The Positive Face of Electroconvulsive Therapy

My younger son who lives on the same landmass as me reads the Guardian newspaper (slightly left) whereas my favourite newspaper poison is the Telegraph (slightly right). So it was a pleasant surprise when he emailed me with a link to a Guardian piece (24.4.2017)  by one of its columnists, Andrew Mayers . Its headline was “Drugs didn’t work for my brother. Electroconvulsive Therapy did.” He went on, in a lengthy article, “how doctors tried everything in an effort to treat the depression that engulfed my brother. In the end the only thing that did any good was ECT”….”my brother ended up getting four amazing unexpected years of vitality: not a bad result from a seizure lasting less than a minute”. That piece overall is as moving as it is enlightened. It deserves to be read by a wide readership in which I include medical colleagues. Andrew’s brother Stephen sadly died later from a heart attack.

I pull away from it reluctantly to address other recent medical studies and comments on ECT. The first port of call is the justly distinguished Dr James Le Fanu, physician, a general family doctor background, who for so many years has produced a weekly column in The Daily Telegraph which respects the views of non-doctor folk who write to him presenting  problems discussed in his column. The briefest description of James that I can think of is Medical Polymath. (Irish doctors may recall his work with Dr Petr Skrabanek, another distinguished iconoclast, who sadly died all too early aged 54, in1994).

In a Telegraph column of 5th December 2016 James focused on the considerable interest that a modified version of the much frowned-on electroconvulsive therapy (first introduced 80 years ago) should be found to induce a rapid and robust improvement, in just over a fortnight in those who have not responded to medication. He elaborates but I will cut to his end remark that those wishing to know more  can Google “McNight, Kellner,Pride, clinical psychiatry”.

Clinical Psychiatry News (16/02/2017) Covers a European College of Neuropharmacology Congress and declares “Data grow in support of ECT for depression”. There is much detail concentrating on mostly older patients and the shape and duration of the electrical stimulus to the brain. But it is worth noting a comment from Dr Charles Kellner, professor of psychiatry at the Icahn School of Medicine at Mount Sinai, New York. He claims that ECT is well established as effective in elderly populations with depression and is noted for its ability to rapidity curb suicidal ideation, as shown from his study. This showed an 85% drop in suicidality in patients by the end of their ECT treatment course.

Dr Kellner queers his pitch a bit  by announcing “ECT would be one of the very best treatments in all of medicine” if not for several factors.” But this  is where he goes off the rails in my book.  I quote “ECT cannot prevent relapse unless it is used as maintenance therapy, and various degrees of negative cognitive impact can come with the procedure,” . He does goes on to the fact that ECT has been stigmatised by the popular media and by the narrow anti-psychiatry clique. The phrase that humorously crosses my mind is “with friends like that who needs enemies”! Let me be quite clear I have not the slightest doubt that Dr Kellner is a kind and caring doctor.

I would also aver that ECT is indeed  one of the best treatments across the whole of medicine. Would we belittle an antibiotic which cured a severe pneumonia because that patient might or might not have a recurrence of that illness? I have known patients profoundly depressed who received ECT thirty plus years ago and still no recurrence. If a patient gets 4 or 8 yrs complete relief following a course of ECT for an acute mental illness and it recurs perhaps 8 years later and ECT is again successful that is truly remarkable; especially when likely as not antidepressant medication would have been prescribed without any or adequate effect. In the context of severe mental illness the severity of the suffering, so often prolonged before effective ECT treatment commences is indeed lamentable.

Dr Kellner ominously mentions “various degrees of negative cognitive impact can come with the procedure”. Lets talk about memory and ECT. Some basics. Lets go back to the cognitive 3 Rs. (1) Registration: by this I mean that for something to be remembered the person must first consciously notice, take in, the item. If not then there is no possibility of its being recalled/remembered if asked about it. (2) Having successfully Registered the item for it to be Retained when asked about it later the person can reasonably be expected to (3) Recall it lets say minutes or hours later.

When patients are severely depressed, withdrawn and/or agitated because of their tortured mental distracted state the kind of questioning and memorising they may undergo in simple memory testing can lead to a false conclusion of impaired memory functioning since they seem quite unable to answer appropriately. This of course can lead understandably to diagnostic thoughts of dementia. In the context of ECT which of course administered under a general anaesthetic (which can lead to some, usually, short-lived confusion). I recall decades ago, a young trainee psychiatric nurse declared his opinion to me that he didn’t really think much of ECT as a treatment. My response was to assure him he was entitled to express that opinion but that is was not an informed one and to muddy the waters further stated impishly, “actually, I have improved patients memory with ECT”. What heresy was this? Quite simply, the impaired Registration in memory caused by the illness distraction and which could lead to faux memory impairment, had been removed by the course of ECT.

My behaviour in that exchange with the young nurse may very well have seemed rather harsh if not downright rude. But we already knew each other sufficiently well that no umbrage was taken .

Over subsequent decades there has been a plethora of papers published around the refinement of the electrical stimulus with the intention of reducing any post ECT “various degrees of negative cognitive  impact”. During those years clinicians in the field have declared the importance of the ECT producing an actual epileptiform fit or seizure (of course ensuring within the process that associated muscular movements are reduced by the judicious use of a muscle relaxant delivered by the anaesthetist). Without that seizure component the patient is merely the recipient of a general anaesthetic, albeit of short duration. Nevertheless that carries a patient risk factor of its own without any benefit.

Recently, quite out of the blue the thought struck me that I could not recall any patient of mine ever complaining of post ECT memory problems. Neither in talking informal shop over the decades with colleagues where not infrequently specially noted patient management difficulties might be discussed did post ECT memory problems crop up.

A thought. I can think of no other specialty across the whole spectrum of medical/surgical activity in which an ill informed public and a very few doctors have been allowed to publicly inhibit the use by doctors of the most effective treatment and relief of profound suffering associated with such as psychotic depression. It may annoy some folk when I mention that in the 1970 edition of Curran and Partridge, Psychological Medicine, where in the section dealing with indications for ECT( they preferred the term ‘Electrical Treatment’) it states,“The treatment is of established value only in (1) states of depression, (2) states of excitement, (3) confusional states. Yes ,I have read the journals since but I can also recall the benefits of these almost unmentionables today.

What Mr Andrew Mayers, a journalist, has written should help to improve public perception of ECT and its benefits. Is there another journalist of the national “Dailies” who can claim to have made such a positive difference in our medical psychiatric world? I salute him.

Dr Dermot J Ward

(First published in IRISH MEDICAL TIMES, 2nd NOVEMBER 2017 titled ‘The Positive Face of Elctroconvulsive Therapy.’)