ECT in The New Statesman

On 3 August 2022 The New Statesman (UK edition) ran an article on electroconvulsive therapy (ECT): “We need reasoned debate on ECT, not polarisation”. The authors are two psychiatrists, Rebecca Lawrence and Stephen Lawrie, who both work in Scotland. Lawrence works in the field of addiction and has herself had several courses of ECT. Lawrie has had a career in neuroimaging.

So how do they go about starting this reasoned debate? Their chosen words are not ones you particularly associate with reason: hideous, awful, unbearable, brutal, terrible, anguish, desperate, discombobulating, clinging fears.

The first three – hideous, awful, unbearable – are used to refer to depression, the disorder for which ECT is most commonly used as a treatment.

As for brutal and terrible, the article says:

“When first used, it was brutal – often given on a daily basis without anaesthetic or muscle relaxant. This caused terrible harm and broken bones were common.”

This shows a lack of knowledge of the history of ECT. Although most hospitals were using mainly modified ECT (that is, with anaesthesia and muscle paralysing drugs) by the late 1950s, unmodified ECT (without anaesthesia and muscle paralysing drugs) continued to be used occasionally in the United Kingdom into the 1980s. And is still used in some other countries. In the 1940s and 1950s there were a few psychiatrists who experimented with intensive ECT on a daily basis, but most patients had courses of treatment given two or three times a week.

As for anguish: “But now there is no pain, and any anguish experienced is due to the underlying depression”. I am not sure what the authors mean by this. Are they referring to people’s very understandable anxiety about undergoing a medical procedure? Or their concern that they will be left with memory loss? But in any case it is common for psychiatrist’s to blame patients’ depression for anything untoward.

Desperate refers to the psychiatrists’ attempts to save lives with ECT. “There are worse experiences in medicine, many desperate attempts to save lives that hurt more, but are thought worthwhile.” The authors do not mention any evidence to support this view.

Discombobulating? It is a word that was invented in America in the 1820s when it was fashionable to make up Latin sounding words for humorous effect. Apparently it means confusing or disconcerting. The authors say:

“Having ECT is frankly discombobulating – during the course of treatment you can feel bewildered and, afterwards, many people will have memory holes for that period – or even for previous memories.”

So, having acknowledged that “the memory problems linked to ECT have been underestimated and understated, with little support provided”, they then go on to describe them with a joke word.

What then, do the authors suggest for those who have suffered memory loss? Bizarrely, they say:

“A subsequent visit to the ECT suite could brush away clinging fears, and peer support, which one of us has given informally, can help. Above all, people should be taken seriously.”

It is not however taking people seriously to dismiss memory loss as “clinging fears” that can be brushed away by a visit to the ECT suite.

This is hardly the “balanced coverage” the authors call for.

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Teenagers, antidepressants and a stem4 survey

On 3 August 2022 inews ran an article with the headline “One in three teenagers given antidepressants as lack of mental health services puts pressure on GPs to help” by health correspondent Paul Gallagher, along with a stock photograph of someone lying on a couch. Anything wrong with a picture of some pills?

The article says:

“Some 37 per cent of 12-to-18 year-olds now claim to have been prescribed antidepressants to treat depression or other mental health conditions at some point during their lives, rising to 43 per cent among 19-to-21 year-olds, a survey has found.”

Where does this statistic come from? It does not come from recently published National Health Service (NHS) statistics, which showed that 180,455 15-19 year olds and 11,878 10-14 year olds were prescribed antidepressants in the year 2020/21. Those figures represent approximately 1 in 17 15-19 year olds and 1 in 28 10-14 year olds prescribed antidepressants in one year. It is impossible to say from the figures how many teenagers will be given a prescription over a period of several years as some of the same people will appear in the statistics for more than one year.

The inews article says that the figures come from a survey of 2000 young people across the UK carried out by stem4, a youth mental health charity. A quick search reveals that it was a survey commissioned by the Good Morning Britain (GMB) TV programme. GMB tweeted: “An exclusive GMB survey with charity Stem4 has found that 4 in 10 young people between 12 & 21 have been prescribed antidepressants for their mental health difficulties.” The segment can be seen on youtube.

The presenter asks Nihara Krause, psychologist and chief executive of stem4, how the survey was carried out. Krause replies that they “sampled a national sample of 2006 young people aged between 12 and 21”. The presenter then asks for confirmation that this was a general sample and that the participants had not necessarily got mental health issues or been seeking advice. Krause confirms that it was a general sample.

So how did stem4 find this general sample of young people? Turning to their website, there is a press release which says:

“More than a third (37%) of 12-to-18 year-olds now claim to have been prescribed antidepressants to treat depression or other mental health conditions at some point during their short lives, rising to 43% among 19-to-21 year-olds.”

The press release says that the survey was carried out by SurveyGoo:

“Survey of 2,007 regionally representative young people aged from 12 to 21 carried out Survey Goo between 15th to 19th July 2022”.

SurveyGoo is “a specialist agency in the creation and delivery of PR surveys and polls” that “makes creating and conducting online PR surveys as simple as possible”. Until they can tell us a little more about their methodology, I shall remain sceptical about these particular statistics.

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ECT: when is a shock not a shock?

I a previous post I talked about how psychiatrists used the term electric shock in the early days of electroconvulsive therapy (ECT) but in more recent decades have taken to using terms such as electric current, charge, stimulus, etc.

Psychiatrists are always trying to find new ways of describing ECT to make it sound more benign. The most recent version of the Royal College of Psychiatrists’ patient information leaflet, for example, has replaced the term electric current with the term stimulating electrical pulses.

I have just come across a novel approach by NHSinform in Scotland:

“When receiving ECT, you will be given an anaesthetic and medication that relaxes your muscles to begin with. Electrodes will be placed on your head that give an electrical “shock” to your brain.”

This is refreshingly honest – but why the inverted commas?

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On the fast track to treatment resistance

J. John Mann has an academic job title that takes up more than 3 lines of text. Here it is:

“The Paul Janssen Professor of Translational Neuroscience (in Psychiatry and in Radiology) and a former Vice Chair for Research in the Department of Psychiatry at Columbia University. He is Director of Research and Director of Molecular Imaging and the Neuropathology Division at the New York State Psychiatric Institute.”

And he has thought up a new psychiatric acronym ASAP, which was the subject of a presentation at the May 2022 annual meeting of the American Psychiatric Association.

ASAP stands for the Columbia University Accelerated Sequential Antidepressant Protocol. Aimed at primary care physicians, it recommends that depressed patients should be started on an SNRI and then, “as soon as initial therapy looks unlikely to succeed” (that is, he says, after 2-4 weeks ), an antidepressant from a different class should be added. If that doesn’t work the combination should be switched or an antipsychotic, etc. should be added.

No need to worry about side effects because, the professor suggested, “medications with different biological profiles may create effects that cancel each other out; for example, one medication may be sedating while the other is stimulating.”

“The goal is that by 12 weeks—the window in which treatment response is most likely—a patient will have tried medications targeting a broad range of biological targets. If the patient is not responding at this stage, he or she may be considered treatment resistant and more aggressive interventions such as ketamine, transcranial magnetic stimulation, or electroconvulsive therapy may be advised.”

And if “busy primary care doctors” cannot take all this in, help is on hand in the form of an app to “guide people through the ASAP process” in an average of 40 seconds, thus saving “valuable clinician time”.

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The serotonin theory on the Science Media Centre

Ratio of women to men prescribed antidepressant drugs in England = 2 : 1

Ratio of female to male experts commenting on depression on the Science Media Centre = 1 : 2.5

Ratio of female to male lines of text = 1 : 3.5

I have written before about the predominance of men commenting about depression on the Science Media Centre. The latest figures come from a 20 July 2022 piece on the Science Media Centre about a review paper published in Molecular Psychiatry looking at the serotonin theory of depression which had generated headlines such as “Little evidence that chemical imbalance causes depression, UCL scientists find” (in The Guardian).

The Science Media Centre found seven experts to comment on the review – five male professors from institutions in London and Oxford, a female professor from the University of Denmark and a female post-doctoral researcher from the University of Antwerp. There was also an anonymous spokesperson from the Royal College of Psychiatrists.

What did they all say?

Gitta from Copenhagen says depression is a “heterogeneous disorder with potentially multiple underlying causes” and then talks about “synaptic 5-HT concentration”. 

Livia from Antwerp says that antidepressants are effective even if “understanding of the biological causes of depression moves away from theories focused solely on serotonin”.

Michael from London says, with a slight lack of certainty: “What remains possible is that for some people with certain types of depression, that changes in the serotonin system may be contributing to their symptoms” and comes up with a paracetamol analogy for antidepressants. He then says that there is “consistent evidence” that antidepressants “can be life-saving”. (I would be curious to know where this “consistent evidence” is).

David from London says that it is premature to dismiss “the serotonin hypothesis of depression at this point”.

Phil from Oxford says that depression is a “complex heterogenous condition” and then defends the serotonin theory.

Allan from London says that “most psychiatrists adhere to the biopsychosocial model” before discussing brain 5-HT1A receptors and concluding that there is “good evidence of the efficacy and acceptability of serotonergic antidepressants”.

Another David from London says that the chemical imbalance theory of depression is outmoded but goes on to say that it is “very clear that people suffering from depressive illness do have some abnormality of brain function, even if we do not yet know what this is…”, which sounds pretty much like a chemical imbalance theory to me.

So there is still plenty of support for the serotonin theory of depression, with a couple of nods towards heterogeneity and complexity. Looking at the (partial) list of disclosures of interest this is not surprising. And quite apart from financial conflicts of interest, the Science Media Centre centre has chosen experts who have devoted their careers to investigating brain biochemistry.

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ECT and esketamine research in the Netherlands

It is rare to see a university psychiatry department putting out a communication that says anything negative about electroconvulsive therapy (ECT). But on 15 July 2022 the University Medical Centre Groningen (UMCG) in the Netherlands published a piece in which ECT is described in the following terms:

“ECT is an invasive treatment that involves long hospitalizations, repeated anaesthesia, and sometimes leads to lasting injury including damage to memory.”

The reason for this rather less than positive description of ECT is revealed in the next sentence: “Treatment with esketamine in the form of a drink possibly offers a good alternative to ECT”. It is when promoting alternative treatments that psychiatrists occasionally deviate from the standard “safe and effective” pronouncements on ECT.

A team at UMCG under professor of psychiatry Robert Schoevers has been awarded 3.2 million euros to compare the effects of ECT and ketamine on depressed (but not psychotic or bipolar) patients. They are trying to recruit 172 patients and the communication ends with an email address for those who want more information about participating in the research.

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Antidepressant prescribing in England 2021/22

The latest annual figures on the prescribing of drugs used in mental health in England have just been published (7 July 2022) and the media headlines are predictable: “Antidepressants: Figures show a rise in people taking the drugs”.

There has indeed been a rise in the number of people prescribed NHS antidepressants in the community. An estimated 8.32 million people (8.25 million of them over the age of 18) were prescribed antidepressants in 2021/22, an increase of 5.72% over the previous year. By my reckoning, that is between one in five and one in six adults in England.

The statistics look at five groups of drugs: antidepressants; hypnotics and anxiolytics; antipsychotics; drugs used to treat ADHD; and drugs used to treat dementia. Women are in the majority in every group except for drugs used to treat ADHD. All groups were prescribed more to people living in deprived areas.

Women in their fifties are the most common group to receive prescribing for antidepressants (and also hypnotics/anxiolytics and antipsychotics).* Overall, women account for 66% of those prescribed anti-depressants.

Women account for 61 per cent of patients receiving hypnotics/anxiolytics but in the under 20 age group, it is males who are in the majority.

Nearly one in fifty of the adult population are receiving antipsychotic drugs.

The statistics refer to the five groups of drugs as “medicines used to improve mental health in England”. Is mental health improving? How would they know?

When it comes to depression, the statistics have this to say: “Antidepressant drugs are licensed to treat major depression…. It is a serious illness and very different from the common experience of feeling unhappy or fed up for a short period of time.” And one in five to six of the population have this serious illness? Perhaps it is time to reformulate descriptions of depression now it has become such a common experience. The statistics point out that antidepressants can be prescribed for conditions other than depression, such as chronic pain.

The statistics only cover drugs prescribed in the NHS and dispensed in the community. They do not include drugs used in hospitals, prisons or private medicine. It would be interesting to know how many people take privately-prescribed antidepressants, especially now high-street chemist Boots have recently introduced a service where you can get online or phone consultations and prescriptions for antidepressants for £65 a month.

*8 July 2022 I changed the wording to the exact wording used in the statistics: “in 2021/22, the most common group to receive prescribing for antidepressants, antipsychotics, and hypnotics and anxiolytics was female patients aged between 50 to 59” as my previous wording “most likely to be prescribed…” suggested that women in their fifties had the highest rate of prescriptions, which is not necessarily true. For example, about one in ten women in their 90s were prescribed antipsychotics, the highest rate of any group.

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ECT in Queensland: patient information leaflets

The Australian state of Queensland has just (July 2022) produced a new patient information leaflet about electroconvulsive therapy (ECT): A Guide to Electroconvulsive Therapy (ECT) for Consumers and Carers. The cover shows six smiling people with beautiful white teeth.

In the introduction chief psychiatrist John Reilly emphasises how ECT has changed since 1938, claiming “the side effects have reduced”. Technology changes; they had bakelite plugs, we have computers. But that does not necessarily lead to a reduction in side effects.

The first sentence of the guide reads:

“Low level electric current was first used to induce seizures in 1938.”

Low level electric current? I have tried unsuccessfully to find a definition of “low level”, but references generally seem to be of currents an order of magnitude smaller than those used in ECT.

The guide explains:

In many conditions, including severe depression, there is a change in the normal brain function and in some brain chemicals including adrenaline, serotonin and dopamine. ECT appears to balance the activity of these chemicals or ’neurotransmitters’.

While some psychiatrists are trying to distance themselves from the brain biochemical theory of depression, it is still much in evidence in ECT patient information leaflets.

How does the guide treat memory loss – a common effect of ECT? Retrograde amnesia (the loss of past memories) is mentioned only in the “immediately after treatment” section, in a way that is unlikely to alert patients to the fact that they might permanently lose memories from months or years previously:

“It is normal for patients to have difficulty remembering events that happened immediately before and after ECT treatments.”

As for anterograde memory (the ability to form new memories), there is a mention in the “short-term” section, with claims that it usually only lasts a few days or weeks, followed by a claim that ECT “can actually improve memory function”.

The leaflet ends with a long list of “responsibilities” (“If you are to have ECT treatment you must agree to the following”) which includes a requirement to “consider carefully the treatment offered to you and not refuse it because of fear or lack of knowledge or misinformation.” Presumably they are not worried about patients who agree to treatment because of a lack of knowledge or misinformation.

Finally, readers are referred to a similar leaflet with the same smiling faces: “A form of ‘brain electricity’ is needed to release these chemicals (called neurotransmitters)”; “Once you are asleep the doctor will activate a part of your brain with a measured electric stimulus”; “There is no evidence that ECT causes brain damage or any harmful changes in personality”, etc. There are onward links to a couple more official leaflets and a warning that some websites are “are ill informed and deliberately ‘anti ECT’”.

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ECT: nothing mild about it

On 26 June 2022 The Observer published an article about electroconvulsive therapy (ECT) with the title “Brain damage claim leads to new row over electroshock therapy”. The article referred to mild electric shocks inducing mild fits.

In fact there is nothing mild about either the electric shock used in ECT or the seizure it induces. Modern ECT machines operate with a current of 900 milliamps. For comparison:

Current used in to control children’s behaviour with painful electric shocks at the Judge Rotenberg Institute = up to about 45 milliamps

Current used in stunning or killing a sheep = 1000 milliamps

The electric shocks used in ECT are powerful, although an anaesthetised patient will not of course feel the shock.

As for the fit induced in ECT, it is a tonic-clonic (grand mal) seizure, rather than the petit mal type where someone does not fall down or convulse. The only reason patients undergoing ECT do not convulse is because they have been given a muscle paralysing drug with the anaesthetic.

Before you can even begin to discuss the risks of ECT, you have to be honest about the nature of the treatment.

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Ugg boots, The Black Dog Institute, ECT and the Churchills

June 1st was the first day of winter in Australia. It was also Ugg boots day, when the manufacturers of Ugg footwear suggested people should wear their boots to work and make a donation to The Black Dog Institute at the University of New South Wales. Ugg Express said they would in turn donate 10 per cent of their profits from the sale of their boots on 1 June to the Institute.

The Black Dog Institute’s director of fundraising and partnerships and the marketing manager of Ugg Express were excited about the fundraising initiative, according to an article in The Advocate, an “online service dedicated entirely to promoting the activities of not-for-profits and charities”.

The article quoted Amy:

“The Black Dog Institute helped me by facilitating access to the resources I needed to get help for my suicidal thoughts… The ironic thing is that of all the treatments I’ve received (which has included 72 electroconvulsive therapy), ‘talk therapy’ has been the most effective and long-lasting.”

But if anyone is inspired by Amy’s experience to turn to the Black Dog Insitute, there is a warning in large bold print at the end of the article that The Black Dog Institute is “not a crisis centre and cannot provide crisis support”. Telephone numbers for emergency services and Lifeline are given out.

The article says:

“The term ‘black dog’ is said to be coined by Winston Churchill who used it to describe his prolonged fits of depression from which he suffered.”

In fact, the use of the term “black dog” to describe a dark mood long pre-dates Winston Churchill. It was used, for example, in correspondence between Samuel Johnson and Hester Thrale in the 18th century and has much older origins.

Winston Churchill did not have psychiatric treatment, but was prescribed drugs such as amphetamines and barbiturates by his doctor, Lord Moran. He was also a heavy drinker. His wife Clementine and daughter Sarah both underwent ECT. Sarah Churchill died from an overdose of barbiturates.

The Black Dog Institute was set up 20 years ago by Professor Gordon Parker, who has already featured on this blog (here), when he misquoted a Wikipedia article while acting as an expert witness in a legal case. Their stated aim is “to create a mentally healthier world for everyone”. Have they had any success? Has the world got mentally healthier over the past twenty years? How would we know?

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