Lifestyle Choices

Electro-convulsive therapy (ECT) is like banging a TV set when it does not work. However, the crudity of whamming a 100-volt electric shock through someone’s brain does not take away the fact that this technique has saved people’s lives when all else has failed. As with every new and seemingly successful physical treatment of mental ailments, such as tranquillizers and anti-depressants, ECT has a history of gross overuse. It has also been misused in some institutions as a form of control or punishment.

ECT produces a temporary epilepsy. It was started on the theory (later found to be untrue) that epilepsy and schizophrenia never co-exist. It was therefore used to treat schizophrenia but with no success beyond a significant placebo effect. However, the technique was also used on people in severe depressive states with incredible results. In a few weeks people who were expected to remain in hospital for months or even years were recovering from the blackest and whitest of depressions.

The technique involves passing a 100-volt electric shock between two electrodes placed on either side of the head. Before receiving this shock, which causes a temporary epileptic fit, you are anaesthetized with an injection and then given a short-acting muscle relaxant so that the body movements resulting from the epileptic fit are minimized. All that is usually visible of the fit is a jerky twitching of the toes and fingers. After a few minutes you wake up, sometimes with a headache — or else you fall into a natural sleep. There are a number of theories as to why it all works:

• The procedure becomes an expiation of guilt.
• Such a complicated manoeuvre involving loss of consciousness has a strong placebo effect.
• Monoamine levels in the brain are raised, giving an anti- depressive effect.
• Circular, self-reinforcing, depressive/negative circuits in the brain are broken apart by the shock, which has an enormous voltage compared to the tiny electric currents within the normal brian.
• The placebo effect cannot be the only reason for success, as people given mock ECT — the whole procedure without the shock— do not do so well.

Who is it suitable for?

ECT should be used only for those in black or white depression who do not respond to anti-depressants or in whom a delay in treatment (anti-depressants usually take two weeks to be effective) might be dangerous. ECT is the most effective known treatment for black or white depression. However, because of its mode of action and side-effects, it should be used only when absolutely necessary. I would not like tohave it done to me unless I was really desperate and every other treatment had failed.

Side-effects and risks

• Temporary confusion, loss of inhibition of feelings and loss ofmemory. For six to seven weeks after ECT the brain waves measured on an electro-encephalogram (which records electrical brain waves with electrodes placed on the scalp) are abnormal. During this period you may be less inhibited than usual, you may get confused (for example, about dates), and your memory may be worse, especially about the few weeks or months preceding the ECT treatment. All these effectsimprove, with the exception of permanent loss of particular memories before the ECT, though not the loss of the capacity to memorize. However, with many repeated courses of ECT there is some, though conflicting, evidence of permanent loss of capacity to memorize and loss of sharpness of intellectual function. Confusion and memory disturbance are lessened by the use of unilateral ECT, that is, a shock through one side of the brain only, though this may reduce the effectiveness.

* Headache, temporary muscle aches. (Before the days of muscle relaxants, the epileptic seizure sometimes used to fracture bones by the sheer power of the muscle contraction.)

* Risks. The anaesthetic risk, as in any minor operation; a temporary rise in blood pressure which can be dangerous to those prone to stroke; temporary effects on the rhythm of the heart which may be dangerous to those with heart conditions.

Drugs interactions

Chlorpromazine and drugs used to lower blood pressure may be dangerous because of a temporary lowering of blood pressure (before the temporary rise) due to the ECT.

• Heart conditions, especially after a heart attack.
• Recent stroke.
• Recent bone fracture or weakened bones.
• Thrombosis in the legs, because the seizure may cause a clot of blood to break off and get stuck in the lungs.
• Peptic ulcer — tendency to bleed may be increased.
• Acute respiratory infection — increases the anaesthetic risk.

Dosage

Usually a course of five or six electro-convulsive shocks is given, two a week, for three weeks. Although the treatment can be given on an out-patient basis, it generally necessitates admission to hospital.

Neurosurgery

Brain surgery is not recommended as a first-line treatment for depression. Although I cannot conceive or imagine being in a state so terrible that I would want or agree to have my brain cut, there are people walking around today thankful for their operation. Brain surgery for depression is usually carried out only when all the following conditions are evident: you have been ill for at least 10 years; your life is intolerable, you are totally incapacitated, and have a high risk of suicide or death; and you have not responded to all other treatments.

Some intolerable, chronic, untreatable severe depressions have improved enormously, with a “stereotactic limbic leucotomy”, which breaks some of the pathways in the limbic tracts (pathways in the brain related to emotion). Accompanying changes in personality (for instance, increased impulsivity) are much smaller since the advent of more refined techniques of operation which are made on far more restricted

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