Electroconvulsive therapy (ECT) has come a long way since earlier, darker days when it was known as electric shock therapy and conjured images from One Flew Over the Cukoo’s Nest.
But just when it seems that ECT’s reputation is starting to recover, new criticisms are emerging.
Most recently, concerns have been raised about the use of ECT for involuntary patients in Victorian public hospitals.
Discussions about the treatment of severely depressed patients are important, but in order to have a robust community debate, we need to set a few things straight about the risks and benefits of ECT.
What is ECT?
Modern ECT is a treatment process where a generalised seizure is induced by the application of a brief electrical current to a patient’s scalp.
A general anaesthetic is used, along with medication to temporarily relax or paralyse the patient’s muscles. Paralysis-inducing medication prevents the violent muscle jerks most people associate with having a seizure.
The patient (under anaesthetic) is totally unaware of the experience of the electrical current or the seizure itself.
ECT is most commonly used to treat severe depressive illnesses and on occasion, schizophrenia and other rarer disorders. A course usually involves six to 12 treatments over several weeks.
Why choose ECT?
ECT is the most effective and rapidly acting treatment for depression. It provides much more rapid treatment than antidepressants, which typically takes at least two to four weeks to have an effect.
In people with severe depression, around seven out of 10 patients will get better with a course of ECT. These are much better odds than antidepressant medications, a single course of which will usually result in recovery in only four out of 10 patients.
What are the side-effects?
With improved knowledge of ECT administration over the past few decades, we have been able to minimise its side effects although some remain.
There are always risks associated with undergoing a general anaesthetic, although the anaesthetics used for ECT are usually very brief and rarely cause problems.
The most significant side effect is memory impairment. In most patients this is confined to a brief period around the time of the ECT treatment. More rarely, it can affect short-term memory.
These impairments can be difficult to distinguish from memory lapses caused by depression itself but nonetheless cause substantial distress. They’re certainly significant enough to justify ongoing attempts to improve ECT and develop alternative treatment options.
This is something our research centre is actively engaged in. We’re currently trialing the use of a magnetic stimulus to induce seizures – a technique known as magnetic seizure therapy – which seems to not have these memory-related effects.
But this doesn’t diminish the usefulness of ECT as it currently stands.
All Australian states and territories (and most parts of the Western world) have provisions for the treatment of patients with severe mental illnesses without consent.
This occurs when the patient’s illness is believed to impair his or her capacity to understand the need for treatment, or where the patient is likely to put themselves or others at risk in some substantial way.
Legislation will typically allow for involuntary admission to hospital and, in some jurisdictions, pharmacological or other treatments without consent.
One scenario involving ECT is the treatment of those with severe depression. A patient may be so unwell that they stop eating and drinking, placing themselves at immediate physical risk.
Such depression is often associated with severe suicidal ideation, when patients will be constantly attempting to find the means to end their lives. This scenario is a medical emergency because even with close supervision, patients can be at substantial risk.
Under these circumstances, ECT is the only treatment available that’s likely to result in a rapid improvement in symptoms - potentially saving the individual’s life.
Regulation of ECT
Given the impact of involuntary ECT on basic human rights, it’s clear we need substantial checks in place to regulate the provision of involuntary treatment.
But we also need to ensure that the health system can adequately provide potentially life-saving treatment to restore an individual’s health and capacity to make their own choices.
It has been proposed in Victoria that greater restrictions be placed on the provision of ECT to non-consenting patients, by either banning ECT or mandating an independent process of review of each case prior to treatment.
Banning involuntary ECT would likely result in poorer outcomes for patients and possibly even deaths.
While the notion of independent review prior to treatment seems an attractive way to balance human rights and clinical considerations, this isn’t necessarily the case if it denies patients timely access to the treatment.
If a system of review is implemented, this must be accompanied by an appropriate increase in mental health service resources to ensure the system can respond in a timely manner.
Independent reviews need to take place rapidly – sometimes out of standard working hours – to ensure the health and well-being of acutely depressed patients isn’t compromised.
Expanding treatment options
Health and research funding agencies have correctly recognised the need to invest resources into early intervention in mental illnesses.
But there’s also an urgent need to invest substantial resources into improving treatment options for patients with the most severe and persistent mental illnesses.
This will require enhanced resourcing of mental health services and greater investment in research to develop new and better treatments for these acutely ill patients.