successfully treat the currently intractable conditions for which ECT is used, then it would be time to bid farewell to ECT. In the meantime, it seems to me that it has a useful, if very limited, role to play.
William Reville is associate professor of biochemistry and director of microscopy at University College Cork