Electro-convulsive therapy – a bad rep?

Electro-convulsive therapy

Electric shock treatment of any nature has an image issue – courtesy of Josef Mengele’s horrific experiments in the holocaust where high-voltage electric shocks were administered under the guise of testing endurance; the SANDF 1970s aversion therapy to ‘cure’ homosexuals and death-row prisoners being led to the electric chair, strapped down and then fried in front of an audience. Then came the early attempts at electroconvulsive therapy (ECT), also known as shock therapy. Medications, like insulin, were first used to induce seizures in 1938. Insulin causes a sudden drop in glucose, which causes the brain to develop seizures as a sign of distress. That’s because blood glucose is the only ‘fuel’ the brain can use for its energy needs, if deprived of glucose.

A year later, electric currents were used to induce seizures. It was a barbaric procedure, with patients suffering unsurprisingly huge amounts of anticipatory anxiety – not to mention frequent bone fractures from arching and thrashing in response to the current.

The equally brutal practice of psychosurgery, in the form of lobotomies, was another popular ‘cure’ for mental illness at the time.

ECT was abandoned in the 1950s when psychoactive medicines were introduced and re-emerged in the 1970s – despite its stigma – to help the mentally ill who were unresponsive to psychoactive medications and psychotherapies.

ECT, for the treatment of severe depression, has seen another resurgence in the last 10 years largely due to refinement of the procedure – making it safer and less traumatic. It involves electric currents being passed through the brain. These currents trigger a generalised cerebral seizure, which in turn causes changes in brain chemistry that can immediately reverse symptoms of certain mental illnesses. It’s a last-ditch attempt to reboot the brain’s operating system, which gives hope to those who are not responding to any other methods of treatment for mental illness.

Dr Gerhard Grobler, President-Elect of the South African Society of Psychiatrists (SASOP) says, ‘Without ECT, at worst, these patients would not survive; at best, lead tragic lives.’

But has ECT entirely overcome its bad reputation? ‘To a certain degree,’ says Dr Grobler, ‘but there are still detractors – some vociferous.’ He says one of the reasons for the stigma is that, until 2002, ‘unmodified ECT treatment’ was still legal. In this procedure, high doses of electricity were administered without anaesthesia or muscle relaxants. However, stringent regulations in the Mental Health Care Act have made it illegal and unmodified treatment hasn’t been practised for the last 15 to 20 years. However, despite a call by WHO for the worldwide banning of unmodified treatment, it is still practised in countries like Japan, India and Nigeria.

So what happens during ECT? This account by one patient vividly describes the experience: ‘The doctor presses a button. Electric current shoots through my brain for an instant, causing a grand mal seizure for 20 seconds. My toes curl. It’s over. My brain has been “reset” like a wind-up toy. I wake up 30 minutes later and think I’m in a hotel room in Acapulco. My head feels as if I’ve just downed a frozen margarita too quickly. My jaw and limbs ache. But I feel elated. On the anniversary of my first electroshock treatment, I was clearheaded and even-keeled. Two and a half years later, my medication keeps my illness in check, and I’m saner than I’ve ever been. If I could only remember the capital of Chile.’

To the observer, it may initially feel like watching a scene from One Flew over the Cuckoo’s Nest but it is in fact a medical procedure, meticulous in its preparation and execution by an anaesthesiologist, psychiatrist and nurses. An IV is inserted, sensors or electrode pads (each about the size of a 50c coin) are attached on the sides of the head, and an electroencephalogram or EEG measures the electrical activity in the brain.

A pulse oximeter allows them to measure the amount of oxygen in the blood. An anaesthetic is injected into the IV and the patient drifts off for five to 10 minutes – all it takes, say fans of ECT, to ‘shock a broken mind into recovery’. A muscle relaxant is injected to help prevent convulsions during the seizure and a mouth guard is sometimes placed between the teeth.

The button is pressed and the electrical current passes with a force of from 70 to a maximum of 450 volts (the electric chair uses 2 000 and a wall socket around 250). The current induces a seizure that lasts between 45 and 60 seconds.

Doctors monitor the seizure by placing a blood pressure cuff around the forearm or ankle area, preventing the muscle relaxant from paralysing those muscles. Uncontrolled jerking movements of the limb are the only indication the doctor will have that there is a seizure.

It’s all over in about 15 minutes. A few minutes later the effects of the short-acting anaesthetic and muscle relaxant begin to wear off and the patient is taken to recovery. Patients say they wake up confused, their memory blank, but hopefully with a brain that’s been shocked into healing.

Although the exact mechanism is little understood, psychiatrists agree that it’s all about hormones. Dr Grobler says it has to do with rewiring the brain.

‘The magnetic stimulation and convulsion is a wake-up call for the brain to release massive amounts of neurotransmitters: dopamine, serotonin, endorphins, norepinephrine and acetylcholine. All natural feel-good neurochemicals. It’s the chemistry,’ says Dr Pierre Cilliers, a psychiatrist specialising in ECT in Cape Town. ‘Hormones are activated, which play a huge role in mental illness – postpartum blues, menopause depression. Their proper functioning is essential to a healthy mind as much as to a healthy body. Hormones are released by the brain’s endocrine glands, the hypothalamus and the pituitary. These master glands, which lie deep in the middle of the brain, are directly stimulated when seizures are induced by electricity or by medicine. Such stimulation re-establishes the proper glandular functions of the brain, bringing all the other glands into line, including those that affect mood, thought and motor functions.’

Dr Grobler says that having an electric current pass through your brain for 45 to 60 seconds is not a panacea for all mental illness, but it has had excellent results in patients with treatment-resistant illness. ‘Not all conditions respond to ECT and, for those that do, it is almost always their only hope.’

Anti-ECT activists see it differently, saying it damages the brain. They believe the patient is dazed, confused and disorientated and therefore cannot remember or appreciate current problems. Patients just ‘pack up their troubles in a vacuous or fuzzy kit bag,’ they say, and add that ‘the greater the brain damage, the more likely that certain abilities and memories will never return. It is the way in which psychiatrists sometimes choose to deal with troubled and troublesome minds. Rather like the now unpopular lobotomy, we question this dubious method of obliterating rather than dealing with emotional distress.’

A 45-year-old woman, who had 18 ECT treatments over six to eight weeks for intractable, dangerous depression appears to back this up. ‘I’ve been asked over and over again whether undergoing electroconvulsive therapy was a good decision. And whether I would have ECT again under the same circumstances. The only honest answer I can give is that I have no idea. To say whether ECT was the right treatment for me, I would have to compare my life before ECT to my life now. And I simply cannot remember life before ECT. In particular, I cannot remember much about the two years leading up to my ECT treatments. That period, along with much of the preceding years, is memory that I lost in exchange for the hoped-for benefits of ECT.’

Detractors have an ally in the form of Scientologists who are vociferously against the practice, saying it is brutally cruel and should be outlawed. They do, however, have a penchant for slamming all psychiatrists who they believe are ‘the sole cause of decline in this universe’ and ‘reincarnated evil’.

Scientologists disagree with what thousands of scientific research studies in reputable, peer-reviewed journals have shown: that most, if not all, brain disorders are caused by chemical imbalances in the brain.

Neither Dr Grobler nor Dr Cilliers are cavalier about the use of ECT in treating depression. They say that ECT isn’t taken lightly and is not the first line of treatment.

‘In fact, it is the third or fourth. We only treat patients who are very, very ill and whose quality of life is limited, where severe depression is accompanied by detachment from reality (psychosis), a desire to commit suicide, hurt someone else, refusal to eat, schizophrenia, severe mania as part of a bipolar disorder, impaired decision-making, life-threatening impulsive behaviour, substance abuse and catatonia,’ says Dr Cilliers.

‘In such conditions, electroshock may be life-saving. ECT is also not the end of the line for patients. After six to 12 treatments, they usually need to continue with medication. More often, it includes antidepressants or other medications or psychological counselling (psychotherapy). It needs to be said that no scientific, valid research proves the alleged brain damage caused by ECT, but some evidence exists indicating that untreated mental illness leads to brain atrophy.’

ECT was the last resort for another two patients. One received a medication for treatment-resistant depression and anxiety after they had ECT. ‘That particular medication saved my life and gave me precious recovery. But I might not have been alive to try it if I had not been given ECT first.’

The other adds, ‘Friends and family say that I’m less gloomy than I was; cheerful and less brash. They say I’ve softened a bit, though my basic personality has indeed returned.In part, I attribute my gentler attitude to the truly humbling experience of having myself disappear. I attribute my change to a renewed desire for peace in my life.

‘I’m now dedicated to managing my depression and living a satisfying life day by day. I feel that if I can make the best of the moment, then the future will take care of itself.’

As in all medical procedures, the benefits come with a risk and a price. The most distressing side-effect of ECT is memory loss, which doctors say is a transient result. ECT can affect memory in several ways. Patients have trouble remembering events that occurred before treatment began, a condition known as retrograde amnesia. It may be hard to remember things in the weeks or months leading up to treatment, although some people do have problems with memories from years back as well. The period of treatment may pass in a haze, as one patient recalled. ‘I felt like a zombie and couldn’t recall events that occurred during the weeks of treatment.’

Some people have trouble with remembering events that occur even after ECT has stopped. These memory problems usually improve within a couple of months, but some patients have complained of permanent memory loss. For many, ECT is the only hope − and the loss of memory is a trade-off for quality of life and often survival. ECT can’t cure personality disorders or take away trauma. It can buy precious time to find treatments that do work for them, prevent the tragedy of suicide and help patients live − and like − their lives a little more.

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