Into the Void

“A functioning police state needs no police.”
— William S. Burroughs

“Shock Therapy” is that ugly dog collar and backpack combination that they use in some detention centers to control kids with behavior problems. Yes, read that to mean psychological problems. Don’t get me started on behaviorists. It is used as a behavior modification technique, often without the use of psych meds, to create an aversion to the undesirable behavior.

However, we are talking about ElectroConvulsive Therapy – ECT.

ECT is a pretty drastic measure. They put you under general anesthesia then give your head a big jolt electricity – so big that it would induce convulsions if they didn’t knock you out and paralyze you first. It is one of the last remaining vestiges of a truly brutal era in psychiatry.

There are less extreme modalities available these days. Transcranial Magnetic Therapy is one. See if you can find the IEEE Spectrum at your library. There was a really good article in the March 2006 IEEE Spectrum last month. High-tech devices have fewer side-effects and if used appropriately they are quite effective.

A well-meaning but completely ignorant individual recently tried to convince me that ECT works by activating the parts of the brain that aren’t working right when you’re depressed. If anything, ECT overloads and suppress areas that you *don’t* want to be active. Along with pretty much everything else between the electrodes.

But the fact of the matter is that the way they usually do ECT, they don’t target problem areas and they don’t target specific desirable pathways. They overload the entire brain and if you weren’t anesthetized and paralyzed you’d go into grand mal seizures. In the old days, people who had ECT often broke teeth and bones during the procedure. Many patients suffer permanent memory loss and severe cognitive deficits – not all, but many do. It remains to be seen whether the current (no pun intended) methods produce the kind of brain damage seen in in earlier days.

The point is, there are modern options that should be considered in many cases.

Before you go in for ECT, please ask yourself some questions. What non-medical options have you explored? You can’t settle down enough to do your usual stress-busting activities, you can’t still your mind enough to even begin meditating, you’re afraid to go outside and run around to let off steam? Biofeedback isn’t even working any more, maybe because you’re outside of the normal operating parameters of the equipment available to you?

There is a series on PBS called “Second Opinion.” In the Depression episode, they made ECT sound like a miracle cure for depression. The reporting was unbelievably one-sided. They didn’t cover any of the magnetic therapies so anyone using PBS for their information doesn’t have the whole story. Furthermore, they trivialized the side-effects of ECT by saying, in effect, that it’s far preferable to have a permanent cognitive deficit than to be depressed. It was a fun show, but it was dumbed down way too much to be useful in making an informed decision.

I see that one of the sponsors provided the folks who did the show only limited access to information on MedLine. It appears that they prescreened the data made available – that is, they only provided articles that supported their agenda. Remember that PBS shows often have corporate sponsors who may want, say, to convince the public that an old-fashioned and therefore less expensive modality is better.

CLIC-on-Health provided Second Opinion wiith our pre-determined search access to MedlinePlus.

ECT is somewhat of a black art. The doctors have no idea how or why it works. From Wikipedia:

The exact mechanisms by which ECT exerts its effect are not known, but studies show that repeated applications have effects on several kinds of neurotransmitters in the central nervous system. ECT seems to sensitize two subtypes of serotonin receptor (5-HT receptor), thereby strengthening signaling. ECT also decreases the functioning of norepinephrine and dopamine inhibiting auto-receptors in the locus coeruleus and substantia nigra, respectively, causing more of each to be released.

The National Institutes of Mental Health (NIMH) also say that the doctors don’t know how or why ECT works. Furthermore, it isn’t totally clear which patients ECT is likely to help the most, nor is there any way of telling in advance if a particular patient is likely to have an adverse experience.

Much additional research is needed into the basic mechanisms by which ECT exerts its therapeutic effects. Studies are also needed to better identify subgroups for whom the treatment is particularly beneficial or toxic and to refine techniques to maximize efficacy and minimize side effects. A national survey should be conducted on the manner and extent of ECT use in the United States.

In fact, one conclusion of that article is that ECT is in use only because it’s been in use for so long.

ECT has been underinvestigated in the past. Among the most important immediate research tasks are:

• Better understanding of negative, positive, and indifferent responses should result in improved treatment practices.
• Identification of the biological mechanisms underlying the therapeutic effects of ECT and the memory deficits resulting from the treatment.

Better delineation of the long-term effects of ECT on the course of affective illnesses and cognitive functions, including clarification of the duration of ECT’s therapeutic effectiveness.

• Precise determination of the mode of electrode placement (unilateral versus bilateral) and the stimulus parameters (form and intensity) that maximize efficacy and minimize cognitive impairment.
• Identification of patient subgroups or types for whom ECT is particularly beneficial or toxic.

The World Health Organization (WHO) reiterates the statement that little is known about how ECT works on depression and that little is known about the after-effects of the treatment. In fact, they suggest that the therapeutic effects of ECT may be a result of the anesthesia or even of the nursing care and not to the actual electric shock at all.

Electroconvulsive therapy (ECT) is sometimes used to treat severe depressives who do not respond to drug treatment. A recent review and meta-analysis concluded that ECT is probably more effective than drug therapy, though the underlying mechanism is not known. The authors state that “any differences between ECT and drug therapy might not be attributable to the stimulus or shock alone, but could be due to other components of the ECT procedures (including anaesthetic and nursing care)” (100). Only one trial included in the meta-analysis provided data on cognitive functioning: patients treated with ECT had more word recognition errors after treatment compared to patients treated with simulated ECT. At six months this difference was no longer observable. The authors require more evidence for the efficacy of ECT in the subgroups of patients who are presently most likely to receive it: those with treatment-resistant depression and older patients.

Now for adverse effects:

In one recent study of almost 25,000 treatments, a complication rate of 1 per 1,300 to 1,400 treatments was found. These included laryngospasm, circulatory insufficiency, tooth damage, vertebral compression fractures, status epilepticus, peripheral nerve palsy, skin burns, and prolonged apnea.

During the few minutes following the stimulus, profound and potentially dangerous systemic changes occur. First, there may be transient hypotension from bradycardia caused by central vagal stimulation. This may be followed by sinus tachycardia and also sympathetic hyperactivity that leads to a rise in blood pressure, a response that may be more severe in patients with essential hypertension. Intracranial pressure increases during the seizure. Additionally, cardiac arrhythmias during this time are not uncommon (but usually subside without sequelae).

Also, the NIMH makes it very clear that ECT is only effective for a very limited group of illnesses.

The consideration of ECT is most appropriate in those conditions for which efficacy has been established: Delusional and severe endogenous depressions, acute mania, and certain schizophrenic syndromes. ECT should rarely be considered for other psychiatric conditions.

The law requires that a patient give informed consent. In order to give informed consent, the patient should be told about the risk of cognitive deficits and memory loss, particularly since there is a tendency to misrepresent ECT as a “quick fix” to get the patient back to work sooner. Some patients can never go back to work after ECT.

The NIMH is recommending that doctors get patient consent before each treatment in the series, not just for the series as a whole. That way the patient can assess the damage being done and refuse further treatments if necessary. The NIMH assumes that there is a statistically significant risk that a patient who is cognitively impaired by the procedure, even if the damage is only temporary, will not be capable of initiating a request to stop.

This recommendation sounds chillingly like the advice being given to prevent non-consensual sex. I won’t go so far as to call ECT “brain rape,” but only because that particular phrase has already been used by the writer William S. Burroughs in “Meeting of International Conference of Technological Psychiatry” to describe a prefrontal lobotomy. (ed2k link to William S. Burroughs – “Call Me Burroughs” – requires winrar to unarchive.)

That being said, if your doctor insists upon you having ECT, you don’t have much of a choice, do you?

UPDATE 4/15/2007:
Sylvia Caras of People Who accepted this post for inclusion on her own site. Stop over to People Who and check out the tremendous amount of excellent mental health advocacy information she offers.