Category Archives: ECT

More on ECT and Other Treatments

By Dr David Laing Dawson

Throughout medical history, every treatment that actually works becomes overused.

Examples today include treatment for high blood pressure, statins, mastectomies, arthroscopies, opioids for pain, antibiotics, aspirin…..

When a treatment is found to work, the criteria for use informally expands until large studies find this to be either detrimental or unhelpful and then the practice shrinks. The current opioid crisis is a good example. The struggle to control the overuse of antibiotics is another.

ECT was first used in 1938 and found to be dramatically effective for patients with very severe depression, intractable mania, and some forms of psychosis. This at a time when there were no other explicitly effective treatments. This at a time when most of these cases were thought hopeless and all other treatments constituted a mix of hocus pocus and wishful thinking.  The very first patient to receive ECT was a man found by police wandering in the Rome train station muttering gibberish to himself. After this first rather unrefined ECT treatment the patient was discharged from hospital fully oriented and talking sensibly.

ECT was also introduced at a time when depression could reach a point of severity to justify the adjectives “stuporous”, “vegetative”, “retarded”. People died in this state from the consequences of malnutrition, starvation, unrecognized infections, and all the problems associated with total immobility. For this subset of severe depression ECT is a miraculous and dramatic (sometimes temporary) cure. It similarly had stunning results with intractable mania and catatonia, and pretty good results with something called “agitated depression”.

Hemingway was hospitalized with a form of psychotic depression (severe depression with agitation and some paranoia), was treated with ECT and returned home to work. For eight months or more he wrote at his standup desk somewhat unsuccessfully, drank too much, relapsed, and was readmitted to hospital. This time he talked his way into being discharged without treatment. And then he killed himself.

Through the 40’s, 50’s, and 60’s ECT became overused, both excessively used for single intractable cases, and used to “treat” many problems that simply don’t respond to ECT. Then our new drugs began to replace ECT, attitudes changed, One Flew Over the Cuckoos Nest hit the big screen, and, perhaps more significantly, with our new drug treatments, very few people got to the late stage of depression and psychosis we called, “stuporous”, “vegetative”, “retarded”, “agitated” and “catatonic”.

Over the years I have received heart felt thanks from a few people for whom I recommended ECT.

And it seems clear to me that all or most of those people who complain of the barbarity and after-effects of ECT are victims of that overuse mentioned above.

There are many human conditions for which ECT is not helpful, but, in some of those cases, once used, ECT becomes the perceived cause of all succeeding problems.

In reality ECT remains a very safe and effective treatment for serious depressive illness. Today it is mostly used when trials of medication have failed. Curiously, though pilloried and thought to be barbaric by some, ECT is actually one of most dramatically effective and safe treatments in all of medicine.

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On ECT and The Variability of Bodily Experience

By Marvin Ross

ECT or shock therapy has to be the most contentious treatment in all of medicine, in part, due to its depiction in films which is highly negative. My initial view of it was coloured by my favourite aunt when I was a kid. She had what in those days (1950s or 1960s) was a nervous breakdown. Her husband had died and then her brother (my father) died suddenly of a heart attack.

One of her symptoms was unusual pains in her chest and back for which no organic cause could be found so her physician nephew had her admitted to a private sanitarium rather than the infamous Toronto Hospital for the Insane at 999 Queen St W ( actually the Ontario Hospital and now the Center for Addiction and Mental Health). She underwent a series of ECT treatments and was eventually discharged.

After discharge, she confessed to me that after each treatment, the staff asked her how she felt and if she was still experiencing the pains. She told me that if she said yes, she got more shocks so she told them she was fine, the pain had gone away and she was discharged. But, she told me, she still had the pains. I can’t recall how long after but she died of a stroke. I’ve always wondered if they had missed atherosclerosis as diagnostic skills were quite primitive in those days as was treatment for heart and stroke compared to today.

Fast forward to the late 1990s and I was a regular visitor to the psych unit at our local hospital. One of the patients was a young mother with schizophrenia who, I was told, attempted to kill herself and her young children. She was getting ECT. A few months later, I was picking up a coffee at the hospital snack bar when an attractive woman said hello to me.

“You don’t recognize me, do you” she said.

“I’m so and so and this is the new me post ECT. I was discharged, I feel really well and I’m here for an outpatient visit with my psychiatrist”

Psychiatric Times just ran an interview with the author of a new book called Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy by Jonathan Sadowsky, PhD. The one question he was asked that I found very interesting was this:

“Patients have both attested to damage it has done and expressed gratitude for the relief and hope it can provide.” How do you explain this seemingly paradoxical disparity in the experiences and opinions of patients?

The answer was what I have tried to say about medical treatments and recovery in schizophrenia in general but not as elegantly as this author. This is what he had to say:

“The human body is not a mass-produced machine, where given inputs such as therapies produce automatic and predictable results. Most clinicians and lay people know this but often act as if they don’t. One result of this mechanistic conception is resistance to the variability of bodily experience. But this variability is easy to show.”

And so, some people do well and others do not just as some drugs work well for some people and in others not only don’t work but have horrific side effects. We are all different and good clinicians have to recognize (and do) that trial and error is required to find the correct treatment for any given individual.

In a recently released study out of the Karolinska Institute in Sweden, it was found that there is considerable variability in the efficacy of anti-psychotics to prevent relapses in patients with schizophrenia. This study involved 29,823 patients aged 16 to 64 years with a median follow-up of 6.9 years. It was also a naturalistic study where each patient served as his/her own control to avoid selection bias. Long-term injectable antipsychotics, paliperidone and zuclopenthixol and the oral clozapine had the lowest risk of rehospitalization.

Going back to ECT, another recent study found that remission rates for patients with severe mood disorder are lower among those who have had ECT as inpatients. Earlier studies had shown that ECT leads to better remission rates in people with major depressive disorder and results in reduced mortality.

The bottom line is that despite the bad press that ECT and other treatments may have in the media or among the general population, many will experience positive outcomes. Keep an open mind.

On ECT, Jack Nicholson and One Flew Over the Cuckoo’s Nest

David Laing DawsonBy Dr David Laing Dawson

In my addendum to Marvin’s blog last week I referenced Jack Nicholson in One Flew Over the Cuckoo’s Nest. I’m sure everybody got the reference. Some of those scenes are burned into the collective imagination. And I was a fan of both Ken Kesey’s novel and the movie. I say ‘was’, because as great as Nicholson’s performance, as great as Milos Forman’s direction, and Louise Fletcher’s acting, the movie may have played a minor role in the demise of the Mental Illness treatment system of North America and a return to incarceration in jails and prisons for thousands of the mentally ill, to say nothing of an unwarranted negative public reaction to ECT.  At least unwarranted since it has become more selectively and carefully used to treat only patients with severe illness not responding to medication.

The novel rose out of Mr. Kesey’s part time work as an attendant on the night shift of a Veteran’s Hospital, while taking part in a CIA sponsored experiment with psychedelic, hallucinogenic drugs, in the late 1950’s.

Movies are magic, and they play fast and loose with the truth. In the sound and fury of them, in our vicarious pleasure of escaping our bonds, seeking revenge, getting back the man or woman of our dreams, and saving the world, we often miss a few nuances and incongruities.

Randle McMurphy does embody the free rebellious rule-breaking individual confronting oppressive institutional authority as personified by Nurse Rached. And the movie makes us root for him and hate Nurse Rached. Her ultimate weapons being ECT and Lobotomy.

Now there certainly is some truth to those big overcrowded wards of large mental hospitals being run by nurses whose prime directive was to keep everything peaceful, under control, with a modicum of care and nurturing on the side. And the doctor often was, as described by sociologists, the absent father whose power could be invoked by the nurses, as in “You just wait until your father gets home.”

But here are some of the nuances in that film that slip by us: All but a couple of the patients on that ward are voluntary and could leave any time they wanted. And McMurphy, well, he is a charming psychopath, and he has faked insanity so he could be transferred to that hospital from a prison. His most recent conviction is for statutory rape with his defense being, “She came on to me.” That would imply that McMurphy had sex with a 13 or 14 year-old child at the time the book was written.

Our attitudes have shifted a little since that film was made. Today McMurphy might be charged with “sexual assault” “rape of a minor” “sexual molestation of a minor”. He would be placed on a sexual offense registry, and the public and our courts would show him little sympathy. And, I suspect, that if I were asked to provide a psychiatric evaluation of McMurphy, I would be telling the court that he is high risk to re-offend.

On the other hand, if any actor could make us root for a pedophile it would be Jack Nicholson in his prime.

The American Psychiatric Association Annual Conference 2015 and Silly Season

newer meBy Marvin Ross with an Addendum by Dr David Laing Dawson

This year, the American Psychiatric Association (APA) is having its annual conference in Toronto starting May 16 and, again, they are being picketed. While most Canadians are enjoying the first long weekend of summer opening cottages, having picnics, planting their gardens and enjoying the fireworks –a hold over from our colonial heritage celebrating the birthday of Queen Victoria – anti-psychiatrists are marching.

Strangely, this is not an unusual event. The APA is the only medical organization that is regularly picketed and this year, opponents of electroconvulsive shock therapy (ECT), are gathering at Toronto’s City Hall Square to march across the street to the Sheraton Hotel. This is a rather curious locale since the conference is at the Metro Convention Centre about a mile from the hotel.

According to the facebook manifesto “this psychiatric organization constantly deceives, minimizes and generally lies about the devastating trauma, permanent memory loss and brain damage caused by electroshock. It actively promotes ECT and holds continuing education courses, funded by Big Pharma, at all its annual meetings.”

It goes on to say that “In its 2007 official policy position statement, the APA claims, “Electroconvulsive therapy is a safe and effective evidence-based medical treatment. ECT is endorsed by the APA when administered by properly qualified psychiatrists for appropriately selected patients.”

The APA and The National Institute for Health and Care Excellence (NICE) in the UK do not endorse the use of ECT based on a whim or without proper evidence and they do not recommend it for everyone. ECT is used for rapid improvement, in the short term, of these symptoms

  • Severe depressive illness or refractory depression.
  • Catatonia.
  • A prolonged or severe episode of mania.

It should only be used if other treatment options have failed or the condition is potentially life-threatening (eg, personal distress, social impairment or high suicide risk).

A metaanalysis published in 2014 that compared ECT with the newer transcranial magnetic stimulation concluded that ECT is the leading therapeutic modality for patients with treatment resistant depression.

ECT can be helpful! Now I would join the protesters if psychiatrists dragged unsuspecting patients out of their hospital beds, hustled them down the hall to a room where they attached electrodes to their heads and zapped them with electricity.

But this does not happen!

There is this thing know as informed consent and every patient, or their substitute decision maker if they are not competent, signs one. Before a doctor can treat – be it ECT or pumping toxic chemicals into the body to rid it of cancer – the patient must understand the potential risks and benefits of the treatment before consenting to it. With ECT, the patient is in extreme distress, nothing else has helped and they are desperate for relief.

For some stranger like those marching at the Sheraton Hotel in Toronto to think they can decide what is good or not good for a patient takes an enormous amount of chutzpah.

A Personal View of ECT from Dr David Laing Dawson

The year was 1969. I was a psychiatric resident in a new open-door nicely appointed psychiatric ward and I didn’t think much of ECT. It had been overused in the past, but all specialties of medicine have a history of finding a treatment that works (finally!) and then over-using it, from antibiotics to every kind of surgery. Still, it just felt wrong to induce a seizure, a convulsion, to fix a mental disorder, especially when we had no clue why it actually worked.

So I avoided using ECT, and had managed without it for about a year and a half.

And then a man in his twenties was admitted to my care. He was thin, almost emaciated, and not talking. He had been living in a small room in the back of his parents’ downtown apartment and had gradually ceased to look after himself or get out of bed. Now he lay on his back in a hospital bed. He did not speak. He made no eye contact.

I sat beside him and talked. Nothing. Over time I gave him several medications and then withdrew them. Nothing. I hauled him out of bed each day for a week, and, holding his arm, walked him around the hospital ward. Nothing. We could keep him hydrated with some nutrients but he was still not eating.

So it came down to ECT. Six treatments. His mood brightened. He made eye contact. He ate. He talked to me. He remained my patient for a few months, moving to the day hospital and then outpatients. Because he now talked with me I could figure out what medications might keep him well.

And for five years after that, every year, I received a Christmas card from him thanking me.

And today, perhaps with thanks to Jack Nicholson, of all the treatments and procedures administered by modern medicine for serious illness, ECT is one of the safest, most effective, and very carefully restricted and monitored.