Electroconvulsive Therapy: Is it as Sinister as it Seems?
What
mental picture does the term “shock treatment” invite? Many picture a protesting patient strapped
down against his or her will, shocked violently with electricity until finally
stumbling away broken, drooling, and forever marked. Some
may not even know the procedure is still in active practice. Most would not rush to recommend its use to a
loved one in crisis.
Electro-Convulsive Therapy (ECT), formerly
known as electroshock, is the practice of manufacturing a seizure by passing
electric current through the brain. It
is used to treat patients with severe depression and other psychiatric
illnesses. Although many advances have
been made since its debut in 1938, ECT is still considered a highly controversial
practice. ECT’s longstanding stigma is a
barrier to the exploration of its concrete risks and potential benefits.
Stigma
According
to Shorter and Healey (2007), two well-known professors of the history of
medicine and psychiatry, respectively, “ECT has produced relief from acute
symptoms and saved lives, but its image as a psychiatric tool is stereotyped as
dangerous and inhumane” (p. 3). The ironclad
stigma of ECT was born of several sources.
The first source would be its own admittedly checkered past. Kellner (2011) found that ECT’s very
effectiveness during a time of limited treatment options encouraged its widespread
and sometimes ill-advised use for many different disorders (p. 41). He asserted that ECT was “clearly overused –
even abused” (p. 41). This indiscriminate use of ECT helped breed
both a negative public opinion and a warped understanding of the procedure’s
purpose. This was only the beginning.
Additionally,
the early years of ECT lacked the safety precautions necessary to prevent
injury and severe memory loss. Sinernart,
(2011) noted, patients given electroshock in its earliest form were not sedated
or given muscle relaxers. Sine waves
were used, which are long pulses of electricity; these were harmful to
long-term memory (p. 9). However, he
also clarified that lasting memory loss has since been decreased by the use of
brief pulses of electricity, while the use of sedation and muscle relaxants has
solved the previous problem of broken bones (p. 9). Unfortunately, developing these improvements
involved a clumsy trial and error process.
As Shorter and Healy (2007) noted, “There were no institutional review
boards to access ethics in those [early] days, no protocol minutely determined
in advance. These early researchers did
not realize that history would later judge their efforts as ‘abuses’ – and damn
the entire therapy” (p. 140). Hindsight
really is 20/20. But in defense of ECT,
many medical procedures have been improved over time through a problem solving
approach. Few procedures, however, have
suffered the consequences of their experimentation to the degree ECT has.
A
nod of reluctant admittance must be given to the distasteful, but undeniable
fact – ECT in early years was not always used with the best of intentions or for
its true purpose. Shorter and Healy
(2007) found, “The charge that ECT was used in a punitive manner in these
asylums is not fiction. Indeed, it was
sometimes administered in totally untheraputic ways to keep patients in line
and passive” (p. 93). This was the
catapult for the media’s strong and unfavorable impact on public perception of
ECT.
Indeed,
the media has helped form ECT’s seemingly unshakable ECT. A look
at popular fiction and movies in past decades show that writers and filmmakers
did not bother to research modern day ECT before portraying it. Shorter and Healey (2007) stated, “No movie
has ever depicted ECT administered with a muscle relaxant or an anesthetic (p.
150). They also included the opinion of New
York psychiatrist, Louis Linn, “Hollywood had frightened the … out of everybody
about ECT” (p. 150). In some cases, may
this misleading have even been deliberate? Keltner (2009) noted, “In One Flew Over the Cuckoo’s Nest, the American public was propagandized
into believing ECT to be barbaric, punitive, and void of therapeutic value” (p.
66). Movie images can be extremely
powerful, influencing attitudes for decades to come. Movies of today continue
to suggest the purpose of the procedure is to punish and control, rather than to
help and provide relief. The press has also had its collective finger in the
stigma pie. In their research of press commentary on ECT
between 1994 and 2004, Shorter and Healy (2007) found “out of 93 [newspaper] articles,
58% made positive mention of ECT” (p. 246).
Just under half the newspapers could not hold back if they had nothing
nice to say. Whether this was
investigative journalism at its best or a continued assault on ECT remains
debatable.
A
significant contribution to ECT’s stigma has been a legitimate fear of the side
effects, perhaps the most detrimental being loss of memory. As Kellner (2011) stated, “Memory is special,
even sacred to some people, because it defines one’s sense of self and identity”
(p. 41). This is a valid concern that
requires critical thinking to weigh the risks against the benefits. However, Fink (2009), a renowned researcher
and physician, reassured, “There is no longer reason to fear that ECT will
permanently erase learned skills, the memory of important life events, or the
ability to recognize family members”, (p. 35).
Society has not yet registered the fact that this type of memory loss
ceased to occur once modifications were introduced.
Part
of ECT’s stigma is a simple extension of mental illness stigma. Feldman and Crandall (2007) found “people are
more willing to socially reject individuals with disorders they perceive to be
high on personal responsibility, dangerousness, rarity, or some combination of
the three” (p. 148). Consequently, if
the average person may distance themselves from those with mental illnesses they
consider rare, what must they think of those who have ECT? Even with its markedly high success rate, ECT
is most often recommended for those deemed treatment resistant to medication. For those already experiencing alienation,
the decision to pursue ECT may take them even farther away from acceptance of
the general population. Feldman and Crandall (2007) affirmed, “stigma
may prevent some from seeking professional help (Robertson & Donnermeyer,
1997) and render others less likely to adhere to treatment (Sirey et al.,
2001), ultimately compromising the therapy process (Davison, 1976)” (p. 138).
Furthermore,
the stigma of ECT doggedly follows those who have elected its use. Fink (2004) found several professionals in
the field of psychology have suffered from severe depression and chose to have
ECT. (p. 32). He stated that upon
sharing his decision with a colleague, one man received the following response,
“disbelief that a rational, educated scholar would allow himself to be
subjected to this primitive treatment” (p.32).
Even those who have experienced success with ECT have felt discouraged
when speaking up about its validity.
Fink (2004) relayed one woman’s experience in her own words, “I’ve
started telling people about the ECT. My
admission is typically met with uncomfortable silences and abrupt shifts in
topics” (p. 33). This type of negative
response may prevent a patient who has experienced success with ECT from
revisiting the option in the future, which is disconcerting because of the high
relapse rate. ECT can be used as a
valuable tool to dig out of deep, unrelenting depression and regain quality of
life. Shorter and Healy (2007) suggested:
Unbridled
psychiatric illness has a fury that makes it among the most terrible of all
diseases. Losing your faculties in the
prime of life, immobilizing despair that leaves you wishing for death,
delusional thoughts that see the world as alien and threatening – few illnesses
are as life crushing as these. ( p.4).
When society views
those who access ECT as damaged victims instead of informed, active decision
makers, the stigma is implicitly reinforced.
This point aptly illustrates how the stigma has stolidly remained
unbroken for over 84 years.
Shorter (2004) advised that the simple fact
that no one quite knows how ECT works has played a relevant role in its stigma.
It is difficult to defend something that science, itself, cannot explain (p. 96). Shorter and Haley (2007) found studies have,
however, consistently shown that ECT works even when other therapies fail (p. 7). They
reiterated, “We still know neither what causes mental illness or how to cure
it. But denying patients the benefits of
an effective therapy on the grounds that is theoretically poorly understood
would be unethical” (p. 7). Indeed, if
only the general public would concede the point that although it is not known how it works, it does work. For patients out of options, it is worth a
look.
Many
considering ECT are highly suicidal, many so deeply depressed they have lost
all semblance of a normal life, and some so disconnected from reality that they
can no longer function independently.
Dramatic improvements in daily functioning have been gained by patients
receiving ECT. In order to dispel ECT’s
stigma, the public must not only be better educated about the procedure itself;
they must also be shown its benefits and lack of harm. They need to meet and talk with a patient who
has received ECT to confirm the treatment does not turn them into a zombie,
devoid of knowledge and incapable of holding a meaningful conversation.
Risks
ECT
carries minor and major risk factors.
Minor side effects include headache, dizziness, disorientation,
confusion, and nausea on the days of treatment.
Major risks include complications with anesthesia, memory loss, and a potential
decline in cognitive functioning.
Studies show ECT to be a surprisingly safe
procedure. Greenberg and Kellner (2005) found
it to be “the safest procedure performed under general anesthesia, with a
reported mortality rate of 0.002%” (p. 275).
However, a patient considering ECT should remember that any procedure
performed under anesthesia carries some serious risks, including death.
Greenber
and Kellner (2005) described memory loss as a primary concern with two major
components to be considered: the loss of
memories before ECT treatment and the decreased ability to retain new memories
after the procedure. The decreased
ability to retain new memories is temporary (p. 275). They noted:
“this deficit typically resolves
within 1 to 3 weeks after a course of ECT.
It is the reason that driving is proscribed and increased supervision
may be required for a period after a course of ECT” (p. 275). This research shows the frequent complaints with
memory following treatments to be a bothersome, disconcerting, but ultimately passing
concern (p. 275).
Greenberg
and Kellner (2005) found that the loss of memories prior to treatment is more
extensive. They noted: “Commonly, many
memories from 1 to 3 months will be lost.
The amnesia is most dense for events most proximal to the course of ECT”
( p. 275). Along that line of thinking, a
patient undergoing ECT for relief of severe depression or psychosis may lose
memories from a time period of great despair.
This memory loss must be weighed against a respite from intense pain and
suffering.
Fink
(2009) urged that the issue of memory loss should be acknowledged, but not
exaggerated. He stated, “There are
serious issues in the subject of memory loss, yet overemphasizing them has led
to tragedies as patients are discouraged from seeking appropriate help by the
unnecessary magnification of a minor and mostly temporary effect” (p. 104). Unnecessary fear may hold patients back from
seeking help, while simultaneously prolonging their suffering. This does not seem to be a worthwhile
endeavor, since most candidates for ECT would likely report they could not
imagine feeling worse than they do at the height of their illness.
In
regard to the potential decline in cognitive functioning, Sienaert (2011) found: “After
ECT, patients can experience difficulties in their ability to acquire and
retain new information. This anterograde
memory impairment will, for the most part, recover to baseline levels by 1
month follow up” (p. 9). Fink (2009) added that executive functions
(recall, problem solving, planning, and follow through) are often compromised
by the symptoms of mental illness, as well as psychotropic medications. However, activists against ECT point to the
procedure as the sole reason for these memory complaints (pp. 36- 37). Sienaert (2011) countered: “Patients show high degrees of satisfaction,
… cognitive side effects are generally transient, and that effective ECT can be
achieved with minimal cognitive side effects.
Research to further minimize cognitive side effects, without sacrificing
efficacy, is ongoing” (p. 10).
Fink
(2009) described the informed consent process that educates patients on these
risks before they commit to this course of treatment. The process includes explanation of the risks
and benefits of ECT, alternative treatment options with their risks and benefits,
and the risks of no treatment at all.
Patients are also provided this information in a written format and may
watch a short video illustrating the modern method of the procedure. Patients
or their guardian sign a written consent form before beginning treatments. The opportunity to back out or discontinue a
course of set treatments is always present (p. 116). It is
beneficial, when faced with such a serious dilemma, to have the basic facts
about ECT explained in terms that are easily understood and dispel many common
myths. For instance, one brochure ( Channing Bete Company, Inc. 2009),
explained “Myth: ECT is painful. Fact:
During the procedure, the patient sleeps peacefully and feels no
discomfort”.
A patient receiving ECT is prepped as if for a
surgical procedure. They are given
muscle relaxers and then put under an anesthetic. While receiving a fluid IV and oxygen, electrodes
are connected to the scalp, and finally brief, therapeutic pulses of
electricity are passed. Afterwards, the
patient is moved to a recovery area to regain consciousness under careful monitoring
(Channing Bete Company, Inc., 2009).
This is far from the general public’s conception of ECT, which Shorter
and Healy (2007) described as “images of spasms, fits, shock, coma, and shame”
(p. 2). Over the years, ECT has evolved
into a quiet, respectful experience.
Many patients who have received ECT are the procedure’s best advocates
and are called on to allay the anxiety of patients who are deliberating the
option.
Benefits
Keltner
and Boschini (2009) found that ECT’s success rate at relieving symptoms of
severe depression and other psychiatric illnesses is highly favorable with “up
to 90% of desperately ill individuals report[ing] relief” ( p. 67). It is
an extremely fast and for some, the only, way out of intense suffering. Again, its stigma puts ECT at the back of the
line as a viable treatment option. Shorter
(2004) stated, “Clinicians are reluctant to recommend ECT to patients to avoid
upsetting them with the fearsome words and thus break the therapeutic alliance”
( p. 96). This seems unfair to the
patient, who should have all options clearly presented to them. Patients should be treated with respect and
allowed the autonomy to weigh the risks versus benefits for themselves. Many of them are suffering not only from symptoms,
but from side effects of psychotropic medications – some of which can be incredibly
invasive.
Additionally, ECT’s rapid response to suicidal
ideation has been proven to save lives.
One author noted, “ECT may be lifesaving for patients who are severely
suicidal, malnourished from depression, or catatonic” (Kellner, 2011, p.
41). When lives are at stake and
suffering is intense, time is of the essence.
ECT’s value is tied not only to its effectiveness, but also to its
speed.
However, the relapse rate after ECT must be
examined. Sienaert (2011) describes
relapse as the return of the symptoms after a successful course of treatment (p.9). He also noted “Relapse rates as high as 64%
to 84% are reported, and relapse predominately occurs within the first 6 months
after a successful treatment course” (p. 9).
Therefore, ECT should not viewed be a cure, but a way to prompt a
remission. Used in combination with
other therapies, its ultimate goal should be to maintain remission as long as
possible.
Proactively, many clinicians design a follow
up medication regime combined with talk therapy to keep depression at bay. As crises arise over time, many patients are
encouraged to explore the idea of maintenance ECT as part of their treatment
plan. After all, many have landed at ECT’s door due to medication failure. If medication wasn’t successful in abating
symptoms in the first place, how can it be expected to keep a patient in
remission? Sienaert (2011) noted, “Most
clinicians are convinced that relapse rates can be further reduced by adapting
[ECT continuance] treatment schedules to symptom emergence in each patient” (p.
9). This individualized approach is
logical as depressive episodes can be triggered by the ebb and flow of everyday
life and its accompanying stressors.
In conclusion, ECT is a safe, effective
treatment. It is crucial to change the
mindset that seeking help for physical health conditions is perfectly
acceptable, while seeking help for mental health conditions is considered
taboo. Shorter (2004) noted, “A
treatment of proven safety and reliability is within reach for them. It is madness not [emphasis added] to use the full resources of scientific
medicine” ( p. 96).
ECT
should be socially acceptable. It is
imperative, as Fink (2004) stated to, “roll back the unethical restrictions
that commit our most disadvantaged citizens to unnecessary chronic illness,
prolonged hospital care, and even death” (p. 36). The brain is a mysterious and powerful organ. To neglect the care of this precious part of
the body because of society’s misconceptions about seeking or choosing a
particular type of treatment is senseless.
In the words of Hippocrates, “Men ought to know that from nothing else
but the brain come joys, delights, laughter and sports, sorrows, griefs, despondency,
and lamentations” (Fink, M.D., 2009, p. 3).
References
Channing Bete Company, Inc. (2009). What You Should Know about Electroconvulsive Therapy (ECT) [Brochure].
Feldman, D. B., & Crandall, C. S. (2007). Dimensions
of mental illness stigma: What about mental illness causes social rejection?
Journal of Social and Clinical Psychology, 26(2), 137-154.
Fink, M. (2004). A
new appreciation of ECT. Psychiatric Times, 21(4), 32-33, 35-37.
Fink, M. (2009). Electroconvulsive therapy: a guide for professionals & their
patients. New York: Oxford University Press, Inc.
Greenberg, R. M.,
& Kellner, C. H. (2005). Electroconvulsive therapy: A selected review.
The American Journal of Geriatric Psychiatry, 13(4), 268-81.
Kellner, C. H., M.D. (2011). Electroconvulsive therapy:
The second most controversial medical procedure. Psychiatric Times, 28(1),
41-41 ,47.
Shorter, E. (2004). The history of ECT: Unsolved
mysteries. Psychiatric Times, 21(2), 93-96.
Shorter, E. & Healy, D. (2007). Shock therapy. New Brunswick, New Jersey, and London: Rutgers University Press.
Sienaert, P. (2011). What we have learned about
electroconvulsive therapy and its relevance for the practising psychiatrist.
Canadian Journal of Psychiatry, 56(1), 5-12.
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