Sunday Times of London
DECEMBER 09 2001
It has a brutal history. We don't know how, or even if, it works. So why do we still give electric shocks for depression? Kathy Brewis investigates.
Some countries refuse to use it. Scientists have little idea how it works, and precious few doctors have been properly trained to administer it. But in contrast with much of the rest of Europe, patients in Britain are routinely sedated and shot through with electricity, in an attempt to fix their troubled minds. The horror stories surrounding electroconvulsive therapy (ECT) abound. This is the poet Sylvia Plath's grimly eloquent account from her autobiographical novel The Bell Jar: ''Don't worry,' the nurse grinned down at me. 'Their first time, everybody's scared to death.' 'I tried to smile, but my skin had gone stiff, like parchment. Doctor Gordon was fitting two metal plates on either side of my head. He buckled them into place with a strap that dented my forehead, and gave me a wire to bite.
'I shut my eyes. There was a brief silence, like an indrawn breath. Then something bent down and took hold of me and shook me like the end of the world. Whee-ee-ee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant. 'I wondered what terrible thing it was that I had done.'
In the popular mind, ECT is barbaric, a brutal abuse of power by men in white coats. Its portrayal in films such as One Flew over the Cuckoo's Nest and famous real-life cases from the 1950s and 60s have only added to the guilty verdict. Ernest Hemingway, given about a dozen shocks in an attempt to ease his recurring depression, found the resulting memory loss unbearable and shot himself a few days later. 'What is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business?' he asked. Vivien Leigh underwent a series of shock treatments as part of a 'care' regime for manic depression, which left her, as her husband Laurence Olivier put it, with 'slight but noticeable personality changes... She was not, now that she had been given the treatment, the same girl that I had fallen in love with'.
So far, so damning. So how can ECT continue to be used as a treatment for depression, albeit with modifications (now the patient is anaesthetised, and a muscle relaxant is given to prevent the body jolting and possible broken bones)? The answer is simple: it is still used because most psychiatrists believe that it does some good - that it can even save lives. The Royal College of Psychiatrists, the professional body to which all psychiatrists belong, claims an 80% success rate for the estimated 12,000 Britons who receive ECT for severe depression each year. But there is a reason why ECT has been so demonised, beyond the violent images and a level of distrust of psychiatrists: nobody has adequately explained what goes on when those 220 volts zip through your brain. 'It works, we're just not sure how,' psychiatrists say. One doctor described it thus: 'Psychiatrists are constrained to tuning very high-tech internal combustion engines, but they are only allowed to listen to the exhaust note. Sometimes slamming the bonnet makes it go. If it works, why not?' Which sounds scarily cavalier.
There has, however, been a scientific drive to understand ECT. In recent years, various hypotheses have been put forward to explain how ECT might be acting on the brain, all of which assume that depression is a physical illness. One theory is that inducing a seizure causes a shift in the body's neuroendocrine system so that stress hormones are kept in balance. Another is that artificially inducing a seizure somehow taps into the brain's natural ability to stop seizures. A third idea is that the electricity somehow changes the level of chemicals in the brain. These are tiny pieces of an intricate jigsaw that may or may not fit together one day.
Now leading researchers here and in the United States are making an extraordinary claim: ECT works by causing brain cells to be renewed. It has been known since the mid-1990s that new nerve cells (neurones) form throughout a person's life in the hippocampus, a brain structure known to be involved in memory and emotion. An American team led by Professor Ronald Duman at Yale university, and others, suggest that depression, particularly if it is stress-associated, results from the death of vulnerable neurones in a region of the hippocampus called CA3. Some of the features seen in depression, such as poor concentration and memory, could reflect this loss of nerve cells - indeed, brain scans of severely depressed patients show that the hippocampus is smaller than it should be. Both antidepressants and ECT have been shown to induce brain cells to produce a protein called brain-derived neurotropic factor (BDNF), which promotes the growth, repair and resilience of neurones. It has been observed that, following ECT, new neurones form and existing ones sprout new connections. Various studies taken together have led to a dramatic hypothesis. 'The research suggests depression causes neuronal cells to be damaged and antidepressant treatments cause the neurones to be regenerated,' says Professor Ian Reid of Dundee university. 'It may be that some of the treatments that people think are rather crude are in fact quite effective rescuers of the dying neurone.'
If this turns out to be true, the potential applications could go beyond treating depression to more obvious neurodegenerative conditions such as Alzheimer's and Parkinson's diseases.
ECT's origins go back to the turn of the 20th century, when mentally ill patients tended to be locked up in asylums and left. Psychiatrists started to experiment with a variety of new 'treatments' for the severely ill, including lobotomy and temporary, insulin-induced coma. One doctor had the idea, based on the (untrue) belief that epilepsy and schizophrenia could not coexist, of injecting epileptics with serum from schizophrenic patients, and injecting schizophrenics with the stimulant Metrazol to induce a seizure. The latter was a hideous procedure - the patient would convulse violently and often vomit - but for mysterious reasons it tended to reduce the symptoms.
In the 1930s, Ugo Cerletti, an Italian psychiatrist, wondered about using electricity as a way to induce a seizure more quickly than with Metrazol. With his assistant, Lucio Bini, he experimented on dogs and found that, yes, electricity could indeed induce a fit. They also sent their assistants to observe pigs being stunned by electricity before slaughter - clearly it was important to get the dose right. By 1938, Cerletti and Bini felt ready to test their method on a human. Their subject was a Milanese man who had been found mumbling incoherently to himself in the railway station. Electrodes were applied to his temples, an orderly put a rubber tube between his teeth to stop him biting his tongue, and the electricity was applied. The patient's muscles jolted but he was not rendered unconscious. 'Not again, it's murderous!' he pleaded - but they carried on. After several shocks they stopped, and he spoke more coherently. After 10 treatments, they claimed, the patient was released 'in good condition and well-oriented', and a year later he had not relapsed.