Dialogue: Big questions hang over shock therapy

JOHN READ* outlines the pros and cons of ECT treatments and suggests thatits continued use should be opened to discussion.

Congratulations to Hake Halo, Carl Perkins and the other 93 children of Lake Alice for winning their battle for compensation for the punitive use of electric shock treatments, and to our Government for admitting fault and apologising.

But perhaps we need some discussion about the fact that today 18 hospitals in New Zealand run ECT (electroconvulsive therapy) clinics.

First, what happened in Lake Alice bears little resemblance to normal use of ECT, which is administered, with muscle relaxants and general anaesthesia, to the head not the legs. The purpose of ECT is not to punish but to alleviate mental illnesses through electrically induced convulsions.

(It was originally designed to treat schizophrenia, on the mistaken assumption that because schizophrenia and epilepsy were antagonistic to each other schizophrenia could be cured by causing seizures.)

Second, we must remember that other medical treatments besides ECT have unfortunate side-effects. The question is: do the benefits outweigh the risks?

ECT often results in the loss of memories and difficulty in retaining new information. These effects usually last only a few weeks. However, ECT causes longer-lasting (sometimes permanent) memory loss for events occurring a few weeks before and after treatment.

Advocates suggest this is a small price to pay. Some even argue that the absence of the memory of events of the hospitalisation might be as much a blessing as a loss.

Critics point out this is precisely the period that must be remembered so that the person can figure out what went wrong in their life and plan better ways of coping next time those events happen.

Early ECT advocates acknowledged that the benefits come as a direct result of brain damage, suggesting a mental patient can think more clearly and more constructively with less brain in operation.

Now the connection between brain damage and benefits is not mentioned. The memory loss is not called brain damage; it is usually described as minimal and temporary or subjective memory loss, implying that patients imagine it.

Dr Karl Pribram, of Stanford University's Neuropsychology Institute, stated: "I'd rather have a small lobotomy than a series of electro-convulsive shocks. I know what the brain looks like after a series of shocks and its not very pleasant."

This is unsurprising. ECT uses currents hundreds of times greater than that for which the brain is designed.

The risks include damage to the blood-brain barrier, disruption of protein synthesis, epilepsy and death, usually from heart failure.

ECT supporters claim it is no more dangerous than minor surgery under general anaesthetic. This ignores the fact that a course of ECT involves at least six individual shocks over several weeks and is therefore at least six times more dangerous than a single operation.

The official mortality rate varies from three to 30 for every 100,000 individual shocks. Other researchers have found the rate ranging from 150 to 1150 deaths. What benefits should these risks be weighed against?

The repeated claim that ECT prevents suicide has no research backing. ECT does produce rapid symptom reduction for many depressed people and some people diagnosed as schizophrenic, the two groups most frequently given ECT.

However, studies show that these improvements disappear within four to eight weeks, by which time ECT recipients are no different and sometimes worse, than those who didn't get ECT.

Rather than abandoning ECT, supporters recommend maintenance ECT whereby people are shocked once a month for years. Critics compare this to recharging distressed human beings like car batteries.

Nobody knows how ECT works. Many studies find no difference when the treatment is compared with simulated ECT (where anaesthesia is given without shock or convulsion). Thus, part of the cure is a placebo effect created by positive expectations.

For years one English hospital used a procedure which never produced convulsions. The professionals were, nevertheless, so convinced of ECT's effectiveness that they were using it twice as often as the national average.

Another hypothesis about how ECT works is that it frightens us into changing our behaviour to avoid further shocks. The first successful ECT was in 1938. The recipient, hearing Dr Cerletti discussing whether to give a second shock, suddenly ceased his usual gibberish (unaffected by the first shock) and became coherent.

He shouted: "Not another! It will kill me!"

Whether the effective use of ECT on restless Second World War battleship crews on long runs and on the Vietnamese people worked through fear is unknown.

In my experience of helping to administer ECT in the mid-70s (using the modern version involving anaesthesia), I found those who queued with resignation to be almost as unsettling as those who trembled in fear, begging not to be given it.

Could it, literally, be the shocking that does the trick? Cerletti's obituary in the American Journal of Psychiatry lists ECT among treatments ranging from the cruel to the bizarre, intended to shake-up the psychic economy of mental patients.

Also on the list were surprise baths, sudden showers, rotating machines, intimidation systems and blood-letting as methods of inducing shock.

When ECT recipients were asked how it works they said (in order of frequency): "I don't know"; "It gives you a shock"; "It makes you forget".

Other issues need discussion. Why are roughly half of all ECT recipients women over-45? Why are women in general twice as likely as men to get ECT? Under what circumstances, if any, can ECT be considered appropriate for Maori?

In the past decade England has cut its usage by half. Five American state legislatures and some European nations have imposed restrictions. Should New Zealand consider similar legislation? Would this unnecessarily restrict the use of clinical judgment?

Professionals have diverse views. A British survey found that many never give ECT and that most of it is given by just one-fifth of those qualified to do so.

Discussions about ECT can degenerate quickly. It is described as barbaric and as torture. Critics are portrayed as ideologically motivated, anti-psychiatry, or accused of frightening patients. Recipients who complain are told their memory loss is part of their illness.

An American ECT advocate recently berated nurses, social workers, physicians, psychotherapists, psychologists, clergy and lay groups, many led by former patients, for trying to restrict its use.

I hope discussion on this matter will be respectful, especially towards ECT recipients who contribute to New Zealand's attempt to address this important but complex issue.

*Dr John Read is a senior lecturer in psychology at the University of Auckland.