tag:theconversation.com,2011:/us/topics/ect-1549/articlesECT – The Conversation2023-12-06T13:27:31Ztag:theconversation.com,2011:article/2178892023-12-06T13:27:31Z2023-12-06T13:27:31ZHow electroconvulsive therapy heals the brain − new insights into ECT, a stigmatized yet highly effective treatment for depression<figure><img src="https://images.theconversation.com/files/563043/original/file-20231201-17-j1qrjt.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2059%2C1454&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Electroconvulsive therapy involves inducing a controlled seizure under anesthesia.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/human-brain-impulse-concept-futuristic-royalty-free-illustration/1177917141">Inkoly/iStock via Getty Images Plus</a></span></figcaption></figure><p>When most people hear about <a href="https://theconversation.com/electroconvulsive-therapy-a-history-of-controversy-but-also-of-help-70938">electroconvulsive therapy, or ECT</a>, it typically conjures terrifying images of cruel, outdated and pseudo-medical procedures. Formerly known as electroshock therapy, this perception of ECT as dangerous and ineffective has been reinforced in pop culture for decades – think the 1962 novel-turned-Oscar-winning film “<a href="https://www.britannica.com/topic/One-Flew-over-the-Cuckoos-Nest-film-by-Forman">One Flew Over the Cuckoo’s Nest</a>,” where an unruly patient is subjected to ECT as punishment by a tyrannical nurse.</p>
<p>Despite this stigma, ECT is a <a href="https://doi.org/10.1056/nejmra2034954">highly effective treatment for depression</a> – up to 80% of patients experience at least a 50% reduction in symptom severity. For one of the <a href="https://doi.org/10.1016/S0140-6736(20)30925-9">most disabling illnesses</a> around the world, I think it’s surprising that ECT is <a href="https://doi.org/10.1097/yct.0000000000000320">rarely used</a> to treat depression.</p>
<p>Contributing to the stigma around ECT, psychiatrists still don’t know exactly how it heals a depressed person’s brain. ECT involves using <a href="https://www.ncbi.nlm.nih.gov/books/NBK538266/">highly controlled doses of electricity</a> to induce a brief seizure under anesthesia. Often, the best description you’ll hear from a physician on why that brief seizure can alleviate depression symptoms is that ECT <a href="https://www.uhhospitals.org/services/adult-psychiatry-psychology/ect-suite/about-ect-procedure">“resets” the brain</a> – an answer that can be fuzzy and unsettling to some.</p>
<p>As a <a href="https://scholar.google.com/citations?hl=en&user=tDUCQ3UAAAAJ">data-obsessed neuroscientist</a>, I was also dissatisfied with this explanation. In <a href="https://doi.org/10.1038/s41398-023-02631-y">our newly</a> <a href="https://doi.org/10.1038/s41398-023-02634-9">published research</a>, my colleagues and I in <a href="https://voyteklab.com">the lab of</a> <a href="https://scholar.google.com/citations?user=ydFvGx0AAAAJ&hl=en">Bradley Voytek</a> at UC San Diego discovered that ECT might work by resetting the brain’s electrical background noise.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/AcmarVpo2xE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Despite its high effectiveness in alleviating depression symptoms, misperceptions about ECT made it unpopular.</span></figcaption>
</figure>
<h2>Listening to brain waves</h2>
<p>To study how ECT treats depression, my team and I used a device called an <a href="https://www.ncbi.nlm.nih.gov/books/NBK563295/">electroencephalogram, or EEG</a>. It measures the brain’s electrical activity – or brain waves – via electrodes placed on the scalp. You can think of brain waves as music played by an orchestra. Orchestral music is the sum of many instruments together, much like EEG readings are the sum of the electrical activity of millions of brain cells.</p>
<p>Two <a href="https://doi.org/10.1038/s41593-020-00744-x">types of electrical activity</a> make up brain waves. The first, oscillations, are like the highly synchronized, melodic music you might hear in a symphony. The second, aperiodic activity, is more like the asynchronous noise you hear as musicians tune their instruments. These two types of activities coexist in the brain, together creating the electrical waves an EEG records.</p>
<p>Importantly, tuning noises and symphonic music shouldn’t be mistaken for one another. They clearly come from different processes and serve different purposes. The brain is similar in this way – aperiodic activity and oscillations are different because the biology driving them is distinct.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/563769/original/file-20231205-27-cj7f46.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram showing EEG reading of neural oscillations and aperiodic activity" src="https://images.theconversation.com/files/563769/original/file-20231205-27-cj7f46.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/563769/original/file-20231205-27-cj7f46.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=134&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563769/original/file-20231205-27-cj7f46.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=134&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563769/original/file-20231205-27-cj7f46.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=134&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563769/original/file-20231205-27-cj7f46.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=169&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563769/original/file-20231205-27-cj7f46.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=169&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563769/original/file-20231205-27-cj7f46.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=169&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This diagram shows two EEG readings: One signal contains slow neural oscillations and the other contains only aperiodic activity. Although these signals can be tricky to visually distinguish, certain data analysis methods can help tease them apart.</span>
<span class="attribution"><span class="source">Sydney Smith</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>However, the methods neuroscientists have traditionally used to analyze these signals are <a href="https://doi.org/10.1038/s41593-020-00744-x">unable to differentiate</a> between the oscillations (symphony) and the aperiodic activity (tuning). Both are critical for the orchestra, but so far neuroscientists have mostly ignored – or entirely missed – aperiodic signals because they were thought to be just the brain’s background noise.</p>
<p>In our new research, my team and I show that ignoring aperiodic brain activity <a href="https://doi.org/10.1038/s41398-023-02631-y">likely explains</a> <a href="https://doi.org/10.1038/s41398-023-02634-9">the confusion</a> behind about how ECT treats depression. It turns out we’ve been missing this signal all along.</p>
<h2>Connecting aperiodic activity and ECT</h2>
<p>Since the 1940s, ECT has been associated with <a href="https://doi.org/10.1176/ajp.99.4.525">increases in slow oscillations</a> in the brain waves of patients. However, those slow oscillations have never been linked to how ECT works. The degree to which slow oscillations appear is not consistently related to how much symptoms improve following ECT. Nor have ideas about how the brain produces slow oscillations connected those processes to the pathology underlying depression. </p>
<p>Because these two types of brain waves are <a href="https://doi.org/10.1007/s12021-022-09581-8">difficult to separate in measurements</a>, I wondered if these slow oscillations were in fact incorrectly measured aperiodic activity. Returning to our orchestra analogy, I believed that scientists had misidentified the tuning sounds as symphony music.</p>
<p>To investigate this, my team and I gathered three EEG datasets: one from nine patients with depression undergoing ECT in San Diego, another from 22 patients in Toronto receiving ECT and a third from 22 patients in Toronto participating in a clinical trial of <a href="https://doi.org/10.1001/archpsyc.58.3.303">magnetic seizure therapy, or MST</a>, a newer alternative to ECT that starts a seizure with magnets instead of electricity.</p>
<p>We found that aperiodic activity increases by <a href="https://doi.org/10.1038/s41398-023-02634-9">more than 40% on average</a> following ECT. In patients who received MST treatment, aperiodic activity increases more modestly, <a href="https://doi.org/10.1038/s41398-023-02631-y">by about 16%</a>. After accounting for changes in aperiodic activity, we found that slow oscillations do not change much at all. In fact, slow oscillations were not even detected in some patients, and aperiodic activity dominated their EEG recordings instead.</p>
<h2>How ECT treats depression</h2>
<p>But what does aperiodic activity have to do with depression?</p>
<p>A long-standing <a href="https://doi.org/10.1038/mp.2010.120">theory of depression</a> states that severely depressed patients have too few of a type of brain cell called inhibitory cells. These cells can turn other brain cells on and off, and maintaining the balance of these on and off states is critical for healthy brain function. This balance is particularly relevant for depression because the brain’s ability to turn cells off plays an important role in <a href="https://doi.org/10.2174%2F1570159X1304150831150507">how it responds to stress</a>, a function that, when not working properly, makes people particularly vulnerable to depression.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/563047/original/file-20231201-21-7jfwil.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Microscopy image of a long green neuron touching a red neuron" src="https://images.theconversation.com/files/563047/original/file-20231201-21-7jfwil.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/563047/original/file-20231201-21-7jfwil.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=596&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563047/original/file-20231201-21-7jfwil.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=596&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563047/original/file-20231201-21-7jfwil.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=596&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563047/original/file-20231201-21-7jfwil.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=749&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563047/original/file-20231201-21-7jfwil.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=749&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563047/original/file-20231201-21-7jfwil.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=749&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This microscopy image shows a mouse inhibitory neuron (red) contacting a pyramidal neuron (green).</span>
<span class="attribution"><a class="source" href="https://flic.kr/p/J8HizN">McBain Laboratory, NICHD/NIH via Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Using a <a href="https://doi.org/10.1016/j.neuroimage.2017.06.078">mathematical model</a> of cell type-based electrical activity, I linked increases in aperiodic activity, like those seen in the ECT patients, to a huge <a href="https://doi.org/10.1038/s41398-023-02634-9">change in the activity</a> of these inhibitory cells. This change in aperiodic activity may be restoring the crucial on and off balance in the brain to a healthy level. </p>
<p>Even though scientists have been recording EEGs from ECT patients for decades, this is the first time that brain waves have been connected to this particular brain malfunction.</p>
<p>Altogether, though our sample size is relatively small, our findings indicate that ECT and MST likely treat depression by resetting aperiodic activity and restoring the function of inhibitory brain cells. Further study can help destigmatize ECT and highlight new directions for the research and development of depression treatments. Listening to the nonmusical background noise of the brain could help solve other mysteries, like how the brain changes in aging and in illnesses like schizophrenia and epilepsy.</p><img src="https://counter.theconversation.com/content/217889/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sydney E. Smith does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Electroconvulsive therapy often evokes inaccurate images of seizing bodies and smoking ears. Better understanding of how it reduces depression symptoms can illuminate new ways to treat mental illness.Sydney E. Smith, Ph.D. Candidate in Computational Neuroscience, University of California, San DiegoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2065802023-08-24T20:20:46Z2023-08-24T20:20:46ZFriday essay: ‘black bile’, malaria therapy and insulin comas – a brief history of mental illness<p>Possibly the earliest account of a disturbed mind is recorded in a 3,500-year-old <a href="https://en.wikipedia.org/wiki/Vedas">Hindu text</a> that describes a man who is “gluttonous, filthy, walks naked, has lost his memory and moves about in an uneasy manner”.</p>
<p>In the Bible’s Old Testament, in the first <a href="https://www.britannica.com/topic/Books-of-Samuel">Book of Samuel</a>, we read that King David simulated madness to gain safety: </p>
<blockquote>
<p>And he changed his behaviour … and feigned himself mad in their hands, and scrabbled on the doors of the gate, and let his spittle fall down upon his beard.</p>
</blockquote>
<p>In the <a href="https://www.britannica.com/topic/The-Book-of-Daniel-Old-Testament">Book of Daniel</a>, we find a vivid description of King Nebuchadnezzar’s mental state: </p>
<blockquote>
<p>And he was driven from men, and did eat grass as oxen, and his body was wet with the dew of heaven, till his hairs were grown like eagles’ feathers, and his nails like birds’ claws.</p>
</blockquote>
<p>The ancient Greeks made early attempts to explain madness. In the 5th century BC, <a href="https://fherehab.com/learning/humors-ancient-mental-health">Hippocrates</a> viewed it as seated in the brain and influenced by four bodily fluids: blood, phlegm, black bile and yellow bile. </p>
<p>The Greek physician Galen, who practised in Rome 600 years later, argued that depression was caused by an excess of black bile (hence the term “melancholia”, from <em>melan</em>, black, and <em>khole</em>, bile). </p>
<p>His contemporary, <a href="https://www.britannica.com/biography/Aretaeus-of-Cappadocia">Aretaeus of Cappadocia</a>, colourfully described how, if black bile moves upwards in the body, “it forms melancholy; for it produces flatulence and eructations [or, belches] of a fetid and fishy nature, and it sends rumbling wind downwards, and disturbs the understanding”. </p>
<h2>A troubled mind, possessed</h2>
<p>During the Middle Ages, monasteries preserved the view of madness as an illness, and of those afflicted as sick rather than sinful. At the same time, the more sinister belief that the <a href="https://pubmed.ncbi.nlm.nih.gov/25208453/">principal cause</a> of the troubled mind was possession by spirits or the devil prevailed.</p>
<p>Sufferers were taken to sanctioned healers for <a href="https://theconversation.com/exorcisms-have-been-part-of-christianity-for-centuries-107932">exorcisms</a>, a practice still carried out today in some cultures. People who failed to respond to such treatment might then seek out a celebrated expert. </p>
<p>Consider Hwaetred, a young man living in what is now England in the 7th century, who became tormented by an “evil spirit”. So terrible was his madness that he attacked others with his teeth and killed three men with an axe when they tried to restrain him. Taken to several sacred shrines, he obtained no relief. His despairing parents then heard of Guthlac, a monk who lived a hermit life north of Cambridge. After three days of prayer and fasting, Hwaetred was purportedly cured.</p>
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<a href="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">St Francis Borgia Helping a Dying Impenitent – Goya (1788)</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Over time, the role of religious authorities in mental illness dwindled, and the medical profession claimed the exclusive practice of the healing arts. Insanity once more came to be seen more as a physical malady than a spiritual taint. Even so, life for the mentally ill could be appalling. </p>
<p>During the 17th century, religiously inspired persecution of the mentally ill was justified by the clerical hierarchy, and treatment was often some combination of neglect and bestial restraint. </p>
<p>Psychiatrists Martin Roth and Jerome Kroll <a href="https://books.google.com.au/books/about/The_Reality_of_Mental_Illness.html?id=pCQ4AAAAIAAJ&redir_esc=y">describe</a> the insane in this period as “miserable individuals, wandering around in village and in forest, taken from shrine to shrine, sometimes tied up when they became too violent”.</p>
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Read more:
<a href="https://theconversation.com/the-invention-of-satanic-witchcraft-by-medieval-authorities-was-initially-met-with-skepticism-140809">The invention of satanic witchcraft by medieval authorities was initially met with skepticism</a>
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</em>
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<h2>A watershed: asylums</h2>
<p>The late 18th century was a watershed in the history of psychiatry. The insanity of England’s <a href="https://www.bbc.com/news/magazine-22122407">King George III</a> revealed society’s ambivalence to the mentally ill (vividly captured in the 1994 film <a href="https://www.imdb.com/title/tt0110428/">The Madness of King George</a>). </p>
<p>In France, <a href="https://www.britannica.com/biography/Philippe-Pinel">Philippe Pinel</a> released the chains that had fettered the “lunatic” for centuries, ushering in an unprecedented phase of benevolent institutional care. </p>
<p><a href="https://dictionary.apa.org/moral-therapy">Moral therapy</a>, a form of individualised care in small hospital settings, was promoted by English Quakers at the <a href="https://en.wikipedia.org/wiki/The_Retreat">York Retreat</a> and gradually supplanted inhumane physical treatments such as purging, bleeding and dunking in cold water.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/BHNSAK8d3qc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">English society’s ambivalence to the mentally ill in the 18th century is depicted in the 1994 film, The Madness of King George.</span></figcaption>
</figure>
<p>As populations grew and urbanised, the sheer numbers of mentally ill people in burgeoning city slums demanded action. An institutional solution emerged. </p>
<p>Asylums (from the Greek word meaning “refuge”) were built in rural settings with the best of intentions, planned to be havens in which patients would receive humane care. In the serenity of the countryside, and through carrying out undemanding tasks, they could be distracted from their internal torment and find dignity far from the bustling crowd. </p>
<p><a href="https://www.britannica.com/biography/Daniel-Defoe">Daniel Defoe</a>, the English writer, remained unconvinced: “This is the height of barbarity and injustice in a Christian country; it is a clandestine Inquisition, nay worse.”</p>
<p>Although conceived in a spirit of optimism, asylums tended to deteriorate into centres of hopelessness and demoralisation. They soon became overcrowded dumps. Institutions built for a few hundred people were soon holding thousands. Very few residents were discharged; many stayed for decades. Brutal oppression replaced anything that might have resembled treatment; malnutrition and infectious disease became rife.</p>
<p>In the grim environment, people were shut away and forgotten. With them out of sight and out of mind, a loss of public interest and political neglect became the norm.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=483&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=483&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=483&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=607&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=607&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=607&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Asylums were conceived optimistically, but more often housed oppression than treatment. Picture: The Hospital of Bethlehem.</span>
<span class="attribution"><span class="source">Wellcome Collection</span></span>
</figcaption>
</figure>
<p>The brooding building on the hill came to symbolise the stigma and fear attached to mental illness. By the mid-19th century, critics were voicing concerns that asylums had become human warehouses that entrenched mental illness rather than curing it. </p>
<p>The combination of powerless patients, hospitals run more for the convenience of staff than for the benefit of the sick, inadequate inspection by state bodies, and lack of resources led at times to quite disgraceful conditions. Unwittingly, the spread of asylums also triggered the movement of psychiatry away from the mainstream of medicine.</p>
<p>The conditions of the asylums are evocatively described in Henry Handel Richardson’s Australian novel <a href="https://www.textpublishing.com.au/books/the-fortunes-of-richard-mahony">The Fortunes of Richard Mahony</a>. We read of Richard’s decline, probably from syphilis affecting the brain, which at that time afflicted a large proportion of mental patients.</p>
<p>Towards the end of the novel, his wife comes to visit him in the asylum:</p>
<blockquote>
<p>She hung her head … while the warder told the tale of Richard’s misdeeds. 97B was, he declared, not only disobedient and disorderly, he was extremely abusive, dirty in his habits … he refused to wash himself, or to eat his food … she had to keep a grip on her mind to hinder it from following the picture up: Richard, forced by this burly brute to grope on the floor for his spilt food, to scrape it together, and either eat it or have it thrust down his throat … There was not only feeding by force, the straitjacket, the padded cell. There were drugs and injections, given to keep a patient quiet and ensure his warders their freedom.</p>
</blockquote>
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<strong>
Read more:
<a href="https://theconversation.com/the-case-for-the-fortunes-of-richard-mahony-by-henry-handel-richardson-24474">The case for The Fortunes of Richard Mahony by Henry Handel Richardson</a>
</strong>
</em>
</p>
<hr>
<h2>Great and desperate cures</h2>
<p>In the asylum, psychiatry turned into a modern medical discipline. The
accumulation of thousands of patients provided the first opportunity
to study mental illness systematically and to develop theories about its
causes. </p>
<p>The idea that these conditions were due to brain alterations, and especially degenerative processes, became dominant, encouraged by the discovery of the cerebral pathology associated with <a href="https://www.healthline.com/health/neurosyphilis">neurosyphilis</a> and <a href="https://theconversation.com/what-causes-alzheimers-disease-what-we-know-dont-know-and-suspect-75847">Alzheimer’s disease</a>. A similar degenerative process was proposed by the great German psychiatrist <a href="https://www.britannica.com/biography/Emil-Kraepelin">Emil Kraepelin</a> to cause <a href="https://www.sciencedirect.com/topics/computer-science/dementia-praecox">dementia praecox</a> – later renamed “schizophrenia” – leading to pessimism about the possibility of recovery.</p>
<p>But the priority for asylums was to relieve the suffering of overwhelming numbers of disturbed patients. Psychiatrists grasped for “great and desperate cures”. <a href="https://en.wikipedia.org/wiki/Henry_R._Rollin">Henry Rollin</a>, an English psychiatrist and medical historian, captures the intense zeal:</p>
<blockquote>
<p>The physical treatment of the frankly psychotic during these centuries makes spine-chilling reading. Evacuation by vomiting, purgatives, sweating, blisters, and bleeding were considered essential […] There was indeed no insult to the human body, no trauma, no indignity which was not at one time or other piously prescribed for the unfortunate victim.</p>
</blockquote>
<p>Treatments were sometimes based on rational grounds. Malaria therapy, for instance, was launched as a treatment for neurosyphilis by the Viennese psychiatrist <a href="https://www.britannica.com/biography/Julius-Wagner-Jauregg">Julius Wagner-Jauregg</a> in 1917, earning him a Nobel Prize ten years later. </p>
<p>The high fever caused by the malarial parasite disabled the <a href="https://www.britannica.com/science/spirochete">spirochete</a> that caused neurosyphilis, but the hope that it would be equally effective for other forms of psychosis was soon dashed. The wished-for panacea was not to be.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Malaria therapy, a treatment for neurosyphilis, earned its inventor a Nobel Prize.</span>
<span class="attribution"><span class="source">Jimmy Chan/Pexels</span></span>
</figcaption>
</figure>
<p><a href="https://www.britannica.com/science/insulin-shock-therapy">Insulin-coma therapy</a> was introduced by Manfred Sakel in the 1930s in Vienna and was soon being used in many countries to treat schizophrenia. An insulin injection was administered six days a week for several weeks, producing a state of light coma lasting about an hour, because of reduced glucose reaching the brain. </p>
<p>Many years later, an investigation carried out in the Institute of Psychiatry in London, a leading research centre at the time, showed conclusively that the coma itself was of no therapeutic value. Any positive change was probably due to the staff’s painstaking care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/girl-interrupted-interrogates-how-women-are-mad-when-they-refuse-to-conform-30-years-on-this-memoir-is-still-important-199211">Girl, Interrupted interrogates how women are 'mad' when they refuse to conform – 30 years on, this memoir is still important</a>
</strong>
</em>
</p>
<hr>
<h2>ECT and lithium</h2>
<p>The first widely available and effective biological treatments for mental illness were developed in the asylum. The discovery in 1938 of <a href="https://theconversation.com/electroconvulsive-therapy-a-history-of-controversy-but-also-of-help-70938">electroconvulsive therapy</a> (ECT) by <a href="https://www.psychiatrictimes.com/view/ugo-cerletti">Ugo Cerletti</a> and Lucio Bini, two Italian psychiatrists, led to a dramatically effective treatment for people with severe depression. </p>
<p>ECT was eagerly adopted in practice, but its history illustrates a typical pattern of treatment in psychiatry: unbridled early enthusiasm is later tempered by a protracted process of scientific evaluation. </p>
<p>The same can be said of the use of brain surgery to modify psychiatric symptoms. This was pioneered in 1936 by Portuguese neurologist <a href="https://www.britannica.com/biography/Antonio-Egas-Moniz">António Egas Moniz</a> (another Nobel Prize winner in the field of psychiatry) and surgeon Almeida Lima, and remains controversial in psychiatry to this day.</p>
<p>A momentous breakthrough was the discovery in 1949 by <a href="https://www.nature.com/articles/d41586-019-02480-0">John Cade</a>, an Australian psychiatrist, of lithium as a treatment for manic excitement. The lithium story reveals how the incorporation of a new medication into psychiatric practice is not always smooth. </p>
<p>Several US and Danish psychiatrists had experimented with lithium in the 1870s and 1890s, only to have their work ignored until Cade’s rediscovery. It was another 18 years before lithium was shown to prevent the recurrence of severe changes of mood, its primary clinical use now.</p>
<p>Major tranquillisers were added to the growing range of psychiatric medications after being discovered fortuitously in 1953. An antihistamine used to calm patients undergoing surgery was shown to reduce the torment of psychotic patients, but without making them sleepy. </p>
<p>Shortly after this, the US psychiatrist <a href="https://www.nytimes.com/1983/02/14/obituaries/nathan-kline-developer-of-antidepressants-dies.html">Nathan Kline</a> discovered that a drug being tested for its effect in patients with tuberculosis had antidepressant properties — the forerunner of medications for depression. All these drugs radically transformed the practice of psychiatry. </p>
<h2>Freud, ‘talking cures’ and shell shock</h2>
<p>A very different aspect of mental health care arose in the 1890s, outside
the asylum. Concerned with neurotic conditions, the new treatment grew chiefly out of neurology but was also influenced by a scientific interest in hypnosis and the unconscious. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=816&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=816&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=816&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1025&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1025&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1025&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sigmund Freud.</span>
<span class="attribution"><span class="source">Max Halberstadt/Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Sigmund Freud conceived a dynamic model of the mind in which, through the mechanism of repression, painful or threatening emotions, memories and impulses are prevented from escaping into conscious awareness. </p>
<p><a href="https://theconversation.com/a-dangerous-method-in-defence-of-freuds-psychoanalysis-5989">Psychoanalysis</a> grew to become an integrated set of concepts about normal and abnormal mental functioning and personality development, and spawned a new method of psychologically based treatment. Psychoanalysis emerged as a major theoretical underpinning of contemporary “talking cures” (psychotherapies), and its influence spread far beyond treating mental ill-health.</p>
<p>Both world wars profoundly influenced the field. The high incidence of “<a href="https://theconversation.com/shell-shock-treatments-reveal-the-conflict-in-psychiatrys-heart-29822">shell shock</a>” in World War I drove home the lesson that mental illness could affect not only those genetically predisposed, but even the supposedly robust. It soon emerged that anyone exposed to traumatic experiences was vulnerable. </p>
<p>A positive outcome from World War II was the development of techniques for screening large numbers of recruits, which revealed the substantial prevalence of emotional problems among young adults. </p>
<p>The need to treat numerous psychiatric casualties led to the development of group therapies. These paved the way for the so-called <a href="https://en.wikipedia.org/wiki/Therapeutic_community">therapeutic community</a>, based on the idea that an entire ward of patients could be an integral part of treatment.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ehPcYibzUKc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Group therapy, as depicted in One Flew Over the Cuckoo’s Nest.</span></figcaption>
</figure>
<p>The idea of deinstitutionalisation began to gather pace in the 1960s, driven by a burgeoning civil-rights movement. <a href="https://www.penguin.com.au/books/asylums-9780241548004">Asylums</a>, an influential book at the time by sociologist Erving Goffman, containing his minute observations of the sense of oppression experienced by patients in these “total institutions”, was one catalyst for their closure. </p>
<p>Hundreds of thousands of long-stay patients began to be transferred to alternative accommodation and specialist care in the community, a process that is still in progress.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-body-keeps-the-score-how-a-bestselling-book-helps-us-understand-trauma-but-inflates-the-definition-of-it-184735">The Body Keeps the Score: how a bestselling book helps us understand trauma – but inflates the definition of it</a>
</strong>
</em>
</p>
<hr>
<h2>What is mental illness?</h2>
<p>It is challenging to define what makes a pattern of behaviour and experience a mental disorder. Generally, such a pattern – or “syndrome” – is considered to be a disorder if it is associated with psychological distress, such as intense and prolonged anxiety or sadness, or significant dysfunction, such as a serious impairment in functioning in one or more key areas of daily life. </p>
<p>If the pattern is short-lived, relatively mild, or entirely understandable in light of the trials and tribulations of the person’s life, it should be seen as a problem in living rather than a mental disorder. Such problems may still benefit from consultation with a mental health professional despite not being diagnosable disorders.</p>
<p>This definition of what counts as a mental disorder also clarifies what is not a mental disorder. Merely being unusual or violating social norms does not mean a person has a disorder. </p>
<p>It is difficult sometimes to decide whether a new kind of behaviour is a mental disorder. For instance, should <a href="https://theconversation.com/no-youre-probably-not-addicted-to-your-smartphone-but-you-might-use-it-too-much-89853">excessive smartphone use</a> or <a href="https://theconversation.com/gambling-on-pokies-is-like-tobacco-no-amount-of-it-is-safe-51037">compulsive gambling</a> be counted as diagnosable addictions?</p>
<h2>Troubling cases</h2>
<p>These decisions about what to include under the umbrella of mental illness are fraught, and there have been some troubling historical cases when disturbing decisions were made or proposed. </p>
<p>In the 1850s, for example, Samuel Cartwright, a physician from Alabama, proposed a new diagnosis called “<a href="https://www.nytimes.com/2000/01/15/arts/bigotry-as-mental-illness-or-just-another-norm.html">drapetomania</a>” to explain why African-American slaves would wish to escape their servitude. </p>
<p>He recommended slaves should be treated kindly and humanely to prevent the disorder, but whipped if this treatment failed. A more patent abuse of the concept of mental illness would be hard to imagine, and it should be noted that other physicians ridiculed Cartwright’s proposal at the time.</p>
<p>Two other controversial cases date to the last century. In the early 1970s, one of us (Sidney) stumbled across disturbing media reports that many political and religious dissenters and human-rights activists in the Soviet Union were being labelled as mentally ill and detained in mental hospitals indefinitely or until they renounced their “disturbed ideas”. </p>
<p>For instance, <a href="https://en.wikipedia.org/wiki/Petro_Grigorenko">General Pyotr Grigorenko</a> criticised the privileges of the Soviet elite and publicly espoused the rights of the <a href="https://en.wikipedia.org/wiki/Crimean_Tatars">Crimean Tatar</a> ethnic minority group. He was diagnosed with paranoid tendencies, one symptom being his “reformist ideas”, and forcibly committed to a psychiatric facility. </p>
<p>In effect, Soviet psychiatry’s definition of mental illness, and psychosis in particular, was so broad that political beliefs about the desirability of social change were recast as delusions.</p>
<p>The second case comes from the US. <a href="https://daily.jstor.org/how-lgbtq-activists-got-homosexuality-out-of-the-dsm/">Until 1973</a>, homosexuality was defined as a sexual deviation and included in the set of recognised mental disorders. Under pressure from civil, women’s and gay rights activists, it was removed from the diagnostic manual.</p>
<p>Noting such cases, whenever the boundary of a mental illness is expanded to include new diagnoses or loosen old ones, some critics will worry we are treating normal behaviour as a pathology and that we will harm people by labelling them. And whenever the boundary contracts, others will worry that people with psychological troubles are being excluded from clinical care. </p>
<p>Deciding what is and isn’t a mental illness is difficult, but has marked consequences.</p>
<hr>
<p><em>This is an edited extract from <a href="https://scribepublications.com.au/books-authors/books/troubled-mindSees-9781922585875">Troubled Minds: Understanding and treating mental illness</a> by Sidney Bloch and Nick Haslam (Scribe Publications), published 29 August 2023.</em></p><img src="https://counter.theconversation.com/content/206580/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Haslam receives funding from the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Sidney Bloch does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Humans have attempted to understand and treat mental illness for centuries – from ancient Greek medicine, Middle Ages exorcisms and the rise of asylums, to modern medical breakthroughs.Sidney Bloch, Emeritus Professor in Psychiatry, The University of MelbourneNick Haslam, Professor of Psychology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1821352022-05-05T18:00:24Z2022-05-05T18:00:24ZHow treaties protecting fossil fuel investors could jeopardize global efforts to save the climate – and cost countries billions<figure><img src="https://images.theconversation.com/files/461418/original/file-20220504-16-lkr3zr.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5082%2C3520&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The threat of expensive payouts may already be having an effect.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/foot-sections-of-pipeline-which-will-carry-oil-from-the-news-photo/52832800?adppopup=true">Tom Stoddart/Getty Images</a></span></figcaption></figure><p>Fossil fuel companies have access to an obscure legal tool that could jeopardize worldwide efforts to protect the climate, and they’re starting to use it. The result could cost countries that press ahead with those efforts billions of dollars.</p>
<p>Over the past 50 years, countries have signed <a href="https://investmentpolicy.unctad.org/international-investment-agreements/iia-mapping">thousands of treaties</a> that protect foreign investors from government actions. These treaties are like contracts between national governments, meant to entice investors to bring in projects with the promise of local jobs and access to new technologies.</p>
<p>But now, as countries try to phase out fossil fuels to slow climate change, these agreements could leave the public facing overwhelming legal and financial risks.</p>
<p>The treaties allow investors to sue governments for compensation in a process called <a href="https://www.iisd.org/itn/en/2014/08/11/aron-broches-and-the-withdrawal-of-unilateral-offers-of-consent-to-investor-state-arbitration/">investor-state dispute settlement</a>, or ISDS. In short, investors could use ISDS clauses to demand compensation in response to government actions to limit fossil fuels, such as canceling pipelines and denying drilling permits. For example, TC Energy, a Canadian company, is currently seeking <a href="https://www.reuters.com/legal/litigation/tc-energy-seeks-nafta-damages-over-canceled-keystone-xl-project-2021-11-23/">more than US$15 billion</a> over U.S. President Joe Biden’s cancellation of the Keystone XL Pipeline.</p>
<p>In a study published May 5, 2022, in the journal Science, we estimate that <a href="https://doi.org/10.1126/science.abo4637">countries would face up to $340 billion</a> in legal and financial risks for canceling fossil fuel projects that are subject to treaties with ISDS clauses. </p>
<p>That’s more than countries worldwide put into climate adaptation and mitigation measures combined in <a href="https://www.reuters.com/legal/litigation/tc-energy-seeks-nafta-damages-over-canceled-keystone-xl-project-2021-11-23/">fiscal year 2019</a>, and it doesn’t include the risks of phasing out coal investments or canceling fossil fuel infrastructure projects, like pipelines and liquefied natural gas terminals. It means that money countries might otherwise spend to build a low-carbon future could instead go to the very industries that have <a href="https://theconversation.com/what-big-oil-knew-about-climate-change-in-its-own-words-170642">knowingly been fueling climate change</a>, severely jeopardizing countries’ capacity to propel the green energy transition forward.</p>
<h2>Massive potential payouts</h2>
<p>Of the world’s 55,206 upstream oil and gas projects that are in the early stages of development, we identified 10,506 projects – 19% of the total – that were protected by 334 treaties providing access to ISDS. </p>
<p>That number could be much higher. We could only identify the headquarters of project owners, not the overall corporate structures of the investments, due to limited data. We also know that <a href="https://www.jonesday.com/en/insights/2022/02/climate-change-and-investorstate-dispute-settlement">law firms are advising clients in the industry</a> to structure investments to ensure access to ISDS, through processes such as using subsidiaries in countries with treaty protections. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/461313/original/file-20220504-16-x863of.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Maps showing where these treaties are used." src="https://images.theconversation.com/files/461313/original/file-20220504-16-x863of.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461313/original/file-20220504-16-x863of.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=678&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461313/original/file-20220504-16-x863of.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=678&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461313/original/file-20220504-16-x863of.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=678&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461313/original/file-20220504-16-x863of.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=852&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461313/original/file-20220504-16-x863of.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=852&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461313/original/file-20220504-16-x863of.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=852&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://doi.org/10.1126/science.abo4637">K. Franklin/Science based on K. Tienhaara et al.</a></span>
</figcaption>
</figure>
<p>Depending upon future oil and gas prices, we found that the <a href="https://doi.org/10.1126/science.abo4637">total net present value of those projects</a> is expected to reach $60 billion to $234 billion. If countries cancel these protected projects, foreign investors could sue for financial compensation in line with these valuations. </p>
<p>Doing so would put several low- and middle-income countries at severe risk. Mozambique, Guyana and Venezuela could each face over $20 billion in potential losses from ISDS claims.</p>
<p>If countries also cancel oil and gas projects that are further along in development but are not yet producing, they face more risk. We found that 12% of those projects worldwide are protected by investment treaties, and their investors could sue for $32 billion to $106 billion. </p>
<p>Canceling approved projects <a href="https://doi.org/10.1126/science.abo4637">could prove exceptionally risky</a> for countries like Kazakhstan, which could lose $6 billion to $18 billion, and Indonesia, with $3 billion to $4 billion at risk.</p>
<p>Canceling coal investments or fossil fuel infrastructure projects, like pipelines and liquefied natural gas terminals, could lead to even more claims.</p>
<h2>Countries already feel regulatory chill</h2>
<p>There have been <a href="https://www.iisd.org/system/files/2022-01/investor%E2%80%93state-disputes-fossil-fuel-industry.pdf">at least 231 ISDS cases</a> involving fossil fuels so far. Just the threat of massive payouts to investors could cause many countries to delay climate mitigation policies, causing a so-called “regulatory chill.” </p>
<p>Both <a href="https://capitalmonitor.ai/institution/government/cop26-ambitions-at-risk-from-energy-charter-treaty-lawsuits/https:/capitalmonitor.ai/institution/government/cop26-ambitions-at-risk-from-energy-charter-treaty-lawsuits/">Denmark and New Zealand</a>, for example, seem to have designed their fossil fuel phaseout plans specifically to minimize their exposure to ISDS. <a href="https://www.euractiv.com/section/energy/opinion/energy-charter-conference-a-ministerial-without-ministers/">Some</a> climate policy <a href="https://www.ibanet.org/Climate-crisis-Impact-of-Energy-Charter-Treaty-on-clean-energy-transition-raises-concern">experts</a> have suggested that Denmark may have chosen 2050 as the end date for oil and gas extraction to avoid disputes with existing exploration license holders.</p>
<p>New Zealand banned all new offshore oil exploration in 2018 but did not cancel any existing contracts. The climate minister acknowledged that a more aggressive plan <a href="https://capitalmonitor.ai/institution/government/cop26-ambitions-at-risk-from-energy-charter-treaty-lawsuits/">“would have run afoul of investor-state settlements.”</a> <a href="https://doi.org/10.1016/j.esg.2021.100118">France revised a draft law</a> banning fossil fuel extraction by 2040 and allowing the renewal of oil exploitation permits after the <a href="https://www.vermilionenergy.com/our-operations/europe/france.cfm">Canadian company Vermilion</a> threatened to launch an ISDS case.</p>
<h2>Securing the green energy transition</h2>
<p>While these findings are alarming, countries have options to avoid onerous legal and financial risks. </p>
<p>The Organization for Economic Cooperation and Development is <a href="https://www.oecd.org/investment/investment-policy/investment-treaties.htm">currently discussing proposals</a> on the future of investment treaties.</p>
<p>A straightforward approach would be for countries to terminate or withdraw from these treaties. Some officials have <a href="https://doi.org/10.1111/1758-5899.12355">expressed concern</a> about unforeseen impacts of unilaterally terminating investment treaties, but other countries have already done so, <a href="https://www.citizen.org/wp-content/uploads/pgcw_fdi-inflows-from-bit-termination_finaldraft.pdf">with few or no real economic consequences</a>. </p>
<figure>
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</figure>
<p>For more complex trade agreements, countries can negotiate to remove ISDS provisions, as the United States and Canada <a href="https://www.iisd.org/articles/usmca-impact-north-american-trade">did when they replaced</a> the North American Free Trade Agreement with the United States-Mexico-Canada Agreement.</p>
<p>Additional challenges stem from “sunset clauses” that bind countries for a decade or more after they have withdrawn from some treaties. Such is the case for Italy, which <a href="https://borderlex.net/2022/04/25/ect-negotiations-members-eye-june-deal-announcement/">withdrew from the Energy Charter Treaty</a> in 2016. It is <a href="https://icsid.worldbank.org/cases/case-database/case-detail?CaseNo=ARB/17/14">currently stuck</a> in an ongoing ISDS case initiated by the U.K. company Rockhopper over a ban on coastal oil drilling. </p>
<p>The Energy Charter Treaty, a special investment agreement covering the energy sector, emerged as the greatest single contributor to global ISDS risks in our dataset. Many European countries are <a href="https://borderlex.net/2022/04/25/ect-negotiations-members-eye-june-deal-announcement/">currently considering</a> whether to leave the treaty and how to avoid the same fate as Italy. If all country parties to a treaty can <a href="https://scholarship.law.columbia.edu/cgi/viewcontent.cgi?article=1153&context=sustainable_investment_staffpubs">agree together to withdraw</a>, they could <a href="https://doi.org/10.1093/icsidreview/sit051">collectively sidestep</a> the sunset clause through mutual agreement. </p>
<h2>The global transition</h2>
<p>Combating climate change is not cheap. Actions <a href="https://www.ipcc.ch/report/sixth-assessment-report-working-group-3/">by governments</a> and the private sector are <a href="https://www.iea.org/articles/the-cost-of-capital-in-clean-energy-transitions">both needed</a> to slow global warming and keep it <a href="https://www.ipcc.ch/sr15/">from fueling increasingly devastating disasters</a>.</p>
<p>In the end, the question is who will pay – and be paid – in the global energy transition. We believe that, at the very least, it would be counterproductive to divert critical public finance from essential mitigation and adaptation efforts to the pockets of fossil fuel industry investors whose products caused the problem in the first place.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/182135/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Thrasher receives funding from Open Society Foundations and the Rockefeller Brothers Fund.</span></em></p><p class="fine-print"><em><span>Kyla Tienhaara receives funding from the Canada Research Chairs Program (Government of Canada). She provides pro bono advice for a number of non-profit organizations working on climate and investment issues. </span></em></p><p class="fine-print"><em><span>Blake Alexander Simmons does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new study adds up the potential legal and financial risk countries could face from hundreds of agreements, like those under the Energy Charter Treaty.Rachel Thrasher, Law Lecturer and Researcher at the Boston University Global Development Policy Center, Boston UniversityBlake Alexander Simmons, Postdoctoral Research Fellow in the Human Dimensions of Natural Resources, Colorado State UniversityKyla Tienhaara, Canada Research Chair in Economy and Environment, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1759692022-02-10T16:16:02Z2022-02-10T16:16:02ZElectroconvulsive therapy: calls to have it suspended ignore the evidence<figure><img src="https://images.theconversation.com/files/445701/original/file-20220210-41044-1blmfu.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5076%2C3379&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Arguments to suspend ECT are based on selective and poor-quality assessments of the evidence.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-stethoscope-on-stack-paper-270530237">Micolas/ Shutterstock</a></span></figcaption></figure><p>Around <a href="https://bpspsychub.onlinelibrary.wiley.com/doi/10.1111/papt.12335">2,500 people</a> in England receive electroconvulsive therapy (ECT) every year. This is a last resort treatment, used to help alleviate severe depression in people who have failed to respond to other treatments. ECT is administered by passing a small electrical current around the head of an anaesthetised person to induce a seizure.</p>
<p>Many misunderstandings persist about ECT’s effectiveness and safety. Part of this is due to <a href="https://www.sciencedirect.com/science/article/pii/S1935861X16301978?via%3Dihub">negative portrayals</a> of the therapy in movies and TV. But scientists themselves have long been divided over its use, largely because of the selective portrayal of evidence presented in studies. </p>
<p>In 2020, a group of UK-based mental health professionals, patients and relatives wrote to the Care Quality Commission (the independent regulator of health and social care in England) calling to immediately suspend ECT. <a href="https://www.bbc.co.uk/news/uk-52900074">In their letter</a>, they said ECT comes with a high risk of permanent memory loss and may cause death. They also wrote that research had failed to determine whether or not ECT actually works in treating depression. The basis of their argument against ECT came primarily from <a href="https://www.cambridge.org/core/journals/epidemiology-and-psychiatric-sciences/article/abs/effectiveness-of-electroconvulsive-therapy-a-literature-review/069E1BBD117AE2B57314FF48A841309D">two reviews</a> – the most recent of which was <a href="https://connect.springerpub.com/content/sgrehpp/early/2020/04/02/ehpp-d-19-00014.abstract">published in 2020</a>. </p>
<p>It’s understandable that people may be concerned about the safety and efficacy of this treatment. But <a href="https://www.cambridge.org/core/journals/epidemiology-and-psychiatric-sciences/article/critique-of-narrative-reviews-of-the-evidencebase-for-ect-in-depression/9661DA40F061600ED202C716C154E4BB#article">our latest paper</a> has shown that these arguments to suspend ECT are based on selective and poor-quality assessments of the evidence. We also show that when we take a close look at the research, ECT remains an effective treatment for people with severe depression.</p>
<h2>Low quality</h2>
<p>Our paper sought to analyse the published studies, including those cited in the two reviews that were referred to in the letter calling for ECT to be suspended.</p>
<p>We show that both of these reviews (a type of study which combines and summarises all of the data on a particular topic) failed to follow <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3789163/">standards of practice</a> when making their analyses. They also failed to engage with <a href="https://en.wikipedia.org/wiki/Open_science#:%7E:text=Open%20science%20is%20the%20movement%20to%20make%20scientific,that%20is%20shared%20and%20developed%20through%20collaborative%20networks.">open science</a> procedures, such as publishing a protocol outlining the plan for the review in advance. This means that both reviews would be considered of <a href="https://amstar.ca/Amstar-2.php">low quality</a> in the academic community – and shouldn’t be relied on as accurate and comprehensive summaries of the available evidence. </p>
<figure class="align-center ">
<img alt="Young woman wearing a lab coat reviews some research papers." src="https://images.theconversation.com/files/445702/original/file-20220210-48251-1s9oavs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/445702/original/file-20220210-48251-1s9oavs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445702/original/file-20220210-48251-1s9oavs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445702/original/file-20220210-48251-1s9oavs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445702/original/file-20220210-48251-1s9oavs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445702/original/file-20220210-48251-1s9oavs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445702/original/file-20220210-48251-1s9oavs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some reviews did not meet research standards.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-attractive-female-scientist-graduate-student-284233613">anyaivanova/ Shutterstock</a></span>
</figcaption>
</figure>
<p>These reviews argue ECT isn’t effective by only counting the number of trials that have published significant findings. This misleading approach gives equal weight to a study’s results – regardless of the number of people included in the study, the study’s primary aims or the quality or strength of the findings. The authors of the 2020 review even used a scale they developed on their own to rate the quality of each ECT trial. This makes it likely their own biases may have influenced the findings of their review.</p>
<p>To ensure our own analysis was accurate, we used a widely accepted method to assess the quality of scientific trials called the <a href="https://methods.cochrane.org/bias/resources/rob-2-revised-cochrane-risk-bias-tool-randomized-trials#:%7E:text=RoB%202%20Version%202%20of%20the%20Cochrane%20risk-of-bias,different%20aspects%20of%20trial%20design%2C%20conduct%2C%20and%20reporting.">Cochrane risk of bias tool</a>. This tool looks at whether a trial might be prone to specific biases that might work to show a favourable result – such as only reporting positive outcomes in ECT trials. Using this tool, our analysis revealed that these studies have no specific bias that favours ECT. </p>
<h2>Reviewing the evidence</h2>
<p>Our review analysed the publicly available data in ECT studies to show it is effective at producing rapid and large reductions in depression symptoms. Indeed, our review showed that ECT is among the most effective treatments currently used for severe depression. </p>
<p>Another argument against electroconvulsive therapy concerns the negative side effects it may have on memory. But again, our research revealed that any studies that have found negative effects on memory were of poor quality. Some studies even used a survey to ask participants about subjective memory complaints, and didn’t have a group who hadn’t received ECT to compare the results against. Some of the reviews we looked at even ignored most evidence on memory functioning, only mentioning just one of 75 published studies on the subject.</p>
<p>Research that looked at <a href="https://www.sciencedirect.com/science/article/pii/S0006322310005986?via%3Dihub">84 studies on ECT</a> even shows that memory problems that happen after a course of ECT are only temporary, and improve after 15 days. Many brain functions, such as problem solving, also improved after ECT. However, ECT’s effect on autobiographical memory (personal memories) is not well studied.</p>
<p>Calls to suspend or even ban electroconvulsive therapy outright – especially those based on the biased evidence presented by two reviews – may be ignoring the fact good evidence shows ECT is an effective treatment for people who have severe, treatment-resistant depression. But it will still be important for future trials to better understand any potential side-effects – and how these can be minimised.</p><img src="https://counter.theconversation.com/content/175969/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sameer Jauhar receives funding from the National Institute for Health Research Biomedical Research Centre at South London and Maudsley National Health Service Foundation Trust and King’s College London. SJ has also been funded by a JMAS (John, Margaret, Alfred, and Stewart) Sim Fellowship from the Royal College of Physicians, Edinburgh.
SJ has received honoraria for educational talks given on antipsychotics by Janssen, Lundbeck and Sunovian.
</span></em></p><p class="fine-print"><em><span>Keith Laws does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Previous research on this therapy has been poorly conducted and biased.Keith Laws, Professor of Cognitive Neuropsychology, University of HertfordshireSameer Jauhar, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1399382020-06-03T13:57:49Z2020-06-03T13:57:49ZNo evidence that ECT works for depression – new research<figure><img src="https://images.theconversation.com/files/339506/original/file-20200603-130934-5cy08f.jpg?ixlib=rb-1.1.0&rect=2%2C1%2C995%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients undergo ECT under general anaesthetic.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/focus-on-hand-patient-hospital-ward-589302497">Thaiview/Shutterstock</a></span></figcaption></figure><p>Many people will be familiar with electroconvulsive therapy (ECT) as a historical treatment for “mental illness”, in which an electrical current is passed through the brain to trigger seizures, with the aim of somehow treating the illness. In fact, ECT is still being administered to about a million people each year to treat severe depression, including <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/papt.12160">about 2,500 in England</a>, under anaesthetic. The majority are women, and over 60 years of age.</p>
<p>In <a href="https://connect.springerpub.com/content/sgrehpp/21/2/64">a new review of the research</a>, published in Ethical Human Psychology and Psychiatry, we suggest that there is no robust evidence that ECT works as a treatment for depression and the negative impact on patients set against any potential benefits is so appalling that ECT cannot be scientifically or ethically justified.</p>
<h2>The evidence base</h2>
<p>Despite its continued use, there have been no ECT vs placebo studies for 35 years. In fact, there have – surprisingly – only ever been 11 such studies, in which a control group has received the general anaesthetic but not the electricity or, therefore, the convulsion – and even these studies have been deeply flawed.</p>
<p>ECT enthusiasts argue the lack of any new placebo research is because it is unethical to withhold a treatment that is “known” to be effective and which definitely “saves lives”. This argument, however, means that the dwindling number of psychiatrists still using ECT are doing so outside the parameters of science in general and evidence-based medicine in particular.</p>
<p>In the UK, the National Institute for Health and Care Excellence (NICE) <a href="https://www.nice.org.uk/guidance/ta59">recommends the use of ECT</a> in some cases of prolonged or severe manic episodes or catatonia where other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening.</p>
<p>Although some people who have received ECT <a href="https://www.bbc.co.uk/programmes/b07187xv">do believe</a> it has saved their lives, there is still no study evidence that ECT is more effective than placebo for depression. Many others believe it has irreparably damaged their lives. </p>
<h2>Other reviews and meta-analyses</h2>
<p>My colleagues and I <a href="https://www.ingentaconnect.com/content/springer/ehpp/2017/00000019/00000001/art00002;jsessionid=2k6a40i48hffu.x-ic-live-01">have previously published</a> several <a href="https://www.cambridge.org/core/journals/epidemiology-and-psychiatric-sciences/article/effectiveness-of-electroconvulsive-therapy-a-literature-review/069E1BBD117AE2B57314FF48A841309D">reviews</a> of the 11 studies. These have shown that there is only very weak evidence, in some of the studies, for only a minority of patients, that ECT can temporarily lift mood slightly. The reviews also demonstrated that there is no evidence whatsoever that any such effect lasts beyond the last treatment (ECT is typically administered in a series of about eight treatments). </p>
<p>There is also no evidence that it saves lives or prevents suicides, despite the claim by some ECT advocates that it does – a claim that is then used to justify a risk of brain damage. Brain damage has been dismissed as the wrong term but I am not sure what else to call reported persistent or permanent memory loss in <a href="https://www.nature.com/articles/1301180">between 12%</a> and <a href="https://www.bmj.com/content/326/7403/1363">55%</a> of patients. It is sometimes argued that “modern” ECT is safer than it used to be, and that the memory loss is caused by the depression rather than the electricity, but there is no research evidence for either of these claims.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/339512/original/file-20200603-130955-a47gol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/339512/original/file-20200603-130955-a47gol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339512/original/file-20200603-130955-a47gol.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339512/original/file-20200603-130955-a47gol.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339512/original/file-20200603-130955-a47gol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339512/original/file-20200603-130955-a47gol.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339512/original/file-20200603-130955-a47gol.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">ECT being performed in at Winwick Hospital, 1957.</span>
<span class="attribution"><a class="source" href="https://ccsearch.creativecommons.org/photos/f8648128-2d18-46e2-ac10-5a20be4b7402">University of Liverpool Faculty of Health & Life Sciences</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p><a href="https://www.nature.com/articles/1301180">Some have asked</a> how come <a href="https://www.nature.com/articles/1301180">other reviews and meta-analyses conclude</a> that ECT is effective and safe? A reasonable question that deserves an answer.</p>
<p>The new study, co-authored with Irving Kirsch, associate director of placebo studies at Harvard Medical School, possibly the world’s leading researcher on the placebo effects of psychiatric treatments, answers this question.</p>
<p>Besides analysing the 11 studies in greater detail than ever before, giving them each a quality score based on 24 methodological criteria, we also evaluated the only five meta-analyses ever conducted on this tiny, and deeply flawed, body of literature. </p>
<p>To guard against bias (and I am indeed biased against ECT, because of its lack of evidence base and the damage I believe it has caused to hundreds of thousands of people) my own ratings of the 11 studies were compared to blind ratings, on carefully defined criteria, by a colleague, <a href="http://www.open.ac.uk/research/people/lm29454">Laura McGrath</a>, who had no knowledge of, or particular interest in, ECT.</p>
<p>The five meta-analyses included between one and seven of the 11 studies and in each paid little or no attention to the multiple limitations of the studies they included. </p>
<p>The 11 studies we looked at had a mean quality score of 12.3 out of 24 – and eight scored 13 or less. Only four studies described how they randomised subjects and then tested this. None convincingly demonstrated that they were double-blind (where neither the participants nor the experimenters know who is receiving a particular treatment). Five selectively reported their findings. Only four reported any ratings by patients. None assessed the quality of life of patients. </p>
<p>There were other flaws including small study sizes, no significant differences with another treatment, mixed results (including one where the psychiatrists reported a difference but patients didn’t). Only two of the higher quality studies reported follow up data.</p>
<p>We concluded that the quality of the studies is so poor that the meta-analyses were wrong to conclude anything about efficacy. </p>
<p>There seems to be no evidence that ECT is effective for its target diagnostic group – severely depressed people, or its target demographic – older women (therein lies a broader set of issues), or for suicidal people, people who have unsuccessfully tried other treatments first, involuntary patients, or adolescents. </p>
<p>And given the high risk of permanent memory loss and the small mortality risk, this longstanding failure to determine whether or not ECT works means that its use should be immediately suspended until a series of well-designed, randomised, placebo-controlled studies have investigated whether there really are any significant benefits against which the proven significant risks can be weighed.</p>
<p>As Kirsch says: “I don’t think many ECT advocates understand just how strong placebo effects are for a major procedure like ECT. The failure to find any meaningful benefits in long-term benefits compared to placebo groups are particularly distressing. On the basis of the clinical trial data, ECT should not be used for depressed individuals.”</p><img src="https://counter.theconversation.com/content/139938/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Read does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Study finds there is still no evidence that ECT is effective for depression – 80 years after its introduction.John Read, Professor of Clinical Psychology, University of East LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/380252015-09-06T20:08:31Z2015-09-06T20:08:31ZBack to black: why melancholia must be understood as distinct from depression<figure><img src="https://images.theconversation.com/files/93483/original/image-20150901-25748-1pqq056.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Melancholia may be a distinct type of depression, with its own clinical signs and symptoms</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/helga/4723657763/">Helga Weber/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>First described by Hippocrates, “melancholia” or melancholic depression was considered a specific condition that commonly struck people out of the blue – and put them into the black. In modern times, it came to be described as “<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1979411/">endogenous depression</a>” (coming from within) in contrast to depression stemming in response to external stressors. </p>
<p>In 1980, the third edition of the Diagnostic and Statistical Manual (<a href="http://www.terapiacognitiva.eu/dwl/dsm5/DSM-III.pdf">DSM-III</a>), the official classificatory system of the <a href="http://www.psychiatry.org/">American Psychiatric Association</a>, re-modelled depressive disorders. The new classification operated largely on degrees of severity, comprising “major” depression and several minor depressions. </p>
<p>This is how depression came to be modelled as a single entity, varying only by severity (this is known as the dimensional model). And over the last decade, this model has been extended to include “sub-clinical depressions”, which is basically when someone is sad or down but not diagnosable by formal mental illness criteria. </p>
<h2>Problematic model</h2>
<p><a href="http://www.oup.com.au/titles/academic/psychology/9780199921577">The changes generated concern</a> about the extension of “clinical depression” to include and “pathologise” sadness. While everyone feels down or sad sometimes, normally these moods pass, with little if any long-term consequences. </p>
<p>The boundary between this everyday kind of feeling down and clinical depression is imprecise. But the latter is associated with a greater severity of symptoms, such as losing sleep or thinking life isn’t worth living, lasts for longer and is much more likely to require treatment.</p>
<p>The dimensional model is intrinsically limited; “major depression” is no more informative a diagnosis than “major breathlessness”. It ignores the differing – biological, psychological and social – causes that may bring about a particular depressive condition and which inform the most appropriate therapeutic approach (be it an antidepressant drug, psychotherapy or social intervention). </p>
<p>Ignoring the cause of depression leads to both under-treatment, such as failure to prescribe an effective medication, and over-treatment, such as prescription of medication that’s unnecessary and may have side effects.</p>
<p>The model also essentially marginalised melancholia as a categorically different type of depression, with progressive DSM manuals according it insignificant status as a major depression “specifier” (an addendum to a diagnosis intended to provide more detail). </p>
<p>As a specifier, and not a disorder in its own right, melancholia is not considered categorically separate to other types of depression. And this matters – much less research and training is devoted to it as a result, and doctors are often unaware of its clinical implications. </p>
<h2>A distinct pattern</h2>
<p><a href="http://www.blackdoginstitute.org.au/public/research/meetourresearchers/gordonparker.cfm">My research team</a> is trying to establish melancholia’s categorical status and detection, and so improve its management. Here’s what we know – or think we know - about the distinctness of melancholia.</p>
<p>First, it shows a relatively clear pattern of <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733615/">symptoms and signs</a>. The individual experiences profound bleakness and has no desire to socialise, for instance, finding it hard to obtain any pleasure in life or to be cheered up. </p>
<p>Sufferers also experience a lack of energy and have difficulty concentrating, although they generally show “diurnal variation”, reporting improvement in mood and energy as the day goes on. Reflecting changes to their sleep/wake cycle, people with melancholia tend to wake early in the morning. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=554&fit=crop&dpr=1 754w, https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=554&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=554&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People with melancholic depression may feel no pleasure in socialising or regular activities.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-161548835/stock-photo-lone-man-is-sitting-at-the-table-in-conference-hall-rear-view.html?src=TSYwkSoBp1HczwYLv80nxA-3-3">Maxin Blinkov/shutterstock</a></span>
</figcaption>
</figure>
<p>Episodes commonly emerge “out of the blue”. Even if it follows a stressor, it’s disproportionately more severe than might be expected and lasts longer than the stressor. </p>
<p>We’ve <a href="http://www.ncbi.nlm.nih.gov/pubmed/22868058">progressively developed</a> a clinician-rated measure (the SMPI or Sydney Melancholia Prototype Index) that has about 80% accuracy in differentiating melancholic and non-melancholic depression. When we add course of illness, causal and other clinical factors, we’ve been able to statistically <a href="http://www.ncbi.nlm.nih.gov/pubmed/25565428">differentiate melancholic and non-melancholic depression</a> at a high level.</p>
<h2>Physical underpinnings</h2>
<p>Melancholia has a strong genetic contribution, with sufferers likely to report a family history of “depression”, bipolar disorder or suicide. It’s largely biologically underpinned rather than caused by social factors (stressors) or psychological factors, such as personality style.</p>
<p>The illness is also unlikely to respond to placebo, whereas major depression has a <a href="http://www.ncbi.nlm.nih.gov/pubmed/1388334">placebo response rate</a> in excess of 40%. But melancholia shows greater response to physical treatments, such as antidepressant drugs (especially those that work on a broader number of neurotransmitters), and to ECT (electroconvulsive therapy). ECT is rarely required, however, if appropriate medications are prescribed. </p>
<p>Melancholia shows a lower response to psychotherapy, counselling and psychosocial interventions - these treatments are more salient and effective for non-melancholic depression. </p>
<p>It’s useful to draw an analogy here with diabetes: while Type 1 is more a biological disease state and generally requires drug treatment (insulin), Type II is more likely to reflect other factors, such as obesity. The latter generally benefits most from non-drug strategies, such as exercise and dietary changes. </p>
<p>Melancholia shows similar “treatment specificity”, with medication being the treatment of choice.</p>
<h2>Tracing biological origins</h2>
<p>Melancholia has long been thought to have <a href="http://www.ncbi.nlm.nih.gov/pubmed/7458567">primary biological origins</a>, including perturbations in the hypothalamic-pituitary-adrenal (HPA) axis, in sleep architecture and in neural circuits.</p>
<p>Early this year, our research team <a href="http://www.ncbi.nlm.nih.gov/pubmed/1388334">published a neuroimaging study</a> that suggested a differential key “signature” marker found only in people with melancholic depression (when compared to people with non-melancholic depression and non-depressed controls). </p>
<p>We showed incoming connections to the brain system that control attention (the insula) were halved, while connections from the insula to the brain’s executive control centre were also decreased. </p>
<p>The implications of these findings will require further investigation, but they could mean that a disruption to brain connectivity may explain some of melancholia’s symptoms. </p>
<p>Clearly, melancholia needs to be recognised as a distinct psychiatric condition – not simply as a more severe expression of depression. This recognition could lead to improved clinical and community awareness, which is important because managing melancholia requires a specific treatment approach.</p><img src="https://counter.theconversation.com/content/38025/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gordon Parker receives funding from the National Health and Medical Research Council and has been a paid speaker for several drug companies. He is affiliated with the University of New South Wales and was the founding director of the Black Dog Institute <a href="http://www.blackdoginstitute.org.au/">http://www.blackdoginstitute.org.au/</a>.</span></em></p>Melancholia has a strong genetic contribution, so it’s largely biologically underpinned rather than caused by social factors (stressors) or psychological factors, such as personality style.Gordon Parker, Scientia Professor , UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/33122011-09-29T04:12:09Z2011-09-29T04:12:09ZIt’s time to move on from ECT’s shocking past<figure><img src="https://images.theconversation.com/files/3936/original/Irina_Souiki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">ECT is the most rapid and effective treatment for depression but it's still plagued with stigma.</span> <span class="attribution"><span class="source">Irina Souiki</span></span></figcaption></figure><p>Electroconvulsive therapy (ECT) has come a long way since earlier, darker days when it was known as electric shock therapy and conjured images from <a href="http://www.imdb.com/title/tt0073486/">One Flew Over the Cukoo’s Nest</a>. </p>
<p>But just when it seems that ECT’s reputation is starting to recover, new criticisms are emerging. </p>
<p>Most recently, concerns have been raised about <a href="http://www.theage.com.au/victoria/mental-health-care-inquiry-20110905-1juiy.html">the use of ECT for involuntary patients</a> in Victorian public hospitals. </p>
<p>Discussions about the treatment of severely depressed patients are important, but in order to have a robust community debate, we need to
set a few things straight about the risks and benefits of ECT.</p>
<h2>What is ECT? </h2>
<p>Modern ECT is a treatment process where a generalised seizure is induced by the application of a brief electrical current to a patient’s scalp. </p>
<p>A general anaesthetic is used, along with medication to temporarily relax or paralyse the patient’s muscles. Paralysis-inducing medication prevents the violent muscle jerks most people associate with having a seizure. </p>
<p>The patient (under anaesthetic) is totally unaware of the experience of the electrical current or the seizure itself. </p>
<p>ECT is most commonly used to treat severe depressive illnesses and on occasion, schizophrenia and other rarer disorders. A course usually involves six to 12 treatments over several weeks. </p>
<h2>Why choose ECT?</h2>
<p>ECT is the most effective and rapidly acting treatment for depression. It provides much more rapid treatment than antidepressants, which typically takes at least two to four weeks to have an effect. </p>
<p>In people with severe depression, around seven out of 10 patients will get better with a course of ECT. These are much better odds than antidepressant medications, a single course of which will usually result in recovery in only four out of 10 patients.</p>
<h2>What are the side-effects?</h2>
<p>With improved knowledge of ECT administration over the past few decades, we have been able to minimise its side effects although some remain.</p>
<p>There are always risks associated with undergoing a general anaesthetic, although the anaesthetics used for ECT are usually very brief and rarely cause problems. </p>
<p>The most significant side effect is memory impairment. In most patients this is confined to a brief period around the time of the ECT treatment. More rarely, it can affect short-term memory. </p>
<p>These impairments can be difficult to distinguish from memory lapses caused by depression itself but nonetheless cause substantial distress. They’re certainly significant enough to justify ongoing attempts to improve ECT and develop alternative treatment options. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/3960/original/Picture1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/3960/original/Picture1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/3960/original/Picture1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/3960/original/Picture1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/3960/original/Picture1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/3960/original/Picture1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/3960/original/Picture1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Magnetic seizure therapy is likely to have fewer side effects than ECT.</span>
<span class="attribution"><span class="source">MAPrc</span></span>
</figcaption>
</figure>
<p>This is something our research centre is actively engaged in. We’re currently trialing the use of a magnetic stimulus to induce seizures – a technique known as <a href="http://www.maprc.org.au/brain-imaging-and-neuroscience">magnetic seizure therapy</a> – which seems to not have these memory-related effects. </p>
<p>But this doesn’t diminish the usefulness of ECT as it currently stands. </p>
<h2>Involuntary ECT</h2>
<p>All Australian states and territories (and most parts of the Western world) have provisions for the treatment of patients with severe mental illnesses without consent. </p>
<p>This occurs when the patient’s illness is believed to impair his or her capacity to understand the need for treatment, or where the patient is likely to put themselves or others at risk in some substantial way. </p>
<p>Legislation will typically allow for involuntary admission to hospital and, in some jurisdictions, pharmacological or other treatments without consent. </p>
<p>One scenario involving ECT is the treatment of those with severe depression. A patient may be so unwell that they stop eating and drinking, placing themselves at immediate physical risk. </p>
<p>Such depression is often associated with severe suicidal ideation, when patients will be constantly attempting to find the means to end their lives. This scenario is a medical emergency because even with close supervision, patients can be at substantial risk. </p>
<p>Under these circumstances, ECT is the only treatment available that’s likely to result in a rapid improvement in symptoms - potentially saving the individual’s life. </p>
<h2>Regulation of ECT</h2>
<p>Given the impact of involuntary ECT on basic human rights, it’s clear we need substantial checks in place to regulate the provision of involuntary treatment. </p>
<p>But we also need to ensure that the health system can adequately provide potentially life-saving treatment to restore an individual’s health and capacity to make their own choices. </p>
<p>It has <a href="http://www.theage.com.au/victoria/mental-health-care-inquiry-20110905-1juiy.html">been proposed in Victoria</a> that greater restrictions be placed on the provision of ECT to non-consenting patients, by either banning ECT or mandating an independent process of review of each case prior to treatment. </p>
<p>Banning involuntary ECT would likely result in poorer outcomes for patients and possibly even deaths. </p>
<p>While the notion of independent review prior to treatment seems an attractive way to balance human rights and clinical considerations, this isn’t necessarily the case if it denies patients timely access to the treatment. </p>
<p>If a system of review is implemented, this must be accompanied by an appropriate increase in mental health service resources to ensure the system can respond in a timely manner. </p>
<p>Independent reviews need to take place rapidly – sometimes out of standard working hours – to ensure the health and well-being of acutely depressed patients isn’t compromised. </p>
<h2>Expanding treatment options</h2>
<p>Health and research funding agencies have correctly recognised the need to invest resources into early intervention in mental illnesses. </p>
<p>But there’s also an urgent need to invest substantial resources into improving treatment options for patients with the most severe and persistent mental illnesses. </p>
<p>This will require enhanced resourcing of mental health services and greater investment in research to develop new and better treatments for these acutely ill patients.</p><img src="https://counter.theconversation.com/content/3312/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Fitzgerald receives funding from NHMRC to support research into alternative forms of treatment to ECT such as MST and rTMS. He has also received equipment for research from Magventure A/S, Brainsway Ltd and Medtronic Ltd. </span></em></p>Electroconvulsive therapy (ECT) has come a long way since earlier, darker days when it was known as electric shock therapy and conjured images from One Flew Over the Cukoo’s Nest. But just when it seems…Paul B. Fitzgerald, Director School of Medicine and Psychology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.