The Good, Bad and Ugly of Electroconvulsive or Shock Therapy

There is something about the words “ETC Folder” written down the spine of a K-Mart folder in big blue texta that concentrates the mind about current mental health treatments.

I recently saw this folder through the large glass windows of a nurses’ station in a major Tasmanian mental health facility. On reading I imperceptibly straightened my posture and searched my person for any visible signs of incipient insanity.

Electroconvulsive or shock therapy consists of the application of an electric current to the brain in order to induce a seizure similar to those experienced in epilepsy. Induced seizures have had a role in the treatment of people with mental health problems since the 15th century, mainly because of the mistaken belief that people with epilepsy did not suffer from psychosis.

The induction of the seizure was originally achieved by the ingestion of compounds such as camphor. The use of electrical current to produce the seizures dates from the 1940s after two Italian doctors decided it would be a good idea to see if inducing an electrical current to the brain would produce reason from unreason. To this day medical practitioners do not know how ECT works.

Many of us think that ECT, or electroconvulsive or “shock” therapy, is restricted to Hollywood dramas such as One Flew Over the Cuckoos Nest, however the signs are that ECT usage in Australia is increasing.

Shock therapy has never really recovered from its initial ugly reputation. Sylvia Plath’s frightening poem The Hanging Man still evokes the fear of such a physical treatment to a delicate organ like the brain:

By the roots of my hair some god got hold of me.
I sizzled in his blue volts like a desert prophet.
The night snapped out of sight like a lizard’s eyelid.

High profile cases have also led to a fear of ECT. For example the suicide of Ernest Hemingway in 1961 following a course of ECT at the Mayo Clinic caused the therapy to come under close scrutiny. Hemingway told a biographer after his treatment:

Well what is the sense of ruining my head and erasing my memory which is my capital, and putting me out of business. It was a brilliant cure but we lost the patient ….

However you will find just as many people saying that ECT is the reason they can lead happy productive lives and that any loss of memory might be an acceptable trade off.

USA identity Kitty Dukakis said:

For me the memory issues are real but manageable. Things I lose generally come back … I hate losing memories which means losing control over my past and my mind, but the control ECT gives me over my disability, depression, is worth this relatively minor cost. It just is.

American writer Andy Behrman has ignited interest in ECT with his recent memoir, Electroboy. Although Behrman underwent ECT for bipolar disorder (a rather uncommon reason for undergoing ECT) he feels it helped with his recovery. Behrman says about his ECT:

I wake up thirty minutes later and think I am in a hotel in Acapulco. My head feels as if I have just downed a frozen margarita too quickly. My jaws and limbs ache. But I am elated.

In recent times some of the more unsightly aspects of ECT have been modified by the use of anesthetics, lower voltages and a more personal and subtle method of delivery.

I should state my opinion here that I do not agree with intrusive physical treatments for mental health problems. My personal view is based on nothing other than that the belief that we know some things to be fundamentally wrong and nothing can make them right.

Into this category I place the Kardashians, bras for toddlers and several wars I can think of. Some things are just wrong: let’s not get involved in the first place. However I realize that this It’s Wrong!. Don’t Do It! argument is not going to work with most thinking people therefore I will attempt to argue the point on a more empirical level.

The fact is that the use of ECT is growing. In 2009 the Sydney Morning Herald reported that forcible treatments using ECT had doubled in the previous decade. A Herald Sun article for the same year pointed out that the marked growth in ECT treatments was not only in the public sector with ECT use in the private sector having tripled over the past six years.

The Herald Sun article also revealed that in 2007, 203 ECT treatments were performed on children younger than 14 and 55 treatments were given to children aged four or younger.

These figures reflect a disturbing trend that tends to afflict those with mental health issues. This is a tendency for treatments like ECT to “get out of control” and be applied wholesale in an inappropriate manner. The main reason for this seems to be the imbalance in power between those administering the treatment and those receiving it.

One of the reasons for this imbalance is the fact that the patient is mentally afflicted and therefore does not have the ability to articulate their opposition. Therefore there is not the brake on inappropriate or excessive treatment that is found where the consumer is more voluble and seen as completely compos.

There has been some attempt to remedy this imbalance. Generally it is the case that if a doctor thinks a person requires ECT, they have to go to the Mental Health Tribunal in their state and seek a treatment order. However there is still going to be a huge imbalance in power. The SMH article, referred to above, pointed out ninety eight per cent of applications for involuntary ECT had been approved. In other words once a psychiatrist makes up his or her mind that you need ECT, the chances of you having that decision set aside by a Mental Health Tribunal are not great.

The reason for this is that very few people actually have legal representation during a Mental Health Tribunal hearing. Not only that but during a hearing the doctor’s opinion is generally treated as being that of an expert witness. This means it requires another “expert” namely another psychiatrist, to oppose that viewpoint. In order to be even remotely fair the Mental Health Tribunal needs to provide funding for a “second opinion” to that of the doctor seeking the treatment order. This does not appear to be something that Governments feel inclined to provide.

Even if there were to be a “second opinion” provided by the Tribunal there would still be great difficulty in finding another psychiatrist who would speak up against ECT either in general or in that particular case, because psychiatrists in general do not know much about how the treatment works therefore it is difficult to oppose it.

The paucity of evidence on ECT arises from the fact that it cannot be the basis for rigorous experimentation because few people would voluntarily choose to be part of a trial which involved shocking the brain. Most of the evidence relating to ECT therefore comes from animal studies and there has to be serious reservations about whether that evidence applies to humans, particularly where complex processes such as potential loss of memory are concerned.

The main reason for keeping ECT in the psychiatric tool box, despite continuing concerns from various sectors about potential damage to the memory or indeed the brain itself, is because of its vaunted use for those suffering from Treatment Resistant Depression. This is where two types of anti depressant have been tried and not worked. In an ideal world generally a person would have to be at serious risk of suicide, starving themselves to death or be verging on catatonia (a state where the person becomes unresponsive) before ECT would be considered.

Only about 60% to 70% of people respond to antidepressant therapy and of the remaining 30% about only one third will remain Treatment Resistant after various strategies have been tried. However just how useful is ECT in treating Treatment Resistant Depression? The response rate is good in people with TRD, with some 50% to 70% of people with this problem responding to ECT. However the relapse rate from ECT is also particularly high with this group of medication resistant persons. Therefore one must seriously question whether ECT is the best answer for this group.

Speaking from a consumer point of view the reason for this initial response and high relapse rate could be the “behavioural modification” factor. Just as I straightened myself up at the very sound of ECT, some people could find the whole concept so frightening that they do initially respond to a first treatment with the hope of avoiding further treatments.

Keeping ECT in the psychiatrists’ armory needs to be considered in the light of the fact that the treatment does have a strong emotive effect and this could be causing patients, especially people who have not yet sought treatment, from seeking adequate psychiatric treatment.

Not only that, but there is a serious problem with people giving “informed consent” for ECT. If you imagine someone with the worst depression possible then that person is most likely mentally “trapped” in the negativity of that situation and would not be able to imagine a less intrusive way of treating the situation. In other words the actual state of being profoundly depressed means that you are incapable of giving informed consent because our beliefs and cognition are mediated through our feelings. Therefore the very condition which ECT is supposed to cure works against informed consent.

Probably the best way for people who feel they might be at risk of having ECT in the future and wish to avoid it is to appoint friends or relatives as their “guardians” if such a situation should arise and then clearly specify in advance that ECT is not to be considered under any circumstances.

On the positive side there has been some work done on magnetic stimulation of the brain as an alternative to ECT at the University of Tasmania. Also we could all eat more Tasmanian salmon with the essential fatty acid ethyl eicosapentaenoic acid being used successfully in one case study to augment antidepressant treatment for suicidal ideation and social phobia.

Another alternative being considered for emergency treatment of severe drug resistant depression are so called “club drugs” or psychedelics. One of these drugs being considered which could replace ECT for short term treatment of high risk depression is ketamine, Yes, it is used by vets but we need to be open minded in our bid to replace ECT.

An article on the neurobiology of psychedelic drugs and their implications for the treatment of mood disorders by Franz Vollenweider and Michael Kometer in 2010 set the neuroblogging community alight with arguments that there was a place in the modern therapeutic arsenal for drugs formerly regarded as “recreational”.

According to The Neurocritic, one of the more engaging neurobloggers:

Human clinical trials of ketamine as a rapidly acting antidepressant aren’t especially new. A randomized, double-blind study in 2000 involved administration of saline or a single sub anesthetic dose of ketamine (0.5 mg/kg intravenously) to nine depressed patients, seven of whom completed the trial (Berman et al. 2000). Within 72 hrs, amelioration of depressive symptoms was observed. Half of the treated patients showed a 50% or greater improvement in depression scores. However, these therapeutic effects weren’t very long-lasting, returning to baseline levels in 1-2 weeks.

While such left field responses to the ECT dilemma need to be treated with cautious skepticism it is important to keep an open mind as to what we could use instead of ECT in order to avoid tunnel-thinking about the issue.

The routine approval of ECT treatment orders by Mental Health Tribunals is also in trouble in my view. After all involuntary ECT is strictly a no-go area according to the World Health Organization. The WHO simply says It’s Wrong! Don’t Do It! with its injunction in the WHO Resource Book on Mental Health, Human Rights and Legislation.

There are no indications for the use of ECT on minors, and hence this should be prohibited through legislation.

The WHO Resource Book also stipulates that ECT should not be considered an “emergency” treatment.

SOURCES

Treatment Resistant Depression: Therapeutic trends, challenges, and future directions, Al –Harbi K S,King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia, Dove Medical Press Ltd, http://www.dovepress.com/treatment-resistant-depression-therapeutic-trends-challenges-and-futur-peer-reviewed-article-P, 2010

The quoted SMH Article: http://www.smh.com.au/national/shock-therapy-forced-on-patients-20090605-byi6.html

The quoted Herald Sun Article: http://www.heraldsun.com.au/news/more-news/child-shock-therapy/story-e6frf7kx-1111118657718

Ketamine Article from The Neurocritic: http://neurocritic.blogspot.com.au/2010/08/ketamine-for-depression-yay-or-neigh.html

Transcranial Magnetic Stimulation in Psychiatry: http://www.musc.edu/tmsmirror/intro/layintro.html

Article on Relapse Rates from ECT: http://www.psychweekly.com/aspx/article/ArticleDetail.aspx?articleid=52