For 79 years, electroconvulsive therapy has been used to treat psychiatric illness, even though no one knew exactly how it worked. Stigmatised by scary images of the ‘shock therapy’ of the 1950s, the treatment became widely feared.
But doctors are finally figuring out how it functions, and the treatment no longer looks like something out of a horror film. Electroconvulsive therapy might finally shed its bad reputation.
By Xanthe Hunt
IT IS five-o’clock in the morning, but the clinic is already coming to life: the shuffle of efficient morning shift feet replacing the exhausted steps of the night staff.
In a small, neat operating room in the building’s north wing, the therapy team moves into action like a well-oiled machine.
Outside, in the melamine-floored corridor, Nurse Sarah Bembie explains what is happening on the other side of the mint-green wall.
“The first patient arrives before sunrise, and lies here,” says Bembie, who has been a nurse at the Cape Town psychiatric clinic for close to seven years.
She points to a low, railed cot lying abandoned and superfluous in the hallway.
“Then we ask the patient: ‘Can you confirm that you have not had anything to eat for at least six hours?’, and, ‘Is all your jewellery off?’”
If the patient says yes to both, then their drip is inserted and anaesthetic administered. Then muscle relaxant, bite plate, and electrodes: one little suction pad connecting a wire to each temple.
“The pads send the electricity through the patient’s brain; it’s only a weak current, but we put a bite plate in their mouth so they don’t bite themselves when they receive the shock.
“After three minutes, it is all over,” she says.
Then the patient is wheeled out to wake up and reorient themself in the recovery room. After an hour or so, it’s back down the hall for a normal day of group therapy and craft classes.
“People are surprised that ECT still happens,” says Bembie. “But it’s done a lot: some of the doctors swear by it.” She shrugs. “It works.”
BEMBIE IS right on both counts: ECT is still a widely-prescribed treatment for psychiatric illness, both in South Africa and globally, and many people are taken aback when they learn that this is the case.
First used in the asylums of Europe, ECT was the brainchild of Professor Ladislas von Meduna, a Hungarian neurologist who observed that psychiatric patients with epilepsy appeared calmer after a seizure.
By 1934, von Meduna had successfully treated catatonic patients (whose ability to move and behave ‘normally’ is severely impaired) with “induced convulsions” – electric shocks.
But this was before the days of the anaesthesia and informed consent which are now mandatory for the use of ECT, and so von Meduna’s ‘shock therapy’ soon got a bad reputation.
Dr Janine Benson-Martin is a consultant psychiatrist at Valkenberg Psychiatric Hospital in Cape Town, and her area of research is the use of ECT in South Africa today. Benson-Martin explains that negative perceptions about the treatment are still widely held.
“It’s definitely a barrier to patients that they think ECT is this inhumane thing that’s done when you’re still wide awake.”
Like Benson-Martin, Dr Gerhard Jordaan, the clinical head of the psychiatric unit at Tygerberg Hospital in Bellville, agrees that people tend to assume ECT is an out-dated, brutal and “archaic” procedure.
However, he explains, ECT today looks completely different from when it was first used.
“Today, a very weak electric current is directed through the fronto-temporal areas of the brain – just above and in front of the ear – for one to two seconds, just long enough to cause a grand mal convulsion, or ‘fit’.
“The electrode pads are either placed both on one side – in which case there is usually less short-term memory loss – or one each side of the head, which helps people more rapidly,” says Jordaan.
“Short-term memory loss is still a side-effect, but is almost always temporary. Disorientation can arise from anaesthesia, but that doesn’t last either.
“Today,” he stresses, “patients are always fully anaesthetised, given muscle relaxants, and have their heart-rate and oxygen-levels monitored the entire time.”
But, despite the fact that ECT has only been performed on anaesthetised patients since the 1960s, and muscle relaxants are used to lessen the violent convulsions (à la Jack Nicholson as R.P. McMurphy in One Few Over the Cuckoo’s Nest), negative perceptions still prevail.
MARTHA MANNING, a Professor of Clinical Psychology at George Mason University in Virginia, USA, underwent ECT after battling major depression for ten years without respite. She reveals that, despite her professional qualification, she was still terrified of trying the “scary” treatment.
“Before I went for it, I’d heard almost nothing about ECT, except for the negative images in literature and the media. The term “shock therapy” was scary. But I was in big trouble,” she explains.
“Because I ‘think like a psychologist’, I’d put therapy first for years,” she says, “But I had a seven-year-old and a large family, and I felt like I had to do anything to try to stay in this world.”
To date, Manning has had four courses of ECT. A standard course varies between six and twelve sessions. In each session, the electrode pads (wires with ‘sucker-like’ electrodes at the end) send between 30 and 180 seconds worth of a weak electric current through the brain.
“I felt much better afterwards,” says Manning. “It’s like the doctors on TV when they use shock pads – a defibrillator – to bring a patient back to life. It’s a simplistic comparison, but one that fits for me.”
Manning has since authored Undercurrents: A Life Beneath the Surface, which chronicles her experience of ECT, and, she says, aims to dispel the perception that it still entails being handcuffed to a bed while conscious, and experiencing violent, bone-fracturing shaking.
But Elsabé Brits, an acclaimed science journalist from Cape Town, who, like Manning, has authored a book about living with psychiatric illness, is more moderate in her praise for the treatment.
Hospitalised in June 2001 when she began to show signs of psychiatric illness, Brits was recommended ECT when a three-week barrage of medications failed to help her brain chemicals, and thus her mood, stabilize.
“It does work,” says Brits, “They prescribe it when your meds don’t work, or if you’re very suicidal.
“But you have headaches. You wake up with temporary memory loss. I mean, you re-read the same magazine because you can’t remember that you’ve read it already,” she explains.
“As I said, it helps, but ECT is quite a dramatic therapy.”
Dramatic is an accurate appraisal, and not only because ECT involves shooting electricity through the most complex and sensitive organ in the human body: it is dramatic because doctors have been using it with much success for 79 years, and only now are they beginning to surmise how it works.
“AFTER THE negative perceptions people have based on what they’ve seen in movies, the next biggest barrier to people who need it having ECT, is that we weren’t sure how it works,” says Benson-Martin.
Now, thanks to the research of Professor Andrew Leuchter and his colleagues at the University of California, this is no longer the case.
“Over the years, our studies have led us to believe that depression is a state of increased connectivity among the various brain regions and structures,” says Leuchter, explaining that this means some parts of the clinically depressed patient’s brain are ‘hyperactive’, bombarding other brain regions with signals.
“What treatments like ECT do is to decrease this connectivity by resetting brain activity,” he explains.
“Our theory is that depression arises from a dysrhythmia – an abnormal network of connections that occurs in the brain. By stimulating these networks repetitively with ECT we believe that the networks will ‘reset’ to a normal configuration and the depression will resolve,” he says.
So, like an abnormal heartbeat can cause heart problems, which pace-makers are used to regulate, abnormal brain activity can cause depression, and that is what the ECT fixes.
The electric current, then, seems to repair not individual neurons, as previously guessed, but rather corrects the mechanism that regulates how the brain’s activity takes place.
Brits and Manning agree that not knowing how ECT works made making the leap to treatment more fraught. So, with Leuchter’s discovery, psychiatrists like Jordaan and Benson-Martin believe, patients will be more inclined to give ECT a chance.
Add to this an awareness that the treatment has changed drastically since its inception, and ECT might finally shake off its bad reputation.