Former Australian Paralympian Tamara Nowitzki has just published a book about her life entitled No Ordinary Girl. Tamara, a swimmer, won a silver medal at the Sydney 2000 Paralympics.
“Tamara was diagnosed with DRD [dopa-responsive dystonia] at the age of 25, after a diagnosis of Cerebral Palsy at 13 months. Since this diagnosis Tamara has struggled with depression, anxiety and obsessive-compulsive disorder resulting in trialling numerous medications, hospitalizations and more than 22 electroconvulsive therapies”.
Guidelines on the use of electroconvulsive therapy (ECT) describe it as a treatment for which there are “no absolute contraindications”, a treatment which can still be used regardless of illness or disability. Some reports of ECT use on people with dystonia being treated for depression or schizophrenia have reported a short-lived improvement of dystonia symptoms.
There has been some controversy surrounding the current Paralympics and their sponsorship by Atos, the firm which carries out work capability assessments for the Department of work and pensions. Atos has produced a series of documents covering various conditions. They have the rather grand title of Evidence Based Protocols for the Disability Analyst. Atos explains:
“These protocols have been developed by Atos Healthcare as reference documents to be consulted by you, when necessary, in your role as a Disability Analyst .The EBM [Evidence Based Medicine] protocols also drive the LiMA [Logic integrated Medical Assessment] rules….
All protocols are reviewed and updated on a three year rolling basis and are subject to both internal Quality Assurance and external Quality Assurance, from a recognised expert in each field…”
When it comes to the protocol on depression it appears that it is more than 3 years since it has been updated – there are no references from the past 10 years. Here is what it says about ECT:
“ECT entails administrating an electric charge to the head of a patient under a general anaesthetic in order to produce a generalised convulsion. The therapeutic agent is the convulsion; a normal course is 6–12 treatments at a rate of 2-3 per week.
The risk of death is similar to that of general anaesthesia for minor procedures, about 2 deaths per 100,000 procedures. There is no evidence that it causes brain damage or permanent intellectual impairment. Unilateral ECT is less likely to cause memory loss.
ECT is reserved for cases of resistant depression unresponsive to
pharmacotherapy, especially those with psychotic or marked biological symptoms. The presence of biological and psychotic features of depression predicts a good response to ECT.
ECT produces a more rapid resolution of depression compared to antidepressant medication and may be lifesaving in severe depression. However antidepressant medication should be continued following a successful course of ECT.”
The “therapeutic agent” is actually thought to be a generalised seizure, rather than convulsion. With the use of muscle paralysing drugs convulsions are in any case reduced. But it is the next section, on psychosurgery, that makes me really wonder about the “external Quality Assurance, from a recognised expert in each field”.
This is what they say about psychosurgery:
“In extremely rare cases of chronic disabling depression, when all other treatments have failed, the extreme option of psychosurgery may be considered. About 50 operations are performed each year in the UK, (involving the implantation of yttrium seeds into the forebrain, just in front of the 3rd ventricle).”
Nobody in the UK has had yttrium seeds implanted into their brain since 1996, over 15 years ago. It stopped in 1996 and since then surgeons carrying out the operations have used other methods, for example cutting away brain tissue or electrocoagulation. And to find “about 50” operations being performed every year in the UK you have to go back to the early 1980s, before the Mental Health Act 1983 regulated psychosurgery. That is 30 years ago.
There is no excuse for the protocol to be so out of date. This information is freely available for example in this report from the Royal College of Psychiatrists which gives figures up to the year 2000 and also makes it clear that yttrium seeds are no longer used.
There are probably, however, still people of working age with yttrium seeds in their brain, so it would be worth mentioning this, as a treatment of the not-so-distant past. It would also be worth mentioning DBS (Deep Brain Stimulation) as a treatment for depression, just in case anyone walks into an assessment with wires in their brain.