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Monday, November 10, 2008

Shock and Cure

For regular readers (and Google Analytics assures me I do have some - hello), this post may be a bit of a change of pace.

Many mental health blogs have alerted readers to the case of Ray Sandford, a Minnesota man who's being given ECT (electroconvulsive therapy), as an outpatient, against his wishes. Encouraging people to write to the Governor of Minnesota in protest, Philip Dawdy of the Furious Seasons said
I am officially neutral on voluntary ECT--if someone wants it, it's their brain--but involuntary ECT is barbarous and amounts to torture. If anyone would like to defend involuntary ECT, let me hear from you. If you make a good argument, I might even post it.
I have nothing to say about Mr Sandford's case, but I'll defend involuntary ECT in general. Why? Because I believe the evidence supports it, but if I'm honest, the reason I'm writing this is because of my granddad.

During the 1940s and 1950s my grandfather, at the time a junior doctor, suffered from several bouts of severe depression. Antidepressants not yet existing, the only available treatment was ECT. He was given it - with his consent - and it worked. In fact, he was given ECT using a number of different stimulus parameters and he says that bilateral treatment rapidly lifted his mood while unilateral was useless.

ECT was the only thing that could lift my grandfather out of his illness. Fortunately, he never became so ill that he was unable to give his consent. But if he had - if his depression had ever got so bad that he could not summon up the courage to receive treatment, if he had given up on life or just given up talking - then all this would have meant was that he needed ECT even more. If his illness had robbed him of the wish to get better, as I know it nearly did, it would have been a tradgety for his doctors to not have helped him fight back.
  • Sometimes consent is a luxury
My argument is that involuntary ECT is sometimes justified because in psychiatry, involuntary treatment is sometimes necessary, and ECT is sometimes the only treatment that works. Some people object to all forced treatments, whether ECT, or medication, or anything else. I respect this, and I agree that in principle, treatment should only ever be given with consent. Adults should not be treated if they have made an informed choice not to be - as patients we have a right to autonomy, including a right to refuse treatment and even a right to die.

However - in psychiatry, things are not so simple. It's often those who are most ill, those who have the most to gain from treatment, who are most likely to refuse it. From my own experience I know how even moderate depression can warp your thinking - severe illness can lead people to be, temporarily, unable to make informed decisions. They may not know that they are ill, or they may not be able believe that there is any hope of recovery.

If someone is in such a state - whether they are extremely depressed, manic, or psychotic - it would be cruel and neglectful not to treat them, by any means necessary. Surely that's common sense - if your friend was blind drunk and tried to drive home because he thought he was completely sober, you'd be responsible for his safety if you didn't try to stop him. If I got drunk and started acting stupidly I'd want my friends to look after me, and when I woke up the next morning, I'd be angry if they hadn't.

Many people are concerned about psychiatrists forcibly treating patients as a punishment or as a way of keeping them quiet. I don't know how often this happens, but whenever it does, it needs to be stopped. No-one would disagree with that. But these aren't the only reasons why people are treated without their consent. Sometimes it really is for their own good.

The costs and the benefits of any treatment have be balanced, which is difficult, and it may be difficult to decide whether someone is able to give informed consent. Mistakes will be made. This is why I have no opinion on Ray Sandford. He may or may be the victim of a mistake, and I don't think anyone who hasn't met the man can judge that.
  • ECT works
ECT of course has a bad reputation. Dawdy calls it "barbarous" - he's much more restrained than some. It's true that ECT is a crude procedure, in the sense that we don't know how it works. But it does work. There's very strong evidence that ECT is highly effective for depression - ECT is much more effective than the placebo "sham ECT", showing that the benefits are real and not simply placebo. ECT is also effective in other acute psychiatric states; e.g. according to the U.S. Surgeon General's office
Accumulated clinical experience—later confirmed in controlled clinical trials, which included the use of simulated or “sham” ECT as a control — determined ECT to be highly effective against severe depression, some acute psychotic states, and mania. No controlled study has shown any other treatment to have superior efficacy to ECT in the treatment of depression.
Any psychiatrist who has used it will agree. I know that many people feel very strongly about ECT, including some who are likely to be reading this. Some people have had very negative experiences. But not everyone has. I was going to cite a list of references to surveys on patient views of ECT here, but I decided against it. There are dozens of papers and as many different findings.

Rose et. al. (2003) reviewed the literature and found an enormous range of opinions, from strongly positive to strongly negative, amongst ECT patients. This paper is fairly skeptical, and reports that a third of people given ECT report memory problems. My grandfather didn't - his memory is fading now, because he's 85, but he managed to carry on a career as a very succesful doctor for 50 years. The debate over the costs and benefits of ECT is an important one. This paper appeared in the British Medical Journal, the official publication of the British medical establishment. The debate is not being suppressed. I've read this paper. I'm not ignoring the voices of the ECT survivior movement, but they are not the only ones.

ECT is a controversial therapy, but there's no doubt that it has helped many people, and in some cases it is certainly the only treatment that works. Official guidelines, such as those of the British NICE agency, all advise that ECT should only be used as a last resort where other treatments have failed. No-one is rushing to give ECT to everyone, but when all else has failed, it can work. And if someone is too ill to give their consent, and all else has failed, forced ECT remains an option. It is an extreme one, but I can honestly say that if I, or anyone in my family, ever became so ill that this was the only option, I would want it done.
  • Conflicts of Interest?
Just to be clear: I have never received or been offered ECT, but like my grandfather I suffered from moderate-to-severe depression for a long time. I'm currently taking 40mg per day Celexa (citalopram.) Like ECT, SSRIs have a bad reputation. My experiences have been entirely positive. With citalopram I've gained energy, optimism, and the ability to enjoy life. The worst thing I've suffered has been a dry mouth. In general, I am strongly pro-psychiatry, and I work as a researcher on the neurobiology of depression and antidepressant action. I'm not medically qualified. I am a big fan of David Healy (like me, a defender of ECT), but have a very low opinion of people like Szasz and Laing.

Update : 12 . 11 . 2008 16:20 GMT
Philip Dawdy put a portion of this post up on Furious Seasons, where it sparked a, well, a lively debate.

Thanks to an anonymous commenator (below) who did some googling and found that Mr Sandford's residence, Victory House, seems to be a home for people suffering from Alzheimer's Disease. Although I still make no comment on Mr Sandford, this might be of interest to any who dislike the idea of involuntary "outpatient" ECT.

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