In the eyes of the public, electroconvulsive therapy isn't particularly popular. "It's an odd treatment in that it's actually been around for 80 years, so a lot of people might think 'God, I can't believe they're still doing that'," says Declan McLoughlin, research professor of psychiatry at St Patrick's University Hospital and Trinity College Dublin.
“The reason we’re still doing it is because it’s still very effective. And it’s still more effective than any other treatment available for depression.”
Electroconvulsive therapy, or ECT, formerly electro-shock therapy, is used to treat certain mood disorders but is most commonly used for severe depression. Patients are put under general anaesthetic, then the brain is stimulated by passing electricity through electrodes placed on the head. This induces a brief seizure and, over the course of six to eight treatments, an antidepressant effect.
In the realm of treating life-threatening depressive episodes, McLoughlin says it’s the single most effective option. It’s “the gold standard”.
In Ireland, about 450,000 people are affected by depression at any one time, according to Aware, an organisation which supports those with depression. Some 6,000 people in severe stages of depression are admitted to Irish psychiatric hospitals every year, accounting for 30 per cent of all admissions.
Worldwide, some 1.4 million people receive ECT every year, with about 250 people having the treatment annually in Ireland. It’s typically deployed for the one-third of patients who develop “treatment-resistant depression”.
“By the time you’re onto your fourth or fifth line of different antidepressant drugs, the chances of responding to another are perhaps in the order of about 10 per cent, while the chances of responding well to the ECT are about 50 per cent,” McLoughlin explains.
Paradoxically, the worse the depression, the better ECT will help. Those who are acutely ill or psychotic “have about an 80-90 per cent chance of recovery with ECT”.
Faster than anti-depressants
ECT works faster than anti-depressants, according to McLoughlin, and patients may see an improvement after about four or five treatments, or two to three weeks. ECT works by promoting the growth of new connections in certain brain regions, including in the hippocampus, which has an important role in mood and memory.
However, its use remains controversial. “The opposition, at one level, is surprising; this is a treatment with a very strong scientific evidence base for its effectiveness – especially in people with serious depression, it can be a life-saving treatment,” says McLoughlin.
One major concern has to do with its side effects, the most common being diminished autobiographical memory – or the ability to remember our experiences in relation to a certain time and place.
Recently, McLoughlin led a team that trialled a different way of administering ECT and the findings were published in the American Journal of Psychiatry in February.
With the commonly used “bitemporal” ECT, electrodes are placed on each temple to administer the shock. McLoughlin’s study found that by using a stronger charge and placing one electrode on the temple, and the second nearer the top of the head (“unilateral” ECT), the side effects were diminished.
“What we found basically is that by changing the electrode positions, [ECT] had less of an effect on memory than in the conventional bilateral or bitemporal ECT,” he says. “At the same time, the concern people had was that this would be a less effective treatment, but we found that wasn’t the case at all.”
He hopes by improving the side effect profile, the treatment may become more widely accepted. “By and large, the side effects are transient, but anything we can do to minimise that is a good thing.”
Though the “vast majority” fully recover, some have reported permanent memory loss after ECT, though McLoughlin says accounting for memory loss is difficult. For one, the instruments used to measure autobiographical memory are based on recall tests, which he says aren’t always fully reliable. Also, as he puts it, severe depression is “toxic” for the brain – the condition itself can lead to memory loss.
The bulk of evidence supporting ECT is by no means new, but opposition extends beyond side effects. “I think a lot of the public perception comes from so much stigmatising and incorrect media portrayals about ECT,” says McLoughlin. “[Framing] ECT as an instrument of punishment, or people being coerced to have the treatment, which is not that common at all.”
He acknowledges it’s an unusual thing to do; the treatment sounds odd, even archaic, but in reality is “perhaps no weirder or stranger than somebody cutting you open to remove your appendix”.
Depiction in film
For many, ECT’s mention may conjure a picture of two heavy-set orderlies holding a patient down in some oppressive, bleak asylum setting. Its depiction in film is often sensationalised and visceral.
One Flew Over the Cuckoo's Nest is a "classic example" of ECT's use as a negative force – Nurse Ratched holds the keys to the "Shock Shop" and we see it dished out as a punitive measure. Another popular example McLoughlin mentions is in the Clint Eastwood movie Changeling. In the movie, set in 1928 and "based on true events", ECT features in a distinctly negative light, despite not yet being invented.
When it was created in 1938, ECT was a “game changer” in psychiatry. Film portrayals in the 1940s were quite favourable, but “a few years later, the depiction was very much an instrument of repression and a shorthand, I think, for the medical profession and psychiatry in particular being ‘mind controlling’. . . trying to control individuals,” says McLoughlin.
He explains that assumptions often prevail and ECT can create anxiety among a patient’s family members, but patients themselves rarely raise the same concerns.
“It’s really remarkably unusual that people who are sick with severe depression have those sort of media ideas of having ECT. . . Really, the big question is, ‘Will this make me better?’ That’s the primary focus of people who are sick.”
In recent months, the conversation around ECT has focused on patient consent. Until February, a person could be detained under the Mental Health Act and undergo ECT despite being “unwilling”. In 2013, 46 people received ECT who were either “unable or unwilling”, with one patient recorded as “unwilling” by two consultant psychiatrists.
McLoughlin welcomes recent changes to the Act and says the move protects patients’ rights: “Before the law was changed, it did mean someone who was detained possibly could be made to have ECT, even if they had the capacity to say, ‘Well, I really don’t want this treatment, thank you very much.’”
People can still be given ECT under the Mental Health Act if they're deemed to lack the capacity to give consent. Last month, two orders were made by the High Court for people to receive the therapy; one in the case of a 16-year-old girl and another a 62-year-old man.
According to McLoughlin, determining a patient lacks the capacity to consent is not a “trivial” matter. It involves referrals by two consultant psychiatrists, according to the MHC guidelines.
“You need to bear in mind people have a right to treatment as well. If they’re severely ill – possibly mute or bed-bound and immobile, not eating, not drinking and they’re wasting away and unable to advocate for themselves – there needs to be procedures for those people to access what certainly could be for them a life-saving treatment,” he says.
Such robust evidence in support of ECT begs asking why it’s a last-resort treatment. “That’s the million dollar question. I wouldn’t advocate ECT as a first-line treatment, but it should be considered as a third- or fourth-line treatment,” says McLoughlin. “I think one of the issues is that because of the limited availability of the treatment, it ends up being used as a last resort.”
It is estimated that some 400 people a year need ECT in Ireland based on epidemiological analysis, yet only 257 people received it in 2013, according to the latest figures available from the Mental Health Commission. Patients spanned 18-93 years of age, with more women (169 – 63.4 per cent) receiving it than men (94 – 36.6 per cent).
Disparity in provision
The disparity in provision can partly be blamed on access; there were 65 approved centres in 2013, 41 of which did not have an ECT facility in operation. Overall, just 17 centres provided ECT in Ireland in 2013.
McLoughlin mentions counties Cork and Kerry, which have a combined population of 600,000-700,000 and no ECT centres. Sending a severely depressed patient hundreds of kilometres away for treatment is far from ideal and they are likely to decline, he says.
The reasons for the shortage in centres aren’t exactly clear. Besides possible “ideological cultural reasons”, McLoughlin says it could be due to a lack of training and practice – the fewer ECT centres, the less experience and familiarity doctors get and the less likely they are to recommend its usage.
“Pretty much anybody who’s had a patient who has responded well to ECT remembers that strikingly and thinks about it for the next patient – ‘Is this someone I should be referred for ECT?’”, he says.
There’s still room to refine ECT further, with the goal being a wider acceptance based on evidence, rather than common misconceptions: “I hope with our research we can give the public some reassurance around the ongoing effectiveness of the treatment,” he says.
Prof Declan McLoughlin’s team is currently looking for healthy volunteers to take part in depression research. For more information, contact email@example.com