Electroconvulsive therapy (ECT) is the oldest treatment in psychiatry that's still in use today. ECT uses a brief electrical current to induce a generalized seizure. No-one knows why, but in many cases this rapidly alleviates depression - amongst other things.The problem with ECT is that it may cause memory loss. It's hotly debated how serious of a problem this is, and most psychiatrists agree that the risk is justified if the alternative is untreatable illness, but it's fair to say that whether or not it's not as bad as some people believe, the fear that it might be, is the main limitation to the use of the treatment.
Wouldn't it be handy if there was a way of getting the benefits of ECT without the risk of side effects? To that end, people have tried tinkering with the specifics of the electrical stimulation - the frequency and waveform of the current, the location of the electrodes, etc. - but unfortunately it seems like the settings that work best, tend to be the ones with the most side effects.
Enter magnetic seizure therapy (MST). As the name suggests, this is like ECT, except it uses powerful magnets, instead of electrical current, to cause the seizures. In fact though, the magnets work by creating electrical currents in the brain by electromagnetic induction, so it's not entirely different.
MST is thought to be more selective than ECT, in that it induces seizures in the surface of the brain - the cerebral cortex - but not the hippocampus, and other structures buried deeper in the brain, which are involved in memory.
It was first proposed in 2001, and since then it's been tested in a number of very small trials in monkeys and people. Now a group of German psychiatrists say that it's as effective as ECT, but with fewer side effects, in a new trial of 20 severely depressed people. Ironically, they work on Sigmund Freud Street, Bonn. I am not sure what Freud would say about this.
The trial was randomized, but not blinded: it's hard to blind people to this because the equipment used looks completely different. Nor was there a placebo group. All the patients had failed to improve with multiple antidepressants, and psychotherapy in almost all cases, and were therefore eligible for ECT. If anything, the MST group were slightly more ill than the ECT group at baseline.
The ECT they used was right unilateral. This is probably not quite as effective as stimulation which targets both sides of the brain (bitemporal or bifrontal), but has fewer side-effects.
So what happened? After 12 sessions, MST and ECT both seemed to work, and they were equally effective on average. Some patients got much better, some only got a bit better.What about side effects? MST was noticeably "gentler", in that it didn't cause headaches or muscle pain, and people recovered from the seizures much faster (2 minutes vs 8 minutes to reorientation) after MST. This may have been because the seizures (as assessed using EEG) were less intense.
In terms of the all-important memory and cognitive side effects, however, it's not clear what was going on. They used a whole bunch of neuropsychological tests. In some of them, people got worse over the course of the sessions. In others, they got better. But in several, the scores went up and down with no meaningful pattern. If anything the MST group seemed to do a bit better but to be honest it's impossible to tell because there's so much data and it's so messy.
Unfortunately the tests they used have been criticized for not picking up the kinds of memory problems that some ECT patients complain of e.g. the "wiping" of old memories. For some reason they didn't just ask people whether they felt their memory was damaged or not.
Overall, this trial confirms that MST is a promising idea, but it remains to be seen whether it has any meaningful advantages over old school shock therapy...
Kayser S, Bewernick BH, Grubert C, Hadrysiewicz BL, Axmacher N, & Schlaepfer TE (2010). Antidepressant effects, of magnetic seizure therapy and electroconvulsive therapy, in treatment-resistant depression. Journal of psychiatric research PMID: 20951997
14 comments:
Just for our info., will you please list the general ranges of current strength used and magnetic field strengths in the cases of ECT, MST, TCM etc. and how they differ from Dr. Persinger's design of the Cap for transcendental experience?
Thanks
For some reason they didn't just ask people whether they felt their memory was damaged or not.
I'm not sure I understand how this is a good way to tell if they've had memory loss or not. This might not be a great analogy, but the way I see it, it's like someone coming home to a really cluttered house and being asked, "Is anything missing?" How exactly are they supposed to answer? I stress, though, that this may not be a good analogy.
Do you know what sorts of questions were asked to both groups?
Navaneethan: You're right that asking people about memory loss is kind of paradoxical - if the memory was completely lost, how would you tell if it was gone? - but it's widely done in ECT research. What some people report is that they can no longer remember memories that they know they used to be able to remember e.g. their wedding day (at an extreme example).
Now just about everything about this is controversial but some people do report it. It would be useful to at least ask people whether (they think) it happens with MST. If they don't think it does, it would make a lot of people more willing to accept it.
Call me when they blind this procedure, with a control group comparison. Oh and with a larger sample too. Otherwise it is just another psychiatric snake oil treatment waiting to be validated. Sort of like TMS???
Do you ever wonder what scientists will be saying a 100 or 200 years from now about using magnets on the brain, or surgery, or electricity, or even drugs to cure what ills mankind?
Anonymous #1: To be fair it's a new technique, hard to study because the patients involved are so ill, and harder to do double-blind than TMS or deep brain stimulation (where you can just turn the stimulator off). You could do a blinded study of MST, but it would be a big undertaking.
Still, we do need better studies and hopefully we'll see some soon.
When Thomas Satz wrote his iconoclastic 'Myth of Mental Illness' back in the seventies, he pointed out that there was no record of a psychiatrist EVER having undergone ECT. Does anyone know whether psychiatrists have since gathered enough faith in their own brain-frying techniques as to undergo their own treatments? Even a single case? Perhaps it's because psychiatrists' memories are more important than those of their vulnerable, depressed patients.
Try to imagine a standard surgical technique which no single qualified surgeon had ever undergone themselves, despite having identical symptoms to their patients... and ask yourself whether you would be somewhat suspicious.
And as for what Freud might have thought! His theories may not have been unfalsifiable, unsystematic, unverifiable... but at least he had a theory... which is more than you can say for anyone of these psychiatrists playing at Dr. Frankenstein with their ECT machines.
Notice the lack of placebo in trials like this. Until I see a convincing theory proposing a mechanism for how ECT - or MST for that matter - works then I'm going to assume that they work in much the same way as fake surgery....... placebo is a more rational explanation than anything I have read elsewhere. And if we're going to have placebo... then can't we have one that's a bit less barbaric?
mount analogue: I once observed a session of ECT at my local psych hospital. I was asked to sit out of one patient's session, because the patient was a local psychiatrist at the hospital.
A relative of mine, a very eminent medical doctor in the UK, underwent ECT. He reported that bilateral ECT worked for him; right unilateral didn't. But he only told me about that because we're blood relations.
I suspect that the lack of psychiatrists who are on record as having had ECT is a factor of the stigma of ECT rather than the actual properties of it. Noone wants to be known as "that guy/woman who needed ECT".
To elaborate on that: although one would hope that psychiatrists would be the most open people in regards to their own psychiatric problems, in my experience, it's the opposite.
For a psychiatrist to admit that they suffer from a psychiatric disorder would be to admit that one's on the "other side of the wire".
Mental illness is at least as prevalent amongst mental health professionals as it is amongst other people. Probably more so. But it's less talked about. Because the attitude is "us and them".
For an oncologist to admit they had cancer would be no big deal. Maybe even a plus. For a psychiatrist to admit they had bipolar would be like General Petraeus admitting he was a terrorist. Which is very sad, but true.
Kay Jameson is the exception that proves the rule. She's the only one.
Psychiatry is swamped by mental illness -- usually the Axis II and substance varieties. My God if anyone has ever had the misfortune of trying to have a career in an academic psychiatry department then one would be well versed in the manifestations of Cluster B (narcissistic and borderline) character pathology. Unfortunately ECT or magnet therapy would do little to treat those afflicted.
"....on the other side of the wire" seems like an eminently reasonable explanation for why so few psychiatrists openly admit to undergoing ECT. I think came across a little brusque this morning. I must learn not to post before my morning coffee. Sorry!
Even if ECT is just a placebo, as a last resort it certainly seems to work - and if we all start doubting its veracity, we'll destroy the only mechanism that makes it do so.
Thanks
Anonymous: Well, no comment about that. But mood disorders are also prevalent in my experience. I don't know if psychiatry is any different from the rest of academia in that regard. Personally I think it's no bad thing, I don't think you can really understand either mania or depression unless you've experienced them, so it can only help psychiatrists to understand what they're doing...
mount analogue: No problem - far better brusque and intelligent than nice but stupid :)
This mindhacks post from a few years back cites some research that indicates that psychiatrists experience mental health issues at a rate higher than both doctors in other fields and the general population.
http://mindhacks.com/2008/02/15/them-and-us/
Maybe they could try, that, forget name...uh...let's see...there's one person...then another...and they...uh...um..put a wire...no, that's not it...
I know! They talk!
Whew. Glad I remembered that.
This magnetic stuff is the classic Machine that Goes Beep from 'The Meaning of Life'.
ECT or magnets in the brian or whatnot might be good for very limited types of patients — those who are severely depressed, unresponsive to psychological intervention AND medically ill.
I can tell you though, in no uncertain terms, that in my experience ECT is often given in lieu of a human psychotherapeutic relationship. It's given to people who need a listening ear and help with real life circumstances. I've seen it again and again. And this magnet thing is just a variation on the theme.
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