Electroshock Therapy – More than Shock Value
Every year in Britain 20,000 people are on the receiving end of 100,000 treatments. In the US 100,000 patients get more than half a million treatments a year.
It’s not a new drug or revolutionary type of surgery but, amazingly, electroconvulsive therapy or ECT. In these days of holistic medicine, and particularly when the efficacy of “talking cures” has been so soundly proven, this seems an astonishing, almost barbaric, revelation.
Electroconvulsive therapy, also known as shock treatment, is primarily used to treat severe depression. It involves the passage of up to 170 volts of electricity through the human brain. In bilateral ECT, electrodes are placed on the patient’s temples. With unilateral ECT the electrodes are placed over the front and back of one side of the head. The applied voltage can be anywhere from 70 to 170, and the current from 500 to 100 milliamperes the power consumed by a 100 watt bulb flashed for one half to one second. The result is similar to a grand mal epileptic seizure and indeed that is its purpose.
It is believed that the induced seizure causes chemical changes to the brain which normalizes moods and alters pain perception. But since nobody really fully understands how ECT works, its efficacy has been likened to kicking a malfunctioning TV set. If you do it long enough and hard enough you may just produce the desired result.
ECT is unlike any other treatment in psychiatry. It’s a therapy which still arouses such passionate controversy that, after 60 years, supporters and opponents cannot even agree on its name. Proponents call it electroconvulsive therapy and say it’s unfairly maligned, poorly understood and remarkably effective even a life saver (see box p4) for severely depressed individuals.
Critics still call it by its old name, electroshock. They say it temporarily lifts depression by causing transient personality changes similar to those seen in head injury patients: euphoria, confusion and memory loss. Both camps agree that this is a simple procedure. So simple in fact that an advert for the most widely used shock machines in America tells doctors that they need only set a dial to a patient’s age and press a button.
In fact, the patient’s age, and gender, are often a determining factor for the use of ECT. The majority of treatments of ECT are administered to the elderly. Numbers rise sharply after the age of 40 with the majority of treatments given to those between the age of 61-80. Women receive twice as much ECT as men. As many as 3,000 of these treatments in the UK are compulsory.
In the elderly, depression can often be triggered or worsened by the individual’s fears of losing their memory or health, both of which ECT is known to affect, creating a vicious circle of depression and ECT. In addition, doctors’ enthusiasm for this “simple” cure may prompt them to ignore or trivialize underlying health problems which would respond to less drastic, but more time consuming, treatment. One US survey found that 91 per cent of 658 outpatients checked were found to have medically induced psychiatric disorders. In other words what was causing their strange behaviour was a medical condition which had gone undetected. (Psychiatry Victimizing the Elderly, Citizens Commission on Human Rights, 1995).
ECT rates rise sharply for women in their fifties. But are they really so depressed or have doctors failed to take a proper medical history? It’s not uncommon for women having estrogen replacement to experience mood swings, changes in appetite, altered sleep patterns and pain perception (see WDDTY, 1994; 4(10):1-3) all symptoms of depression.
While psychiatrists constantly reassure us that patients are happy with the results of ECT, surveys of user’s suggest that many recipients are deeply divided. In a survey by MIND, the UK’s leading mental health charity, 43 per cent of patients said they found ECT helpful, 37 per cent said it was unhelpful and 20 per cent said it made no difference.
In plain language this means that more than half of those treated found ECT did not help their condition or made it worse (Experiencing Psychiatry, Mind/Macmillan 1993). A survey by the United Kingdom Advocacy Network (UKAN) was even more revealing since less than a third of respondents found ECT helpful. Two thirds regarded their experience as unhelpful and half of these believed themselves to be damaged by the procedure (Openmind 78, 1995:11-4).
ECT does have a small, positive track record in relieving the severe symptoms of depression. But the overwhelming evidence confirms that benefits are short lived (Lancet, 1980; i: 1317-20; Br J Psych, 1985; 146: 520-4; BMJ, 1984; 288: 22-5). Those patients who do not respond to drug treatment are more likely to relapse soon after ECT (J Clin Pcychoparmacol, 1990; 10: 96-104). Because nearly half of those patients who “recover” after ECT will relapse within 12 weeks without drug treatment (Acta Psych Scand, 1973; 49:386-92), it is usually given in conjunction with a course of antidepressants, which carry their own risks (see WDDTY, 1995; 6(6): 1-3).
It has also been postulated that doctors’ “once a depressive, always a depressive” ethos is what places ECT in such high regard with the psychiatric community. Seen from this perspective there are no ECT failures, “only patients with recurring depressive episodes who require ongoing psychiatric treatment, intensive and maintenance, by turns” (J Mind and Behaviour, 1990; 11:489-512).
In addition, patients are rarely informed about the nature of treatment and the potential side effects. As many as 89 per cent in one survey were aware that a general anaesthetic was used, but less than half were aware of other crucial information relating to ECT such as the fact that an electrical current was passed through the brain. Only 16 per cent knew a convulsion was induced, and there was poor awareness of the number of treatments involved. In addition, 40 per cent believed it would cure their depression (Psych Bulletin, 1989; 13:161-5).
Studies which show that ECT cures depression are often measured in terms of symptom reduction and seldom reflect on quality of life and social functioning (National Institute of Mental Health, 1985). Yet it is in this category where the majority of side effects longer term memory loss, apathy, learning difficulties, loss of creativity, drive and energy fall. These may last for weeks, months or even forever. Of all of these, memory loss is the most common.
In California in 1990, out of 656 complications reported as being the result of ECT, 82 per cent were from memory loss (California Department of Mental Health, November 1991). ECT has other side efffects as well. More than 17 per cent are related to apnea (cessation of breath). It can also cause heart problems, stroke and falls, resulting in fractures. In a research study about patients’ experience of ECT, five out of 100 patients experienced symptoms which they attributed directly to ECT (Psychiatric Bulletin, 1989; 13:161-5). Memory loss can mean loss of bad memories which fuel depression, but equally good memories which can help to sustain a depressed individual.
In one study more than half of the patients felt they had not regained normal memory function three years after receiving ECT (Br J Psych, 1983; 142:1-8). This is not new information. In the 1950s, when ECT was even more widely used than today (usually on male schizophrenics), an American psychologist conducted autobiographical interviews with people about to have ECT and a control group who did not have ECT. Four weeks later he questioned both groups about the same information and found a marked incidence of amnesia in the ECT group but none in the non ECT group.
A year later the ECT patients had still not recovered their memories (J Nervous and Mental Disorders, 1950; 111: 359-81).
Evidence suggests that bilateral ECT causes the greatest degree of memory loss. Between 60-70 per cent of those receiving bilateral ECT reported memory problems six to nine months after treatment (Biol Psych, 1979; 14:5). However, in his book Toxic Psychiatry (Harper Collins, 1993), Peter Breggin, a vociferous critic of ECT, dismisses the commonly held assumption that unilateral ECT is that much safer. It has been proposed that ECT “works” by damaging the brain. Indeed, it is the damage which Peter Breggin believes explains its “effectiveness”.
EEG results a month after unilateral ECT confirm that it is possible to detect which side of the brain had been damaged (Changes: Int J Psychol and Psychother, 1992; 10(2):126-35).
Currently there is no firm guidance as to how often ECT should be used or when it should be discontinued if no response has occurred. Previous guidelines by the Royal College of Psychiatrists suggest a maximum of eight properly administered treatments in the absence of any clinical improvements, although the American Psychiatric Association recommends that the indication for more ECT should be reassessed after six to 10 treatments. However, it has been shown that some psychiatrists prescribe a fixed number of treatments without a clinical review in between (Br J Psych, 1981; 139: 563-8). Since recovery is often made after a few treatments a set number of treatments should not be prescribed.
Much of the vagueness in this area can be traced to financial considerations. In the US ECT is looked upon favourably by insurance companies who, while limiting funds for psychotherapy, place no such restrictions on the use of ECT. In fact Medicare, the federal government’s insurance programme for the elderly, has become the single biggest source of reimbursement for ECT.
It pays psychiatrists more for ECT than it does for medication checks or psychotherapy. The cost per treatment generally ranges from $300 to more than $1000 for sessions which take five to 15 minutes. This makes ECT one of the most profitable procedures in medicine. In the State of Texas, 65 year olds get 360 per cent more ECT than 64 year olds. The reason? Medicare pays.
Overall, medicine has failed to prove its case for ECT. Doctors prefer it because it’s easy and it constitutes “doing something” for a condition which perplexes them. However patients’ views are still best summed up by Ernest Hemingway’s comment to his biographer A E Hotch, after the experience of more than 20 shock treatments at the prestigious Mayo Clinic (and shortly before he blew his brains out): “It was a brilliant cure. . . but we lost the patient”.
Sidebar: Making sense of ECT
Evidence about the efficacy ECT is confused and opinions are divided. Overall it appears to have immediate, the temporary, beneficial effects where:
- Depression is characterised by psychotic features
- An individual has lost the will to live, doesn’t sleep and is refusing food
ECT doesn’t work for:
- Parkinson’s disease
- Alzheimer’s disease
- Violent behaviour
- Obsessive-compulsive disorders
- Depressed individuals who do not respond to drug treatment
ECT is rarely used for cases of:
- Mania
- Schizophrenia
- Epilepsy
- Autism
- Dementia
ECT is sometimes used on high risk patients who should avoid antidepressants. Its use for the following people is highly controversial:
- Pregnant women
- Children
- Individuals with AIDS
- Diabetics
- Multiple Sclerosis sufferers
- Heart transplant patients
Sidebar: What is a safe dose?
Although the dose should be corrected according to the individual patient, often it is determined by habit rather than rational assessment (Br J Psych, 1992; 160: 621-37). Individual patients have individual seizure thresholds that is they require different amounts of electrical current to produce a seizure. This figure can vary by as much as 40 fold (Arch Gen Psych, 1987; 44:355-60; Psych Clin North Am, 1991; 14:803-43). The seizure threshold is higher for men than it is for women and rises with age.
The aim of ECT should be to use the minimum amount of current necessary, within an optimal seizure length of between 20 to 50 seconds, to produce the seizure. Anything more can produce brain damage (N Eng J Med, 1993; 328:839-46). Psychotropic drugs can raise seizure thresholds. So can some of the anesthetics used during the procedure. This may cause physicians to give a bigger “fixed” dose, sometimes as much as 2.5 times greater than the seizure threshold, on a just in case basis, resulting in brain damage (Am J Psych, 1986;143:596-601). Higher doses are also routinely used because doctors believe they produce fast “results” (N Eng J Med, 1993; 328:839-46).
A dose below an individual’s seizure threshold can increase the risk of cardiovascular complaints (Convulsive Ther, 1989; 5:35-43; Anaesth Intensive Care, 1988. 16:369-71; Am J Psych, 1984; 141:298-300)Surveys in the UK have shown that among doctors below consultant level there is no consistent method of training in ECT. Some did not recall ever being taught to administer ECT. Many did not have copies of relevant guidelines, and consultant supervision was rare (Psych Bulletin, 1993; 7(3):154-5; Br J Psych, 1992; 160:621-37).
Sidebar: ECT – Kill or Cure?
While ECT is traditionally viewed as a last resort in treatment, studies show that practitioners often opt for combined drug and ECT treatment as a first line for severely depressed patients. While the medical profession believes ECT is a “life saving option”, there is no evidence for this. Although we know it can kill, there are few figures to show how often it does. Risk of death from ECT is under reported internationally. In the UK there is no audit of ECT use. In the US no national records are kept (except in the state of Texas) so it impossible to quote accurate figures.
The figure which is often quoted, 1 death per 10,000 patients, has an intriguing history. It is taken from the standard textbook Electroconvulsive Therapy by Robert Abrams (Oxford University Press). The author, however, is a director of one of the largest manufacturers of ECT equipment in the US. The figure, which appeared in the 1988 version, was dropped in the 1992 version, replaced by a figure of 1 in 50,000 treatments.
As the average number of treatments per patient in the US is five, the figures are, in fact, the same.Because ECT requires a general anesthetic the risk of death should, at the very least, reflect the overall risk from this procedure 4.5 per 10,000. In addition the elderly, who receive most treatments, are much more likely to die from the procedure. Research from the State of Texas puts the figure at an alarmingly high 1 in 200. In 1993 a study at Browns University of patients 80 years and older, 27 per cent of patients were dead within a year, compared to 4 per cent of a similar group treated with antidepressives. Within two years 46 per cent of ECT patients were dead vs 10 per cent of those on drugs (USA Today, Dec 6, 1995). Similarly high death rates can be found in the UK (Br J Psych, 1980; 137: 9-16).
Other studies show high suicide rates following ECT (Arch Gen Psyh, 1976; 33: 1029-37; Br J Psych, 1992; 160: 149-53). In psychiatric hospitals the rate of suicide is 50 per 100,000 four times the national average.
Sidebar: Alternatives to ECT
First of all establish whether you are suffering from depression or whether there is an underlying medical condition which is responsible for how you feel. In his book Prescription for Nutritional Health (Avery, 1990), Dr James Balch believes that in most cases the elderly are merely suffering from physical problems related to their age. “Senility occurs in old age but is really not very common. . . Many of those diagnosed as senile are actually suffering from the effects of drugs, depression, deafness, brain tumours, thyroid problems, or liver or kidney problems. Nervous disturbances, stroke and cerebral dysfunction are considered symptoms of the senility syndrome. Often a nutritional deficiency is the cause.”
Consider the following dietary measures:
Irrational behaviour can sometimes be the result of food allergies (J Affective Disord, 1981; 3:291; Compr Psychiatr, 1976; 17:335). Individuals suffering from irritability, depression, hyperactivity, fatigue and anxiety need an immediate full medical physical check up and a complete test done to look for allergies which can cause mood changes.
Depression is a common symptom of folic acid deficiency (Biol Psych, 1989; 25(7): 867-72; Prog Neuropsy choparmacol Bio Psychiatry, 1989; 13(6): 841-63; Lancet, 1990; 336: 392-95). In addition to taking supplements of folic acid, supplements of vitamins B (Br J Psych, 1982; 141:271-2; Acta Med Scanda, 1965; 177: 688-9) and C (Am J Clin Nutri, 1971; 24: 432-3; J Orthomol Med, 1987; 2(4): 217-8) could help. Also deficiencies in calcium, iron, copper, magnesium, potassium and essential fatty acids have been implicated in depression. Blood tests and hair analysis can reveal if you are deficient in these substances.
A good wholefood diet will help the body manufacture serotonin and norepinephrine the important neurotransmitters (messenger cells which move between the nerve cells and the brain) which help to regulate moods. But these neurotransmitters are mainly derived from amino acids which it can be difficult for the body to manufacture in large enough amounts. You can try supplements of tryptophan (Psycho Med, 1978; 8: 49-58; Arch Gen Psych, 1990; 47: 411-8), L-phenylalanine (J Clin Psych, 1986; 47(2): 66-70) and the less widely available L-tyrosine (Adv Biol Psychiatry, 1983; 10:148-59). As you may require mega doses of these, they are best taken under the supervision of a nutritionist experienced in this area.
Thyroid problems either hypo or hyperthyroidism can often lead to mood swings which are swiftly but mistakenly labelled depression. Cutting down or eliminating iodized salt from your diet may produce results (see WDDTY, 1996 7(7): 2-5), as will cutting out caffeine and refined sugar.
Trace metals like lead cadmium and mercury in a person’s system can also lead to behavioural disorders. Chronic bouts of depression are among the most common symptoms of mercury poisoning from dental amalgam, according to Hal Huggins (It’s All In Your Head, Avery, 1993).
Therapy can help
There is plenty of evidence to show that “talking cures” can be an effective means of dealing with depression.
A recent survey showed that counselling with a view to problem solving was as effective as a course of antidepressants (BMJ, 1995; 310: 441-45).
Don’t rely on your GP for this; seek out an experienced counsellor.
Exercise regularly
An hour of aerobic exercise three times a week has been shown to significantly improve levels of depression (BMJ, 1985; 291: 109).
Consider herbal medicines
Hypericin, a constituent of St John’s Wort (hypericum perforatum) can boost the level of norepinephrine. In one trial of 15 women given a standardized extract of hypericin, all felt better and none suffered side effects (Arnzeim Forch, 1984; 34: 918). (See also BMJ, 1996; 313: 253-8).
Yohimbine, obtained from African tree bark, has demonstrated a positive effect on moods. One study of nine patients who had failed to respond to at least two anti depressant medication trials, which included fluvoxamine, were given yohimbine while continuing with the fluvoxamine.
Three of the patients experienced a marked improvement in mood. Side effects of insomnia and anxiety decreased as the dose of yohimbine was lowered (Biol Psychiatr, 1995; 38:765-7).
Sidebar: WDDTY verdict
Is depression a greater risk than ECT? This is the question which medicine should seek to resolve. Even if it is, there remains the question of whether earlier detection and possible preventative procedures would reduce the need for such a drastic measure as ECT. The combination of drugs and ECT has been poorly researched, and nobody knows for sure what damage we may be doing. Patient’s views are seldom taken into account when discussing the efficacy of ECT yet clearly more than half find it distressing, damaging and/or of little value.
Proponents of ECT are hard pressed to produce any evidence that the effects of treatment last more than a month or two. This seems to be the heart of the matter. To subject patients to such a physiologically and emotionally devastating form of treatment for such paltry benefit seems to show flagrant disregard for the primary tenet of the Hippocratic Oath, “First do not harm”. If ECT were a drug surely its widespread use would not be justified. Furthermore ECT, like so many of the most controversial medical treatments, highlights social issues which are difficult to resolve, such as our attitudes to the elderly, women and any other group which doesn’t “fit” into society’s frame of reference. There is an urgent need for well conducted, qualitative and quantitative research which takes into account all of these factors
- This article first appeared in the November 1996 (Volume 7 Number 8) edition of What Doctors Don’t Tell You.
