Making sense of ECT

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What is ECT and why is it controversial?
What is it used for?
What do I need to know before I have ECT?
When should you avoid having ECT?
Where will I have my treatment?
What should I expect from a treatment session?
What’s the difference between bilateral and unilateral ECT?
How many treatments will I need?
How does it work?
Does it save lives?
What are the side effects of ECT?
What are the added risks for older people?
What are the alternatives to ECT?
What do mental health service users say about ECT?
What questions should I ask my doctor?
References
Useful organisations
Further reading

This booklet is for anyone who wants to know about electroconvulsive therapy (ECT). ECT is one of the most controversial treatments in modern psychiatry, used mainly for severe depression, which has not responded to other treatments. For some people, it has been a life-saver; but others have found it far from helpful, and consider the risk of its potential long-term side effects to be unacceptable.

What is ECT and why is it controversial?

ECT involves sending an electric current through the brain to trigger a seizure, or fit, with the aim, in most cases, of relieving severe depression. The treatment is given under a general anaesthetic and uses muscle relaxants, so that the muscles do not contract, and the body does not convulse during the fit.

Currently, there is no clear explanation of how ECT works, and this is a cause of controversy. On the one hand, its critics describe it as a crude treatment that causes brain damage; on the other hand, its supporters defend it as an effective and life-saving technique. (See How does it work?)

People’s experience of ECT varies enormously. It’s a short-term treatment, which can’t directly address underlying despair or practical problems, and does not prevent future depression. Memory problems are widely reported, though for some people they are only temporary. Some people feel violated by ECT.

Mind conducted a survey, in 2001, of mental health service users who had received ECT. It found that as many people found it unhelpful as helpful:

‘I would happily die rather than have ECT again.’ (Woman, Yorkshire.)
‘If I had not received ECT I would be dead by now.’ (Woman, Staffordshire.)

In a survey conducted by the ECT Accreditation Service (ECTAS – also see below) between September 2004 and February 2006, 72 percent of service users said that ECT had been helpful, 20 per cent said that it had had no effect, and 5 per cent said they would not want it again. 14 per cent believed that it had changed or saved their lives.

Many psychiatrists are convinced that it is an effective treatment for seriously depressed people, when no other treatment has been effective or available. They would argue that it is a suitable treatment when it is important to have an immediate effect; for example, because a person is so depressed that they are refusing to eat or drink, and are in danger of kidney failure.

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What is it used for?

ECT has been used to treat all types of mental distress in the past. It is now most commonly used to treat severe depression and, occasionally, mania, schizophrenia and catatonia.

In 2003, NICE (National Institute for Health and Clinical Excellence) published guidance recommending that ECT is used ‘only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with severe depressive illness; catatonia; a prolonged or severe manic episode’.

In treating schizophrenia, the ECT Handbook (published by the Royal College of Psychiatrists) recommends that ECT should be limited to patients who are unable to take clozapine (an antipsychotic drug given to those who are not helped by other antipsychotics), or who respond poorly to it, when psychotic symptoms (such as hallucinations) accompany a mood disorder (such as depression) or great agitation or immobility, and treatment recommendations for severe depression or mania would apply.

Because, when it works, ECT usually works very quickly, some psychiatrists think it is the best treatment for severe postnatal depression. It can minimise the time that the new mother is not able to care for and bond well with her baby. (See Understanding postnatal depression.)

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What do I need to know before I have ECT?

The law states that people have the right to make an informed decision about which of a number of treatment options to choose, and whether, or not, to accept the treatment a doctor suggests. To consent properly to a particular treatment, people need enough information to enable them to weigh up the risks and benefits of having it.

ECT and consent to treatment
Before any treatment begins, the doctor should provide you with full information about the specific nature of the treatment, any side effects or risks involved, how the treatment will be given, and what the alternative treatments are, including the alternative of having no treatment at all. Information should be given in language that you can understand. This means that technical information should be explained, using everyday terms. It also means that if your first language is not English, and your understanding of English is not adequate for you to understand fully, you should be provided with an independent interpreter. Having a relative or friend acting as a translator is not good enough. You should be able to have the information in writing, and have someone go through it with you, face to face.

It can be hard to take in a lot of new information in one go, especially if you are depressed and taking medication. You should not be afraid to ask your psychiatrist, or another member of staff, to explain it to you more than once. The Royal College of Psychiatrists recommends that you have a friend, relative or advocate with you, when you are given the information, so that they can go over it with you again. You should be allowed time, afterwards, to decide whether, or not, to go ahead with the treatment, before signing a written consent form specific to the proposed treatment. The Royal College of Psychiatrists also recommends that, if your relatives or close friends disagree with your treatment, this should be recorded in your notes, together with the reasons for proceeding with the treatment.

If you have signed a consent form, you should be informed that you can change your mind at any stage in the treatment and that, should you do so, the treatment will be stopped. You should also be told how you can tell staff if you have changed your mind. At each stage of the treatment, the doctor should confirm with you that you are continuing to consent. (The ECT Handbook contains an example consent form to be used by medical staff and patients at each stage of the treatment.)

Consent under the Mental Health Act 1983 (in force until September 2008)
ECT can only be given without consent if you are detained in hospital under the Mental Health Act 1983, and this is authorised by a doctor appointed by the Mental Health Act Commission (a second opinion appointed doctor, or SOAD). This doctor must visit you and consult with your own doctor, a nurse, and another professional involved in your care who is neither a doctor nor a nurse.

The only exception to this is in an emergency. In such cases, treatment can begin, under section 62 of the Act, pending the arrival of the SOAD, if you lack the capacity to consent, in a life-threatening situation, where the common law might be invoked. (For more advice on your rights, contact Mind’s Legal advice line, or your local PALS service (in England) or Community Health Council (in Wales).

Changes made by the Mental Health Act 2007 (in force from October 2008)
The new Mental Health Act 2007 introduces new safeguards for patients: ECT can be given only if you consent and the treatment is appropriate. In addition, if you are over 18, the doctor in charge of treatment or a SOAD must certify in writing that you are capable of understanding the procedure and consenting to it; if you are under 18, a SOAD must certify in writing that you are capable of understanding and consenting to the treatment.

If you are not capable of giving consent (i.e. you lack capacity), a SOAD must certify in writing that you are not capable of understanding or consenting to the treatment, but it would be appropriate for the treatment to be given, and giving it would not conflict with any advance directive (a statement about treatment you would not wish to have should you become incapacitated) you previously made, or a decision made by a person who has power of attorney for you, or the Court of Protection. The SOAD must also consult two other mental health professionals, one of whom should be a nurse and the other neither a nurse nor a medical practitioner, and neither of which should be the doctor in charge of your case.

Section 28 of the 2007 Act amends section 62 of the 1983 Act (urgent treatment) so that, when the treatment is ECT, urgent treatment can only be given only when it is immediately necessary to save your life or to prevent a serious deterioration in your condition.

(For more detailed information on the Mental Health Act, and consent to treatment, see Mind Rights Guide 3: Consent to treatment, and Mind’s web-based Legal Briefing 1: Amendments made to the Mental Health Act 1983 by the Mental Health Act 2007. For information about advocacy, see The Mind Guide to Advocacy.)

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When should you avoid having ECT?

Before a course of ECT treatments, you will need a full medical examination. You will be asked about your medical history, any medicine you are taking, any drug allergies, and whether you are pregnant. If you have any physical problems, these should be treated, as far as possible, before you have ECT. The ECT Handbook emphasises that the risks and benefits of the treatment must be carefully assessed, and that you and your family should be involved in the discussion. (See below for a checklist of questions to ask.) The NICE guidelines say that the risks of ECT may be enhanced during pregnancy, in older people, and in children and young people, and so doctors should exercise particular caution when considering the treatment for these groups.

Cardiovascular (heart and circulation) problems
When assessing whether to give you ECT, it’s important that doctors take into account any heart and related problems you may have. The NICE guidelines say ECT ‘causes changes in cardiovascular dynamics, which dictates the need for special caution in those individuals who are at increased risk of a cardiovascular event.’ It may also be hazardous to give you an anaesthetic if you have a serious chest disease.

Pregnancy
ECT is occasionally used in pregnancy. However, an anaesthetist may not be happy about giving a general anaesthetic to a pregnant woman, except in a medical emergency.

Medication
The British National Formulary (BNF) advises caution in using ECT in someone who is taking SSRI antidepressants (selective serotonin re-uptake inhibitors), because prolonged seizures have been reported with the SSRI fluoxetine. Caution is also advised with amitriptyline (a tricyclic) and phenelzine (a monoamine oxidase inhibitor or MAOI). Drugs that raise the seizure threshold (so that a higher dose of electric current has to be used – see below) should also be avoided. This includes benzodiazepine tranquillisers.

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Where will I have my treatment?

People usually receive ECT as inpatients in a hospital, although outpatient treatment is possible. The ECT Handbook recommends that the ECT treatment centre should consist of a suite of three rooms: a waiting area, a treatment room and a recovery room. The suite should be organised so that patients are able to move easily from waiting room, to treatment room, to recovery room.

The waiting area should be comfortable and provide a relaxing environment.

In the treatment room, in addition to the ECT machine, there should be all the equipment required for monitoring and resuscitation, including a defibrillator (a machine to restart the heart should it stop beating), oxygen, and a standard box of drugs, in case of medical emergency. There should be a trained nurse manager in overall charge of the ECT session; a nurse, who the patient knows and trusts, should be with the patient during all stages of treatment; there should be a nurse trained in resuscitation with each unconscious patient; and the medical staff should consist of a senior psychiatrist, a senior anaesthetist, and an assistant to the anaesthetist.

In May 2003, the Royal College of Psychiatrists, in partnership with the Royal College of Nursing and the Royal College of Anaesthetists, established the ECT Accreditation Service (ECTAS) to promote better standards of ECT practice in the UK and the Irish Republic. ECTAS promotes best practice in ECT clinics and its accredited clinics are shown on the Royal College of Psychiatrists website.

ECTAS reports that there are fewer clinics offering ECT than in the past, and, although this may mean that standards are higher in the more specialist clinics that remain, it also means that people may have to travel long distances in order to receive treatment, or may not be offered it at all. ECTAS is committed to supporting research into cognitive impairment and memory problems associated with ECT.

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What should I expect from a treatment session?

ECT is carried out under a general anaesthetic and with a muscle relaxant. Because of the anaesthetic, you must not eat or drink anything for at least six hours beforehand. You will lie on a bed, and your jewellery, shoes and any dentures will be removed. You should not be wearing any hair lacquer, creams, make-up or nail polish, or have any metal slides or grips in your hair.

Once you are comfortable, you will be given a general anaesthetic, via an injection. Later, while you are unconscious, you will receive an injection of muscle relaxant to minimise the convulsions caused by the electric current. Because of the muscle relaxant, you will be given oxygen, and the anaesthetist will look after your breathing, using a face mask and a pressure bag. Two padded electrodes will be placed on your temples, either one on each side of your head (bilateral ECT), or both on the same side (unilateral ECT). (See below for more information.) A mouth guard will be placed in your mouth, to stop you biting your tongue.

Modern ECT machines deliver a series of brief, high-voltage, electrical pulses, about 60 to 70 pulses a second, for three to five seconds, which results in a seizure, or fit. This will cause you to stiffen slightly, and there will be twitching movements in the muscles of your face, hands and feet. The seizure should last 20 to 50 seconds.

The seizure threshold
The strength of electric current needed to produce a fit is called the seizure threshold. This varies from person to person. It is higher in men than in women, and it increases with age, meaning that older people need a stronger electric current to produce the desired effect. The ‘dose’ of electric current given to you will be adjusted to take this into account. Other things that affect it are the exact position of the electrodes on your head, the amount of anaesthetic you have been given, and other medication you may be taking. If the dose is too low (below the threshold), there will be no benefit from the ECT. But the higher the dose, the greater the risk of unpleasant side effects, so it’s important to keep the dose as close as possible to the threshold.

Immediate after effects
After the convulsion, the mouth guard is removed and you will be turned on your side. The anaesthetist will provide oxygen until the muscle relaxant wears off (after a few minutes) and you start breathing on your own again. You will slowly come round, although you may feel very groggy. You may sleep for up to an hour after treatment. The immediate effects of ECT include headache, confusion, nausea, disorientation, loss of memory, apathy, aching muscles and physical weakness (see below ). If you are an outpatient, you will need to have someone with you to accompany you home. You should not drive, and you should not return alone to an empty house.

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What’s the difference between bilateral and unilateral ECT?

ECT may be given by placing one electrode on each temple (bilateral) or by placing both electrodes on one temple (unilateral), and this makes a difference to the effect ECT will have. The risk of side effects such as memory loss and cognitive impairment is greater when electrodes are applied bilaterally, but reducing the risks involved also reduces the effectiveness of the treatment. In unilateral ECT, electrodes are usually placed on the ‘non-dominant’ side of someone’s brain, as this causes less harm than if they are placed on the ‘dominant’ side. (Also see below  for more information.)

The ECT Handbook recommends that:

• bilateral or unilateral placement should be decided on an individual basis
• this decision should be part of the process of informed consent
• when a rapid and complete response is the main concern, bilateral placement is better
• when minimising cognitive side effects is the main concern, unilateral placement is better.

Bilateral placement is preferable:

• if unilateral ECT has not been adequate in the past
• if it is difficult to say which is the dominant side of the brain
• for mania, because there is inadequate evidence for unilateral ECT as a treatment for mania.

Unilateral placement is preferable if:

• the rate of improvement is not so critical
• the person has responded well to unilateral treatment in the past.

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How many treatments will I need?

The ECT Handbook says there should not be a pre-set number of treatments, but that you should be assessed after each treatment to see if another one is necessary.

Most people respond to a course of between four to eight treatments, although older people and men may need more. It’s usual to stop after eight, or so, treatments, if there has been no change at all in the patient’s symptoms, although The ECT Handbook suggests a maximum of 12. The treatments should normally take place twice a week, although three treatments may be given in one week in severe or life-threatening illness.

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How does it work?

There is no clear explanation for how ECT works.

The ECT Handbook admits that ‘convulsive treatments were developed in the context of ideas about the nature of mental illness and its relation to epilepsy that are now known to be incorrect’. However, it goes on to say that ECT is known to adjust the levels of brain chemicals which are involved in mood regulation, such as serotonin and noradrenaline, and to enhance the activity of dopamine. Recent studies in animals suggest that it may stimulate the production of new nerve cells and stimulate the brain to protect itself against stress. This finding fits both the observation that it is effective, and the suspicion that it causes damage: in repairing the damage caused by ECT, the brain perhaps repairs other faulty systems too.

The electrical activity in the brain that ECT causes is accompanied by increases in blood flow, oxygen levels and use of glucose in the brain. The blood-brain barrier also becomes more permeable during ECT. (The blood-brain barrier is a physiological mechanism, which acts to prevent a large number of harmful substances from crossing the protective cell membranes and entering the brain cells. It becomes more permeable as a result of stress.)

Brain damage
Some psychiatrists believe that ECT works by causing brain damage. People may experience a temporary lifting of mood after ECT, but this can be explained by post-traumatic euphoria, which typically follows head injury. Head injury can also cause amnesia (memory loss), denial, wide and unpredictable mood swings, helplessness, submissiveness, confusion and disorientation.

Dr Peter Breggin, a well-known critic of modern psychiatry, has reviewed the research conducted on ECT and concluded that it was the brain damage caused by ECT which explained its so-called ‘effectiveness’. Ironically, a leading supporter of ECT in the USA, Dr Max Fink, has also stated that where there is no evidence of brain damage, there is no improvement: ‘Where there is no evidence of impaired mental function and no electroencephalographic alteration [changes in recorded brain waves] clinical improvement does not occur.’

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Does it save lives?

‘It was a life-saver to me, as I was very depressed and highly suicidal.’
(Woman, Wiltshire, Mind survey).

‘After ECT I suffered the most severe depression imaginable for three and a half years during which time I tried to commit suicide as I could not bear it any longer’
(Respondent to UK Advocacy Network ECT Survey).

ECT does sometimes prevent death when someone is profoundly depressed, no longer eating or drinking, and in a critical state. But there is no good evidence that ECT prevents suicide.

In one study, Prudic and Sackeim concluded that ECT has a profound short-term beneficial effect on suicidal feelings, but admitted that this is not the same as preventing suicide. ‘Although ECT is not considered a treatment for suicidal behaviour per se, it may decrease or prevent suicidal behaviour, presumably due to its effectiveness in treating the illnesses characterized by suicidal symptoms.’ Other studies have shown that psychiatric hospital admission can increase the risk of suicide.

A study of the long-term outcomes of ECT, published in 1996, showed that the risk of death from all causes was doubled, and relapse, recurrence, and readmission to hospital more likely in those treated with ECT. Some of these deaths were due to heart disease (which is linked to depression) while others were suicide; there were also other causes.

People whose experience of ECT is overwhelmingly negative may well feel more suicidal after treatment, especially if they were treated against their will, which has been many people’s experience in the past.

(For help with suicidal feelings, see Useful organisations, and Mind’s booklets, How to cope with suicidal feelings and How to help someone who is suicidal.)

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What are the side effects of ECT?

The most important side effect of ECT, and the one which causes most concern, is memory loss. In addition, immediately after treatment people experience drowsiness, confusion, headache and nausea (feeling sick), aching muscles, and loss of appetite. Other effects include apathy, and loss of creativity, drive and energy. Very rarely people may experience prolonged fits as the result of ECT, especially if they are taking drugs or have medical conditions which lower the seizure threshold. Some people may become very confused between treatments, and on rare occasions may become restless or agitated. The use of anaesthetic carries risks of illness and a very small risk of death separate from the ECT procedure itself.

Some of the symptoms listed above may subside quickly, but memory loss, emotional blunting, and learning difficulties may last for weeks, months, or even permanently.

Loss of memory
The NICE guidance says:
‘ECT may cause short- or long-term memory impairment for past events (retrograde amnesia) and current events (anterograde amnesia). As this type of cognitive impairment is a feature of many mental health problems it may sometimes be difficult to differentiate the effects of ECT from those associated with the condition itself. In addition there are differences between individuals in the extent of memory loss secondary to ECT and their perception of the loss. However, this should not detract from the fact that a number of individuals find their memory loss extremely damaging and for them this negates any benefit from ECT.’

Memory loss can mean losing both good and bad personal memories, and having difficulty remembering new information. Comments recorded in Mind’s 2001 survey suggested that psychiatrists have seriously underestimated the potential extent and devastating effects of memory loss in some people:

‘I don’t play the piano, organ or violin any more, as I can’t remember how to. It seems my long-term memory has gone forever. Memories from my past five years, and more, have become either vague or have gone.’
(Man, Berkshire.)

I qualified as a maths teacher. Following all this ECT, I have no understanding of the maths concepts used in my further education courses, or even O-level standard.’
(Woman, Cleveland.)

Psychiatric research reflects users’ reports that memory loss can persist, and that this is different from the memory loss caused by depression. In one study, more than half of the patients (55 per cent) felt that they had not regained normal memory function, three years after receiving ECT.

An American psychologist conducted detailed autobiographical interviews with 19 people who were about to have ECT, and with a control group who did not have ECT. He then questioned both groups about the same information afterwards. He found that all the 19 patients showed a number of instances of forgetting their former memories, unlike the control group whose memories were unchanged. He followed up half of the ECT patients a year later, and there had been no return of the lost memories.

In another study, it was reported that memory complaints are common six to nine months after bilateral ECT, and were reported by 60 to 70 per cent of patients interviewed.

Bilateral versus unilateral ECT
It is recognised that bilateral ECT causes more severe memory loss than unilateral. In unilateral ECT, the electrodes are applied to the non-dominant side of the brain, to focus energy away from the speech centre. (The speech centre is usually on the left-hand side in right-handed people, but not always.)

Peter Breggin has criticised the theory that unilateral ECT is a less harmful procedure. He points out that non-dominant brain functions include: ‘the creative faculties, such as imagination, and the use of metaphor; visual and spatial capacities, as well as musical and motor abilities, such as co-ordination, dance and athletics; the quality or vibrancy of personality; initiative and autonomy; and insight.’

Other critics have commented that unilateral ECT: ‘assumes that one side of the brain is less valuable than the other. Humanistic psychologists would not agree. Instead, they might argue that the non-dominant side is essential to creativity. The placing of the electrodes unilaterally increases the concentration of current in one part of the brain, and the damage to this part is more severe than in bilateral ECT. EEG results one month after unilateral ECT confirm that it is possible to detect which side of the brain is damaged.’

The emotional impact
The emotional and psychological effects are under-estimated and under-researched. A report from the USA points out that studies measure successful outcome in terms of reducing the symptoms, rather than quality of life and social functioning.

Under the Mental Health Act 1983, many people have received ECT against their will, and this may influence the number of people who feel abused by the treatment. The following quotes are from the Mind survey, 2001:

‘I felt very much that I was being punished for not coping and being out of work. I still feel this. I felt empty and numb.’
(Woman, Birmingham.)

‘I was an outgoing, fairly confident person, and now I feel worthless and scared.’
(Woman, England.)

‘ECT was done to me, not done for me. That’s the total sense of how it felt. It paralleled sexual abuse, which I experienced as a child. Someone doing something to my body against my will.’ (Woman, Surrey.)

In depression, some people may feel guilt-ridden, and believe they are evil or harmful to others. They may see ECT as being a deserved punishment, and it can confirm the very feelings of worthlessness that characterise depression. In Mind’s 2001 survey, 22 per cent of recent recipients felt that they were being punished.

Physical injury
Injuries to teeth and mouth are risks associated with ECT, because the electrical stimulus contracts the jaw muscles, bypassing the muscle relaxant. High stresses during the forceful closure of the jaws can cause tooth damage, despite mouth guards.

Spontaneous seizures following a course of ECT are rare, and not more common than in the general population. They were reported by one per cent of the respondents to Mind’s 2001 survey.

Deaths following ECT are relatively uncommon, but do happen. It’s been estimated that the risk is about 4.5 deaths per 100,000 treatments, or four or five among 16,700 patients. This is no higher than the risk associated with having a general anaesthetic. (Also see Does it save lives?)

Side effects mentioned in Mind’s 2001 survey
Not everyone feels damaged by ECT, but for those who do, the feelings can be devastating. Mind’s 2001 survey was not scientific research, but does reflect the experiences of 418 people; one third of whom found ECT helpful.

The following short-term side effects (lasting up to six weeks) were reported. (They are listed, here, in order of frequency, with the most frequent first):

• headaches
• drowsiness
• confusion
• loss of past memories
• dizziness
• disorientation in time or space
• difficulty concentrating
• inability to remember new information
• suicidal tendencies after the treatment
• apathy
• inability to recognise people
• loss of reasoning ability
• fear and anxiety
• feelings of helplessness
• sense of betrayal
• visual problems
• loss of previous skills (reading, music, languages)
• sleep problems
• feelings of worthlessness
• neck or back pain
• loss of creativity
• epileptic seizures
• sexual difficulties.

Permanent side effects, in order of frequency, were:

• loss of past memories
• difficulty concentrating
• fear or anxiety
• inability to remember new information
• feelings of worthlessness
• feelings of helplessness
• sense of betrayal
• loss of previous skills
• loss of creativity
• suicidal tendencies after the treatment
• loss of reasoning ability
• sleep problems
• confusion
• apathy
• headaches
• inability to recognise people
• disorientation in time and space
• personality changes
• neck or back pain
• visual problems
• sexual difficulties
• drowsiness
• muscle ache
• dizziness
• nausea
• epilepsy

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What are the added risks for older people?

There are additional concerns in using ECT for older people, as there are with many medical procedures. The risks of treatment include an increased chance of heart problems, stroke and falls. The effect on an ageing brain is also recognised as potentially more damaging, with a greater possibility of memory loss.

Older people will be at much higher risk of dying than younger ones, but this age group is seen as more likely to be at risk of dying from the inability to eat or drink during severe depression, and so the benefits are seen as outweighing the risks.

ECT is sometimes considered less risky for older people than taking tricyclic antidepressants, which can have an adverse effect on the cardiovascular system. Opinion is divided about whether the newer SSRI drugs are any better. A survey of psychiatrists working with older people found that those who did choose the newer drugs often did so because of cardiovascular risk. Some psychiatrists believe that, since these antidepressants are safer, there is now no reason to choose ECT rather than drug treatment for older people.

Antidepressants and ECT are not the only possible treatments for depression: counselling and psychotherapy are under-used for older people.

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What are the alternatives to ECT?

There are many possible causes of depression, including life events, and psychological, social, biochemical and genetic factors. All of these interact to some degree. There are, consequently, various approaches to treatment. If the NICE guidelines are being followed, you will only be offered ECT (in most cases) if you have tried other treatments and found them unsuccessful, unhelpful or unacceptable.

Antidepressant drugs
The NICE guidelines on depression say that antidepressants should be used for severe depression, alongside other therapies. People have very varied responses to medication. But there are different types of antidepressant available, and you may need to try several before finding one that works. Information about all if the different antidepressants currently prescribed in the UK is available in Making sense of antidepressants.

Talking treatments
Your GP should be able to refer you for cognitive behaviour therapy, psychotherapy or counselling, which can help you to deal with the problems underlying and surrounding your depression. These treatments provide an opportunity for you to talk, in a way that assists you to understand yourself better, and help you to work out a more positive and constructive way of approaching problems. Your local Mind association may offer free, or low-cost, talking treatments. (Also see Useful organisations.) (See Mind’s booklets, Understanding talking treatments, Understanding depression and Making sense of cognitive behaviour therapy.)

Arts therapies
Therapies using art, music, drama, dance or creative writing may be very powerful in helping to lift depression. Even someone who is so profoundly depressed they can’t speak may be moved by music or poetry, which then begins a process of recovery. These therapies are available in some psychiatric units and community mental health facilities. (See Mind’s Arts therapies factsheet.)

Complementary therapies
Complementary and alternative therapies can be particularly helpful when people are experiencing stress-related symptoms, anxiety and depression, and are not concerned with merely treating symptoms. There are many different therapies, including homeopathy, herbal medicine, acupuncture, aromatherapy, meditation, reflexology, neurolinguistic programming, and various types of massage.

Physical activity
Physical activity has proved to be very beneficial when tackling problems like depression. It works by changing levels of chemicals in the body that influence mood. Exercise is recommended for depression in NICE guidelines. (For more information, see The Mind guide to physical activity.)

Self-help groups
Many people experiencing emotional distress find it helpful to share their feelings with others going through similar difficulties. There are self-help organisations for people suffering from depression. (See Useful organisations, or ask at your local Mind association.)

Transcranial magnetic stimulation (TMS)
Neurologists have been using TMS as a research tool for some time, and it seems clear that it may be useful for treating depression. It involves creating magnetic fields through an insulated coil conducting an electric current, which is placed on the surface of the scalp. Rapidly changing magnetic fields cause electrical currents to flow within the brain. This affects the nerve function, without causing an epileptic fit. The technique has been investigated in various ways, by using different positions of the coil, by stimulating different areas of the brain, and by changing the signal frequencies, for example. The first trials of TMS for depression used only small, selected groups of patients, with no control group for comparison. As a result, it was not clear whether this was really an effective treatment for depression. More recent research continues to suggest that it may become an alternative to ECT.

It is considered to be a safe procedure. The most important safety concern is the risk of seizures, but no seizures have been reported since the introduction of guidelines for safe use of the technique. This may seem a strange concern, given that ECT is considered to have failed if it does not cause a seizure. But, if similar results can be achieved without seizure, it would be a great advantage. There may be some local scalp pain or headache at the time of treatment, but there have been no reports of harmful effects.

The technique is still being researched, and is not yet available as a treatment. NICE guidance on TMS for depression, produced in November 2007, states that as there is still uncertainty about whether TMS is really an effective treatment, how long its effects might last, and how it is best applied, it should only be used in research studies designed to establish these factors.

Vagus nerve stimulation (VNS)
VNS was initially developed for treating epilepsy, but has been tried for depression in the last few years. It involves placing an electronic device under the skin in the left chest wall, with an electrode connecting it to the left vagus nerve in the neck. Putting the device in place takes about an hour. Once working, it sends mild, electrical pulses to the nerve, at intervals.

Side effects can occur, but usually only when the stimulation is on. They include voice alteration, shortness of breath, neck discomfort, and coughing, all of which apparently diminish over time. It’s reported to lift depression, but, like TMS, is still being researched and is not generally available in the UK.

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What do mental health service users say about ECT?

The following are quotations from reporters to Mind’s survey in 2001:

‘The effect of the treatment was amazing. All psychotic thoughts diminished, and I started to feel as if I was finally being lifted from the big, black hole I had been in. I honestly believe that, had I not received ECT, I would not be living the full, happy and healthy life that I am living today.’

‘Under no circumstances would I choose to have ECT. I would rather go down fighting than submit to that abomination.’

‘It just seems to help me out of my depressed state of mind very quickly.’

‘It was hell on earth.’

A consumer survey by the Service User Research Enterprise at the Institute of Psychiatry in 2004, collating users’ views on ECT ‘in their own terms’, found that there were twice as many very negative testimonies as very positive ones. This type of qualitative research has had an important influence on how ECT is perceived by both the Royal College of Psychiatrists, who have since changed the information they produce on ECT, and NICE, who take the views of health service users into account when producing their guidelines.

Clearly there is a wide split among people who have had ECT about how helpful it is. While it is most often found helpful in the short term, people may find that its long-term effects are disappointing. This supports its use as a way of treating people whose depression is so severe that their life is in danger. One service user, who has commented favourably on his ECT treatment, makes the point that ECT, on its own, is not enough:
‘On more than one occasion in my life, the intervention of ECT has been beneficial and not damaging. The initial help given, it’s been all the more possible to gain from the skills and the patience of a clinical psychologist. It is true that ECT should not be used to excess, and it is also true that usually more than ECT is needed. But the different therapies and treatments can, and should, be seen as complementary, rather than in competition.’

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What questions should I ask my doctor?

If ECT is recommended, you should ask the following questions:

• What is the reason for suggesting ECT?
• What are the risks associated with ECT?
• How could ECT help me?
• What are the side effects?
• Are there any long-term effects?
• Has every alternative treatment been tried, including different drug treatments, or talking treatments?
• What treatment will be offered in addition to, and after, ECT?
• What is the risk of physical deterioration or suicide?
• How many treatments are proposed?
• Is unilateral or bilateral ECT proposed?
• How will the dosage be decided?

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References

British National Formulary 53 (British Medical Association and Royal Pharmaceutical Society of Great Britain March 2008).
Convulsive Therapy – Theory and Practice M. Fink (Raven Press 1973).
‘Electroconvulsive Therapy and Suicide Risk,’ J Prudic and H Sackeim Journal of Clinical Psychiatry 1999:60 (supple. 2).
Depression (amended): management of depression in primary and secondary care (NICE, April 2007).
ECT Survey, UKAN (United Kingdom Advocacy Network) (1996).
Guidance on the use of electroconvulsive therapy, Technology Appraisal 59 (NICE, April 2003).
‘Nature and extent of dental pathology and complications arising in patients receiving ECT’ N. Beli, P. Bentham (1998) Psychiatric Bulletin 22, 562-565.
‘Patients join the fight to curtail shock treatment’ R. Dobson (Health Section) The Independent, 14 February 1995.
‘Recent advances, psychiatry’ D. Lyons, D. M. McLoughlin (2001) British Medical Journal 323, 24 November, 1228-1231.
‘Seven year prognosis in depression: mortality and readmission risk in the Nottingham ECT cohort’, O’Leary DA and Lee AS (1996) British Journal of Psychiatry, 169, 423-429.
‘Consumers’ views of electroconvulsive therapy: a qualitative analysis’, Rose D, Fleischmann P and Wykes, T, (2004) Journal of Mental Health 13(3), 285-293.
Shock Treatment: A survey of people’s experiences of electroconvulsive therapy (ECT) M. Pedler (Mind 2001).
The ECT Handbook, 2nd edition, A.I.F. Scott (ed), Council report CR128 (Royal College of Psychiatrists, 2004).
‘The Mental Health Act Commission Ninth Biennial Report 1999-2001’ (The Stationery Office 2001).
‘The prevention of suicide in patients with recurrent mood disorder’ M. Peet (1992) Journal of Psychopharmacology 6 (2), supplement 334-339.
‘The use of electroconvulsive therapy in elderly depressive patients’ K. Malcolm, M. Pett Antidepressants in the Elderly ed. K. Ghose (Croom Helm 1989).
‘Transcranial magnetic stimulation in depression’ P. D. Reid, P. M. Shajahan, M. F. Glabus, K. P. Ebmeier (1998) British Journal of Psychiatry 173, 449-452.
Toxic Psychiatry P. Breggin (HarperCollins 1993).
Transcranial magnetic stimulation for severe depression, Interventional procedure guidance 242, (NICE, November 2007).
Vagus nerve stimulation (VNS) therapy for patients with depression now available in Europe Porter Novelli (web: www.immedia.it).
Vagus Nerve Stimulation Fact Sheet Cyberonics Europe (web: www.cyberonics.com ).

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Useful organisations

The Association for Post Natal Illness
helpline: 020 7386 0868
web: www.apni.org
Offers advice and support to women suffering from postnatal depression

British Association of Counselling and Psychotherapy (BACP)
Tel: 0870 443 525
web: www.bacp.co.uk
Lists details of local practitioners

Depression Alliance
helpline: 0845 123 2320
web: www.depressionalliance.org
Charity providing information, support and understanding for those suffering from depression

Depression UK
Self Help Nottingham, Ormiston House, 32-36 Pelham Street, Nottingham NG1 2EG
email: info@depressionuk.org
web: www.depressionuk.org
A self-help organisation providing support groups and a free information pack

Help the Aged
207-221 Pentonville Road, London N1 9UZ
tel: 020 7278 1114
web: www.helptheaged.org.uk
Supporting disadvantaged older people

National Institute for Health and Clinical Excellence
www.nice.org.uk
For clinical guidelines on treatment and technology appraisals

Rethink
advice line: 020 8974 6814 tel. 0845 456 0455
web: www.rethink.org
Aims to improve the lives of everyone affected by severe mental illness

Samaritans
write to: Chris, P.O. Box 9090, Stirling, FK8 2SA
helpline: 08457 90 90 90 minicom: 08457 90 91 92
email: jo@samaritans.org
web: www.samaritans.org.uk
24-hour emergency helpline

UK Council for Psychotherapy (UKCP)
tel: 020 7014 9955
web: www.psychotherapy.org.uk
UKCP is the umbrella organisation for psychotherapy in the UK. Lists local practitioners

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Further reading

Alternatives beyond psychiatry ed. P. Stastny and P. Lehmann (Peter Lehmann Publishing 2007
Art of recovery: a pocket guide to recovering from mental illness, S. Heyes (South Somerset Mind 2005)
Climbing out of depression: a practical guide for sufferers S. Atkinson (Lion Publishing 1993)
Depression: The way out of your prison D. Rowe (Routledge 2003)
Depression in later life, J. Manthorpe and S. Iliffe (Jessica Kingsley Publishers 2005)
Going Mad? Understanding mental illness M. Corry, A. Tubridy (Newleaf 2001)
How to cope with memory loss (Mind 2007)
How to cope with suicidal feelings (Mind 2007)
How to help someone who is suicidal (Mind 2004)
Making sense of antidepressants (Mind 2006)
Making sense of antipsychotics (Mind 2007)
Making sense of cognitive behaviour therapy (Mind 2007)
Making sense of coming off psychiatric drugs (Mind 2005)
Making sense of psychotherapy and psychoanalysis (Mind 2004 )
Making sense of sleeping pills and minor tranquillisers (Mind 2007)
Mind Rights Guide 3: Consent to medical treatment (Mind 2008 )
Mind Rights Guide 5: Mental health and the courts (Mind 2007)
Overcoming Depression: A self-help guide using cognitive behavioural techniques P. Gilbert (Constable 2000)
The Mind Guide to Advocacy (Mind 2006)
The Mind guide to managing stress (Mind 2006)
The Mind guide to physical activity (Mind 2006)
The Mind guide to relaxation (Mind )
Toxic psychiatry: a psychiatrist speaks out P. Breggin (HarperCollins 1993)
Understanding bereavement (Mind 2008 )
Understanding depression (Mind 2007)
Understanding mental illness (Mind 2007)
Understanding obsessive-compulsive disorder (Mind 2008)
Understanding postnatal depression (Mind 2008)
Understanding schizophrenia (Mind 2008)
Understanding talking treatments (Mind 2005)

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This booklet was written by Katherine Darton

First published by Mind in 1992. Revised edition © Mind 2008
ISBN 9781874690511
No reproduction without permission