What is ECT and why did Yellowjackets make it look so scary?

Eighty-five years after it was first used, shock therapy remains the most controversial treatment in psychiatry

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As psychiatrist Dr. Plabon Ismail watched the electroconvulsive therapy scene unfold in the opening episode of Yellowjackets, season 2, “I was like, ‘Okay, here we go again.’”

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He wasn’t alone. “I was really excited (like counting down excited) about this season of #Yellowjackets and 7 minutes in they just made ECT look as scary as one flew over (the) cuckoo’s nest …. for the next generation,” tweeted Dr. Jessi Gold, a psychiatrist at Washington University in St. Louis, who earlier had praised the show’s writers for portraying human trauma so realistically. “Can’t wait for more people who need (ECT) not to use it,” Gold said. “NOT good.”

The controversial scene shows teen Lottie, forced into “shock therapy” after her parents plead with a psychiatrist to “fix her,” convulsing and thrashing about on a hospital bed, a bite bar in her mouth, as her head is held down.

It’s an inaccurate depiction of how ECT is performed today, Ismail said. Most everything was “just wrong,” he said, and was more out of the Cuckoo’s Nest era, with no anesthesia or muscle relaxants or EEG monitoring of the brain. “It’s supposed to be the 90s, but it still wasn’t like that then either,” Gold said.

“The patient’s eyes were open during the entire procedure. That would never happen,” said Ismail, the ECT lead psychiatrist at Waypoint Centre for Mental Health Care, in Penetanguishene. “There would be zero convulsions … We don’t have to hold anybody, because they’re not shaking or convulsing violently.”

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Used since the 1930s, ECT is one of the oldest and most controversial treatments in psychiatry. Opponents portray it as a crude and barbaric intervention that causes memory loss and damage to brain cells. Proponents say multiple studies over decades suggest it’s a medically safe, fast-acting and effective intervention for people with gruelling difficult-to-treat depression and other severe disorders like post-partum psychosis.

Here is some of what to know about ECT — how it’s done, why it’s done and why “some people swear by it, and some people swear at it,” sociologist Andrew Skull, author of Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness, said in an earlier interview with the National Post.

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What is electroconvulsive therapy?

During ECT, an electrical current is passed briefly through the brain via electrodes applied to the scalp, causing a rapid discharge of nerve impulses in order to produce a seizure.

It was developed in 1938 by a pair of Italian doctors, Ugo Cerletti and Lucio Bini. Their first patient was Enrico X, a man with schizophrenia found wandering a Rome train station. After 11 sessions of ECT, Enrico’s “schizophrenic mutterings were replaced by normal speech and his pathological jealousy of his wife lifted,” wrote the authors of the book, Shock Therapy.

A patient in 1955 at a mental hospital undergoes electroconvulsive therapy (ECT),
A patient in 1955 at a mental hospital undergoes electroconvulsive therapy (ECT),

Eighty-five years later, there is still no generally accepted theory that explains how it works. “The mechanism of action of ECT remains uncertain,” according to the Canadian Psychiatric Association’s current position statement on ECT, which is under review. “There is no unifying hypothesis for the remarkable efficacy of ECT in treating major depression.”

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Why would you even send an electrical current through someone’s brain to produce a seizure?

One theory is that ECT modulates neurotransmitters, molecules like dopamine, serotonin and norepinephrine that transfer messages between brain cells and that play a role in mental illness, Ismail said.

“We know that it causes nerve growth and improved connections (between neurons), because we see an increase in brain volume following a response to ECT.”

ECT was used, a lot, between the 1930s and 1950s, when there weren’t many other treatments available, but became less popular the 1960s and 1970s with the introduction of psychiatric drugs, and a vocal anti-ECT lobby.

Like in the Cukoo’s Nest, ECT was often used as a method of behavioral control.

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Jack Nicholson getting shock therapy in the 1975 film One Flew Over the Cuckoo’s Nest
Jack Nicholson getting shock therapy in the 1975 film One Flew Over the Cuckoo’s Nest

“That was a really old movie, but people still bring it up every time I do a psychiatric pre-consult for ECT,” Ismail said. “They’ll say, ‘Hey, is it going to be anything like that?’

“We take patients and their families through the process of the procedure. It’s not meant to be punitive; it’s not meant to be harmful. It’s not meant to be painful. And we try to make it as comfortable as possible,” Ismail said.

“When they receive their first ECT treatment, they’re usually like, ‘Oh, so that was it?’”

So, what really happens during ECT?

The treatment has been “refined considerably” over time, according to the Canadian position statement, including with the use of monitored anesthesia and “ultra-brief” pulse stimulation, to reduce memory disturbances.

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In Yellowjackets, Lottie is given an injection into her arm, and not anesthesia administered via an intravenous line. “No self-respecting anesthetist would actually just give an intramuscular injection,” Ismail said.

No anesthesia was used at all in the early days of ECT. Neither were muscle relaxants, and when you induce a seizure in the brain, the whole body convulses. Bone fractures and dislocations were common in the past.

Electrode pads are placed on the head. An EEG records the electrical activity of the brain, which tells doctors when the siezure has started and ended. The heart is also monitored. ECT can cause dramatic swings in heart rate and blood pressure. Patients should be assessed beforehand for pre-existing conditions that might increase the risk of a severe outcome.

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The death rate from ECT has been estimated at two per 100,000 treatments.

The electrical impulse lasts a few seconds. The person seizes anywhere between 15 seconds to one minute. After some time, the anesthetic wears off, “the person comes to their senses, they’re monitored briefly, and then they’re discharged,” Ismail said.

ECT is usually given two to three times per week, for six to 12 treatments. “It used to be that ECT was a measure of last resort, but it isn’t like that anymore,” Ismail said. “A lot of GPs and a lot of family physicians are reaching out to us early on in the treatment.”

Other groups, like the U.K’s NICE (National Institutes for Health and Care Excellence), have said ECT should be used with “caution” and only in restricted circumstances, like in cases of a prolonged or severe manic episode, or catatonia, where the person has stopped moving, eating and drinking. ECT can bring people out of catatonia, quickly.

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A mouth guard is still used, to protect the teeth, and keep people from biting their tongue.

What are the risks?

Complications can include prolonged seizures, cardiac complications, headache, muscle aches and nausea.

The biggest concern is memory loss — retrograde amnesia (people forget events before the ECT) and anterograde amnesia (forgetting events after the seizure).

“A few patients experience longer-lasting subjective memory impairment,” according to the Canadian Psychiatric Association’s position statement. Claims, however, that ECT causes brain damage, the association says, “lack validity; comprehensive and objective reviews of available data do not find credible evidence that ECT causes structural brain damage.”

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Marnie Wedlake is an assistant professor in Western University’s school of health studies who has written about her own experience receiving ECT 30 years ago, when she landed in an asylum, broken “after too many crashes.” The treatments prescribed to fix her “brokenness” included 18 rounds of ECT.

Wedlake remembers crawling up onto the white-sheeted gurney and laying down on her back, her arms at her sides, her head at the end of the bed “nearest to the table that holds the box, the buttons, the dials, the gauges and all of the wires.” She knew how to position her head over a strap that lay across the bed, the kind of belt “an old man might wear to hold up his pants.” Her slippers were removed to expose her toes. One physical sign that a person is truly seizing is by watching if the toes twitch.

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ECT “forever erased chunks of my memory,” said Wedlake, a registered psychotherapist and a founding editor of Mad in Canada, which looks at modern psychiatry through a critical lens.

“Shock therapy is still being given to people because we don’t like the way they’re behaving,” she said. “We’re still controlling behavior — we may not be doing it in as objectionable a way as what was shown in One Flew Over the Cukoo’s Nest. But maybe it’s even more objectionable, because we’re hiding it.”

People no longer convulse, because the person is given drugs “so they’re not flipping around like a fish out of the water on the dock,” she said.

Ismail acknowledged that it’s “not a pretty thing” for those administering ECT to see people shaking violently.

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“All these excuses as to why it is better now are just a veneer, a candy coating over something that is really sour,” Wedlake said. She worries people who consent to ECT aren’t being truly informed of possible risks.

Only 11 studies have ever been conducted comparing ECT with sham ETC, a placebo, and all took place prior to 1985, said Dr. John Read, a professor of clinical psychology at the University of East London.

A review of those 11 studies found most were small, four found ECT was superior to placebo for depression, five found no significant difference and two had mixed results.

“There is no evidence that it actually works better than placebo, which wouldn’t matter too much if there wasn’t so much evidence that it causes severe and persistent memory loss for so many people,” said Read, the study’s lead author.

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“What we don’t know is exactly how many, because the research is pretty poor,” he said.

Read agreed the scene described in Yellowjackets isn’t entirely realistic. People have a full seizure, but it’s controlled by the general anesthetic and muscle relaxants. “There’s trembling of the extremities, the hands and the feet,” he said. “You don’t see thrashing about.

“But in a way, so what? If a person doesn’t have a convulsion, then the treatment is said not to have happened,” he said.

“So, yes, they’re right — you don’t get that thrashing about. They’re wrong to convey that there isn’t a convulsion going on.”

There’s a reason people try to treat epilepsy, he added. “It’s not good for the brain.”

What do proponents say?

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A study published last year in The Lancet Psychiatry involving more than 67,000 people in Ontario who were admitted to psychiatric hospitals with depression over a 10-year period found ECT was associated with a 50 per cent reduction in suicide risk in the year after treatment. In a separate paper, the Toronto researchers also found no significant increased risk for a serious side effect leading to hospitalization, or death, within 30 days for people who had ECT compared to people who didn’t, suggesting the benefits for depression “may outweigh its risks in this population.”

Others have found ECT doesn’t appear to have a greater effect on decreasing suicide risk than other types of treatment.

Ismail said no patient at Waypoint is ever held down, for any reason, and forcibly given ECT. About 80 per cent of people respond to ECT, he said. Any decrease in symptoms would be considered a response, Ismail said.

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Their youngest ECT patient is 17, the oldest, 88. “We get a lot of positive feedback from patients and families,” he said. Last fall, Waypoint expanded its ECT service, from three days a week, to five.

“The younger population are the ones who will advocate for ECT on their own — ‘I’ve done my research, I don’t want to gain weight (a potential side effect of psychiatric drugs), I don’t want sexual side effects, I have a job I want to go back to, I have school and I can’t be wasting anymore of my life struggling with mental illness.’”

With older people who can’t tolerate some of the side effects of psychotropic medications, “it’s the families that are usually reaching out. ‘We need to do something.’”

National Post

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