If you've seen many movies about mental health conditions or about people with mental health conditions, you've probably seen the administration of Electroconvulsive Therapy, or ECT. It's generally pretty terrifying to watch - and nothing at all like ECT treatment really is today. ECT has been depicted in Hollywood since the 1940s - almost as long as the treatment has been around. When we think about ECT, most of us picture people being tied down or wearing a straight-jacket with anything from a sock to a stick placed in the mouth between the teeth. Animal sounds, screams or grunts are vocalized while electrical currents are sent through the patient. The scenes that will be forever in my mind are that of John Nash's treatment in A Beautiful Mind, and the ECT scenes from One Flew Over the Cuckoo's Nest.
But how realistic are these depictions? Like everything in Hollywood, ECT has been given very little accurate reflection and a whole lot of dramatization. Yet, it remains a controversial treatment that continues to receive both rave reviews and unfavorable warnings. So what is it, anyways? And who decides who gets it? My explanation today of ECT applies to ECT as it is administered today. Although applications of ECT have been barbaric in history, today's use of it is far more humane.
ECT is used for the treatment of antisocial behavior, depression and manic depression when other treatments have failed. Informed consent is gathered before its use. Proper channels for receiving authorization in those cases where the patient is unresponsive for any number of reasons vary state to state.
Although most movies depict the patient (victim?) thrashing and terrified, anesthesia has been used since the 1950s, along with muscle relaxants and sometimes a medicine to reduce salivation. Two electrodes are used, and they are either placed both on one side (unilaterally) or one on each side (bilaterally) of the head. Unilateral use can sometimes minimize side effects, so that is usually tried first, but generally bilateral use is what is required to see some positive results.
The ECT machine then delivers a brief electric pulse, usually one and a half times the power of a seizure, which is different for each patient and generally a trial and error type assessment based on sex, age and weight. The ECT shock induces a seizure and the patient convulses for at least 15 seconds. The patient generally has a series of these treatments over a sustained period of time. It varies by patient, doctor, etc.
So how effective is ECT? According to the 1999 Surgeon General's report, it was believed that ECT had a 60 to 70 percent rate of remission, but most of those patients later relapse, usually at around 6 months unless other treatments are used in conjunction with ECT.
What are some of the adverse effects of ECT? The biggest concerns seem to be confusion and memory loss, though the degree is varied. Some people complain of minor muscle aches. Memory issues is the main concern for both providers and patients. Memory loss can be memories from before the treatment, or it can affect memory after treatment. Sometimes it reaches back years, sometimes only months. Some studies have shown that these memories are recovered within 7 months post-treatment. Other studies have shown that up to 50% of patients never recover some or all of the lost memories. Brain structure has been studied to determine the effect of ECT on brain tissue, but no determinative results have been found.
How do people chose whether to have ECT? It's a huge decision for anybody. Lots of pros and cons must be considered. The surgeon general's statement is this: patients should be warned that the benefits of ECT are short-lived without active continuation treatment in the form of drugs or further ECT, and that there may be some risk of permanent, severe memory loss after ECT. However, many situations exist where ECT is a last resort for better health after many, many other approaches have failed. By the time one gets to ECT, a variety of medications, different types of psychotherapy, and countless alternative treatments have been tried at one point or another. ECT can truly be the last hope for a patient when everything else has failed.
The memory loss issues alone are enough for me to decide that I will never participate in ECT, but that is my own personal decision based on other input as well. Recently, at a mental health conference, I met a woman, Linda Andre, who held a PhD and had been an ECT patient. Due to ECT treatment that she did not give consent to receive, she lost all memory of her education, her marriage, and many other life details. Think for a moment about that. Imagine you hold a PhD, but have no recollection of the eight or more years of education you required to earn it. Imagine you have a loving husband whom you don't know nor remember anything about. You don't remember graduating, getting married, or even getting treatment. Who are we without our memories? The sum of our existence is our memories. I can't imagine that all being wiped away.
For some people, little memory loss has resulted and their conditions have improved dramatically and they advocate for continued use of ECT and reduction of the stigma surrounding it. While I don't agree with ECT for myself, I certainly agree that depictions of ECT in movies and other entertainment would better serve us if it more accurately depicted ECT.
What about people who can't give their informed consent? Can someone else consent for them? Most states in the US require a judicial order following a formal hearing before patients involuntarily undergo ECT. I have filled out a psychiatric advanced directive which clearly indicates that under no circumstances do I consent to ECT. General advanced directives are commonplace - they tell your doctor and/or family whether to keep you alive by artificial means, etc. Psychiatric advanced directives do the same, only in regards to your mental health instead of physical health. However, they are not always recognized, depending on state laws, etc., and some states allow your spouse or others to override your personal decisions under certain conditions. Because of this, I have discussed my wishes with my providers and Kyle so that everyone is on the same page regarding my treatment if a situation arises in which I am not able to participate. This is the best approach to any condition, whether physical or mental. Make sure your spouse and your providers know what you want!
Many sources exist on both sides of this issue. I'm just combining what little bit I know here: obviously there are much better authorities on the issue! Linda Andre, who I mentioned earlier, has a book entitled "Doctors of Deception: What They Don't Want You to Know about Shock Treatments". It is a real eye-opener, and very well written. She autographed a copy for me when I met her in October, and let me tell you, I admire her passion on this issue!
Here are a few well-known people who have received ECT and whose stories might provide you further enlightenment on the issue:
Kitty Dukakis - wife of Michael Dukakis
Dick Cavett
Carrie Fisher
Judy Garland
Ernest Hemingway
Marya Hornbacher
Vivien Leigh
Michael Moriarty
Robert M. Persig
Sylvia Plathe
Bud Powell
Yves Saint-Laurent
David Foster Wallace
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