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Catherine Conway
Posted on 25 Mar 2011 9:13 pm

I am a trainee psychiatrist, so you may think I am biased. I am. But please read on, and I will try to explain why.

Before I went into psychiatry, I had seen the same films, the One Flew Over the Cuckoo's Nest, and I thought ECT was barbaric. In the past, as Sen.Norris has stated, it was used as a political instrument of control. That was indeed very very wrong.

As it is used now, ECT is given, under general anaesthetic, to the most severely depressed patients. Approximately 70% of those receiving ECT are those for whom all other treatment options have failed. This is their last hope. The majority receive ECT voluntarily. A very small minority receive it involuntarily. Why? Because they are so ill, so depressed, so mentally unwell, that they have lost capacity to consent to treatment.

Severely depressed patients are among the sickest patients in the hospital. They may be mute, unable to feed or look after themselves, lacking the very will to live, actively suicidal. Psychotically depressed people may believe they are evil, or in fact even already dead inside. In a psychotically depressed patient refusing food or water, ECT is literally life-saving, as it is by far the most effective and fastest way to allieviate their distress. If you were to ban involuntary ECT, you would remove the sickest patients rights to access the best treatment available.

ECT is the most effective treatment for depression, and it can be life-saving. Response rates are 80 -90%. If you have ever seen someone with psychotic depression, and see how their life has shrunk to abject misery, and the failure of medication, of psychotherapy; and you see them regain their health with ECT, you cannot but realise the effectiveness of this treatment.

The criticism has been raised that doctors do not know how ECT works. That is not quite true. ECT stimulates neurogenesis in the hippocampus, in the dentate gyrus, which promotes nerve cell growth. It improves nerve cell signalling, and synaptic connections; precisely the opposite to the effects that untreated chronic depression has on the brain. Antidepressants have a similar effect on the brain, which correlates with their antidepressant effect.

The point has also been made that knowing something does work, but not knowing exactly how it does so, is no reason not to use it. Some folk remedies were known to be useful for years before the active chemical in the plant was extracted and the method by which it acted on the body was elucidated. For example: foxgloves were taken for heart failure before digitalis was found to be the active ingredient; yew tree bark was taken before the chemotherapeutic agents taxanes were synthesised from it. We know ECT works. We know the effects it has on the brain. Do we understand every step in the molecular intracellular signalling pathways? No. But do we know enough to know that it works? I think so.

Much research has been done into the role of ECT and memory. It is known that depression itself affects memory. In fact when people are severely depressed they can exhibit what is called "pseudo-dementia", impaired memory and concentration which resolves on treatment of depression. There are many studies on memory pre-and post-ECT. To date, a metanalysis of studies shows that ECT has no negative effect on testable aspects of memory: short term, working memory, procedural memory, etc. Autobiographical memory has been more difficult to design studies for, but a study is underway in Ireland at present, and it is hoped will provide futher data on this.

I am not aware of a circumstance where doctors can give involuntary ECT under common law. Was not the mental health act set up to safeguard the interests of patients, to ensure that patients got two formal opinions from consultant psychiatrists - which are not taken lightly by any means. If this safeguard was removed, then I believe the human rights of some of the most vulnerable people in our society would be threatened - the right to receive care, and the right to receive it promptly, in a systematic, and not on an ad-hoc basis.

On a final point, recently I attended a conference of the Irish College of Psychiatry. At this, a former patient gave a presentation. He described, in moving terms, how his life was devastated by depression. He became mute, catatonic, psychotic. He was made involuntary, and received ECT after several months of every other treatment avenue being exhausted. Within a short course of 5-6 treatments he was well. He has remained well for several years now, and credits his recovery to the ECT. This patient has written his story down, and has met with the last minister for mental health in order to advocate for ECT for the most vulnerable and ill patients. He even states that if in future he had a relapse, he would want to have ECT again. Would it not be a travesty if his wishes could not be respected?

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