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理解电休克治疗Making_sense_of_electroconvulsive_therapy.(ECT)

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Making Sense
of electroconvulsive
therapy (ECT)


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Contents
Making sense of electroconvulsive therapy (ECT)
What do I need to know before I have ECT? 4
What is ECT and why is it controversial? 6
What is it used for? 8
Where will I have my treatment? 8
What should I expect from a treatment session? 10
What’s the difference between bilateral
and unilateral ECT? 11
How many treatments will I need? 12
Who should avoid having ECT? 12
How does it work? 13
Does it save lives? 15
What do users say about ECT? 16
What are the adverse effects of ECT? 17
What are the added risks for older people? 23
What are the alternatives to ECT? 23
What are the pros and cons of ECT? 27
Index 29
References 30
Useful organisations 32
Further reading and order form 34

This booklet is for anyone who wants to know about
electroconvulsive therapy (ECT). It is one of the most
controversial treatments in modern psychiatry, used for
conditions, such as severe depression, which have not
responded to other interventions. For some people, it
has been a life-saver. But others have found it far from
satisfactory, and consider the long-term side effects to
be an unacceptable consequence.

What do I need to know before I have ECT?
The law states that people have the right to make an informed
decision about which of a number of treatment options to choose,
and whether, or not, to accept the treatment a doctor suggests. To
consent properly to a particular treatment, people need information
to enable them to weigh up the risks and benefits, in the light of
available evidence.

ECT and consent to treatment
Before any treatment begins, the doctor should provide you with
full information about the treatment, any unwanted effects and
what the alternatives to that treatment would be, including the
alternative of having no treatment at all. Information should be
given in language that you can understand. This means that technical
information should be explained, using everyday terms. It also means
that if your first language is not English, and your understanding of
English is not adequate for you to understand fully, you should be
provided with an independent interpreter. Having a relative or friend
acting as a translator is not good enough.
You should be able to have the information in writing, and have
someone go through it with you, face to face. The information should
include the specific nature of the treatment, its purpose, the chances
of its success, any side effects or risks involved, and the way of
administering it.

Making sense of electroconvulsive therapy
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You should also be offered similar information about any alternative
treatments available, and about the consequences that may result
should no treatment be provided.
You should be allowed time, afterwards, to decide whether, or not,
to go ahead with the treatment. You may want to talk this through
with a relative, friend or adviser, before signing a written consent
form specific to the proposed treatment. It can be hard to take in
a lot of new information at one go, especially if you are depressed
and taking medication. The Royal College of Psychiatrists recommends
that you have a friend, relative or advocate with you, when you are
given the information, so that they can go over it again, with you.
You should not be afraid to ask your psychiatrist, or another member
of staff, to explain it to you more than once. The Royal College of
Psychiatrists also recommends that, if your relatives or close friends
disagree with your treatment, this should be recorded in your notes,
together with the reasons for proceeding with the treatment.
When you have signed a consent form, you should be informed that
you can change your mind at any stage in the treatment and that,
should you do so, the treatment will be stopped. At each stage of
the treatment, the doctor should confirm with you that you are
continuing to consent.

The ECT Handbook, which has been produced by The Royal College
of Psychiatrists, states:
‘You can refuse to have ECT and you may withdraw your consent
at any time, even before the first treatment has been given. The
consent form is not a legal document and does not commit you to
have the treatment. It is a record that an explanation has been given
to you, and that you understand, to your satisfaction, what is going
to happen to you. Withdrawal of your consent to ECT will not in any
way alter your right to continued treatment with the best alternative
methods available.’

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ECT can only be given without consent if you are detained in hospital
under the Mental Health Act 1983, and this is authorised by a doctor
appointed by the Mental Health Act Commission (a second opinion
appointed doctor, or SOAD). This doctor must visit you and consult
with your own doctor, a nurse, and another professional involved
in your care, who is neither a doctor nor a nurse. The only exception
to this is in an emergency. In such cases, treatment can begin, under
section 62 of the Act, pending the arrival of the SOAD, for patients
without capacity to consent, in a life-threatening situation, where
the common law might be invoked. (See
Getting the Best from
your Approved Social Worker, details on p. 34.)
For more advice on your rights, ask whether there is an advocacy
service or patients’ council at the hospital. Mind’s Legal Unit and
your local Community Health Council may also be able to help. For
more detailed information on the Mental Health Act, and consent
to treatment, see
Mind Rights Guide 3: Consent to treatment. For
information about advocacy, see
The Mind Guide to Advocacy.
(For details of these and other booklets mentioned here, look
under
Further reading on p. 34, or consult Mind’s website.)
What is ECT and why is it controversial?
ECT involves sending an electric current through the brain to trigger
a seizure, or fit, with the aim, in most cases, of relieving severe
depression. The treatment is given under a general anaesthetic and
using muscle relaxants, so that the muscles do not contract, and
the body does not convulse during the fit.
No-one seems to be able to give a clear explanation of how ECT works,
and this is a cause of controversy. On the one hand, its critics describe
it as a crude treatment that causes brain damage; on the other hand,
its supporters defend it as an effective and life-saving technique.

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Mind conducted a survey, in 2001, of mental health service users
who had received ECT. (
Shock Treatment: A Survey of People’s
Experiences of Electro-convulsive Therapy [ECT].)
It reported that as many people found it unhelpful as helpful:
‘I would happily die rather than have ECT again.’
(Woman, Yorkshire.)
‘If I had not received ECT I would be dead by now.’
(Woman, Staffordshire.)
• 36 per cent of those treated in the last five years found it helpful
in the short term (within the first six weeks of treatment)
• 27 per cent found it unhelpful or damaging in the short term
• 43 per cent felt that it was unhelpful or damaging in the long term.
Two-thirds of all those asked, and almost half of those who had
had ECT in the last two years, would not agree to have it again.
Many psychiatrists are convinced that it is an effective treatment
for seriously depressed people, when no other treatment has been
effective or available. They would argue that it is a suitable treatment
when it is important to have an immediate effect, for example
because a person is so depressed that they are refusing to eat or
drink, and are in danger of kidney failure.
Other controversial issues are also discussed later. They include:
• differences of opinion about how ECT works
• whether, or not, it is always used as a treatment of last resort
• whether, or not, it is effective in preventing suicide
• the adverse effects, including memory loss, which may be very
significant in some people.

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What is it used for?
ECT has been used to treat all types of mental distress in the past.
It is now most commonly used to treat severe depression and,
occasionally, mania, schizophrenia and catatonia.
In treating schizophrenia,
The ECT Handbook recommends that ECT
should be limited to patients who can’t take, or respond poorly to
antipsychotic drugs, when psychotic symptoms (such as hallucinations)
accompany a mood disorder (such as depression) or great agitation
or immobility. It also states that:
‘ECT is unlikely to be effective in the treatment of obsessional
compulsive disorders, but may be of benefit to some patients with
both obsessive-compulsive and depressive symptoms.’
Because, when it works, ECT usually works very quickly, some
psychiatrists think it is the best treatment for severe postnatal
depression. It can minimise the time that the new mother is not
able to care for and bond well with her baby. (See
Understanding
Postnatal Depression, details under Further reading on p. 34.)
Where will I have my treatment?
People usually receive ECT as inpatients in a hospital, although
outpatient treatment is possible.
The ECT Handbook recommends
that the ECT treatment centre should consist of a suite of at least
three rooms. The waiting area should be comfortable and provide
a relaxing environment. Accessible from the waiting area should be
a treatment room, with a recovery area leading off it. The suite
should be organised so that patients are able to move easily from
waiting room, to treatment room, to recovery room.
A nurse, who the patient knows and trusts, should escort the patient
to the ECT suite and, preferably, stay with him or her during all stages
of treatment. In some clinics, relatives or friends are allowed to
accompany patients throughout the treatment, if both agree.

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‘A minimum number of trained staff must be present for a treatment
session to take place. As well as the anaesthetist and psychiatrist,
there must be one person to help with the anaesthesia and one
person to recover each person who has not regained consciousness.’
In the treatment room, an electrocardiogram machine, to measure
blood pressure and temperature, should be easily accessible. There
should also be adequate resuscitation equipment, including a
defibrillator (a machine to restart the heart should it stop beating).
A standard box of drugs should be kept in the unit, in case of cardiac
arrest or medical emergency. All staff working in the ECT unit need
regular training, updating and practice in basic and advanced life
support techniques.
The ECT Handbook states:
‘A senior psychiatrist, preferably a consultant, should be responsible
for ECT clinics and, in particular, must advise on appropriate treatment
facilities, develop a treatment policy, and train and supervise staff.’
Some psychiatric units fall short of these guidelines. A survey of
the 230 sites in England and Wales that provide ECT found that:
• 20 per cent showed ‘substantial departures’ from best policy,
practice and training
• 32 per cent did not have a dedicated ECT suite of three rooms
• 36 per cent did not have a nurse in the recovery room trained in
basic life support and resuscitation techniques
• 27 per cent did not have regular visits from a named consultant
psychiatrist
• 5 per cent did not have either copies of
The ECT Handbook (the
Royal College’s publication) or the hospital’s own policy for ECT.

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What should I expect from a treatment session?
ECT is carried out under a general anaesthetic and with a muscle
relaxant (this is what is known as ‘modified’ ECT). Because of the
anaesthetic, you must not eat or drink anything for at least six hours
before ECT. An anaesthetist, a psychiatrist and one or more nurses
should be present during the procedure. You will lie on a bed, and
your jewellery, shoes and dentures (if necessary) will be removed.
You should not be wearing any hair lacquer, creams, make-up or
nail polish, or have any metal slides or grips in your hair.
Once you are comfortable, you will be given a general anaesthetic,
via an injection. Later, while you are asleep, you will receive an
injection of muscle relaxant to minimise the convulsions caused by
the electric current. Because of the muscle relaxant, you will be
given oxygen, and the anaesthetist will look after your breathing,
using a face mask and a pressure bag. Two padded electrodes will
be placed on your temples (see opposite page). A gag will be
placed in your mouth, to stop you biting your tongue.
Modern ECT machines deliver a string of brief, high-voltage, directcurrent pulses, about 60 to 70 pulses a second, for three to five
seconds, which results in a seizure, or fit. This will cause you to stiffen
slightly, and there will be twitching movements in the muscles of
your face, hands and feet. The seizure should last 20 to 50 seconds.

The seizure threshold
The strength of electric current needed to produce a fit is called the
seizure threshold. This varies from person to person. It is higher in
men than in women, and it increases with age, meaning that older
people need a stronger electric current to produce the desired effect.
The ‘dose’ of electric current given to you will be adjusted to take
this into account.

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Other things that affect it are the exact position of the electrodes
on your head, the amount of anaesthetic you have been given, and
other medication you may be taking. If the dose is too low (below
the threshold), there will be no benefit from the ECT. But the higher
the dose, the greater the risk of unpleasant side effects, so it’s
important to get the dose as close to the threshold as possible.

Immediate after effects
After the convulsion, the gag is removed and you will be turned
on your side. The anaesthetist will provide oxygen until the muscle
relaxant wears off (after a few minutes), and you start breathing
on your own again. You will slowly come round, although you may
feel very groggy. You may sleep for up to an hour, after treatment.
The immediate effects of ECT include headache, confusion, nausea,
disorientation, loss of memory, apathy, aching muscles and physical
weakness (see p. 17). If you are an outpatient, you will need to
have someone with you to accompany you home. You should not
drive, and you should not return alone to an empty house.

What’s the difference between bilateral
and unilateral ECT?

ECT may be given by placing one electrode on each temple (bilateral)
or by placing both electrodes on one temple (unilateral), and this
makes a difference to the effect ECT will have. The National Institute
for Clinical Excellence (NICE) says there is evidence of cognitive
impairment after ECT. This is greater when electrodes are applied
bilaterally. In unilateral ECT, electrodes placed on the dominant side
of the brain cause more harm than if they are placed on the nondominant side (see p. 19 for more information). But reducing the
risks involved also reduces the effectiveness of the treatment.

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The ECT Handbook recommends unilateral ECT when:
• a very rapid response to treatment is less important
• you have responded well to unilateral ECT in the past, and
• it’s thought particularly important to minimise memory loss.
It recommends bilateral ECT when:
• a very rapid response to treatment is desirable
• previous bilateral ECT has been effective, and
• it has not caused significant loss of memory.

How many treatments will I need?
The ECT Handbook says there should not be a pre-set number of
treatments, but that you should be assessed after each treatment
to see if another one is necessary. Most people respond to a course
of between four to eight treatments, although older people and
men may need more. It’s usual to stop after eight, or so, treatments,
if there has been no change at all in the patient’s symptoms. The
treatments should take place two or three times a week, not daily.

The Code of Practice to the Mental Health Act 1983 states that the
proposed maximum number of applications of ECT should be written
down on form 38, when the patient consents to treatment.

Who should avoid having ECT?
Before a course of ECT treatments, you will need a full medical
examination. You will be asked about your medical history, any
medicine you are taking, any drug allergies, and whether you are
pregnant. If you have any physical problems, these should be
treated, as far as possible, before you have ECT.

The ECT Handbook emphasises that the risks and benefits of the
treatment must be carefully assessed, and that you and your family
should be involved in the discussion. (See p. 28 for a checklist of
questions to ask.)

Cardiovascular problems
When assessing whether to give you ECT, it’s important that doctors
take into account any heart and related problems you may have.
It may be hazardous to give you an anaesthetic if you have a serious
chest disease.

Pregnancy
ECT is occasionally used in pregnancy. However, an anaesthetist
may not be happy about giving a general anaesthetic to a pregnant
woman, except in a medical emergency.

Medication
The British National Formulary (BNF) advises caution in using ECT
if the patient is taking SSRI antidepressants (selective serotonin
re-uptake inhibitors), because these drugs may prolong the seizures.
Drugs that raise the seizure threshold (so that a higher dose of electric
current has to be used) should also be avoided. This includes
benzodiazepine tranquillisers. (See Cause for concern, on p. 22)

How does it work?
No theory provides a clear explanation. Some give very little
information.
The ECT Handbook says:
‘[ECT] produces a seizure which affects the entire brain, including
the centres which control thinking, mood, appetite and sleep.
Repeated treatments alter chemical messages in the brain and
bring them back to normal.’
NICE says that it changes the way brain cells respond to their
chemical messengers:
‘Although ECT has been used since the 1930s, there is still no
generally accepted theory that explains its mechanism of action.
The most prevalent hypothesis is that it causes an alteration in the
post-synaptic response to central nervous system neurotransmitters.’

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Psychiatric opinion about how it works is divided. Dr Brian Harris,
a consultant psychiatrist and senior lecturer, is quoted as saying:
‘No-one knows how it works, but it does; quicker than medication’.
The author, Dr Anthony Clare, has said:
‘Interest centres on the possibility that ECT acts on the neurotransmitters believed to hold the cause of severe depression. ECT
certainly affects these monoamines, but in complicated ways, and
it has not hitherto been possible to produce a coherent explanation.’
Dr Simon Green, a psychologist, comments:
‘It does work through changes in brain chemistry, but comparing
this favourably with the current generation of pharmacologically
specific drugs would be similar to the assumption that a broken
television could be mended as readily with a sledgehammer as
with a screwdriver: you might jog the right bit.’
The electrical activity in the brain that ECT causes is accompanied
by increases in blood flow, oxygen levels and use of glucose in the
brain. The blood-brain barrier also becomes more permeable during
ECT. (The blood-brain barrier is a physiological mechanism, which
acts to prevent a large number of substances from crossing the
protective cell membranes and entering the brain cells. It also
becomes more permeable as a result of stress.)

Brain damage
Other psychiatrists believe that ECT works through causing brain
damage. People may experience a temporary lifting of mood after
ECT, but this can be explained by post-traumatic euphoria, which
typically follows head injury. This causes amnesia, denial, euphoria,
wide and unpredictable mood swings, helplessness, submissiveness,
confusion and disorientation.

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Dr Peter Breggin, a well-known critic of modern psychiatry, has
reviewed the research conducted on ECT and concluded that it
was the brain damage caused by ECT which explained its so-called
‘effectiveness’. Ironically, a leading supporter of ECT in the USA, Dr
Max Fink, has also blatantly stated that where there is no evidence
of brain damage, there is no improvement:
‘Where there is no evidence of impaired mental function and no
electroencephalographic alteration [changes in recorded brain waves]
clinical improvement does not occur.’

Does it save lives?
‘It was a life-saver to me, as I was very depressed and highly suicidal.’
(Woman, Wiltshire, ECT six or more years ago).
ECT does sometimes prevent death when someone is profoundly
depressed, no longer eating or drinking, and in a critical state. But
there is no good evidence that ECT prevents suicide.
Even a paper (by David Avery and George Winokur) often cited in
support of the view that ECT prevents suicide, had to conclude that,
in their study, treatment was not shown to affect the suicide rate.
Other studies have shown that psychiatric hospital admission can
increase the risk of suicide.
(If you know someone who is feeling suicidal, you can help by just
being there and listening in an accepting way. Discuss strategies for
seeking help when suicidal thoughts occur. Creating a personal
support list is a useful way of reviewing every conceivable option.
Persuade the person to keep, by the phone, a list of individuals,
helplines, organisations and professionals they can call when they
are feeling suicidal. See
Useful organisations, on p. 30, and Mind’s
booklet,
How to Help Someone Who is Suicidal, details under
Further reading on p. 34.)
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What do users say about ECT?
‘The effect of the treatment was amazing. All psychotic thoughts
diminished, and I started to feel as if I was finally being lifted from
the big, black hole I had been in. I honestly believe that, had I not
received ECT, I would not be living the full, happy and healthy life
that I am living today.’
(Woman, Hertfordshire, ECT in the last two years.)
‘Under no circumstances would I choose to have ECT. I would
rather go down fighting than submit to that abomination.’
(Woman, no area given, ECT six or more years ago.)
‘It just seems to help me out of my depressed state of mind
very quickly.’
(Man, no area given, ECT three to five years ago.)
‘It was hell on earth.’
(Woman, Dorset, ECT three to five years ago.)
There is a wide split among people who have had ECT about how
helpful it is. In Mind’s 2001 survey, of all those asked:
• 29 per cent found the treatment helpful or very helpful in the
short term (within the first six weeks)
• 36 per cent found it unhelpful, damaging or severely damaging.
Among those who had received ECT more recently, the results
were the opposite:
• 36 per cent found the treatment helpful or very helpful in the
short term
• 27 per cent found it unhelpful, damaging or severely damaging.
Over the longer term, a much higher percentage rated the
treatment as unhelpful, damaging or severely damaging:
• 63.5 per cent of all those asked
• 43 per cent of those who had treatment in the last two years.

What are the adverse effects of ECT?
Psychiatry recognises the following risks of ECT:
‘Each application inevitably leads to a variable period of drowsiness,
confusion and anterograde amnesia [forgetting new information],
commonly causes headache and nausea, and may lead to the
occasional loss of personal memories; moreover each application
inevitably requires a brief anaesthetic that involves additional risks
of morbidity and mortality [illness or death] that are slight, but
never negligible.’
In its appraisal document on ECT, NICE says that cognitive
impairment happens immediately after each session, as well as
following a course of treatment. (NICE is due to publish its Final
Appraisal Determination on ECT in January 2003.)
Both critics and supporters have suggested that ECT works through
causing brain damage, or ‘acute organic brain syndrome’ (see p.14).
Some of the symptoms listed above may subside quickly, but memory
loss, apathy (emotional blunting), learning difficulties, and loss of
creativity, drive and energy, may last for weeks, months, or even
permanently.

Loss of memory
Memory loss can mean losing both good and bad personal memories,
and having difficulty remembering new information. (It is, perhaps,
worth noting that people with epilepsy experience memory loss
after a fit.)
Comments recorded in Mind’s 2001 survey suggested that psychiatrists
seriously underestimate the potential extent and devastating effects
of memory loss in some people:
‘Permanent loss of reading and numeracy skills.’
(Man, West Midlands.)

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‘I don’t play the piano, organ or violin any more, as I can’t remember
how to. It seems my long-term memory has gone forever. Memories
from my past five years, and more, have become either vague or
have gone.’
(Man, Berkshire.)
‘I qualified as a maths teacher. Following all this ECT, I have no
understanding of the maths concepts used in my further education
courses, or even O-level standard.’
(Woman, Cleveland.)
‘I can remember hardly anything about my past life, only very little bits.
As for bringing up my three daughters, I can’t remember a thing.’
(Woman, Yorkshire).
According to
The ECT Handbook:
‘The evidence suggests that neither new learning, nor memory
for information from the past, are permanently impaired. Objective
memory impairment (on specific memory tests) is reversible. Some
patients may, however, be left with discrete memory gaps for specific
autobiographical events, the explanation for which is unclear.’
However, psychiatric research reflects users’ reports that memory
loss can persist, and that this is different from the memory loss
caused by depression. In one study, more than half of the patients
(55 per cent) felt that they had not regained normal memory
function, three years after receiving ECT.
An American psychologist conducted detailed autobiographical
interviews with 19 people who were about to have ECT, and with
a control group who did not have ECT. He then questioned both
groups about the same information afterwards. He found that all
the 19 patients showed a number of instances of forgetting their
former memories, unlike the control group whose memories were
unchanged. He followed up half of the ECT patients a year later,

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In another study, it was reported that memory complaints are common
six to nine months after bilateral ECT, and were reported by 60 to
70 per cent of patients interviewed.

Bilateral versus unilateral ECT
Research indicates that the two ECT techniques carry different risks
of memory impairment. It seems that bilateral ECT causes more
severe memory loss than unilateral. In unilateral ECT, the electrodes
are applied to the non-dominant side of the brain, to focus energy
away from the speech centre. (The speech centre is usually on the
left-hand side in right-handed people, but not always.)
Peter Breggin has criticised the theory that unilateral ECT is a less
harmful procedure. He points out that non-dominant brain functions
include:
‘the creative faculties, such as imagination, and the use of metaphor;
visual and spatial capacities, as well as musical and motor abilities,
such as co-ordination, dance and athletics; the quality or vibrancy
of personality; initiative and autonomy; and insight.’
Other critics have commented that unilateral ECT:
‘assumes that one side of the brain is less valuable than the other.
Humanistic psychologists would not agree. Instead, they might argue
that the non-dominant side is essential to creativity. The placing of
the electrodes unilaterally increases the concentration of current in
one part of the brain, and the damage to this part is more severe
than in bilateral ECT. EEG results one month after unilateral ECT
confirm that it is possible to detect which side of the brain is damaged.’

The emotional impact
The emotional and psychological effects of ECT are under-estimated
and under-researched. A report from the USA points out that studies
measure successful outcome in terms of symptom-reduction, rather
than quality of life and social functioning.

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Many people feel abused by the treatment:
‘I felt very much that I was being punished for not coping and being
out of work. I still feel this. I felt empty and numb.’
(Woman, Birmingham.)
‘I was an outgoing, fairly confident person, and now I feel worthless
and scared.’
(Woman, England.)
‘ECT was done to me, not done for me. That’s the total sense of
how it felt. It paralleled sexual abuse, which I experienced as a child.
Someone doing something to my body against my will.’
(Woman, Surrey.)’
In depression, some people may feel guilt-ridden, and believe they
are evil or harmful to others. They may see ECT as being a deserved
punishment, and it can confirm the very feelings of worthlessness that
characterise depression. In Mind’s 2001 survey, 22 per cent of recent
recipients felt that they were being punished.

Physical injury
Injuries to teeth and mouth are risks associated with ECT, because
the electrical stimulus contracts the jaw muscles, bypassing the muscle
relaxant. High stresses are produced during the forceful closure of
the jaws, and tooth damage or loss may result, in spite of the use
of mouth guards.
Spontaneous seizures following a course of ECT are rare, and not
more common than in the general population. They were reported
by one per cent of the respondents to Mind’s 2001 survey.
Death following ECT is relatively uncommon, but does happen.
It’s been estimated that the risk is about 4.5 deaths per 100,000
treatments, or four or five among 16,700 patients. This is no
higher than the risk associated with having a general anaesthetic.

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Side effects mentioned in Mind’s 2001 survey
Not everyone feels damaged by ECT, but for those who do, the
feelings can be devastating. Mind’s 2001 survey was not scientific
research, but does reflect the experiences of 418 people, one third
of whom found ECT helpful.
The following short-term side effects (lasting up to six weeks) were
reported. (They are listed, here, in order of frequency, with the most
frequent first):
• headaches
• drowsiness
• confusion
• loss of past memories
• dizziness
• disorientation in time or space
• difficulty concentrating
• inability to remember new information
• suicidal tendencies after the treatment
• apathy
• inability to recognise people
• loss of reasoning ability
• fear and anxiety
• feelings of helplessness
• sense of betrayal
• visual problems
• loss of previous skills (reading, music, languages)
• sleep problems
• feelings of worthlessness
• neck or back pain
• loss of creativity
• epileptic seizures
• sexual difficulties.

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Permanent side effects, again in order of frequency, were:
• loss of past memories
• difficulty concentrating
• fear or anxiety
• inability to remember new information
• feelings of worthlessness
• feelings of helplessness
• sense of betrayal
• loss of previous skills
• loss of creativity
• suicidal tendencies after the treatment
• loss of reasoning ability
• sleep problems
• confusion
• apathy
• headaches
• inability to recognise people
• disorientation in time and space
• personality changes
• neck or back pain
• visual problems
• sexual difficulties
• drowsiness
• muscle ache
• dizziness
• nausea
• epilepsy

Cause for concern
Giving a muscle relaxant helps prevent broken bones and dislocations
during the convulsions. It also sedates the brain, making it more
difficult to induce a seizure. The voltage has to be increased to reach
the threshold necessary to produce a seizure. Patients are often taking
psychiatric drugs, which also raise the threshold. The Royal College
of Psychiatrists has expressed concern about the effect of such drugs

22 on the safety and success of ECT. They stress more research is needed.
What are the added risks for older people?
There are additional concerns in using ECT for older people, as there
are with many medical procedures. The risks of treatment include
an increased chance of heart problems, stroke and falls. The effect
on an ageing brain is also recognised as potentially more damaging,
with a greater possibility of memory loss.
Older people will be at much higher risk of dying than younger ones,
but this age group is seen as more likely to be at risk of dying from
the inability to eat or drink during severe depression, and so the
benefits are seen as outweighing the risks.
ECT is sometimes considered less risky for the elderly than taking
tricyclic antidepressants, which can have an adverse effect on the
cardiovascular system. Opinion is divided about whether the newer
SSRI drugs are any better. A survey of psychiatrists working with
elderly people found that those who did choose the newer drugs
often did so because of cardiovascular risk. Some psychiatrists believe
that, since these antidepressants are so much safer, there is now no
reason to choose ECT rather than drug treatment for elderly patients.
Antidepressants and ECT are not the only possible responses to
depression. There is a body of knowledge and expertise in
counselling and psychotherapy with elderly people, but these
approaches are under-used. (See Talking treatments, overleaf.)

What are the alternatives to ECT?
There are many possible causes of depression, including life events,
and psychological, social, biochemical and genetic factors. All of
these interact to some degree. There are, consequently, various
approaches to treatment. If the guidelines of the Royal College
of Psychiatrists are being followed, you will only be offered ECT
(in most cases) if you have tried other treatments and found them
unsuccessful, unhelpful or unacceptable, in some way.

23
Most psychiatrists take a primarily biochemical approach to treatment,
and offer antidepressant drugs. If these do not work, they then suggest
ECT. They will not always try all the available types of drugs, nor will
they always consider other approaches, such as talking treatments,
arts therapies, and other alternatives or additions to medication.
The problem with treating depression in this way, as an illness with
a biological basis, is that it often follows a stressful life event, such
as bereavement, divorce or redundancy. People need time and space
to make sense of their pain, and come to terms with loss. ECT seems
inappropriate in such situations, unless the person has become morbidly
preoccupied with the traumatic event, and buried in depression
that looks unlikely to lift.

Antidepressant drugs
People have very varied responses to medication. But there are
different types of antidepressant available, and you may need to try
several before finding one that works. Information about all of the
different antidepressants currently prescribed in the UK is available
in Mind’s booklet,
Making Sense of Antidepressants (see p. 34).
Talking treatments
Your GP is a good starting point for exploring psychotherapy and
counselling, which can help you to deal with the problems underlying
and surrounding your depression. The treatment works by providing
an opportunity for you to talk, in a way that assists you to understand
yourself better. It can then help you to work out a more positive and
constructive way of living. Increasing numbers of GPs are employing
counsellors in their practices, but if not, they should be able to refer
you to other sources of psychotherapy or counselling. Your local Mind
associations may offer free, or low-cost, talking treatments. The
organisations listed on p. 32 can provide details of psychotherapists
and counsellors. Some will operate a sliding scale of fees, which
takes into account people’s financial situation.

24
Cognitive behaviour therapy (CBT) is a practical, short-term aid to
helping someone to cope with depression. A person’s thoughts have
a powerful impact on their feelings and behaviour, and it’s possible
for someone to think themselves into a state of extreme distress.
But it’s also possible to do the opposite, and challenge negative
thought patterns that feed depression. If you think you might be
interested in CBT, talk to your GP about getting a referral to a
clinical psychologist. (See Mind’s booklet,
Understanding Talking
Treatments, Understanding Depression and Making Sense of Cognitive
Behaviour Therapy, details under Further reading, on p. 34.)
Arts therapies
Therapies using art, music, drama, dance or creative writing may
be very powerful in helping to lift depression. Even someone who
is so profoundly depressed they can’t speak may be moved by
music or poetry, which then begins a process of recovery. These
therapies are available in some psychiatric units and community
mental health facilities (see
Useful organisations, on p. 32).
Complementary therapies
Complementary and alternative therapies have proved to be
particularly helpful when people are experiencing stress-related
symptoms, anxiety and depression. They can help people relax and
feel better. Complementary therapists emphasise the connection
between mind and body, and are not concerned with merely treating
symptoms. There are many different therapies, including homeopathy,
herbal medicine, acupuncture, aromatherapy, meditation, reflexology,
neurolinguistic programming, and various types of massage. (For
further information, see Mind’s
A-Z of Complementary and Alternative
Therapies, The Mind Guide to Relaxation, The Mind Guide to
Managing Stress, Making Sense of Herbal Remedies, Making Sense
of Homeopathy and Making Sense of Traditional Chinese Medicine,
details under Further reading on p. 34.)
25
Physical activity
Physical activity has proved to be very beneficial when tackling
problems like depression. It works by changing levels of chemicals
in the body that influence mood. For more information, see
The
Mind Guide to Physical Activity, details on p. 34.
Self-help groups
Many people experiencing emotional distress find it helpful to
share their feelings with others going through similar difficulties.
There are self-help organisations for people suffering from depression.
See Mind’s booklet
Understanding Depression, details on p. 34,
and
Useful organisations, on p. 32. Or ask at your local Mind group.
Transcranial magnetic stimulation (TMS)
In the last 10 to 15 years, interest has grown in this new technique.
Neurologists have been using TMS as a research tool for some time,
and it seems clear that it may be useful for treating depression.
Some researchers feel that it may be an alternative to ECT.
It involves creating magnetic fields through an insulated coil conducting
an electric current, which is placed on the surface of the scalp. Rapidly
changing magnetic fields cause electrical currents to flow within the
brain. This affects the nerve function, without causing an epileptic
fit. The technique has been investigated in various ways, by using
different positions of the coil, by stimulating different areas of the
brain, and by changing the signal frequencies, for example. The
first trials of TMS for depression used only small, selected groups
of patients, with no control group for comparison. As a result, it
was not clear whether this was really an effective treatment for
depression. More recent research continues to suggest that it may
become an alternative to ECT.
It is considered to be a safe procedure. The most important safety
concern is the risk of seizures, but no seizures have been reported
since the introduction of guidelines for safe use of the technique.

26
This may seem a strange concern, given that ECT is considered to
have failed if it does not cause a seizure. But, if similar results can
be achieved without seizure, it would be a great advantage. There
may be some local scalp pain or headache at the time of treatment,
but, so far, there have been no reports of harmful effects.
The technique is still being researched, and is not yet available as a
treatment. In 2001, the Health Technology Assessment Programme
of the Department of Health decided to commission a study
comparing TMS with ECT.

Vagus nerve stimulation (VNS)
VNS was initially developed for treating epilepsy, but has been tried
for depression in the last few years. It involves placing an electronic
device under the skin in the left chest wall, with an electrode
connecting it to the left vagus nerve in the neck. Putting the device
in place takes about an hour. Once working, it sends mild, electrical
pulses to the nerve, at intervals.
Side effects can occur, but usually only when the stimulation is on.
They include voice alteration, shortness of breath, neck discomfort,
and coughing, all of which apparently diminish over time. It’s reported
to lift depression, and is available in various centres throughout
Europe, including the UK.

What are the pros and cons of ECT?
People’s experience of ECT varies enormously. It’s a short-term
treatment, which can’t directly address underlying despair or practical
problems, and does not prevent future depression. Memory problems
are widely reported, though for some people they are only temporary.
Some people also feel violated by ECT.

27
However, ECT can lift depression, and the speed of response may
be an important consideration, for instance in preventing kidney
failure in someone who is not eating or drinking.
ECT may help people enough for them to begin looking for a
different solution. Some people feel that after ECT they are better
able to make use of other forms of treatment and support.
One service user, who has commented favourably on his ECT
treatment, makes the point that ECT, on its own, is not enough:
‘On more than one occasion in my life, the intervention of ECT
has been beneficial and not damaging. The initial help given, it’s
been all the more possible to gain from the skills and the patience
of a clinical psychologist. It is true that ECT should not be used to
excess, and it is also true that usually more than ECT is needed.
But the different therapies and treatments can, and should, be
seen as complementary, rather than in competition.’

Questions to ask your doctor
If ECT is recommended, you should ask the following questions:
• What is the reason for suggesting ECT?
• What are the risks associated with ECT?
• How could ECT help me?
• What are the side effects?
• Are there any long-term effects?
• Has every alternative treatment been tried, including different
drug treatments, or talking treatments?
• What treatment will be offered in addition to, and after, ECT?
• What is the risk of physical deterioration or suicide?
• How many treatments are proposed?
• Is unilateral or bilateral ECT proposed?
• How will the dosage be decided?

28
abuse, sense of 20
advocate 6
alternative treatments 23-25
anaesthetic 6, 10, 13, 20
anaesthetist 9, 10
antidepressants 13, 23, 24
antipsychotic drugs 8
arts therapies 25
bilateral ECT 11, 19
blood-brain barrier 14
brain
- damage 6, 14, 15, 17, 19
- dominant
/non-dominant side 19
- functions 13
cardiovascular system 13, 23
catatonia 8
chemical messages 13
cognitive impairment 11, 17
complementary therapies 25
consent/refusal of treatment 4-6
death 15, 17, 20, 23
depression 6-7, 8, 15, 18, 20,
23, 24, 25, 26, 27
ECT
- helpfulness/harm 7, 11
15-23, 27, 28
- effectiveness 15, 28
electric current 6, 10, 13, 19, 26
electrodes 10, 11, 19, 27
emergency treatment 6, 13
epilepsy 17, 22, 27
equipment 9
frequency of sessions 12
mania 8
medical examination 12
medical history 12
medication 11, 13
memory loss 7, 11, 12, 14,
17-18, 23
Mental Health Act 1983 6
modified ECT 10
muscle relaxant 6, 10, 11, 22
obsessive-compulsive disorder 8
old people 12, 23
oxygen 10-11, 14
physical activity 26
postnatal depression 8
pregnancy 13
preparation for treatment 10, 12
psychiatrist(s) 5, 7, 9, 10, 14,
17, 22, 23, 24
psychotic symptoms 8, 16
schizophrenia 8
seizure (fit) 6, 10, 13, 20, 22, 26
seizure threshold 10, 11, 13, 22

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