Dialogue: Shock-horror accusations add little to ECT debate

By FELICITY PLUNKETT

As a psychiatrist who uses many effective treatments for depression, including electroconvulsive therapy (ECT), I am not in the business of destroying people's brains or minds.

Many websites present the anti-ECT message in a manipulative, shock-horror way that is factually incorrect or distorted. Together with other media, these sites fuel myths and legends about ECT that are incorporated into the collective awareness as established truths.

While some assertions have an undeniable basis in past instances of ECT misuse, such abuses are far removed from present practice.

John Read's alarming Dialogue page article concentrated the argument on the cons, quoted many of these truths as facts and presented only lip-service to the pros. Such polemics are typical of the ECT debate. The nuances were clear - advocates claim or suggest while critics point out. Dramatic bias grabs people's attention more than the boring facts, unfortunately.

The latest shock-horror to hit the headlines was the Lake Alice affair. I, too, am shocked and horrified. Let's be crystal clear: what was done at Lake Alice was not ECT, nor was it therapy, aversion or otherwise. It was appalling, sadistic abuse. I feel angry and ashamed that a person from my profession perpetrated such practices in the name of therapy.

This sordid piece of history has reignited calls to ban ECT and a submission to do just that is before Parliament. But before we throw the baby out with the bath water, we should have more discussion, as Dr Read suggests.

I have been involved in administering ECT for 24 years - as a trainee, then as a psychiatrist. During that time I have not seen any person develop a head injury or brain damage, but I have seen many patients get better, some of whom were close to death from severe mood disorders. Over this quarter-century, there have been huge advances in medical technology, and ECT is no exception.

We do know how ECT works: it increases sensitivity to neurotransmitter systems in the brain involved in the production of depression. This also happens in people who are resistant to medication.

ECT is not a common treatment, not because it is bad, evil or dangerous but because there are effective alternatives and ECT is expensive and labour intensive. Most psychiatrists would rather give a cheap pill that works well for many patients than a treatment involving inpatient admission, two to three doctors, several nurses, a specially equipped room, expensive electronics and costly anaesthetics.

These are the real reasons for ECTs decline over the past 20 years.

Today, the number of ECTs given in the United States per 100,000 population is 20, except for California, which is 10. In the British Isles, it is 22. The number of ECTs given in Auckland is only about 8 per 100,000 population.

So, which patients get ECT? It is certainly not first-line treatment. ECT is often preferred by patients who have had a previous good response. It is given when medication fails to work or if depression is life threatening - for example, when patients stop eating and drinking.

ECT is also the best choice of treatment when the risks of taking antidepressants are greater than those of anaesthesia.

How risky is ECT? The mortality rate from ECT is 2.8 per 100,000 treatments, the same as for anaesthesia alone. The safest antidepressant drugs, the SSRIs, have an unexplained death rate about the same. Other very effective antidepressants have a much higher mortality than either ECT or SSRIs.

For older depressed people with complicating medical problems, any antidepressant medication is risky. Furthermore, people who commit suicide are 30 times more likely than the general public to have depression. The highest risk is in elderly people, the very people who are most at risk from side-effects of antidepressant medications.

Why are more women given ECT? Simply, twice as many women present with depression. This is the same for older people and as women live longer, there are more of them.

Does ECT work? The scientific evidence is overwhelmingly positive. Studies show that 80 per cent of patients respond favourably - a real response, not a result of placebo effect, fear or resignation.

These figures have been confirmed in a closely scrutinised, three-centre study in New Zealand across the past three years. Not many treatments in modern medicine are this effective.

It is true that ECT benefit does not last longer than a few weeks. But medication can then maintain wellness with lower doses or safer drugs, once ECT has worked.

ECT does cause memory loss. So does depression, so do alcohol, benzodiazepines and drugs used to calm patients during x-rays and scans. Depression causes memory loss by preventing the laying down of new memories because of poor concentration. ECT seems to disrupt new autobiographical and factual memories for events around the time of ECT. Research in older people shows that memory abilities recover in most patients by the first follow-up period.

There are strict rules on prescribing ECT written into the Mental Health Act and Protection of Personal and Property Rights Act.

Compulsory treatment is sometimes needed, but only in patients who are so depressed and unable to recover with alternative treatments that they cannot give informed consent. Even then there must be a second professional opinion in agreement and family consultation.

The anti-ECT lobby continually trots out the issue of brain damage. Internet sites have many graphic pictures, but all carefully avoid mentioning that underlying, undiagnosed brain damage may have been the cause of the depression for which ECT was prescribed.

Despite many research studies, no one has yet produced CT or MRI scans of any patient that proves they were normal before and brain-damaged after ECT.

So, what would happen if the lobbyists got their way and ECT was banned?

More people would die from complications of depression, the harmful effects of antidepressants and from suicide.

Many patients would stay in psychiatric wards far longer and some hard-to-treat older patients would be institutionalised earlier.

More importantly, patients would have to suffer the awful, demoralising effects of severe depression for weeks and months longer than necessary, trying one medication, then another, without effect.

Is this really what people want? Alternatively, do people want treatments such as ECT to be given for the right reasons, to the right people and at the right time in their illness? Let's please have some reason to counter the rhetoric.

* Dr Felicity Plunkett is a consultant psychiatrist at Waitakere Hospital.