So do you think that suffering is a disease?

Thanks for taking the time to respond in such detail. There is much there which I must mull over.

‘Patients with MDD have an extremely low quality of life, perhaps the lowest quality of life that it is possible to experience.’

I agree. I have a difficulty in deciding whether it is environment, or life’s experiences, that cause the neuron malfunctions (Szasz’s position) or if depression is the result of a brain disorder, aside from strokes and alzheimers. I think that depression, like physical pain, persists because of an evolutionary benefit to the individual. So the fact that the DSM5 will be removing the bereavement clause from the diagnosis of MDD is a bit depressing. So if ECT can cause an increase in neurons which will benefit us all eventually why not give it to everyone? I myself, am worried about exactly which neurons I will lose. My father, who had a course of ECT for a milder depression, came back in a state of confusion, cognitive impairments, loss of memory and therefore of the self, and a personality change from which he never recovered. Although I know this is only anecdotal experience, I do remain skeptical of the claims.

Following a stroke, most of the “damage” occurs long after the stroke and there is persistent ongoing “damage” for weeks. This “damage” is the natural pruning of neurons that occurs when they have lost contact with the upstream neurons which have been killed during the stroke.

Brains lose cells all the time. Is that normal loss of brain cells to be considered “damage”? There is a great deal of redundancy in the brain, and it can be difficult to notice when there is loss of brain cells because function is preserved pretty well even with substantial losses.

In the case of neuron die-off following stroke, my understanding of it is that it occurs via apoptosis and is an evolved “feature” to preserve functionality of the brain. The brain is active tissue and can support non-functional uncontrolled activation as in a seizure. If you have a seizure when you are running from a bear, the bear is going to catch you and you are going to die. Ablating neurons to minimize the chances of having a seizure would be a good feature to have that might save your life. If you are a cave man and are apt to die before age 40 from being caught by a predator, preserving brain stability is likely more important that preserving neurons that will stave off dementia when you are 70, 30 years past when you are likely to be dead from other causes.

Does ECT cause “damage”? Does untreated depression cause damage? Uncontrolled MDD probably does cause brain damage and increased loss of nerve cells. People with MDD do experience brain shrinkage, reduced blood flow in the brain, reduced metabolic activity in the brain. What triggers brain cells to go into apoptosis is (usually), excitotoxicity. In excitotoxicity, cells are driven into a very high metabolic state which they cannot sustain, which depletes ATP levels, which triggers apoptosis. In this way the cells that are the “weakest link” are ablated, the cells least able to sustain their metabolic activity.

When people experience repeated seizures, there is progressive nerve cell loss. My understanding of that is that the brain is ablating excess neurons to lower the metabolic demand to something that can be sustained. Some of that happens following a stroke, where cells are ablated to reduce local metabolic demand. Does that happen following ECT? I don’t know. There is increased blood flow and increased metabolic activity following successful treatment of MDD by any method.

If there is increased metabolic activity, there is increased neuronal activity. There could be both increased activity and loss of neurons. Neurons are thought to mostly not be replaced, so any loss might be permanent, but there are some indications that there is neurogenesis even in adult brains. There are some indications that SSRIs do increase neurogenesis, and that some of the antidepressant effect of some SSRIs is due to their stimulation of neurogenesis.

If ECT does cause some increased loss of neurons in the short term (weeks), but restores a more normal level of neurogenesis such that there are more neurons present years after treatment than would be present without treatment, I don’t think it is fair to call that “brain damage”. MDD is extremely debilitating. Patients with MDD have an extremely low quality of life, perhaps the lowest quality of life that it is possible to experience. If you have never experienced MDD, it is difficult to appreciate just how low that quality of life is.

‘Damage is not necessary to trigger compensatory pathways.’

So what are your views on ECT? That it causes no damage? What does it do to reduce depression? I am interested in your opinions.

‘Please correct me if I’m mistaken, but I was under the impression that current research had shown MDD to be correlated with reduced activity in the anterior cingulate gyrus (BA25). TMS usually targets this region with magnetic pulses at frequencies which increase neuronal activity.’

I think science has shown that environmental influence can alter the structure of the brain. Science has also demonstrated that, via a measurable and objective test, neurological damage can result in ‘mental’ disorders. But your view that all depression must be caused by the latter is an ideological view and is not scientific. Correlation is not causality.

Therefore your recommended treatment of ECT is also an ideological idea, unless backed up by neurological objective science. Can you explain the theoretical scientific understanding that underpins your treatment? Are you denying the environmental cause of MDD? Is it possible that your ECT treatment results in ‘acceptance’ of conflicting situations that may cause depression through neurological damage?

I have read the papers quoted above in depth. For every paper you can cite me regarding ECT, I can show one that demonstrates different results.

ECT, TMS, DBS. It is just big boys playing with the latest new fangled techie toys, pretending to be doctors whilst stuffing research grants into their back pocket. With the ghost of Walter Freeman looking down with approval. What next? Leucotomy for ADHD anyone? It is all woo. At least homeopathy is relatively harmless.

‘whacking triggers compensatory pathways and those compensatory pathways fix what ever was wrong.’

Similar to Max Fink’s contention that ‘there is a relation between clinical improvement and the production of brain damage’.

I think use of the word fix is currently a moot point.