Wednesday, 31 July 2013

ECT: This is shocking

A recent BBC Newsnight feature asked: “Why are we still using electroconvulsive therapy?” It’s an important question. While crude psychiatric ‘treatments’ from the early-mid 20th century like surgical lobotomies and insulin coma therapy have been recognised for what they really are (dangerous and barbaric) and have been withdrawn from use, electroconvulsive therapy (ECT) has managed to survive.

I first came across ECT back in 1975 when I saw it portrayed in the film One Flew Over the Cuckoo’s Nest. I was at that time working in a small psychiatric unit where the psychiatrist-in-charge was making radical changes - including the removal of bars from the windows and developing a more home-like milieu. His contextual understanding of mental and emotional troubles had a profound influence on my life.

Then, within a few years of seeing One Flew Over the Cuckoo’s Nest, ECT came nearer home as I had the unpleasant experience of accompanying one of my parents to a London hospital for repeated ECT treatments. The whole process was depressing (for both of us) and erased important memories from my parent without any hint of lifting the depression. Since then I have known many people who have endured multiple ECT ‘treatments’.

ECT ‘works’ by inducing a grand mal seizure. This is shocking; there’s no getting away from that. Prof Steven Rose describes it like this: “ECT puts a blast of electricity across the brain, temporarily disrupting communication, killing some cells, erasing recent memory and generally inserting a large clumsy spanner into the brain’s machinery…for any neuroscientist, the thought of such a massive, if brief, intervention into the delicate workings of the brain must be a cause of concern, however well intentioned the therapeutic goals might be”.[1]

This ‘treatment’ inevitably raises ethical issues; not least, when used against a person’s wishes, as still happens here in the UK. But there is another ethical issue: what if a psychiatrist would rather not subject a patient to ECT?  This matter was raised by the Critical Psychiatry Network in a letter to the Royal College of Psychiatry (RCPsych). The request (signed by Dr Joanna Moncrieff and Dr Rhodri Huws) asks “that the College consider dropping the obligation for trainees to conduct ECT during their training.” Now that’s an interesting request.

It is understandable that some psychiatrists would want to take an ethical position against having to administer ECT; rather like doctors are able to opt out of conducting abortions. What is striking is the immediate displeasure by the President of the RCPsych and the strength of the refusal by the follow-up letter ten months later on by the Dean.

I have never thought about it quite like this before, but insisting that all trainee psychiatrists perform ECT must surely act like a filtering system – potentially screening out some very able and conscientious people who are loyal to the “Do no harm” principle underpinning medical ethics; perhaps the very people able to compassionately respond to those suffering with mental and emotional pain.

A willingness to reflect on what we are doing (or asked to do) and why we are doing it is of course essential for progress. This reminds me of R.D. Laing’s experience: “As a young psychiatrist in general hospitals and psychiatric hospitals, I administered locked wards and ordered drugs, injections, padded cells and straightjackets, electric shocks [ECT], deep insulin comas [drug-induced comas] and the rest… I went around in a white coat, with stethoscope, tendon hammer and ophthalmoscope sticking out of my pockets, like any other doctor.  Like them, I examined patients clinically…It looked the same as the rest of medicine, but it was different.  I was puzzled, and uneasy.  Hardly any of my psychiatrist colleagues seemed puzzled or uneasy.  This made me even more puzzled and uneasy.” (Wisdom, Madness & Folly 1985)

In the US, ECT machines are Class III medical devices (Class III includes devices “which present a potential, unreasonable risk of illness or injury”). Any Class III device does of course have to be approved by the FDA for safety and efficacy – though this has been side-stepped by the makers of shock-machines. This is because “Electroshock machines were ‘grandfathered’ into the system when the FDA assumed jurisdiction over medical devices in 1976 (source)”. At long last the FDA is currently requesting this data, but no deadline has been set. This means that the device makers are in fact relying on the clinical literature to infer safety and efficacy. That’s amazing, and alarming. Since Congress ordered the FDA to have shock machines tested back in 1990, the makers and others with vested interests have been dragging their feet to avoid the necessary safety tests (source). In fact, they have even tried to have the Class III status revoked so as to be exempt from Class III conditions.

Early in 2010 Prof David Cohen made clear and definitive recommendations to the FDA concerning the evaluation of ECT devices. Please see his letter to the FDA here, which is made available with his permission. As for any evidence that full and adequate testing is being carried out – still waiting, and waiting.

And yet, in spite of this, shock-machine makers make some very bold claims for success, such as “providing up to an 80% response rate”.  Another maker boasts a similar treatment success: “ECT is an exceptionally effective medical treatment, helping 90% of patients who take it”. And not surprisingly, they promote their devices as safe with assertions like: “the safety of these devices is unparalleled, and as such these devices are an advance that will impact the safety and effectiveness of the ECT treatment.” It is surely time they were made to provide robust data to defend such claims.

But what about brain damage from the use of RCT? The maker, Somatics, make another bold claim in answer to this question: “The available evidence speaks strongly against this possibility.” There are, however, those who would strongly contest this. Traumatising the brain, even with the best of intentions, has got to be hazardous. I also understand that “In rare cases, ECT can cause heart rhythm problems” too. (source)

We know that a single general anaesthetic carries serious risks (hence the patient signs a disclaimer). And even if the estimate of “about five deaths for every million anaesthetics given in the UK” is an accurate one, this is still a risk, especially as some people have 20 or more ECT treatments – each under general anaesthetic.

I wonder if there are any long-term follow up studies showing any possible links to ECT use and later onset dementia, especially bearing in mind the recent research (see The Guardian report here) that raises the possibility that general anaesthetics (especially in older people) may significantly increase the risk for dementia.

Although there are claims of short-term benefit from ECT, this does not prove that ECT is curative. Interestingly, “there is an intriguingly high sham [placebo] ECT response rate in some of the studies” (Rasmussen KG, 2009). Also, I surmise that some people will likely misconstrue the iatrogenic “postictal bliss” - sometimes reported by people following a seizure - with a diminishing or lifting of depression.

What surprises me is that there aren’t more law suits against the makers of these devices – though attorney Kendrick Moxon reports a number of cases. There is another account of litigation here.

Should ECT be banned? I guess you have already made up your own mind on this.  According to attorney Kendrick Moxon,“ECT remains at best, an experimental or theoretical ‘therapy’.” I concur with him that the manufacturers should be made to “prove the safety and efficacy of any ECT devices before more patients are subjected to this damaging treatment.” Otherwise, this long-standing human experiment should be drawn to a rapid close. But “what about individual choice?” you may say. Maybe there’s always a counter argument.

Since electro-convulsive therapy (ECT) was first used 75 years ago there have always been both supporters and critics. ECT continues to have the power to divide as most people seem to either strongly defend its use or to vehemently oppose it. And when it comes to choice: here in the UK trainee psychiatrists have no choice to opt out of administering ECT; some patients are still forced to undergo ECT for their ‘good’; but the makers of shock-machines seem to be a law unto themselves and have chosen, so far, to avoid adequately demonstrating that their machines are safe and effective. Shocking.

Mick Bramham is an Existential Psychotherapist based in Dorset, UK.
He has a particular interest in ethical issues and also how our lives are shaped by the society, circumstances and culture in which we live.
He trained at Regent's College London, and is a member of the Society for Existential analysis. 
Although he has serious concerns about the inappropriate and excessive use of mental health medications, he supports the freedom to choose (to take or not to take these drugs) and the right to be fairly informed of their limits and the risks. He offers support for people who are considering reducing or coming off psychiatric drugs.
He has a long-standing interest in non-clinical (and non-coercive) responses to mental and emotional distress.
You can read more about his work and find his contact details here. You can follow Mick on Twitter @MickBramham

[1] Rose, S. (2006) The 21st Century Brain. UK: Vintage Books

Monday, 15 July 2013

Deep brain stimulation: Treating or tampering with our brains?

A history of trial and error

Tampering with the brain is inevitably fraught with risks. Everything seemed fine when Henry Molaison awoke from the operation to treat his epilepsy. But all wasn’t well: his ability to form new memories was severely impaired. In the words of Benedict Carey: “For the next 55 years, each time he met a friend, each time he ate a meal, each time he walked in the woods, it was as if for the first time”.

When it comes to mental health, there is a history of trial and error with the development and use of brain treatments. The surgical lobotomy (pre-frontal leucotomy) which was widely practiced in the 1950s is one such example, where the aim was to modify the brain to change moods, thinking, and behaviour. Most people will agree, that despite early optimistic reports on its use, it was a crude and disastrous failure that left many people “debilitated by serious brain damage” (Nuffield report p. 3).

Over the years many mental health drugs have been marketed under the pretext that they might correct imbalances in brain function or structure. They do, however, create all manner of unwanted ill-effects and carry serious risks too. What’s more, there is a view that they create rather than correct chemical imbalances in the brain[1]. To those with an entrepreneurial spirit - this apparent failure to consistently, successfully and safely modify the brain to address psychiatric concerns - may seem like a beckoning gap in the market place.

Novel neurotechnologies such as Deep brain stimulation

New procedures (“novel neurotechnologies” as they are often called) are currently being developed to try and adjust how the brain functions. These are already attracting considerable interest and investment. One such novel neurotechnology is Deep brain stimulation (DBS), in which electrodes are implanted deep within the brain and are then connected to a battery that is implanted in the chest. Then an electric current (modulated by a remote control device) is delivered to a specific location within the brain. It is sometimes compared to a heart pacemaker. Well, that’s the theory. [...]