Electroconvulsive therapy, ECT or electroshock therapy is the most controversial treatment in psychiatry, and it’s also the most misunderstood.
It’s impossible to discuss ECT without mentioning One Flew Over the Cuckoo’s Nest because the book, the play and the film have given us the most culturally salient image of the treatment.
Kesey depicts it as little more than tool of oppression to subjugate Randal P. McMurphy who is only in hospital because, as far as he can figure out, “I, uh, fight and fuck too much”.
This negative portrayal is almost standard in the film industry but captures little of the reality of the average ECT treatment, which is usually prescribed for depression of the most severe kind (it is sometimes used for psychosis and catatonia, but much less frequently).
ECT treatment involves passing about 800 milliamps of electricity through the brain. 800 milliamps is a bit more than your average mobile phone battery puts out, but is quite significant as far as the brain is concerned and is enough to cause a seizure.
The current can be applied to both sides of the brain (bilaterally, most common) or one side only (unilaterally, less common), and can take the form of a pulse (most common) or a sine-wave (less common). There is evidence to suggest that different versions have different benefits and side effects, but the choice may depend on national guidelines or clinic preference.
This effect on the brain is essentially the same as an epileptic seizure, but it looks quite different. This is because the patient is given a general anaesthetic, so they are unconscious, and a muscle relaxant, so there is barely any movement.
In terms of physical health risks, ECT is thought to be much safer than most drug treatments and is often prescribed to people in the most fragile state of health (e.g. pregnant women, the elderly) for exactly this reason.
The biggest risk to health is actually the anaesthetic and muscle relaxant drug, which is the main reason a heart and general medical check-up is given before treatment.
ECT is usually given in doses of 6-12 treatments over a similar number of weeks (psychiatrists seem to have a superstition about giving an odd number of treatments for some reason, and so it is usually given in ‘pairs’ of doses), although can be given as a ‘maintenance’ treatment, less frequently, over longer periods.
We still don’t know how ECT works, although effects on brain plasticity (physical change and adaptation) and neurochemistry are being investigated.
In terms of its effectiveness and impact, the whole business of ECT is a complicated issue, but here’s what the current evidence suggests.
At least in the short-term, it is one of the most rapid and effective treatments for severe depression.
It is associated with ongoing memory difficulties, even after the treatment has stopped.
Patients generally view it much less favourably than clinicians, and it is generally viewed negatively by the public and carries significant stigma.
Now here are the caveats: because ECT is typically given to the most severely depressed patients (who likely already have cognitive problems), it is difficult to do ideally balanced, gold standard randomised controlled trials that give a good matched measure of both benefit and side-effects. In fact, these sorts of studies have not been done.
This is why there is disagreement, even with the medical and scientific community, about its effects, both good and bad.
Furthermore, Dr Richard Abrams, one of the leaders in ECT research and author of the standard clinical textbook, has a financial interest in, and reportedly owns, Somatics, one the world’s biggest suppliers of ECT machines and equipment. This makes some people suspicious of his promotion of the treatment.
However, Dr Harold Sackheim, probably the other ‘big name’ in ECT research, has no financial interests in any ECT company and does not receive financial compensation for consultation with the ECT industry.
Importantly, there is considerable individual variation in how people respond to ECT, in terms of their symptoms, post-treatment cognitive impairment, their subjective experience, and their attitudes.
Some people find ECT ineffective and damaging, others feel their life has been saved and their illness properly treated for the first time.
There are many articulate and moving accounts of the treatment on the web. Journalist Liz Spikol found ECT largely unhelpful and suffered debilitating cognitive effects, while surgeon Sherwin Nuland found it was the only thing that helped him recover and return to work.
Perhaps the most controversial topic is involuntary or forced treatment.
The majority of ECT patients volunteer for the treatment (usually on the suggestion of their doctors) and sign a consent form for treatment.
In some countries, where law allows, a minority of patients are treated with ECT against their will, usually if they are deemed to be a danger to themselves or others, and where other treatments have failed.
In a nutshell, it seems to be the most effective treatment for severe depression, seems to impair memory, is disliked and stigmatised, and is difficult to research. Most notably, as a patient, your mileage may vary. Some people have no benefit, some have huge improvement; some have no side-effects, some have ongoing difficulties. Most have some of each.
It’s also really hard to have a sensible discussion about ECT because of the emotions it stirs up. Like any treatment that provokes such opposite reactions from both those that have had it, and those that haven’t, it’s worth learning more with a cool head and an open heart.
I’ve avoided giving my own opinions on the treatment, which, like the evidence are complex, but I hope you’ll learn more, decide for yourself and be able to consider both new scientific evidence and reaction from people you meet who have had, or are considering ECT.
Link to Wikipedia page on ECT.
This interesting study published in Perspectives in Biology and Medicine compared the psychological effect of castration on two quite different groups of people: on people with prostrate cancer for whom the procedure was a medical necessity, and for people who wished to castrate themselves on a voluntary basis.
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