ECT and fMRI in Aberdeen

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)

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7 Responses to ECT and fMRI in Aberdeen

  1. Ian Reid says:

    This is a fair appraisal of the study. The point about non-responders is entirely correct. In our study, the neural changes do correlate with change in symptom score, but the numbers are small and all those who took part did really well. Response rates are very high with ECT treatment as you can see from the Scottish audit reports (www.sean.org.uk). We’ve applied for funding to extend the study to capture non-responders and to follow up those who remain well and those who relapse to determine better the relationships between outcome and imaging findings.

    The point about neurosurgery for mental disorder is an interesting one: the brain areas shown to change in our project are precisely those targetted by anterior cingulotomy for intractable mood disorder. Douglas Steele, co-author of this paper, works with the Dundee University Advanced Interventions team which conducts these rare treatments for patients in the UK (see http://www.dundee.ac.uk).

    We are grateful for your interest and feedback on our work. We also deplore some of the imagery used in media coverage, and agree that some balance is lost in translation to tabloid. I’m nonetheless entirely responsible for the “solving riddles” quote.

    The paper can be downloaded for free from the PNAS website.

    Best wishes,

    Ian Reid

    • Professor John Read says:

      Dr Ian Reid and his colleagues claim to have discovered how electroshock therapy (ECT) works. They found that electrocuting the brain to cause seizures (of the kind the rest of medicine is trying to cure) reduces the ‘connectivity’ between parts of the brain, and suggest that this is somehow a good idea.

      The main problem with their claims (apart from making them on the basis of an astonishing small sample of just nine people) is that ECT does not work. In a review of 60 years of research, which I published with Professor Richard Bentall of Liverpool University in 2010, we could not identify a single follow up study that found ECT to be more effective than placebo (in which the general anaesthetic is administered but the electricity is not). Nor are there any studies which support the oft made claim that ECT reduces suicide risk.

      We did find, however, many studies showing that ECT causes brain dysfunction, most often in the form of memory loss – often long-lasting and sometimes permanent. So what Dr Reid has actually found may actually be yet another example of the negative effects of applying the equivalent of about 150 volts to brain cells equipped to deal with a tiny fraction of one volt.

      The history of psychiatry is littered with treatments touted at the time as safe and effective which turned out to be far from either. It is not so long ago that lobotomies (another treatment based on reducing connections between parts of the brain) was in vogue.

      Professor John Read
      Psychology Dept.
      University of Auckland
      New Zealand
      j.read@auckland.ac.nz

      • Jennifer Morris says:

        In my early twenties I was given ECT following a conversion experience to Christianity. My ECT was combined with an overdose of 3 anti-psychotics to see if it was possible to ‘re-route’ or ‘wipe the brain clean’ ie change my mind. I have since learned that behavioural science was all the rage and a government white paper permitted such an experiment, possibly in the interests of ‘military research’! I was a 23 year old ex-university/art student, with great school qualifications looking forward to a future in Canada as part of a Christian community…needless to say that didn’t happen! ‘Has taken 40 years to get over!!

  2. Cheryl Prax says:

    To me it looks like the damage is where the electrodes are placed. Would the worst damage be on the entry or exit point of the electricity?
    Please sign this ‘Abolish ECT’ e-petition and relegate it to history books like lobotomy. UK citizens or residents only
    http://epetitions.direct.gov.uk/petitions/16278

    Thanks

  3. Chris Dubey says:

    I’m hyperlinking to an article I wrote, more about the traumatic emotional experiences of forced electroshock, including my own experience from 2005-2006.

    A summary of references against electroshock treatment

    http://www.examiner.com/article/a-summary-of-references-against-electroshock-treatment

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