A team of researchers at Aberdeen University have just published a brief report in the Proceedings of the National Academy of Sciences of the United States of America on before-and-after functional MRI scans of the brains of nine people undergoing electroconvulsive therapy (ECT) and found a reduction in a “significant cluster of voxels in and around the left dorsolateral prefrontal cortical region”. The researchers put out a press release which has been remarkably successful in the amount of media interest it has generated.
The Daily Mail’s article, complete with pictures of ECT being administered in the 1950s, a scene from the film One Flew over the Cuckoo’s Nest, and someone with their head in their hands, was typical: “Scientists have finally discovered how one of psychiatry’s most controversial treatments can help patients with severe depression”. The BBC went with a photo of someone with their head in their hands but to their credit decided on a photo of the Aberdeen team instead of a scene from One Flew over the Cuckoo’s Nest and quoted one of the authors, Professor Ian Reid, as saying:
“ECT is a controversial treatment, and one prominent criticism has been that it is not understood how it works and what it does to the brain. However we believe we’ve solved a 70-year-old therapeutic riddle because our study reveals that ECT affects the way different parts of the brain involved in depression connect with one another.”
The patients in this study were being treated at the Royal Cornhill Hospital which in 2010 gave ECT to more people – 59 – than any other hospital in Scotland, although only nine were involved in this study. There didn’t seem to be any attempt to look for an association between improvement in symptoms and changes on the fMRI (or perhaps there was and I missed it). Was there no-one whose symptoms didn’t improve, or improved significantly less than those of the others? The riddle of how ECT works is only going to be solved if it can be shown that the changes are necessary for the treatment to work, and don’t occur when the treatment doesn’t have the desired effect. Otherwise they might just be something that accompany the treatment, rather than the “how it works” bit. But then I suppose “small study may throw some light on how ECT works” doesn’t sound quite so newsworthy as solving 70-year-old riddles or making discoveries.
It is interesting that this seems to be about reducing connections in the brain. As the press release from Aberdeen University says: “treatment appears to ‘turn down’ an overactive connection between areas of the brain that control mood and the parts responsible for thinking and concentrating”.
Reducing connections in the brain is nothing new in psychiatry. Here is how psychiatrists described the purpose of psychosurgery in the 1940s:
“Crudely described the purpose of the operation is to break the connection between the patient’s thoughts and his emotions. It is to relieve mental tension, to take the sting out of experience and thus to favour improvement or to hasten recovery from mental disorder. That at any rate seems to happen in successful cases”. (Board of Control 1947 Pre-frontal leucotomy in 1,000 cases, page 5)