More shock than 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 siezure 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".