On talking of ECT treatment, Mandy asked about use of ECT in the elderly, specifically with regards to side effects.
I'm not particularly pro or anti ECT, any more than I'm pro or anti tablets or pro or anti psychological therapies. Any intervention has potential benefits, risks and side effects. The issue is simply one of offering a choice of the right therapies for the right problem at the right time.
If you had free choice of treatment, rather than the NHS where you can only choose from what's offered to you, what do informed patients choose? The USA shows us this. In America, where patients have informed consent (i.e. are told all the risks and benefits of all options) and through private health care can pay for the treatment of their choice (or go see another shrink who'll take their cash and do it for them), how much ECT is used? Answer : twice as much as in the UK.
The latest DoH data suggests we're undertaking about 4266 sessions of ECT a month in the UK, about 140 a day. From their stats, most (84%) is undertaken with consent.
Why do Americans prefer ECT when given a free choice? Because in a few situations it's a safer and better treatment than alternatives. Bottom line : people can get better much quicker, with fewer side effects than other treatments.
That sounds great, so why's it not used more? Because it's only a few situations where it's the treatment of choice. Severe mood disorders, rare subtypes of schizophrenia and post natal depression are pretty much the only good reasons. Most people with depression don't benefit from ECT, it's only severe depression and depression with marked physical symptoms (the "somatic syndrome" bit) that responds well to ECT.
How is ECT given? You lie down, you have an anaesthetic injection, you go to sleep for about 2 minutes. In that time two handles are put on your head, a charge is delivered and you have a fit. Fit is over stating things. The anaesthetic stops you having a fit, in modern ECT. 5 years ago I timed ECT by watching how long someone fitted for. Nowadays I see nothing as we don't physically move, being anaesthetised and relaxed. Now we look at EEG (brain wave monitoring) to monitor the seizure since the person's relaxed, but typically it lasts 25 seconds or so. A minute later you come round, have a cup of tea and a biscuit and all's done.
Risks? It's been shown to half the incidence of death, compared to tablet/talking therapy treatment. So tablets/talk is twice as risky as ECT for severely depressed folk. Safer than other alternatives, then.
What of long term risks to mind and memory? Some people have no change at all, so have their ECT, are right as rain and go home (having out-patient ECT). Most people are more confused after ECT, for a short while. Some papers show no change to memory over the long term (i.e. after 12 months, memory's the same as before ECT). This paper also confirmed that older patients regained their memory better than younger patients, ECT is often better tolerated and more useful in older adults. Imporantly, everyday memory isn't changed.
This all sounds rather positive. Doesn't ECT cause permanent memory change? Tricky. Maybe yes, maybe no, if it does so it's a rare event (which trials haven't been able to tease out). The problem is that being severely depressed affects our memory, long term. So you can see memory and cognitive changes in folk with severe depression whether they do or don't have ECT. Because depression causes memory change, this makes it really tricky to work out how much ECT adds to the chance of this happening.
What of people in the know, would I want ECT? The Royal College of Psychiatrists surveyed us all, asking us that. If severely depressed, almost every psychiatrist said they'd want ECT. Those who didn't were Child & Adolescent psychiatrists and Psychotherapy psychiatrists who never saw ECT so hadn't formed the opinion on it.
So, if cautiously used for the right folk, I see ECT as a useful thing that may have risks (but the evidence base and clinical experience happily both confirm it's much safer than medication and safer than doing nothing). Serious long term risks (like memory loss) are rare.
Of the thousands of unwell patients in my corner each year, how many do I feel should be offered ECT as the best treatment? Not many. Last year it was just two folk in my whole sector who had ECT.