JACK NICHOLSON has a lot to answer for. One of the knock-on effects of hit 1975 movie was a public backlash against electroconvulsive therapy (ECT). The treatment, used since the 1930s for a wide range of mental health conditions, delivers a jolt of electricity to the brain big enough to trigger a seizure.
The filmâs brutal depiction of ECT and lobbying helped it fall out of favour in the 1980s and 1990s.
But ECT may now be undergoing a revival, led by psychiatrists who champion it because of its success rate. âItâs the most effective treatment we have in psychiatry,â says at Cardiff University, UK, who oversees ECT treatments in the area. A report from the UK Royal College of Psychiatrists last September showed that three-quarters of people with mental health problems felt improvement after having ECT. And psychiatrists say that a similar percentage of people who have schizophrenia that doesnât respond to drug treatment find ECT effective.
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âIâve never seen an ECT treatment that doesnât work,â says , a psychiatrist at the Beth Israel Deaconess Medical Center in Boston.
âPeople have such a skewed view of electroconvulsive therapy. It is seen as primitive and horrificâ
Mounting evidence has convinced the US Food and Drug Administration (FDA) to consider reclassifying ECT devices to make the technology more accessible for people with depression or bipolar disorder. The public will still take some convincing, however. In a 2005 survey in Switzerland, for example, 56 per cent were against ECT, while just 1 per cent said they were in favour.
Perhaps thatâs no surprise â giving someone a seizure to treat a psychiatric illness seems brutal and archaic. Even the name âelectroconvulsive therapyâ isnât very comforting. âPeople in society have such a skewed view on it,â says Farrell. âIt is seen as primitive and horrific.â And until recently we still didnât know how it works.
Thatâs changing too as we learn more about what effects ECT has on the brain. Could this new understanding be enough to rebrand ECT as a modern treatment, and shift the stigma?
The treatment has moved on a lot since Jack Nicholson was pinned down. Nowadays, there arenât really any convulsions. People undergoing ECT are given general anaesthesia and a muscle relaxant. âNothing really moves during the procedure,â says Farrell. âMaybe the big toe twitches, but thatâs it.â
Chemical boost
The way ECT works on the brain is also less brute force than it might seem. For instance, it appears to alter the levels of brain chemicals known to be involved in a range of psychiatric and neurological conditions. Standard antidepressant drugs boost the activity of serotonin, at least partly by limiting the number of serotonin binding sites. ECT .
It also appears to increase brain levels of dopamine â an important chemical for a wide range of brain functions, including learning and movement. This might help explain why the treatment â which causes tremors and movement problems â as well as for psychiatric illness.
There is plenty of evidence that ECT triggers the release of a protein called brain-derived neurotrophic factor, too. This protein spurs the growth and development of new brain cells â a process that happens in healthy brains, but seems to be halted in conditions like depression and schizophrenia. The higher the levels of the protein after ECT, the . And brain regions that appear shrunken in depression â areas involved in emotion and memory â . Again, antidepressants are thought to work the same way.
Some evidence also suggests that ECT might affect the immune system. , Los Angeles, and her colleagues have been investigating whether the activity of any genes related to immune function is turned up or down after people have had ECT.
The tests suggest that a course of ECT causes an initial inflammatory boost, but long-term dampening down of immune activity. This might help explain why the treatment is useful for schizophrenia and depression. Both conditions have recently been linked to the immune system, and clinical trials of anti-inflammatory drugs for both are under way.
But ECT is pretty extreme. General anaesthesia has its own risks and it is usual to have headache, jaw pain and mild confusion for a while after the treatment. Short-term memory problems are common, and a small percentage of people report permanently losing memories of events from around the time of their treatment. And despite the fact that ECT has been around for decades, there are its long-term effects, and how exactly it should be applied.
Antidepressants and antipsychotic drugs also come with side effects. Many people with depression actually feel more suicidal when they start taking antidepressants, and the drugs can also cause nausea, weight gain, fatigue and drowsiness and problems with sexual function. Antipsychotics can have similar effects, along with slow thinking, stiffness and shakiness.
But ECT âremains in the shadowsâ, says , who directs ECT services at the Mount Sinai Hospital in New York City. He describes it as the âsecond most controversial medical procedureâ, after abortion. In the US and UK, only a tiny fraction of people with depression that doesnât respond to medication are offered ECT, despite evidence that it can be effective.
âI know plenty of people for whom ECT worked, and it worked for me temporarily. Itâs kept me hereâ
Many mental health professionals avoid recommending it. Kellner says most of his patients have sought him out personally after doing their own online research.
âThere are very mixed feelings about ECT, even among psychiatrists,â says Kirov. âIf I speak to medical professionals outside of psychiatry, there is almost disbelief that we are using such an archaic practice.â
Despite this, ECT has regained some lost ground in recent years. After looking at how effective it has been, the FDA has developed plans to reclassify ECT devices. If plans go ahead, ECT treatments for many adults with depression or bipolar disorder will be downgraded from the high-risk âClass IIIâ category to a lower-risk âClass IIâ category, which should make it easier for doctors to prescribe and use them.
There are problems with the proposals, though. While the American Psychiatric Association , there are concerns that some conditions are excluded â ECT will remain in the highest-risk category for schizophrenia and mania for example, as well as for use in children and adolescents. But all these groups stand to benefit from ECT, says Kellner.
There is no guarantee that the reclassification will go ahead, either. Similar plans have been derailed in the past, at least partly because of extensive lobbying from anti-psychiatry groups, largely funded by the Church of Scientology. Such groups are already .
Kirov hopes that better education will help reduce the stigma around ECT. For the past five years, he has been running a programme that ensures all of the trainee doctors in Cardiff witness ECT treatment and its effects. âWe get people shuffling in, mute, and the day after treatment they are talking and walking around,â he says. âOnce you see that, youâre a convert.â
The new Brain boom
Electroconvulsive therapy (ECT) might not be widely popular, but other brain-stimulation techniques are booming. Devices that deliver electric currents to the brain â by direct current or magnet â are claimed to boost attention and memory or make us better at maths. You can even buy your own trendy headpiece from Thync, a start-up in San Francisco.
Thyncâs device is designed to alter the brainâs activity by targeting nerves in the neck, to create one of two âvibesâ.
And deep-brain stimulation (DBS) has become more acceptable in recent years, for conditions ranging from depression to Parkinsonâs to obesity. DBS involves drilling a hole in your skull and inserting an electrode into your brain before electrically stimulating it, so it is more invasive than ECT, and comes with added risks of infection after surgery.
The market for neurostimulation devices â which covers DBS, brain stimulation and nerve stimulation â was estimated to be worth $5 billion in 2013, and this figure is expected to double by 2020.
âBrain stimulation is extremely fashionable, but I donât think people put ECT in the same category, even though they probably should,â says George Kirov, who oversees ECT treatments at the University of Cardiff, UK. âIâve seen people refuse ECT and ask for DBS,â he says.
Case study: ECT was like lifting a huge weight
âI attempted suicide five days before my graduation,â says Deena Nyer Mendlowitz, a 39-year-old comedian and writer based in Cleveland, Ohio. Since then, she has received a range of diagnoses and treatments. Every so often a drug would lift her depression and ease her suicidal thoughts, but usually the benefits were short-lived. It wasnât until 12 years later that she was offered electroconvulsive therapy.
âWhen you first hear about ECT, thereâs a scariness to it,â says Mendlowitz. âI was frightened, but when the other thing youâre thinking about is death, youâll try anything.â Mendlowitz would wake up feeling tired and confused, and the treatment didnât have much of an effect at first.
Feeling the effect
On waking after the eighth or tenth treatment, Mendlowitz felt different. âI remember thinking: âoh my god, I think this helpedâ,â she says. âIt was a sudden relief, as if a huge weight had been lifted.â The treatment dispelled Mendlowitzâs suicidal thoughts. âIt saved my life,â she says.
Mendlowitzâs first round of therapy lasted nine months, during which she had 21 ECT treatments. After that she remained well for around a year, but then the thoughts started to return. âI went back to ECT, and it helped a little.â
But when the treatment was ramped up and applied to both sides of her head, she found she started to forget things. âI got my cognitive functioning back, but the memories are gone forever,â she says.
Now, Mendlowitz opts for a combination of psychoanalysis and medication. But she wouldnât rule out using ECT again. âThere definitely is a lot of stigma,â she says. âBut I know plenty of people for whom ECT worked, and it worked for me temporarily. Itâs kept me here.â
This article appeared in print under the headline âCan tainted treatment make a shock return?â
