On a cold Monday in May 2010, Karen escaped, in a panic, from her room in a Birmingham hospital’s psychiatric ward. She arrived at a motorway flyover. Looking down, she watched the traffic, plotting for the perfect time to jump. The flashbacks had become too much. “My only purpose was to end my life,” she recalls. “I did not want to be here.”
Karen’s descent into severe depression had started six months earlier, when her husband had been diagnosed with a life-threatening heart condition and she had dedicated herself to supporting him and their three kids. Her partner recovered and returned to work, but Karen began to struggle psychologically, and in the months that followed she isolated herself from her friends, became anxious and eventually stopped eating. After losing a dangerous amount of weight, Karen saw a psychiatrist, who admitted her to hospital.
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Everyone thought the stress of her husband’s illness was the sole cause of Karen’s downward spiral, but it wasn’t that simple. “Things came back that I’d been burying,” she says. “I wasn’t able to bury them any more.” During an appointment with her psychiatrist in hospital, Karen spoke for the first time about a traumatic event from her childhood. When she was 14, she had been raped by a stranger on her way home from a friend’s house. “I didn’t tell anybody about it. It was a form of self-protection: if I didn’t talk about it, it hadn’t happened,” she says.
After that revelation, flashbacks plagued her. “It was like going through it all over again, what I could feel, what I could see, what I could hear,” says Karen. A week after that meeting with her psychiatrist, she took a step up onto the flyover’s protective metal railing, ready to jump. Within seconds, two passing drivers pulled over, got out of their cars, and prevented her from jumping for long enough for the police to arrive and take her back to hospital.
Beyond the shock
In the past year, more than 18,000 people have been hospitalised in the UK with depression. Many of those people have a severe, treatment-resistant form of the illness, meaning they haven’t had any success with the usual treatments, like psychotherapy and antidepressants.
Some UK psychiatrists choose to offer these patients a treatment that’s clouded in stigma and believed by many to be barbaric and abusive: electroconvulsive therapy, or ECT. In 2016-17, around 1,700 people received ECT in England, Ireland, Wales and Northern Ireland. During the treatment, an electric current is passed through a patient’s brain to induce a seizure.
Early ECT didn’t use muscle relaxants, so it produced violent seizures
Proponents of ECT claim that it is the fastest acting and most effective treatment for severe depression, and argue that the stigma prevents patients from receiving a potentially life-changing therapy. One of those psychiatrists was looking after Karen in December 2010, seven months after her first suicide attempt, and saw the possibility of an effective treatment when nothing else she had tried had helped.
A modern ECT session, says Prof George Kirov, a psychiatrist at Cardiff University’s School of Medicine, goes like this: an anaesthetist inserts a thin tube in the back of the patient’s hand and administers both muscle relaxants and a general anaesthetic, which puts the patient to sleep. An ECT nurse squeezes conductive gel onto a pair of electrodes and holds one to each of the patient’s temples. Another member of the team then sets the level of the electrical current, and pushes a button. Current pulses briefly through the electrodes, eliciting a seizure that lasts between 15 and 40 seconds.
Prof Rupert McShane, a consultant psychiatrist at Oxford Health NHS Foundation Trust, and Chair of the Royal College of Psychiatrists' Committee on ECT and related treatments, explains that the muscle relaxants keep the patient mostly still. “Usually you can see some muscle twitching, but we use an electroencephalogram [which monitors brain activity] to see that the patient is having a fit.”
The procedure is surprisingly quick. The patient wakes up a couple of minutes after their seizure finishes, and they are taken to a supervised recovery room. When they feel up to moving, they are offered a drink and some food. They’ll do this twice a week, for around six weeks.
After Karen’s first session, in December 2010, she woke up to “the worst headache of my life”, she says. Other patients report becoming confused and needing time to remember where they are. During the weeks of treatment, patients often experience memory loss; for the majority, this resolves itself in the months after treatment finishes.
After her fourth session, Karen went back to her ward and asked for a drink. This was a big deal for two reasons. Karen had lost any interest in eating or drinking over the preceding weeks – now she was doing it voluntarily. She had also chosen to speak to someone – another rarity.
With each session she felt progressively better, and eventually started eating on her own. “It felt like there wasn’t something heavy on me any more,” she says. Karen stopped after nine sessions, and her psychiatrist discharged her a few weeks later, in February 2011.
The science
What was going on in Karen’s brain that made her feel better so quickly? No one knows, exactly. What we do know is that the seizure is key: the better the seizure – gauged by certain qualities on the EEG – the greater the improvement. Researchers have found several possible pathways that could be involved (see How does ECT work? below).
Karen’s rapid response was not unusual, however. In 2004, results from one of the largest ever ECT studies were published in the Journal Of Clinical Psychiatry. The study looked at 253 patients with major depressive disorder, and found that three-quarters of them reached remission after receiving ECT.
In this context, remission can mean that mute patients start speaking, or catatonic patients start moving. Suicidal thoughts might recede, and patients may begin to engage with long-term therapy. McShane says that, for people with severe depression, those rates of improvement are considerably better than for antidepressants. But ECT research isn’t without controversy.
Clinical psychologist Dr John Read at the University of East London points out that no placebo-controlled study of ECT has been published since 1985, and those published before then were of “questionable methodological quality”. Without trustworthy placebo-controlled studies, he says, any positive ECT results could simply be due to a placebo effect.
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In contrast, McShane says that the pre-1985 studies have already proved ECT’s effectiveness, and cautions against repeating those studies: “It would be unethical to take a group of people with depression and treat half of the sample with an ineffective, sham treatment.”
Read also has concerns that the effect of ECT doesn’t last, and claims there has never been a long-term follow-up study in which ECT outperforms a placebo. And indeed, Kirov notes that in his clinic, and in others in the UK, about half of patients become unwell again within a year. This is even with the help of antidepressants, psychotherapy and what’s called ‘maintenance ECT’, where the patient continues with ECT, but with decreasing frequency.
Kirov says that relapse is ECT’s biggest problem. “They get back into depression. Not necessarily to the same level, but they go back.” And if relapse is the main problem with ECT, then side effects are certainly the second.
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In 2011, the late actor Carrie Fisher wrote about her experience with ECT in her memoir Shockaholic. But her mostly positive account came with a caveat: “the truly negative thing about ECT is that it’s incredibly hungry and the only thing it has a taste for is memory”.
ECT interferes with memory, both anterograde (the laying down of new memories), and retrograde (recalling things from the past). Anterograde memory problems usually resolve themselves a few months after finishing treatment, but for some individuals – 13 to 55 per cent of people, depending on which study you read – retrograde memory loss can be permanent.
Kirov says that for these people, continuing becomes a personal choice: “Some of them are disturbed by their memory problems and decide to stop.” Karen experienced retrograde memory loss, though it has improved since finishing treatment. “I couldn’t remember things, like what we did on holiday, and that was quite frustrating. But I didn’t like being unwell, so there was a trade-off.”
Reputation problems
Historical scars also mar ECT’s reputation: early applications didn’t use muscle relaxants, so it produced violent seizures where patients occasionally broke bones. Ken Kesey’s 1962 book One Flew Over The Cuckoo’s Nest, and the 1975 movie, depicted ECT as a form of behavioural control for psychiatric patients, perhaps an accurate portrayal of certain hospitals back in the 1950s. And in the 1980s, ECT was used as a ‘treatment’ for homosexuality. This practice didn’t last, but it still remains etched in cultural memory.
The use of ECT is declining in the UK, according to the latest report by the ECT Accreditation Service. “Its portrayal in movies has been profoundly stigmatising, and has misrepresented current practice,” says McShane. He argues that a lack of knowledge around severe depression means the costs and benefits of the treatment cannot be accurately weighed up.
“That discussion often omits the severity of the illness. ECT causes side effects, but so does chemotherapy.” He says that if the public were more aware of the reality of being severely mentally unwell, they might be more accepting of the treatment – “but those patients often don’t want to talk”.
Stigma can affect doctors as well as patients. According to Kirov, most psychiatrists who object to ECT haven’t actually seen it used. To counter misinformation, he encourages every medical student to observe ECT. But he isn’t sure what to do for the public. “It’s hard to change public opinion. People have heard too many bad stories,” he says.
To make matters worse, ECT has become a proxy for a long-argued question: is depression a medical problem, or a social one? Read, who’s critical of ECT, argues the social side, saying that ECT is the most extreme example of the over-medicalisation of human distress: “It’s not an appropriate response to a social problem.” He calls for more work on population-wide wellness, and improved access to a range of psychological therapies and social support. McShane insists that ECT patients “are generally either too ill to make use of psychotherapy, or have already tried it without success”.
Bright future
In the end, Karen needed both ECT and psychotherapy. Her return to health was difficult. She relapsed a few months after her first course of ECT, falling back into severe depression. “I was reliving [the trauma] all the time. I started hearing him constantly talking to me, and I could feel him touching me.”
By February 2012 she was back in a psychiatric unit, sectioned after another suicide attempt. She spent a year and a half trying various other therapies, before starting her second round of ECT in August 2013. At that time, Karen was too unwell to give consent herself, but her family fought for her to receive it.
There is a role for ECT. Banning it would be like removing a lifeline
After three sessions, Karen became calmer. “I had lots of input from then on,” she says. Karen was assigned a new psychologist, who guided her through psychotherapy during her ECT. She continued with the ECT, gradually reducing its frequency, until she was having just one session every three weeks.
In September 2014, she was discharged, and in 2015 decided to stop ECT completely. “I’d got to a point with therapy where I was processing what had happened to me,” she says. In 2016, after three years of therapy, Karen decided to stop that too. She doesn’t regularly see doctors any more, and says that life is finally back to normal for her.
What would have happened if ECT wasn’t an option? “I don’t think I’d be here,” she says. She cautions that while ECT certainly isn’t for everyone, “there is a role for it. Banning it would be like removing a lifeline.”
- This article first appeared in the September 2019 issue of BBC Science Focus Magazine – subscribe here.
- If you have been affected by any issues raised in this article, there is help and advice available here. If you are concerned about the mental health of you or a loved one, please visit your GP.
How does ECT work?
Researchers have discovered some changes in the brain after ECT, but haven’t settled on any definitive answers around how it works. Here are the main contenders:
Hormones and neurotransmitters in the brain
ECT increases the levels of some neurotransmitters (chemical messengers that transmit signals between neurons) and hormones in the brain. Serotonin and dopamine are two neurotransmitters that increase after ECT. Serotonin regulates anxiety and reduces depression, while dopamine affects mood and motivation.
Antidepressants have similar effects on the brain, but as ECT is generally faster acting and more effective than antidepressants, experts believe these changes cannot entirely account for ECT’s benefits.
Increases in the size of the brain’s emotional processing areas
A recent study in humans showed that ECT increases the amount of grey matter in the brain’s hippocampus and the amygdala.
The hippocampus is involved in learning, memory and emotion, while the amygdala plays a role in the processing of emotions. However, this increase in volume of grey matter wasn’t correlated to noticeable changes in the mood of the patients, so more research is needed to establish whether or not this is a contributing factor.
Changes in brain connections
One study has shown that patients with severe depression have more connections between certain brain regions, including the prefrontal lobes, than healthy controls. Experts suggest that these connections could account for the ruminations and hyper-alertness that characterise some forms of depression, so decreasing these connections might help a patient.
According to several studies, after ECT there are fewer connections between prefrontal lobes and other areas of the brain. But ECT may also build new connections in some areas of the brain, so more research is needed.
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