Bipolar disorder Pendulum: stories and information Medication and treatment ECT: answer or anathema? Advocates say it saves lives while opponents say it’s ineffective and harmful. Sarah Owen investigates. After she had been in psychiatric hospital for nearly a year in 2003 with a bipolar depression so deep she’d stopped speaking, my sister Rebecca was given five or six electroconvulsive therapy (ECT) treatments. When her psychiatric nurse asked me to accompany them on the taxi ride to the general hospital where her first session was due to take place, I can vividly recall the mixed feelings I had. On the one hand Rebecca was so lost, so low, that all I wanted was for her to feel happy again. The various drugs she’d tried hadn’t worked, so it was a relief to know that another option was available. On the other hand, I felt scared for her. Even though I’d read up about what modern-day ECT involves, it was impossible to forget the black-and-white footage I’d seen from the 50s and 60s of conscious and terrified patients tied to beds with live electrodes forcibly applied to their heads. The Jack Nicholson film One Flew Over The Cuckoo’s Nest had also helped to shape my negative opinion of ECT. I had so many questions swirling around in my head. Would Rebecca experience any pain or fear? Would the ECT lead to short term memory loss or speech impairment? What long-term effect would ECT have on her brain? And what if this “last resort” didn’t even work? Two weeks later and my sister had started to emerge out of her silent cocoon. Another month later and she left hospital. She has been stable, more or less, ever since. We’ll never be able to say for certain that it was the ECT that lifted her out of her catatonic state, of course. But surely it’s unlikely the improvement was a coincidence. What is ECT? ECT involves passing an electrical current through the brain to produce and epileptic fit. A patient is treated in an operating theatre and is unconscious under a general anaesthetic. “Paddles” containing electrodes are placed on the scalp and a high-frequency electrical pulse triggers a seizure that generally lasts between 20 and 50 seconds. The patient is usually also given a muscle relaxant so that muscle spasms – which could cause serious injuries, such as broken bones from thrashing around – are reduced to small rhythmic movements in the arms, legs and body. Sometimes all that’s seen is a mild twitch when the electrical pulse is passing through the brain. Most units give ECT twice a week. The average course is six to eight sessions, although sometimes up to twelve are needed. How does ECT work? It is not fully understood how or why inducing a seizure can help stabilise mood, but it’s thought that it somehow boosts the chemicals used by nerve endings in the brain to communicate with each other. Recent research also suggests that ECT might stimulate the growth of new blood vessels in certain areas of the brain. Is ECT commonly offered as a treatment? Between 1985 and 2002, the use of ECT in England more than halved, possibly linked to improved psychological treatments and medication for depression. It is recommended in the NICE guidelines for the treatment of bipolar, but only for severe and prolonged mania/psychosis or for severe depression, where other treatment may have failed. What are the side effects of ECT? Many people complain of a headache, aching muscles, a “fuzzy” head and nausea immediately after an ECT treatment but these side effects usually disappear within a few hours. A more serious potential side effect is the memory loss that’s often linked to ECT – some people find that their memory is affected but that it returns to normal over time, while others say that their memory is affected permanently. It’s generally agreed that the more ECT someone is given, the more likely it is to affect their memory. Can ECT only be administered with consent? In the UK, the Mental Health Act 2007 introduced new safeguards for the use of ECT – the treatment cannot be given to a patient with mental capacity without their consent (except in an emergency to save the patient’s life or “to prevent a serious deterioration of the condition”). If the patient lacks capacity, then ECT can only be given if this is not in conflict with an advance directive (where the patient has specified, preferably in writing, beforehand that they don’t want to receive this treatment). The Act states that a second opinion from another doctor has to be obtained before ECT treatment can be administered to patients under 18. Ineffective and inhumane? A UK review of a number of studies on ECT in 2003 found it helpful ranged from 30 percent to over 80 percent, so the jury’s still out on how often ECT is likely to work. Also, many people believe that ECT is a degrading treatment that belongs in the past, that psychiatrists have ignored the severity of the side effects and that it permanently damages the brain. A life saver? It seems Rebecca isn’t the only one who’s been lifted out of a deep depression by ECT when medication wasn’t working. Two other people I’ve spoken to tell a similar story. “I’ve been in the mental health system for 32 years and first had ECT in 1982,” says Stewart Herring, 54, for Perth in Scotland, who has bipolar. “My pattern when I’m extremely depressed is that I stop eating and moving, and once I get into that state none of the various medications I’ve tried seem to be able to lift me out of it. “When I was first offered ECT, the way I saw it was that I had a choice – to continue trying medication that wasn’t working or to try something new that might work. I’ve since had ten courses of ECT over the years and nine of those times it’s worked, returning me to a state where I was actively communicating again. “I have no concerns about the safety of ECT because I trust the doctors who look after me. And although I tend to feel a little bit queasy after the anaesthetic and sometimes I have a headache when I come round, a cup of tea and a biscuit soon sort me out. The confusion I feel afterwards wears off by the time I get back to the ward. “On the downside, I have noticed short-term memory loss. On one occasion I forgot my bank pin number and sometimes I can’t remember how I knew somebody even if I recognise their voice. After three months though, things seem to return to normal. “In spite of the side effects, I would have ECT again. On my advanced statement, where you say in advance the treatment you want to have, I put down ECT because it’s worked in the past. Let’s put it this way – I’ve had both ECT and antipsychotic injections and I’d choose the former over the latter any day. “When I’ve been so low it’s felt that everything has been mentally and physically taken away from me, ECT hasn’t caused me any significant harm yet has made the difference between having a life and not having a life.” Richard, 55, a retired chief financial officer, who was diagnosed with bipolar disorder in 1981, says: “At the worst point of my illness I tried to throw myself out of a top floor window and had six people trying to hang on to me…. Four lots of ECT treatment pulled me out of the depression very quickly after only one week. “There’s a lot of misunderstanding around, but it really helped me. The only thing is that you get buzzy for two minutes when you come round. And the only memory loss I had was about what had happened in hospital – but that wasn’t a bad thing. “There were no headaches, no significant memory loss and no other effects at all. My consultant psychiatrist told me that it’s saved many lives. I think it’s saved mine!” Balance of opinion? Advocates say that the overall benefits of ECT are greater than the overall risks. So while it doesn’t exactly sound like an experience any of us would relish, bearing in mind that statistically 15 percent of people with severe depression will kill themselves, surely it’s an option worth considering if it might restore quality of life or even save a life when nothing else has worked.