Shock therapy must remain available to some
OPINION:Electroconvulsive therapy remains a form of treatment that must be available to some mental patients, writes DERMOT WALSH
IN 1934, a Hungarian psychiatrist, Ladislas von Meduna, made the observation that persons who had epilepsy were less likely to develop schizophrenia. He hypothesised that the seizures that characterise epilepsy prevent persons with the disorder from developing schizophrenia.
This insight was to prove fallacious. Nevertheless, psychiatrists began to believe that if patients who had become schizophrenic were given seizures, their schizophrenia would improve.
Shortly afterwards, psychiatrists began to devise methods of inducing seizures in persons with schizophrenia by injecting them with substances known to produce seizures.
In the late 1930s, two Italian psychiatrists, Ugo Cerletti and Lucio Bini, discovered it was possible to induce a seizure by passing an electric current through the brain without evident adverse effects.
This procedure was widely adopted in psychiatric practice and became known as “straight” electroconvulsive therapy (ECT), because the patient was not anaesthetised and there was no attempt to relax the muscles which contracted in spasm during the seizure.
It became evident that rather than having any major beneficial effect on schizophrenia per se, ECT was effective in cases of severe depression, particularly in a type of depression known as involutional melancholia, typically occurring in middle age or later and characterised by profound slowing of motor and mental activity, which in extreme cases resulted in stupor where the patient, although conscious, was totally unresponsive to outside stimuli, did not speak and refused food and drink.
Such cases, in those pre-ECT days, required tube feeding without consent if they were to survive, and many succumbed. In such cases there was also delusional psychotic thinking in keeping with the melancholic depression – such patients often believed, for example, that they were damned for imagined past sins for which there was no forgiveness and such like. Not surprisingly, suicide was not infrequent.
Later, ECT had become “modified”, where patients were given a light anaesthetic and muscle relaxant so the unpleasantness of “straight” ECT was obviated and the only side-effect of any consequence was slight memory impairment for some hours subsequent to treatment. In a few cases memory impairment was more prolonged, but reversible.
Those of us who remember the remarkable efficacy of this treatment in cases of psychotic depression, then called involutional, were in no doubt as to its value, as were those patients who recovered from this frightening and dangerous illness.
Because up to this time there were few effective treatments available in psychiatry, and anti-depressants were only beginning to be introduced, the use of ECT became widespread and sometimes indiscriminate, so that it was used far beyond the classical cases of psychotic depression.
As anti-depressant usage became more widespread and it was realised that ECT had little or no place in the treatment of schizophrenia, its frequency waned. Furthermore, the old involutional melancholia became less common, either because depression was being recognised and treated earlier, or its characteristics had changed because of cultural or social changes.
The administration of ECT currently has become a much safer and very sophisticated procedure with inbuilt safeguards and modifications and with particular attention to and monitoring of memory status from one treatment to another.
Its use is now governed by rules drawn up by the Mental Health Commission, which have statutory force. A recent survey of the frequency and number of individual treatments in current Irish practice by the commission has shown the extent of its decline, indicating its more appropriate usage.
Notwithstanding this, there are still cases of psychotic depression where, because of the severity of the illness and the failure of anti-depressants and other interventions, patients have progressed to a state of stupor and are neither eating nor drinking. Accordingly, they have lost mental capacity to realise that their illness is life-threatening, are in imminent danger of death and are unable to consent to treatment by ECT.
In such situations, the possible interventions are intravenous feeding (often impracticable) or forced tube feeding, both of which are without consent and are temporary, non-curative measures; alternatively, curative intervention by ECT is possible.
In recognition of this extreme situation, the Mental Health Act, 2001, rightly allows application of the treatment without consent, subject to the rules laid down by the commission.
A further dilemma for psychiatrists is that it is now clear that the efficacy of anti-depressants is limited, and depression in some cases is persistent.
In these circumstances the psychiatrist is in a quandary on whether to discuss with the consenting patient the option of ECT – and whether, in not doing so, he or she faces the ethical responsibility of denying a patient a potentially curative treatment.
How many psychiatrists in such a situation have had patients who have benefited from ECT ask why they were not given the option of this treatment earlier? This dilemma is well exemplified in a recent account in the British Medical Journal – BMJ 2008.337, a2998.
To abolish ECT, as some protagonists have demanded, for patients so impaired by psychotic depression as to lack the capacity to give informed consent, and whose survival is compromised, would be unacceptable clinically and ethically.
Dermot Walsh is a consultant psychiatrist and formerly Inspector of Mental Hospitals