Who needs drugs, when you can just pop in a new battery?

May 24, 2007 9:02 PM

A new wonder drug? Once used in a failed attempt to treat epilepsy, electrical stimulation of the vagus nerve now shows promise in treating severe depression. Billed as a Brain Pacemaker, it's making people happy. Or something: "Doctors began to suspect it held potential for treating severe depression when patients clung to the device, even when it wasn't helping their epilepsy."
posted by IronLizard (48 comments total)

I can't wait to see this done in the back of smoke-filled tatoo parlors. Totally _^[cyber]punk rock.
posted by delmoi at 9:11 PM on May 24, 2007

Oh, and grandma may have been on to something with those magnets.
posted by IronLizard at 9:13 PM on May 24, 2007

Seizures help with mood. For real.
posted by Ironmouth at 9:23 PM on May 24, 2007

If it works, it works, and that's great. But if it is only as effective as drugs, it wouldn't seem to be justified. It'd need to be more effective than drugs before docs and patients would seriously consider surgery and a pacemaker, methinks.
posted by teece at 9:33 PM on May 24, 2007

Seizures help with mood. For real.

I mean, that's the operating principle behind electro-convulsive therapy, isn't it?
posted by grobstein at 9:36 PM on May 24, 2007

Hm... Didn't Niven explore the social implications of this with the whole wirehead thing?
posted by Grod at 10:01 PM on May 24, 2007

“Hm... Didn't Niven explore the social implications of this with the whole wirehead thing?”

It's not stimulating the pleasure center...unfortunately.

“I mean, that's the operating principle behind electro-convulsive therapy, isn't it?”

Yeah. I think ECT induces a gran mal seizure. No one knows how it works or why it's so effective, though. (Nothing known so far is even close to as effective as ECT for major depression).
posted by Ethereal Bligh at 10:15 PM on May 24, 2007

Photoshop contest for MS vs Apple tasps?
posted by well_balanced at 10:21 PM on May 24, 2007

My buddy has epilepsy and one of these pacemakers., magnet in the wallet and all. It's funny when it goes off when he's talking, because his voice gets all hoarse, like talking without breathing. So I can be all "What? What's that, Jon?" Ha, ha, ha.
posted by Ambrosia Voyeur at 10:32 PM on May 24, 2007

I'd had fantasies of becoming the bionic woman- or maybe even the robot in Metropolis- but what it finally came down to in my adult life was a far less sexy version of cyborg. As the pharmaceutical options began to dry up, I almost took part in a study conducted by the makers of this particular pace-maker/peace-maker. I figured I'd been born with faulty equipment, and maybe this was the neuron that I needed.

But when I looked into it, after all the clinical interviews and paperwork, it became quite clear that the response rate is spotty at best- no better and no worse than meds. And since the vagus nerve, like any department in your brain, does more than just have an effect on your mood, hyperstimulating it has all sorts of other unwanted consequences. And on this very point: these links hype the technology as a seamless alternative (rendered in typically Gee-Whiz Wired Magazine rhetoric), with few of the qualifiers and caveats that I was given before I signed on the dotted line. Of course anyone would prefer to just pop in a new battery rather than coping with a regimen of inconsistently effective drugs with all sorts of nasty side effects. But it's not going to be quite that simple for a long long time.

What researchers are beginning to realize- after decades of using ECT (electoconvulsive therapy) and new and intriguing work with transcrancial magnetic stimulation and- to a lesser extent- vagus nerve stimulation- is that there is a critical and still-TBA relationship between electrical stimulation and depression, between the brain and ConEd. It seems odd to think that inducing a grand mal seizure in someone's brain using electrodes, for example, would be the thing that helped an otherwise incurable depression, but ECT has the best response rate- hands down- of any therapy, including every drug. All electrical impulses in the brain are ultimately converted to chemical ones, so this makes some sort of sense. But that's about all that's known of the why and the how.

The technologies that are currently available- such as Vagus Nerve Stimulation and ECT- will eventually be seen as primitive prototypes of what will be much more specific and precise treatments that utilize electrical stimulation to combat depression without some of the formidable baggage that currently comes with these procedures.
posted by foxy_hedgehog at 11:15 PM on May 24, 2007 [5 favorites]

What happens in vagus, stays in vagus.
posted by five fresh fish at 12:10 AM on May 25, 2007 [13 favorites]

Stimulating nerves in vages helps beat the blues. News at 11.
posted by UbuRoivas at 12:14 AM on May 25, 2007

VNS isn't a 'failed' treatment for epilepsy. We use it when meds have failed and brain surgery isn't an option - in other words, maybe 1% of patients with epilepsy can be a candidate for it. Depending on how you look at it, that 1% could be said to have the "most severe" epilepsy.

It makes a measurable difference in seizures for about 50% of those severely refractory patients. That's not bad at all as a therapeutic modality. It rarely cures them, but even a significant decrease in seizures can be great for them.

There are a lot of ways to know that epilepsy and depression are tied together. Valproate, lamotrigine, tiagabine, and (less so) carbamazepine are all anticonvulsant drugs now used by psychiatrists as 'mood stabilizers', being quite effective in treatment of bipolar disorder. Electroconvulsive therapy was tried after it was observed that severely depressed people on the wards who had an epileptic seizure often felt better, mood-wise, for a while. And recent data shows that if a person has ever met the criteria for major depressive disorder, that person is 4x as likely as Joe Average to experience an unprovoked epileptic seizure during the remainder of their life.

Jack Dreyfus, the inventor of the mutual fund, even wrote a book, A Remarkable Medicine Has Been Overlooked, largely based on his experiences with phenytoin, an anticonvulsant he received for another indication, to which he attributed the cure of his lifelong depression. Phenytoin isn't even one of the ones on the psychiatrist's radar for this indication.
posted by ikkyu2 at 1:37 AM on May 25, 2007

Seizures help with mood? Really? My wife is epileptic. She's been seizure free for a while now, but for over a year she was having grand mals about every two to three weeks, and I can sure tell you it didn't help her mood at all.
posted by the dief at 3:46 AM on May 25, 2007 [1 favorite]

When we exited our craft to explore the lifeless planet we found skeletons slumped over brain-stim levers and the food pellets dispensing levers seemed to be untouched.
posted by StickyCarpet at 5:34 AM on May 25, 2007

VNS is one of a few newer (and arguably more humane) physical treatments for depression. Psychosurgery, in a very targeted form, is increasingly being practiced (albeit with very hefty controls, at least at a few centres in the UK, and as high a degree of informed consent as you can get from a seriously depressed person), deep brain stimulation looks pretty interesting too, and there's been some coverage recently in the media about transcranial magnetic stimulation (TMS) as well. It's a pretty interesting field, albeit with a LOT of ethical concerns which are going to need seriously addressing before the treatment becomes anything like mainstream.
posted by terrynutkins at 5:42 AM on May 25, 2007

It's not stimulating the pleasure center...unfortunately.

That would be the nucleus accumbens - ventral tegmental area pathway. When a rat has an electrode placed in that pathway and it's hooked up to a lever in its cage, the rat will press the bar to the point of starvation, ignoring food an water. Its literally the most addicting thing in the world.

The spooky thing about this is that mind control is technologically not all that difficult. You set one of these things up on a human, and just through simple Skinnerian conditioning you could get them to do anything you wanted. If you implanted it with out them knowing it, they would probably just make reasons for the things they were doing and become completely convinced that whatever path you sent them on was the right one.
posted by afu at 6:03 AM on May 25, 2007 [2 favorites]

Jack Dreyfus, the inventor of the mutual fund, even wrote a book, A Remarkable Medicine Has Been Overlooked...

I remember that book well; he sent a copy to every doctor in the US at his own expense during the 1980s when I was in med school and there were copies everywhere. No one seemed to take it too seriously, however. Dreyfus hasn't given up, though.

It seems as though "the best treatment ever" for depression is always popping up somewhere. I used to do a lot of anesthesia for ECT in the early 90s when I was a resident (it is amazing how much better seizures are tolerated when the patient is anesthetized; no more pesky broken bones); at my hospital it has gone through at least one full cycle of falling out of favor, in favor, and out again since then. It seems that most treatments for depression that are deemed effective have a 30-50% success rate-better than placebo, but hardly a cure all. My guess is that this stems in part from the fact that the biological basis for depression is still poorly understood and in part from the fact that "depression" is probably a catch-all term for an entire group/spectrum of disorders.
posted by TedW at 6:27 AM on May 25, 2007

It seems that most treatments for depression that are deemed effective have a 30-50% success rate-better than placebo, but hardly a cure all.

This is true from everything I've read. But interestingly, prozac has one of the best response rates of heavily studied drugs -- more depressed people will respond to it that people in pain will respond to tylenol or advil. Go figure.
posted by teece at 8:58 AM on May 25, 2007

"(Nothing known so far is even close to as effective as ECT for major depression)."

Yup: it fries your brain and gives you weird amnesia, among other things. I.e., the more damaged your brain is the less brain you have to get depressed with, and the less you remember the less you have to be depressed about. Note that ECT triggers seizures, it isn't itself a seizure: the electrical shock itself is a brain trauma. (I hereby solicit correction and clarification from neurologists and such, which I ain't.)

I wouldn't mind some low-powered gentle magnetic stimulation, but a big hard ZAP is a bit much.

"'Depression' is probably a catch-all term for an entire group/spectrum of disorders."

It seems that way to me, in my layperson's opinion, based on depressive episodes I've had that have differed both from each other, from others' descriptions of "depression," and from diagnostic criteria.
posted by davy at 10:36 AM on May 25, 2007

We usually define brain trauma as a physical force acting on the brain to cause injury, like an acceleration or deceleration injury.

ECT is usually done under general anesthesia these days, so there isn't a convulsion associated with it. There is, however, an electrographic seizure; the current somehow sets off rhythmic discharges in the brain. Memory loss and cognitive dysfunction are generally found in those who undergo it. But those weren't healthy people to begin with. Picture someone who stays in bed crying or not moving, all day, every day for a decade. If ECT can get that person out of bed and back to a healthy, happy life, well, that's a net gain, some folks argue.
posted by ikkyu2 at 10:43 AM on May 25, 2007

"We usually define brain trauma as a physical force acting on the brain to cause injury, like an acceleration or deceleration injury [...] an electrographic seizure; the current somehow sets off rhythmic discharges in the brain. Memory loss and cognitive dysfunction are generally found in those who undergo it."

See what I mean? It sounds like 'brain trauma' to me, there's that "memory loss and cognitive dysfunction" part. I understand it might be better in some very rare cases like those you describe, but then most "depressed" people DON'T "stay in bed crying or not moving, all day, every day for a decade."
posted by davy at 10:53 AM on May 25, 2007

Most depressed people don't get ECT either davy, nor is anyone suggesting they should. Frankly I'd like to see ECT go away entirely. But I'd like to have something better to replace it with, too.

The vagus nerve stimulator doesn't do anything like this. Surgeon goes to a nerve in your neck and wraps an induction coil around it; the pacemaker gently pulses the coil every 30 seconds or so. People can burp or be hoarse while the pulse is on - that's about the extent of the side effects. Compared to some of the side effects of other treatments I use, it's pretty benign.
posted by ikkyu2 at 11:02 AM on May 25, 2007

“Yup: it fries your brain and gives you weird amnesia, among other things. I.e., the more damaged your brain is the less brain you have to get depressed with, and the less you remember the less you have to be depressed about.”

That's a distorted way of putting it, if not completely false. There's never been any scientific evidence ever found of long-term brain damage associated with ECT. Yes, it causes amnesia during treatment. Is that damage? Well, it's damaged functioning—but that's distinct from the physical damage you're strongly implying. Specifically your whole "the less brain you have to get depressed with" is just spurious uninformed speculative bullshit on your part.

My speculative, more informed, bullshit is that the gran mal seizures that ECT causes result in a sort of periodic "reboot" and partial "system wipe" (using a computing analogy) that cumulatively disrupt a self-reinforcing depressive cycle that a person's brain has been caught within. Maybe that's not what's happening. And, sure, if it is what's happening, that's a hugely ham-handed way of combating the problem. Also, sure, it's causing an amount of limited, short-term damage. But a lot of the damage it's doing is to systems that are malfunctioning anyway. Back to computing terms, it's not unlike having some applications or OS processes with memory leaks that the OS isn't able to properly contain. Rebooting damages the continuity of functioning and causes problems for the user (for example, maybe the memory leak itself interferes the ability to save the state of an application or its data before a reboot) but it solves the problem (for awhile) when the alternative is to let the whole system be slowly overburdened till it can't function at all. It's trading one big chunk of damage that is still nevertheless much smaller than the cumulative damage that occurs if the problem is untreated. And, as part of the appropriateness of the analogy, none of this is hardware damage.
posted by Ethereal Bligh at 11:15 AM on May 25, 2007 [1 favorite]

And, as part of the appropriateness of the analogy, none of this is hardware damage.

This is actually the most fascinating part of the brain, to me. What is hardware and what is software?

Of course, you have a similar issue with computers: just about anything in software can be done in hardware [assuming you have shitloads of money], and to a lesser, but still very major, extent, the reverse is also true: most hardware can be done in software.

But in the brain, the distinction between "hardware" in "software" is even more messy (if you'll pardon the abuse of the analogy). A silicon computer is pretty much fixed in its hardware -- once completed, the hardware computing set never changes. For a given computer, you can say "that is hardware, that is software." And you can only change the software (generally speaking).

The brain seems to change its hardware, to some degree, throughout its entire functioning life, in addition to rejiggering* its software constantly. It's pretty amazing. And really damn complicated. (And I don't mean to imply too much parallel between computers and brains. Very different things).

* I guess that really should just be "jiggering" there. Huh.
posted by teece at 11:29 AM on May 25, 2007

I'm not arguing, just saying ECT sounds, uh, "ham-handed." And I know the vagus nerve thing doesn't do the same thing; that seems like a step in the right direction, but I'd want 'em to develop it a bit more before I'd ever agree to one. (Ideally I'd like something that requires no surgery or implantation, like special magnets to glue to my foil helmet.)

And E_B, I aiready admitted I might've been wrong on the details since I'm a mostly-uninformed layperson and all, but you got no call to jump in my shit. Might you need Midol or is Plan B in order? (Yes, I know Bligh's a male, which is why I think that's funny: my own "SO" has said to me "I hope your period comes soon!" -- and I'm not female either though she is.)
posted by davy at 11:35 AM on May 25, 2007

Considering the number of drugs/treatments that have negative side effects, it's always encouraging to see something positive.

I still chuckle when reading about Rogaine (minoxidil), the high blood pressure medication with the interesting side effect of growing hair on bald men. The mechanism behind the hair growth is also not understood (but welcome nonetheless).
posted by tommasz at 11:37 AM on May 25, 2007

What I want is a tiny portable Penfield Mood Organ kind of thing. Preferably one that looks like a nose ring.
posted by davy at 11:46 AM on May 25, 2007

“And E_B, I already admitted I might've been wrong on the details since I'm a mostly-uninformed layperson and all, but you got no call to jump in my shit.”

Well, that's true. You did make the disclaimer. And I just recently claimed that I'm forgiving of people who are careful to make such a disclaimer. So, I apologize.

The reason I'm touchy about this is just because there's so much popular bias against ECT. Years ago, when I was hospitalized for major depression and wasn't responding to treatment and the doctors suggested ECT, I ended up rejecting it because of my discomfort about it...even though I researched it and knew all the stuff I'm saying now. I think I was wrong to reject it and I think that I would have been less likely to do so had there not been the bias against it. I'm not saying that was the largest portion of why I rejected it, but I think it was a factor. And the reason this matters is because there's simply no other treatment even remotely as effective as ECT for very severe major depression. I think it's a real shame that it's not used more than it is—and it's not used more than it is mostly, I think, because of a bias against it that has a lot of historical context.
posted by Ethereal Bligh at 11:52 AM on May 25, 2007

Hey tommasz, I'd like to know why my hair's thinning on my scalp but burgeoning all over the rest of me. But then why complain, if I don't trim my ear- and nose-hairs for a year I could make my own weave-wig.

Bligh, how old are you anyway? When was that?
posted by davy at 12:20 PM on May 25, 2007

davy, I'm not thinning and I also have that problem. I got used to the hair stylist offering to trim my eyebrows a while ago.
posted by tommasz at 12:59 PM on May 25, 2007

Yup: it fries your brain and gives you weird amnesia, among other things. I.e., the more damaged your brain is the less brain you have to get depressed with, and the less you remember the less you have to be depressed about. Note that ECT triggers seizures, it isn't itself a seizure: the electrical shock itself is a brain trauma. (I hereby solicit correction and clarification from neurologists and such, which I ain't.)

You are very much mistaken. As others have noted, ECT doesn't cause "brain damage." This is a common misconception, which leads to your next error- confusing the side effects of ECT, i.e. temporary memory loss- with the easing of depressive symptoms.

People who have ECT aren't depressed because they can't let go of difficult memories, they're depressed because the chemical balance and chemical reactions that govern their emotions are awry. Besides, traumas are usually part of long-term memory, which isn't affected by ECT (you'll forget whether to turn right or left after you exit the freeway. You won't forget that your father molested you, that your mother died, that your spouse abused you, etc.)

E_B's analogy of a reboot is, I think, a little more accurate, but depicts the MO in terms of a unilateral "wiping" when the memory loss is far more piecemeal and, again, distinct from becoming undepressed. Memories don't so much disappear as become inaccessible, because the neural links that served as your web of associations through which you accessed them is severed. To offer another analogy, it's like losing your card catalog. But its the severance of those sorts of links that, as E_B suggests, establishes new ones that are closer to normal and functional.

E_B is also absolutely right to say that it is hands down the most effective treatment for depression- the response rate averages out to 70%. And we're talking about 70% of the most severe, treatment-refractory cases of depression, where people are in extreme crisis or at the end of the line as far as treatment options (and by the way, Davy, people only have ECT as a last resort. They aren't "most depressives.") The difficulty calling up and retaining memories is temporary, and while it can be frightening while it's happening, it's better than being dead.

Part of the problem here is coming up with good analogies and metaphors that can make useful sense of how the brain works, It's so irreducibly complex that it's difficult to find a way to talk about it that can do justice to that complexity. The temptation is to see it as a computer- e.g. the software vs. hardware question teece brought up- but, Turing machines aside, brains just don't operate with that sort of distinction. A different tech metaphor- and for me, more helpful- way to think of ECT is to see the brain as a network. ECT is a way of restoring more normal patterns of communication within that network.
posted by foxy_hedgehog at 1:12 PM on May 25, 2007

Yes, I know that currently people only have ECT as a last resort; 40-some years ago it wasn't a last resort. Same with lobotomy. See Bligh's earlier comment for a coherent view. They decided not to give me ECT because 1) I wasn't THAT bad for THAT long and 2) I started babbling about Cuckoo's Nest and Big Brother and the CIA and they said I was too paranoid for it to do much good.

And like I said, this vagus nerve-stim thing sounds better, but still not good enough -- like an implant a la The Terminal Man sounded neato but not good enough. I'd want to try a small portable user-controlled external headset, no implants needed, especially if I got to select my moods and mental states. That'll happen real soon now, like consumer jetpacks and nanny robots, eh?

Now me, I think of the brain as a gland, like the prostate, the adrenals or the testes.
posted by davy at 1:32 PM on May 25, 2007

Er, the "threat" to subject me to ECT was in the late '70s.

Nor am I saying memory loss is always bad: I have a whole list of memories I'd rathe lose. Unfortunately those are the long-term sort that I gather ECT won't get rid of. (Damn damn damn.)
posted by davy at 1:36 PM on May 25, 2007

ECT can cause long-term, permanent brain damage, such as permanent anterograde and retrograde amnesia. I've seen it happen. As a neurologist, I am competent to diagnose and evaluate these changes.

There are also MRI changes in the brain associated with ECT, and there is a proven elevation of risk (eleven-fold in the study I saw) of later developing epilepsy in a person who has undergone ECT.

You, Ethereal_Bligh: I want you to tell someone who developed disabling, intractable, unprovoked daily seizures after ECT that their brain has not suffered "hardware" damage: rather, their new permanent disability is just a side effect of a "software reboot." I want to see you do this. Frankly I wouldn't have the courage to state such a thing to someone who was suffering. You are probably more confident and brave than I am.

As far as I know no one has dissected and analyzed a series of brains of people who've undergone ECT and compared them to a series of similar depressed brains that did not undergo ECT. Someone should do this, because of people like Ethereal_Bligh who want to claim that ECT doesn't cause "hardware" damage but who have no evidence to back up such claims.

I'm a board-certified neurologist and I endorsed this message.
posted by ikkyu2 at 1:37 PM on May 25, 2007

ECT can cause long-term, permanent brain damage, such as permanent anterograde and retrograde amnesia. I've seen it happen. As a neurologist, I am competent to diagnose and evaluate these changes.

There are also MRI changes in the brain associated with ECT, and there is a proven elevation of risk (eleven-fold in the study I saw) of later developing epilepsy in a person who has undergone ECT.

Do you have the cites for either of these? I'd genuinely like to take a look at these studies.
posted by foxy_hedgehog at 1:42 PM on May 25, 2007

Oh, and Davy:

Nor am I saying memory loss is always bad: I have a whole list of memories I'd rathe lose. Unfortunately those are the long-term sort that I gather ECT won't get rid of. (Damn damn damn.)

That's the tragic part. The Madonna lyrics never, ever go away, no matter how many times they strap on the electrodes.
posted by foxy_hedgehog at 1:52 PM on May 25, 2007

“You, Ethereal_Bligh: I want you to tell someone who developed disabling, intractable, unprovoked daily seizures after ECT that their brain has not suffered "hardware" damage: rather, their new permanent disability is just a side effect of a "software reboot." I want to see you do this. Frankly I wouldn't have the courage to state such a thing to someone who was suffering. You are probably more confident and brave than I am.

As far as I know no one has dissected and analyzed a series of brains of people who've undergone ECT and compared them to a series of similar depressed brains that did not undergo ECT. Someone should do this, because of people like Ethereal_Bligh who want to claim that ECT doesn't cause "hardware" damage but who have no evidence to back up such claims.

I'm a board-certified neurologist and I endorsed this message.”

Hmm. Well, my information came from an MD/PhD whose PhD is in neurophysiology. She is familiar with the research and there has been studies done on this subject. As a physician, she's treated patients with ECT. She's also had ECT treatment herself. She does, in fact, know a great deal on this particular topic. Thanks for playing, though.
posted by Ethereal Bligh at 4:28 PM on May 25, 2007

Incidentally, to answer davy's question and provide a bit more context, my hospitalization for depression and that recommendation for ECT was seven years ago. The woman I mention is a lifelong friend of mine. Her MD/PhD is from WU. I called her and asked for her thoughts on the matter. She was emphatic about what the research showed about ECT. That's not to say that she didn't have reservations because the short-term side-effects are pretty bad. In fact, her own experience with ECT was extremely bad, but that's because the tech made some mistake and something badly went wrong with the treatment. She was very cognitively disturbed for about six months, and that's six months she has no memory of. On the other hand, after that time she has had no side-effects.

Now, from my perspective, I think ikkyu2's and my friend's conflicting statements have equal weight. While ikkyu2 is a board-certified neurologist, my friend is also a practicing physician with a PhD in neurobiology (or something neuro-) with experience with ECT in a research hospital along with her own personal experience with it. It's hard to imagine that this intersection of professional and personal interests didn't mean that she was highly informed on the topic, almost certainly in some ways moreso than ikkyu2. But this was when she was a resident and just out of both med school and grad school. As a board-certified neurologist, ikkyu2 is, of course, also a professional expert in the subject.

I belabor this point because of ikkyu2's condescension. It didn't occur to him to ask me for the source of my information. To me, this is an object lesson of some sort, though I don't know exactly how to describe it. For all of us who are laypeople, all we are able to do is to try to evaluate the expert sources we consult. It was the default assumption of ikkyu2 that, since I said something that contradicted his expert opinion, it must be something I made up or concluded myself. In fact, though, I'm repeating verbatim what my own expert source told me. Some people in position would trust their friend, a known quantity with a highly respected professional and educational background, over some guy on the Internet who claims to be a doctor. However, I'm nearly certain that ikkyu2 is who he says he is, and he's earned my respect here, so I'm re-evaluating my position on the matter to "uncertain".
posted by Ethereal Bligh at 4:47 PM on May 25, 2007

I'll chime in here to add that I, too, thought that ikkyu2's post was unnecessarily condescending and hostile. I'm not a neurologist, but I've done plenty of research as a laywoman on this topic, as well as speaking to numerous researchers and practitioners, and his/her assertions contradict most everything I've heard and read.

I also found the post full of assertions about data that are rather poorly explained for a board-certified neurologist, such as

There are also MRI changes in the brain associated with ECT

which is stated without clarification of what these changes are- structural? chemical? other?- and what they might mean for brain function and


there is a proven elevation of risk (eleven-fold in the study I saw) of later developing epilepsy in a person who has undergone ECT.

which is stated without elaborating on what kind of number an 11-fold increase is- i.e. 1 in a million to 11 in a million. I'm eager to hear more about the studies ikkyu2 mentions, but without a better explanation of the data I didn't find the post persuasive. There's also no sense of whether these side effects were from people who had "old school" ECT (i.e. bilateral sine wave stimulation) vs. "new school" ECT (unilateral pulse stimulation) which has become standard practice and has far fewer unwanted side effects.

Ultimately, I think a lot of the sturm und drang on side effects can easily become a red herring. People have to make tough and unwanted choices when they are suffering from a devastating and life-threatening illness. We could do a lot better than ECT, but in the meantime it's easy to underestimate the stakes involved. Under normal circumstances, no one would chose to deliberately expose themselves to radiation, and chemo has horrific side effects, but no one gets their panties in a twist about it because its understood and accepted as a potentially life-saving treatment, albeit one that, like ECT, is in many ways quite primitive and could be, and hopefully will be, vastly improved.
posted by foxy_hedgehog at 5:25 PM on May 25, 2007

I, too, would love to see references for what ikkyu2 said, because everything I've found seems to say exactly the opposite. For example: Does ECT alter brain structure?

RESULTS: ECT-induced cognitive deficits are transient, although spotty memory loss may persist for events immediately surrounding the ECT course. Prospective computerized tomography and magnetic resonance imaging studies show no evidence of ECT-induced structural changes. Some early human autopsy case reports from the unmodified ECT era reported cerebrovascular lesions that were due to agonal changes or undiagnosed disease. In animal ECS studies that used a stimulus intensity and frequency comparable to human ECT, no neuronal loss was seen when appropriate control animals, blind ratings, and perfusion fixation techniques were employed. Controlled studies using quantitative cell counts have failed to show neuronal loss even after prolonged courses of ECS. Several well-controlled studies have demonstrated that neuronal loss occurs only after 1.5 to 2 hours of continuous seizure activity in primates, and adequate muscle paralysis and oxygenation further delay these changes. These conditions are not approached during ECT. Other findings indicate that the passage of electricity, thermal effects, and the transient disruption of the blood- brain barrier during ECS do not result in structural brain damage. CONCLUSIONS: There is no credible evidence that ECT causes structural brain damage.

posted by myeviltwin at 8:08 PM on May 25, 2007

I think there are ambiguities that we laypeople are not in a position to evaluate. Principally, I suspect the division between what ikkyu2 is saying and what I am saying and what we're finding on Internet sources has to do with measurable cognitive changes and measurable physiological changes. I'm pretty sure that the latter hasn't been demonstrated and that there's a consensus that reflects the results discussed in myeviltwin excerpt. That's at the anatomic level at which researchers have looked.

However, it's not clear to me, after reading ikkyu2's comment and finding at least one (admittedly minority) source on the Internet, that there's not some long-term cognitive impairment (excluding memories lost during the treatment) and/or MRI abnormalities.

As to the matter of epilepsy caused by ECT, there is the ambiguity when archaic and improper/accidental treatments are included in the discussion. Excluding those and talking only about properly conducted contemporary ECT, then there's still ambiguity because there's a correlation anyway between chronic major depression and epilepsy. Even so, perhaps there is some risk of subsequent epilepsy resulting from properly conducted contemporary ECT. I don't know. I'd expect to see this come up in even casual research, but I'm not. That could speak to my casual research skills. But, going only by what ikkyu2 has written in this thread, it's also possible that his assertion is anecdotal from his own experience. And the problem with that is that, frankly, physicians are notorious for coming to fringe conclusions based upon their own individual experience in their practice. Not that I'm saying that is necessarily the case here—just that it's a possibility. I'm sure ikkyu2 will come along sooner or later and elaborate.
posted by Ethereal Bligh at 8:48 PM on May 25, 2007

Hey five_fresh_fish, a board-certified neurologist just backed me up (though I'm sure that wasn't his aim), so your chivalric defense of Ethereal Bligh was doubly ridiculous. So kiss my pimply ass: were I to somehow gain YOUR "respect" I'd consider that a mockery of everything I breathe for, which might well cost me my respect for myself. Try addressing me again when you have some idea of what you're talking about, or even when you begin to realize you don't have a clue.

And the next time you encourage Mefites to assassinate a sitting U.S. politician I won't defend you. I won't say free speech is a Bad Thing, I'm just not about to take a metaphorical bullet for a bona fide nitwit.
posted by davy at 11:17 PM on May 25, 2007

E_B, I think it's important to make the distinction between an eleven-fold risk of someone who's had ECT later developing epilepsy, and the idea that ECT causes epilepsy. One is a correlation; that's been made. But just being depressed is a risk factor for developing epilepsy. Since people who receive ECT are by definition severely depressed, we wonder whether that might be enough to account for all the excess epilepsy developing in this population. Here's a nice review.

I don't know how one can characterize the loss of all memory over a six month period as "short term" or "transient," by the way. I suppose a 100 year memory dysfunction could be called "short term," because longer periods of time such as 1000 years do exist. But let's look at seizures from epilepsy. These usually produce only a 30-60 minute period of post-ictal amnesia and confusion, tops. Compared to that, a 6 month period of total memory loss does not seem particularly short-term to me. Clearly the electrically induced seizure differs fundamentally in mechanism somehow from the spontaneous unprovoked epileptic seizure, if it is going to produce these significant memory impairments.

I've seen people cognitively wrecked after ECT. I recall one guy who had 120 involuntary treatments at Letterman Army Hospital in the bad old days of higher current, bilateral stimulation, and no anesthesia. I was interested enough to write to obtain his old record; this was back in the 90's before Letterman closed down entirely. The guy had total, complete anterograde amnesia dating back to 1968 - he was essentially patient H.M., only he'd never had a neurosurgical procedure. Every time he looked in the mirror he was shocked to see an old man looking back at him; he was expecting to see a 23 year old.

He received the involuntary treatments after behavioral problems led to a diagnosis of schizoaffective disorder while his unit was deployed in combat in Vietnam. When I first heard him tell this story, I thought, "Oh geez, another Vietnam 'vet' with a B.S. story, here in the County Hospital." I was surprised to find that his records from Letterman confirmed nearly every detail of the story he told me.

Every time I think of his story I feel a little sick inside. I hope that if I am ever drafted into combat and crack up there, that I do not receive involuntary commitment and ECT, rendering me a walking neurological experiment. Actually I would hope that would never happen to anybody.
posted by ikkyu2 at 4:51 AM on May 26, 2007

Oh, and I think E_B might have misinterpreted me. When I said: "someone should [do a controlled autopsy series on ECT patients], because of people like Ethereal_Bligh who want to claim that ECT doesn't cause "hardware" damage but who have no evidence to back up such claims," I could just as easily have substituted my own name for E_B's.

I, too, would like to be able to make such claims, but I would like to base them on better evidence than what is available. What we have now - what myeviltwin cited above - is absence of evidence; that's not the same as evidence of absence.

If you look at what the NIMH is funding as a surrogate marker for interest and for what we are likely to learn, there's a lot of interest in discovering the effects of ECT and the best ways to perform it, but there's comparatively little interest in figuring out how or why it works. That disturbs me.
posted by ikkyu2 at 5:07 AM on May 26, 2007

ikkyu2 & EB: thanks for the thoughtful responses. I think we're basically all on the same page: I definitely think that more attention needs to be paid to the possible negative consequences of our wonder treatment of the month. I also agree that it's distressing that the approach to ECT is so atheoretical, but that's true of many psychiatric interventions and I think reflects the current state of our knowledge of how the brain works more than something specific to ECT.

Regarding the "absence of evidence" issue, what ikkyu2 is referring to is the perennial problem in interpreting null results. Strictly speaking, null-hypothesis significance tests never provide grounds for accepting the null. In practice, I think it's a question of how many null results pile up before you're convinced. Reading through the paper I linked to, the evidence seems to show that:

- CT and MRI imaging show no abnormalities in those who've had ECT, compared to matched controls.

- animal studies have shown no brain abnormalities after ECT at clinically relevant dosages.

It's true that a controlled autopsy series would be good, but it would also be difficult (you'd have to make sure the ECT and non-ECT groups were matched on other possibly confounding variables, like severity of depression) and expensive (probably you'd need an n in the hundreds to have enough power to find what would likely be a small effect).
posted by myeviltwin at 8:48 AM on May 26, 2007

Oh, also, ikkyu2: I'd like to look at that article you linked but unfortunately my institution doesn't have a sub to Seizure. If you have the time & inclination to send me a copy I'd be obliged...email's in the profile.
posted by myeviltwin at 8:59 AM on May 26, 2007

[take the stfu/dipshit talk to metatalk folks.]
posted by jessamyn at 1:13 PM on May 26, 2007