Depression treatment: drugs, behavioural or electroconvulsive therapy – which works the best?

Eighty years ago at Sapienza University in Rome, Italy, doctors sent a jolt of 100 volts of electricity through the head of a man who had been diagnosed with schizophrenia. Within weeks, he appeared to be better and returned to work as an engineer.

He was the first patient to undergo what was then called ES and is now known as ECT – electroconvulsive therapy. Although his symptoms returned, the doctors knew they were treatable.

The treatment, which remains stigmatised after it was unfavourably depicted in Hollywood films (think One Flew Over the Cuckoo’s Nest), may be about to make a comeback, following a study that suggests it should be made be made available more often and sooner to people with severe depression.

Some suggest it works in 80 per cent of cases. But it is not a panacea; it comes with risks.

My mother was subjected to ECT back in the 1970s. It didn’t cure her. It shocked her back to wellness, briefly and, she says, affected her short-term memory – one of the side effects, along with headaches.

Today the treatment is much more gentle – mild, electrical impulses – and cost effective for what psychiatrists call “treatment resistant” depression which won’t budge after the administration of at least two other options – say drugs and therapy.

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Professor Dan Maixner, who conducted the recent study into its efficacy, observes: “ECT is the best treatment to produce remission. In addition to the clinical idea that ECT should be used sooner, our study adds another perspective, highlighting that ECT is also cost-effective earlier in the treatment course of depression.”

I want to consider this news in an optimistic light, but there is a modicum of cynicism and fear. The treatment must be administered frequently: his team carries out 3,000 procedures on between 150 and 200 patients a year. That’s a lot of treatments, a lot of hospital admissions; the procedure is carried out under anaesthesia. And remission, let’s be clear, is not the same as a cure.

Many treatments have been prescribed in the ‘cure’ for depression. Drugs, in varying doses and different combinations; psychotherapy; cognitive behavioural therapy (CBT). My mother tried them all.

The drugs included fluoxetine (Prozac), amitriptyline, mirtazapine, quetiapine, venlafaxine, imipramine and lithium. The psychotherapist unnerved her because he kept trying to pin her illness on her childhood. “But there was nothing wrong with my childhood,” she protested. “It was perfectly happy, perfectly normal.”

Her single attempt at CBT was enough to put her off forever; the therapist bawled her out for being late because she couldn’t find a parking spot. As for the acupuncturist: to believe that sticking a few pins into a person is going to needle out deep-seated desolation is the stuff of desperation.

Sufferers and their families are often buoyed unrealistically by fanciful treatments only to be bitterly disappointed when they don’t work.

“Botox appears to ease depression,” announced one newspaper headline several years ago. The doctor who made the claim observed, “Maybe the frown is not just an result of the depression; maybe you need to frown to be depressed.” Is that all it takes? To lift a mood so compromised it can result in hospital admission?

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Many of the “treatments” I have read about over the years have been so far-fetched as to be the stuff of fiction. Nicotine? Steady on. Oxygen optimising through deep breathing? How can you when you’re tight-chested with anxiety? Clearing brain plaque. Did you even know you could accumulate plaque there?

Dr Frances Cheng, a specialist in psychiatry at Hong Kong’s Alpha Clinic, says: “The general consensus is that a combination of medication and psychotherapy results in recovery which is achieved more quickly and is more sustained. The most commonly prescribed antidepressants are selective serotonin re-uptake inhibitors (SSRIs).

“There are many types of psychotherapy and different people will find different types of therapies and styles of psychologists and counsellors work better for them. Cognitive behavioural therapy is useful in prevention of relapse or another episode of depression.”

Clinical psychologist Dr Quratulain Zaidi agrees that a combination of drugs and therapy is the best approach and “the evidence-based approach for treatment of serious mental health challenges like depression”.

But she shares my concern about ECT. “Few medical treatments have attracted as much attention as electroconvulsive therapy. It is a treatment subjected to restrictions in many countries, and research suggests the risk of relapse is more than 80 per cent within a year, making continued stabilising treatment necessary,” she says.

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Cheng, however, who has successfully treated patients with ECT, believes “it should be considered an option for the treatment of depression when several medications have failed”.

Professor Dainius Puras, the United Nations Special Rapporteur “on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”, and a doctor with notable expertise on mental health, says views on depression and medication are changing.

“Depression may happen as a severe mental health condition which may need medical treatment – such as antidepressants. But at the other end of the spectrum of what is called ‘depression’ are many more cases of human conditions which are miseries of daily life.”

His concern – and one which is shared increasingly by doctors in the United States and Europe – is that we may be medicating depression when we ought not to be.

“There are many reasons to feel bad – failures in human relationships, violence, poverty and so on. Is this depression? If severe depression is not addressed as a clinical condition, things may worsen,” Puras says.

Of “milder” depression, he says: “Millions of such cases are medicalised, and human conditions of misery treated with antidepressants. This is unacceptable, such tendency does more harm than good.”

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But he says, the “’medicalisation of feelings’ is happening – one in four women in the States is on psychiatric medication, and medical students are receiving biased knowledge that ‘depression is about chemical imbalances’”.

His thinking may be unpopular in an era when misery is often given a medical label, but he believes that a “medical model works only for a small number of the most severe cases of depression. For many ‘milder’ cases, it does not work and is quite possibly even harmful.”

Puras believes that addressing the complex challenges that life presents should not be chemically treated in the first instance, and that instead, a broad range of psychosocial interventions should be employed.

There is no doubt that clinical depression is a desperate illness that needs treatment, and that the combination of the right drugs with the right talk therapy may be the best proven approach. But increasingly doctors worry that misery is being medicated when a patient would be better served by being encouraged to develop coping strategies in the face of life challenges: eating well, exercising regularly, having a purpose, being socially engaged – which may conspire to protect them from future episodes better than drugs would.

Many doctors worry medication may not always be necessary, that it may be a Band Aid for a problem that needs addressing at a deeper level: life changes. As Robert Whitaker, who wrote Anatomy of an Epidemic, observes, we need to shift our focus from illness to promoting wellness. “That’s a different paradigm.”