IIt might seem a surprise to learn that, as a psychiatrist, if I ever had the misfortune of developing a severe depression, my treatment of choice would have been electroconvulsive therapy (ECT). Why? Well, to put it in simple terms, ECT is the fastest treatment for severe depression we currently have to offer – with a recent study in the BMJ that highlights its effectiveness.
For the uninitiated, ECT is a medical procedure in which an anesthetized patient has a small electrical current applied to the scalp in order to induce an attack for the treatment of serious mental illnesses and, sometimes, even neurological disorders. Each treatment takes only a few minutes and is usually given two or three times a week. The duration of the ECT course varies according to the patient's needs, but on average 8 to 12 treatments are administered.
It is almost impossible to talk about ECT without using the word "barbarian". For anyone familiar with the psychiatric condition of Someone Flew Over the Cuckoo's Nest, this is understandable. But a lot has been going on since then. In fact, if you are looking for a word "b" to describe the contemporary ECT process, the top of my list would be "boring" – the use of a general anesthetic and muscle relaxation means that it is probably more drama involved in having an ECT coverage.
This does not mean that ECT is not a significant intervention, but treatments should always be considered in relation to the condition that needs to be managed. Most people would be totally opposed to the idea of a surgeon who amputates his leg. However, if there was a rapid rise from the foot and an amputation was the best option for saving one's life, I suspect most people would consider it a necessity. The context is the key.
With this in mind, it is important to be clear about the term "severe depression". This is absolutely not sadness, an integral part of our universal human experience. Nor is it mild to moderate depression: sustained low mood and / or inability to experience pleasure, accompanied by negative thoughts and changes in bodily functions such as sleep, appetite, energy and libido . This painful and debilitating condition could benefit from improved sleep, diet and exercise, talking therapy and perhaps an antidepressant.
"Severe depression" refers to the pointy end of the spectrum of depression when your mind and body spirals under arrest. The thought becomes so absolutely negative that you could feel totally hopeless. Nihilistic disappointments may emerge, such as the unshakable belief that your body is rotting. Auditory hallucinations can say horrible things. Suicidal thoughts can become constant and irresistible.
In connecting psychiatry, we see individuals who are so depressed that they have become catatonic – a state that means they may not be able to move, talk or eat. Admission to the medical department is necessary to provide nourishment through a nasogastric tube and drugs to reduce the risk of formation of dangerous blood clots due to immobility – seeing one of these patients, it would be forgiven for thinking that the reason for the admission was shock rather than depression.
It is possible to mainly treat these people with drugs such as antidepressants, antipsychotics or mood stabilizers such as lithium. However, it may take several weeks to be effective, if they really are effective, and in the meantime the individual remains in a potentially lethal state.
I have seen many people in a catatonic state respond very well to the ECT. Sometimes, in a couple of treatments, they go from being speechless and immobile to talking and walking – it's amazing to be witnesses. Unfortunately, for others, ECT is ineffective – one of the frustrations of being a doctor sometimes doesn't know why treatments can work brilliantly for one person but not another.
A common criticism of ECT is that we do not know exactly how it works and therefore should not be trusted. If we were to apply this logic consistently, there would be many other effective treatments that we should also give up. Although paracetamol has been in use for over 100 years, we still don't know exactly how it works, but that doesn't stop millions of us from breaking out a couple of tablets when we have a headache.
Undoubtedly, it would be better if we could be clear on how ECT works, also because this could help us develop better treatments: current theories on neuroplasticity, neurotransmitters and inflammation offer fertile ground for innovation . But while we are where we are, I believe we have a responsibility to offer people who have this potentially lethal disease one of the best treatments we currently have.
When I raise the possibility of ECT with patients and their carers, their response is often one of fear, resulting from outdated ideas about treatment. With accurate information most see the ECT more positively, but still worry about what others might think. As often happens in mental illness, the insult is added to the wound by a layer of stigma and shame.
Of course, if you or a loved one are in a situation where ECT is at stake, this should be discussed in depth with your psychiatrist. ECT is not suitable for everyone and, like any other treatment, has potential side effects such as headaches, nausea and memory problems.
He has been with us for over 80 years, so the fact that he remains one of the best treatments for severe depression is rather daunting. That said, hope is generated by new research on treatments such as anti-inflammatory, other forms of neurostimulation, ketamine and psilocybin. I look forward to the day when I will not have to say that ECT would be my treatment of choice if I develop a severe depression because a better option will be available. But, for now, it's one of the best treatments we have for dealing with this life-threatening disease.
• Mariam Alexander is a psychiatrist liaison consultant to the NHS
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