Brain Zap

By Jim McVeagh 07/01/2012


I have been meaning to blog about this article in Stuff on Electroconvulsive Therapy. As with almost every media article I have every seen on the subject, this one is thoroughly biased against ECT. It is as if journalists cannot resist dredging up the checkered and lurid past of ECT and presenting current ECT practice in the same light. I note that the stories of the two people in the article, one intensely negative and one lukewarm positive, are both taken from elderly people who had their ECT decades ago. The first before I was born, in the early fifties, and the second in the early nineties. I would not have been difficult to interview someone who had had ECT in the past couple of years, but this would not be in keeping with the meme of evil psychiatrists and their dark practices.

Modern ECT is performed under general anaesthetic with a dose of muscle relaxant on board. The patient is asleep the entire procedure and the muscle relaxant ensures that the electrically-induced convulsive episode in the brain does not cause convulsion of muscles in the body. The electrical dose is now carefully measured and is far lower than the doses used in the 1950s. Some ECT is now done with electrodes implanted into specific areas of the brain, which further reduces the electrical dose and enhances the effect. These electrodes are removed after the session (in case anyone thinks this may be a re-run of Michael Crichton’s Terminal Man). There is also an increasing tendency to use magnetic, rather than electrical stimulation which may reduce the transient amnesia often caused by ECT. These latter two techniques are still somewhat experimental, but there is a wealth of evidence[1] that ECT in its current form is a valid and useful technique in the treatment of a number of disorders, notably refractory and severe depression.

It is of little surprise that the article goes on to quote Professor John Read who considers ECT to be “dangerous and ineffective”. Little surprise because Dr Read is the author of a recent review paper[2] that came to the conclusion that ECT was no better than placebo. This paper has recently been criticised in the latest issue of International Review of Psychiatry[3] for its excessive reliance on several small randomised controlled trials which compared ECT to placebo and found no difference, and his limited, qualitative method of review.

The paper was also co-authored with Dr. Richard Bentnall whose books Madness Explained and Doctoring the Mind are heavily weighted against the medical model of psychiatry. I have not read the first book, but the latter I found to be  full of psychiatry’s most abject failures while being remarkably free of its successes. I particularly liked the somewhat paranoid feel to the chapter on drug companies. Apparently we have all been duped as to the effectiveness of psychotropic drugs. As a prescriber of said drugs, it is remarkable how stupid I feel not noticing that they don’t work (yes, this is sarcasm).

The irony is that a very recent Cochrane review meta-analysis, that can be found online here, has found only limited evidence that Cognitive Behavioural Therapy itself is effective in treating depression. I have found CBT to be very useful for my patients, so I treat this paper a little skeptically as well.

Psychologists and psychiatrists have been at loggerheads over the treatment of mental illness/behavioural problems for a century and I don’t see it resolving very soon. Unfortunately, the danger of strong anti-medical stances like Dr Read’s is that patients read books like the above and articles such as the one discussed and then decide to stop their medication in an unsupervised fashion, with disastrous results. Of course, Dr Read would dispute this, as he does not think psychotrophic medication works. Yet, I have had two patients die in exactly this way (stopped meds because they heard that they don’t work) in the past 18 months.

As a GP, I long ago adopted the attitude of “whatever works” in trying to help my patients with mental health issues. I regularly prescribe psychotrophic medication and regularly refer to an excellent therapist, often both at the same time. For patients who are clearly severely mentally ill (manic, psychotic, delusional or suicidal), I always refer directly to our mental health unit. Some of these patients may well get ECT (though I can’t recall any), as this is done in Waitemata. I have no preference about this one way or the other. All that really matters is that my patients get better. I sometimes think that academics lose sight of that.

References

1. Carney, S., Cowen, P., Geddes, J., Goodwin, G., Rogers, R., Dearness, K., et al. Efficacy and safety of electroconvulsive therapy in depressive disorders: A systematic review and meta-analysis. Lancet, 2003:361, 799–808.

2. Read, J.  Bentall, R. The effectiveness of electroconvulsive therapy: A literature review. Epidemiologia e Psichiatria Sociale, 2010: 19, 333–347.

3. Allan CL, Ebmeier KP. The Use of ECT and MST in treating depression. International Review of Psychiatry Oct 2011, Vol. 23, No. 5: 400–412

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