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Sunday, 26 February 2012

Electroconvulsive ECT is the most effective treatment for severe depressive disorder - David Healy FIDDAMAN

CARDIFF – No medical therapy is treated more differently by countries, regions, hospitals, and doctors than electroconvulsive therapy (ECT). This is surprising in an era when treatments that work should supposedly be used with some uniformity. In fact, despite a consensus that ECT is the most effective treatment for severe depressive disorder, it comes at the bottom of the list in most treatment regimens for mood disorders.

Some of the unease about ECT stems from psychiatry’s dark past, when patients in many countries had fewer legal rights than prisoners. Not so long ago, physical treatments such as lobotomy and ECT could be inflicted on patients without their consent, and sometimes for punitive purposes.

But there is no comparable protest against the use of antipsychotic drugs, which have similarly been forced on people – and even used to torture prisoners. And, whereas few people now get ECT involuntarily, and in all cases consent is sought, a large and growing number get antipsychotic drugs under false pretences, including children, vulnerable adults, patients with Alzheimer’s, and a host of others whose lives are shortened by treatment, with no effort undertaken to seek their consent.

Although ECT’s opponents believe that it causes brain damage, this is difficult to prove. Like antipsychotic drugs, antidepressants, and tranquilizers, ECT has an immediate organic effect. But, while ECT rarely, if ever, causes clear clinical evidence of brain damage and has not been shown to do so in animal studies, antipsychotic drugs regularly do, in the form of tardive dyskinesia and other syndromes. The same is true of antidepressants.

There is no dispute that ECT can cause short-term memory loss. But critics have found it difficult to demonstrate memory or other cognitive problems that endure beyond three months. Nor can enduring autobiographical memory disturbances and inability to remember lists be readily attributed to ECT, because ECT is rarely given on its own.

Indeed, very few of those who receive ECT do not also receive benzodiazepines, which do cause significant autobiographical memory problems when given alone, and antipsychotic drugs, which cause difficulties with lists of names or telephone numbers, and other comparable problems. Yet these drugs are rarely, if ever, blamed for cognitive disturbances following psychiatric treatment.

The failure of ECT’s critics to demonstrate what to them seems obvious indicates an active conspiracy to minimize treatment-induced problems and to block those who have been injured by treatment from seeking redress. In fact, at recent guideline meetings in the United Kingdom on the issue of ECT, there have been no representatives from psychiatry, but many from patient groups. Organized psychiatry appears to have little interest in ECT, or is scared of harassment from patient advocates.

As a result, even evidence that a person’s mood and clinical state has been significantly improved after ECT can be transformed into evidence of brain damage. When patients come forward to say they were helped by ECT, or a patient’s medical record points to clinical improvement with treatment, the apparent improvements are read as indicating the disinhibition and vacuousness that accompanies brain damage.

There are better targets in mental health than ECT. Where is the concern about the millions who are becoming physically dependent on antidepressants? Where are the protests about the one-year-olds being treated with antipsychotic drugs? How is it possible that, because no company with currently patented drugs is campaigning to help medical and nursing staff recognize the catatonic features displayed by one in ten patients going through a psychiatric unit – features that could be treated rapidly with benzodiazepines or ECT – these features are missed completely? Why is it all but impossible to find anything but vilification of ECT on the Internet, and anything but glowing testimonies about drug treatments?

ECT’s critics seem to think that if they do not protest against its use at every opportunity, its advocates will inflict it on people who do not need it. But, in contrast to psychotropic drugs, there are no marketing departments geared to maximizing ECT.

This visceral focus on ECT has almost certainly led to ever more people ending up on drugs, and ever more brain damage and memory problems as a consequence. It sometimes seems that the critics are behaving according to the romantic illusion that if they can just abolish ECT, mental illness will disappear with it. Sigmund Freud would have been fascinated.

David Healy is Professor of Psychiatry in Cardiff University; he has been involved as an expert witness in homicide and suicide trials involving SSRI drugs, and in bringing these problems to the attention of American and British regulators.

Copyright: Project Syndicate, 2008.

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