[Editor’s note: With Scott, our usual Thursday poster, away on vacation, we bring you another post from frequent guest, Braden MacBeth]
Electroconvulsive therapy (ECT) is an effective treatment for medication-resistant psychiatric disorders. It’s also considered controversial for some reason. Antipsychiatry’s rhetoric surrounding ECT can be heard pretty much anytime the topic comes up in discussion. ECT is often misrepresented in movies such as One Flew Over the Cuckoo’s Nest, The Snake Pit, Requiem for a Dream, and most recently Suicide Squad. There have been many studies on the public’s perception of ECT and these films are cited as a pretty big reason why ECT is perceived so negatively. ECT is often portrayed as a barbaric, painful treatment used to punish patients held against their will in an in-patient psychiatric wing. The anti-science antipsychiatry movement has played this to their advantage, and criticize ECT as it appears in the films as if that’s what ECT is really like. In films ECT isn’t done under sedation, it has horrific side effects, and is incredibly painful. In reality, ECT is nearly painless, has relatively rare side effects that are usually minor, and is incredibly effective. One thing that is consistent across all literature on ECT is that ECT incredibly effective when it’s indicated, but is underutilized because of the stigma.
One Flew Over The Cuckoo’s Nest was not a documentary
Probably the most prominent antipsychiatry organization is the Citizens Commission on Human Rights. While CCHR sounds like an innocuous humanitarian organization, the organization’s singular goal is to perpetuate falsehoods about psychiatry, and they’re bankrolled almost entirely by the Church of Scientology. CCHR has a 32-page handout on psychiatry’s “brutal treatments”. I knew I was in for a treat when the introduction highlights this quote:
Despite the general belief that ECT ceased to be administered with the death of Jack Nicholson’s character of McMurphy in One Flew Over the Cuckoo’s Nest, hundreds of thousands around the world are still subjected to it each year.
– Jan Eastgate, President of CCHR
One Flew Over The Cuckoo’s Nest, released in 1975, it’s so old that the third year med student who saw the film in theaters is now the attending who writes “sub-internship level” on third year med student evaluations and then gives only gives them a pass for an evaluation grade. The book the movie is adapted from was published in 1962. The depictions of psychiatry in the book weren’t even accurate for the time; the majority of lobotomies were performed in the 1940s to 1950s for example. While lobotomies were absolutely horrifying, so were most other things during that time. The Civil Rights Act was passed 2 years after One Flew Over the Cuckoo’s Nest was published. The point is, your criticisms of medical procedures have to be relevant to how they are done today, not how they were more than 50 years ago. Many of the “criticisms” outlined in CCHR’s document are based on information or events from more than 50 years ago.
The majority of CCHR’s arguments against ECT are based on unverifiable testimonials, professionals who don’t represent mainstream psychiatry, questionable research, verifiable falsehoods, trash publications, and legitimate research taken out of context. So about par for the course as far as anti-science movements go. There are a number of outrageous claims made in the CCHR document such as research “revealing” that the death rate from ECT among the elderly receiving ECT is one in two hundred. Their source for this claim is The Practice of Electroconvulsive Therapy: Recommendations for Treatment, and Privileging but there’s published research in Neuropsychiatry citing the exact same manual stating that the ECT may pose less risk of complications in elderly patients compared to pharmacotherapy, and that depressed elderly patients may have a better treatment response to ECT than young adults. The actual mortality rate from ECT is about 2 in 100,000 procedures, less than other operations using general anesthesia.
Overstated risks, understated benefits
The CCHR pamphlet also quotes Dr. Colin Ross (yes, that Colin Ross), a psychiatrist from Texas:
…the literature shows there is a lot of brain damage, there is memory loss, the death rate goes up, the suicide rate doesn’t go down. If those are the facts from a very well-designed, big study, then you’d have to conclude we shouldn’t do ECT… The literature that exists strongly supports the conclusion that it isn’t effective beyond the period of time of the treatment and there are a lot of dangers and side effects and a lot of damage.
I would agree that if the literature showed that ECT was causing brain damage, severe memory loss, death, or provided no benefit psychiatrists shouldn’t perform ECT procedures, but that’s not the case. The literature shows the ECT is safe, effective and has very few side effects. To be fair Ross stated this in 2004, and a huge amount of research has been done since then, but even at that time the research didn’t support his statement. The NIH published a statement based on a Consensus Development Conference held in 1985 and it concluded that the risk of ECT was not different from that risk associated with short-acting barbiturate anesthetics. The complication rate for ECT was 1 per 1,300 to 1,400, and was effective for a number of psychiatric conditions if the patient was not responding to pharmacotherapy. While the study states “There is also objective evidence, based on neuropsychological testing, of loss of memory for a few weeks surrounding the treatment; such objective tests have not firmly established persistent or permanent deficits for a more extensive period, particularly for unilateral ECT”, this was in 1985 and ECT has been studied much more since then and has improved a great deal.
The risk of temporary memory loss is brought up nearly every time ECT is discussed, and the literature shows that temporary memory loss used to be a very common adverse effect from ECT. The memory loss from ECT is temporary in the majority of cases, and memory problems usually resolve after a few weeks. That said, ECT has improved a great deal and the risk of memory loss occurring is much lower, and the degree of temporary memory loss is much less severe. In an editorial published in JAMA Psychiatry in 2017, Dr. Harold A. Sackeim explains that negative adverse effects resulting from ECT are directly related to the time it takes to recover full orientation following a seizure. It turns out that the recovery time had mostly to do with the anesthesia techniques and the dosing of the stimulus (the electric current) used. In the 1980s dosing of the stimulus was administered on a sine wave, and the orientation recovery times averaged several hours. Sine wave stimulation isn’t used at all anymore and was replaced by brief pulse stimulation, which delivers quick pulses of electricity in 0.5-1.5 millisecond intervals. Brief pulse stimulation has recovery times of 45 minutes for bilateral and 30 minutes for right unilateral ECT. Ultrabrief stimulation administers an electrical stimulus on intervals less than 0.3 milliseconds long, and has far fewer cognitive side effects and much faster recovery times, 15 minutes for bilateral and 10 for right unilateral ECT. As a result of improvements to how the electrical stimulus is administered, the risk and severity of negative cognitive effects following an ECT treatment have been reduced drastically.
The most recent research clearly shows that ECT more effective, safer, and has fewer adverse effects than ever before, but is underutilized. A study published in JAMA Psychiatry in 2017 that tracked the outcomes of 162,691 psychiatric inpatients found that 30-day readmission rates for patients with severe affective disorders who received ECT treatments were nearly half compared to those who did not receive ECT (6.6% versus 12.3%). ECT is particularly effective at treating major depression with psychotic features; one study found that remission was achieved in 95% of 77 patients with major depression with psychotic features, and remission was achieved much earlier in treatment. A systematic review published in the Annals of General Psychiatryin 2013 concluded that ECT was “a highly efficient option for treatment of several psychiatric disorders, achieving high rates of success remission, with few and relatively benign side effects”. The evidence shows that CCHR is grossly overstating the risks of ECT while heavily downplaying its potential benefits.
Antipsychiatry political malarkey
While ECT has been proven to be safe and effective, many people in the public believe that ECT is dangerous because the representation of ECT in films is likely the only time they’ll ever see it. That makes them much more easily swayed by the antipsychiatry movement. Antipsychiatry organizations have convinced legislators to propose legislation attempting to ban or arbitrarily restrict the use of ECT. In Pennsylvania, representatives Tom Murt and Stephen Kinsey proposed H.B 1809 that would ban ECT for people under 16. Representative Kinsey’s reasoning for proposing the legislation seems rather questionable to me:
“While ECT remains a controversial treatment for adults, it’s deplorable when done on children who have no say on whether to agree to this brutal treatment,” Murt said in a press release. “Yet, kids are still being shocked today. This treatment can cause brain damage. To me, it’s a form of child abuse. The use of electroshock therapy on children is outright cruel and unacceptable,” Kinsey said. “The side effects of ECT can be debilitating even for adults. Children should not be forced to undergo a treatment that can have a lasting impact on their physical and mental well-being. ECT sends up to 450 volts through a person’s brain, inducing a grand mal seizure. The US Food and Drug Administration reports that these seizures can cause complications including heart attacks, difficulties breathing, confusion, permanent memory loss, brain damage and death.
ECT isn’t controversial in the medical community; ECT has been proven to be effective for severe psychiatric disorders in adolescents. The review published in The Annals of General Psychiatry also stated in its conclusion that “The majority of the studies in the scientific literature show the efficiency of ECT use in adolescents and consider this approach more efficient than psychopharmacotherapy isolated”. Relatively few adolescents in Pennsylvania receive ECT; according the Department of Health and Human Services three adolescents between the ages of 13 and 17 received ECT in 2014. Obviously while this legislation wouldn’t affect many people, the three adolescents who receive ECT are doing presumably receiving treatments at the recommendation of a psychiatrist and are benefiting from it.
It’s not just Pennsylvania either, a bill was proposed on January 24 of this year in Maine to attempt to prohibit the use of ECT on anyone under the age of 18, over 65, or pregnant women. What’s most interesting to me is that the majority of people who receive and benefit from ECT are over 65. According to CCHR’s own statistics, 65-year olds receive ECT at a 360% higher rate than 64-year olds, because that’s when they’re eligible to receive Medicare benefits. As I’ve already stated, research has shown the elderly patients respond better to ECT and can experience less side effects compared to pharmacotherapy. I’m unable to find any reason stated by the representative who proposed the bill, although no reason is what it boils down to anyway. Fortunately, the bill was shot down immediately by the Committee on Health and Human Services.
Conclusion: Cool not cruel
ECT is not like what’s shown in the films, it’s done under anesthesia, it’s low risk, it has rare and often benign side-effects. The antipsychiatry movement wants to make out ECT to be the same as it is in films, a painful procedure done to punish unmanageable, often poor patients. In reality, ECT is almost always done on a voluntary basis, and unfortunately ECT is very expensive making it prohibitively expensive for the majority of patients when it’s not covered by insurance. I’m not going to litigate whether or not it’s ethical for psychiatrists to treat patients involuntarily when done so in accordance with established law and the APA code of ethics, it is. ECT can be an invaluable resource for people suffering from psychiatric disorders that aren’t responding to other treatment modalities.
The antipsychiatry movement does not care about the evidence showing that ECT is safe and effective; the antipsychiatry movement is an anti-science movement after all. The antipsychiatry movement perpetuates so many myths about ECT that even state representatives start to buy into them. Many antipsychiatry organizations such as the Citizens Commission on Human Rights are funded completely or partially by the Church of Scientology. While the history and beliefs of the antipsychiatry movement and its entanglement with the Church of Scientology is something I’d like to explore more in the future, the bottom line is that ECT isn’t something to be afraid of. ECT has improved a lot over the decades and has been a lifesaver for many people. It would be nice if Hollywood portrayed it as such more often.