Those Wacky Psychiatrists

[Silo]

*Originally posted by iampunha *
Why are you comparing ECT to surgery? It isn’t.

Because surgery has no general negative bias towards it. And, more importantly, because there is not much distinction between the fatality rates of surgery patients and the fatality rates of ECT patients.

And don’t put words in my mouth, Silo. Sure, death can result. That isn’t the only way it can go wrong. Other serious injuries can also result.

Did you miss the part about the muscle relaxants being applied before the procedure? A seizure is certainly more dangerous without the muscles paralized. Serious injuries don’t result from modern ECT because it’s in a controlled setting - you are sedated to sleep and chemically paralized from movement that could cause injury.

From my Ab Psych book: “In an ECT procedure, two electrodes are attached to the patient’s head, and an electric current of 65 volts to 140 volts is sent through the brain for half a second or less. After six to twelve treatments, spaced over two to four weeks, …”

Now, this looks to me like electrocuting someone. Several times, in fact. I hope I don’t have to outline for you what can go wrong.

If you’d like to call it as electrocution, more power to you. But I think a better description would be - that the small jolt of electricity applied right is an effective seizure triggering device. Now snap your fingers! – That’s about as long as the electricition lasts, it’s not like they’re firing lightning bolts at these patients. Do you think the seizure causes the post-complications or the electrical trigger?

Some of those myths are founded upon fact, Silo. The broken/dislocated bones, the bruises and other “side-effects” of the artificial seizure caused by ECT are very real. Cerletti abandoned the ECT because he abhorred what happened when the ECT was administered.

In most every medical procedure there is risks. And the ones that you mention are non existant with the current procedure - "The broken/dislocated bones, the bruises " …as I explained above.

Why is it not smart? unethical? and a bunch of other stuff too?

Because, for one, it is occasionally administered against the will of the patient. Because it is still shock therapy and there are still problems with it.

I can’t disagree with you there. I don’t think it’s should be done against consent either. Do you think the procedure is unethical with one’s consent exercised though?

There are problems and risks with everything.

you refer to data over sixty years old. (!)

No, I refer to data about something that happened in 1939.

Ok, 62 years. Considering how things can radically differ in the medical community in just a few years… how is some 62 year old data relevent to the current discussion at hand.

I find it rather interesting that your cite, Silo, has ONE study that says there’s no change in brain anatomy. Need I remind you that one study does not establish medical certainty?

And you haven’t found a site that says otherwise, I don’t see any studies supporting your position. Besides, who would you listen to? A) Some guy from Brazil’s viewpoint? (your link), or the American Psychiatric Association (my link)? Anyway, I’ll try and find time to go dig around tomorrow for some more cites and studies n’ stuff.

Given that ECT deals with people and not numbers, shouldn’t any treatment be considered on a case-by-case basis?

ECT is not considered on a case-by-case basis by the cons, it’s considered on a rare-case basis.

…

[iampunha]

Because surgery has no general negative bias towards it.

But it’s not an accurate comparison, Silo. Surgery generally does not involve sending electric current through people, though I admit my psych book doesn’t cover that so I may be off by some there. Also, with the exception of needles used (for administering of muscle relaxants, for example), ECT isn’t (as far as I have read) invasive, whereas many forms of surgery are.

Did you miss the part about the muscle relaxants being applied before the procedure? A seizure is certainly more dangerous without the muscles paralized. Serious injuries don’t result from modern ECT because it’s in a controlled setting - you are sedated to sleep and chemically paralized from movement that could cause injury.

You are given chemicals to decrease muscle movement (think about it . . . would something that rendered you totally unable to move when you’re working on someone’s brain and sending electric current through it be a good thing?). That does decrease movement. But any time you have memory loss after something, this can’t be a good thing. The sole exception I know of is surgery on the rectal area, where from what I’ve read on this MB one is given something to block formation of memories (should one awaken during surgery, I guess).

If you’d like to call it as electrocution, more power to you. But I think a better description would be - that the small jolt of electricity applied right is an effective seizure triggering device.

Applied right or wrong it is still electrocuting someone, Silo.

Now snap your fingers! – That’s about as long as the electricition lasts, it’s not like they’re firing lightning bolts at these patients.

It takes me relatively less than a half-second to snap my fingers, but maybe I’m just special.

Do you think the seizure causes the post-complications or the electrical trigger?

What I have here says, that the electric current is “a broad insult to the brain that causes neurons all over the brain to fire and all kinds of neurotransmitters to be released, and it affects many other systems throughout the body as well (Kellner, 1999; Fink, 1992).” That’s under “Effectivenmess of ECT”, Chapter 8 of Abnormal Psychology, Fourth Edition by Ronald J. Comer, copyright 2001. So I guess that’s a “the seizure causes the muscles to move and chemicals to go haywire, and the electric current causes the seizure”.

In most every medical procedure there is risks. And the ones that you mention are non existant with the current procedure - "The broken/dislocated bones, the bruises " …as I explained above.

You’re really going to tell me that nobody ever gets hurt anymore as a result of this? Remember that among the injuries are some to the brain, which definitely still occur (studies I cited earlier indicate this).

"Today’s practitioners give patients strong muscle relaxants to minimize convulsions . . . "

Emphasis mine. The danger isn’t all gone. Most of the way, ideally, I agree with you. But let’s not be blind and assume it happens perfectly every time. Doctors aren’t perfect, nor are their assistants.

I can’t disagree with you there. I don’t think it’s should be done against consent either. Do you think the procedure is unethical with one’s consent exercised though?

I would say it depends on the patient. Things where you’re going to send electric current through people need to be handled carefully on a case-by-case basis, in my opinion. So what’s ethical for one case might not be for another.

Ok, 62 years. Considering how things can radically differ in the medical community in just a few years… how is some 62 year old data relevent to the current discussion at hand.

The number of years isn’t the problem I had with your argument. It’s that the data have not changed. In 1939, Cerletti was doing ECTs. In 1960, the same literature indicated that Cerletti was doing ECTs in 1939. In 1990, the same literature . . . you get my point. I don’t see how your argument about data about Cerletti being so old is relevant.

And you haven’t found a site that says otherwise, I don’t see any studies supporting your position.

Calev et. al., 1995, 1991; Squire & Slater, 1983. Squire again in 1977. I believe if you look at my other posts in this thread you’ll see these studies cited again.

Besides, who would you listen to? A) Some guy from Brazil’s viewpoint? (your link), or the American Psychiatric Association (my link)?

What does the “.br” part of my cite have to do with its veracity? From the homepage:

“The epub Group aims at futhering and helping the development of publications on the Internet and in other means of electronic dissemination, such as magazines and scientific journals, books, etc. in the areas of Biology,Medicine and Health.
The epub Group is located and supported by the Center for Biomedical Informatics of the State University of Campinas.”

Hmm . . . looks scientific to me, Silo.

ECT is not considered on a case-by-case basis by the cons, it’s considered on a rare-case basis.

In the case of rare cases, it is considered on a case-by-case basis. I didn’t mean to imply that it was considered for everyone, Silo. I meant that for those in that position it is a case-by-case consideration. This is supposed to be true of all things medical procedures, prescription drugs, etc.

Oh, by the way:

“Like everyone else, Ugo Cerletti initially believed that the application of electric currents to people’s heads would kill them. One day, however, he visited a slaughterhouse where he observed that before slaughtering hogs with a knife, butchers clamped the animals’ heads with metallic tongs and applied an electric current. The hogs fell unconscious and had convulsions, but they did not die from the current itself. Their comas merely made it easier for the butchers to kill them by other means. Said Cerletti: ‘At this point I felt that we could venture to experiment on man.’”

an interesting aside, I think.

[choosybeggar]

iampunha, I think you need a fresh perspective on the application of ECT. The way to consider ECT in a proper light is that it is a highly effective therapy for severe depression that is refractory to drug therapy. Like every other other therapeutic modality know to humankind, there are risks involved in administration of ECT. ECT is considered therapeutically when the probable benefits outweigh the probable risks.

What are the risks of ongoing depression? You seem fond of quoting your abnormal psych book, so why don’t I give you this one as a homework assignment. But make sure you pay extra attention to the parts about depression and suicide.

From emedicine.com (a peer reviewed online medical journal)
**Suicide ranks as a leading cause of death in the US, with a yearly rate of approximately 200,000 attempts. The number of completed suicides for 1998 was 30,575. Suicide continues to rank as the second leading cause of death in adolescents, and represents 10-30% of deaths in those aged 20-35 years. Major Depressive Disorder plays a role in over half of all suicide attempts, while the death rate from suicide among those with affective disorders can exceed 15%. Firearms are the most frequent method used in completed suicides. **

Maybe you aren’t thinking of depression as a potentially fatal condition? In fact it is, and has a fairly high morbidity and mortality. Are there diseases where the consequences of the ongoing disease process are so grave, that the medical comunity feels justified in offering a risky therapy? There are buttloads of them. Chemotherapy for cancer, bone marrow ablation and grafting for leukemia, anticoagulation therapy for patients with deep vein thromboses or atrial fibrillation, stomach stapling surgery for the morbidly obese, and even appendectomy for acute appendicitis are all therapies that have a realistic chance of killing you. Yet, we do these things all the time, justifying our actions on the premise that in high risk situations, intervention, even risky intervention, is more likely to do good than harm.

Which is not to say that I think you accurately portray the risks of ECT. It turns out that short duration, low voltage, DC electrocution does not typically result in permanent harm.

From an emedicine.com article about electrocution
**Low Voltage Alternating Current:
Low voltage is 600 volts or less, the sort of voltage encountered in domestic and industrial wiring. [snip]

Low Voltage:
If there are not significant burns, and if consciousness returns before arriving to or in the ED, full recovery is usual. Rarely, persistent arrhythmias have been recorded. Persistence of unconsciousness leads to a graver prognosis. Full recovery is not expected if unconsciousness persists for 24 hours.

**

Please note that the voltage applied in ECT is at the low end of the low voltage spectrum and that ECT employs direct current, which volt for volt causes less harm than alternating current.

And the conclusion you draw regarding neuromuscular blocade during ECT:

**You’re really going to tell me that nobody ever gets hurt anymore as a result of this? Remember that among the injuries are some to the brain, which definitely still occur (studies I cited earlier indicate this).

"Today’s practitioners give patients strong muscle relaxants to minimize convulsions . . . "

Emphasis mine. The danger isn’t all gone. Most of the way, ideally, I agree with you. But let’s not be blind and assume it happens perfectly every time. Doctors aren’t perfect, nor are their assistants.

**

I don’t have data regarding musculoskeletal injury following ECT, but I have witnessed countless patients undergo neuromuscular blocade. It is routinely used during general anaesthesia. And it’s quite easy to determine if the level of neuromuscular blocade is sufficient to prevent movement. Electrodes are fastened to the forearm and wrist and a current a passed between them. With inadequate blocade, the wrist twitches, but then stops once enough of the blocade agent is administered. In fact, it is much easier to monitor the level of blocade than the level of anaesthesia. This is why some people report that they recall entire surgeries, but could not signal to the surgical team that they were in pain.

As an aside, you are wrong about electricity and surgery. Currents are routinely passed through people during surgery. There’s the little wrist shocker I mentioned above and the Bovie, an electric scalpel/cautery used in almost all of the surgeries I have ever witnessed.

When I look up information regarding permanent sequelae to modern ECT I find:

From emedicine.com
**Electroconvulsive therapy (ECT) is a highly effective treatment for depression and may have a more rapid onset of action than drug treatments. Advances in brief anesthesia and neuromuscular paralysis have improved the safety and tolerability of this modality. Risks include those associated with brief anesthesia, postictal confusion, and more rarely, short-term memory difficulties. ECT is used when a rapid antidepressant response is needed, when drug therapies have failed, when there is a history of good response to ECT, or when there is patient preference. It is particularly effective in treatment of delusional depression. **

The above view is representative of the consensus, IMHO. And you’re right, Iam, there are complications. But one must consider the probable severity of the complications versus probable outcomes in the face of less effective or no intervention.

You and Silo seem to be debating the issue of consent to therapy, as well. I haven’t seen any data regarding ECT without consent in this thread, just your view that it happens. If you have a cite, I’d like to see it. However, I wouldn’t be altogether surprised if this conclusion is based on data. Lots of people are treated without their consent for a host of illnesses. It often happens when patients are determined to lack the capacity to make rational choices about their well-being. Such decisions are not uncommon, particularly with regard to psychiatric patients. In dealing with a severly depressed individual who is rejecting ECT a physician’s thinking might be, “Patient X is rejecting ECT. Patient X wishes to die. Patient X has alienated himself/herself from friends and family as a result of depression. Patient X has been unable to maintain employment as a result of depression. Patient X has been unable to take care of their children as a result of depression. Depression is an organic illness of the brain. The therapy being refused by the patient has a high likelihood of improving their life. Also, Patient X haas confided in me a wish to die and has a plan about how they’ll do it. Therefore, I find that Patient X, due to their severe depression, lacks the capacity to make decisions regarding their psychiatric well-being.” Such would be the scenario for a forced treatment, but even so, the majority of ECT patients are voluntary.

[Tabeitha]

For a personal view of ECT keep reading to continue the debate with no interest in a personal perspective skip this post…

My mother has suffered from Bi-polar/manic depression for as long as I can remember. By the time I was 20 she had been in therapy for 17 years, in and out of psychiatric hospitals, and had tried almost every drug available. None of the drugs worked. Her body developed tolerances to whichever drug they had her on so they would up her dose. After awhile she had severe side effects from the amounts of drugs in her system. Her kidneys started failing, she got stomach ulcers among other things, and she will now spend the rest of her life on a strict diet. Of course once the tolerance to the drug was built up they would switch her to another drug and it would start all over. Usually another suicide attempt came in her adjustment period to the new drug. She switched Psychiatrists quite a few times (partially because of me, I would yell at them because they couldn’t fix her and I thought at the time drugs were a cop out on the therapists side. I was sure there was some deep problem that could be solved with enough therapy.) My mother had ECT done 8 years ago. Yes she had major memory loss that lasted for a few months, but in time her memory became clear. Yes she was disoriented, yes it was horrible seeing the state she was in immediately following ECT. I was terrified for my mom when she told me she was doing this. I was sure she’d become a zombie(Worse so then while on the drugs) In fact the first time I saw her in the hospital following ECT I was sure she was gone. I was sure her brain no longer worked, she just had to be brain damaged. She has now been successfully off drug therapy for the last 8 years. She no longer goes through those deep downs and manic highs. My mother is sharp as a whip. Her life is fulfilling to her now, she is the mother my brother and I always wanted and knew she could be. I can not say that I have noticed any adverse side effects in my mother and when I asked her if she had any she just tells me the last 8 years are the best she has ever felt. I no longer worry about coming home to find my mother half dead (I have found her this way more than once, I truly believe she would have been successful at suicide if my brother and I were not so good at skipping school) I can say this procedure has improved my mothers life as well as mine and our whole family. I am sure some people have adverse effects from ECT, but I am sure my mother would still be living the daily struggle of depression and us with her if it were not for this treatment.

Now back to your debate…
…

[Morrison_s_Lament]

Sorry, but I’ve known plenty of people with the exact same story as your mom - minus ECT.
I am hesitant to attribute all failures to relapse into depression after discharge to the specific therapy administered, especially on an anecdotal basis.

— G. Raven

[Scotticher]

*Originally posted by choosybeggar *
**iampunha,
Maybe you aren’t thinking of depression as a potentially fatal condition? In fact it is, and has a fairly high morbidity and mortality. **

Um…I am giving you the benefit of the doubt, and assuming that you have never read any of iampunha’s posts concerning HIS depression and suicide. Or almost anything ELSE he has said, either.

When he said…

** I had a psych a few years back who contributed in a very key way to helping me not take my own life. In a way I owe him as much.**

He was talking about paralyzing depression, of a kind that made him consider taking his own life. How could he NOT understand that depression is a potentially fatal condition?

You are a medical student, so maybe you understand these things in a different way than the rest of us. But anyone who has actually BEEN there has a unique perspective. Especially someone who has fought through the darkness and come out on the other side.

Please don’t patronize these people.

Scotti

[iampunha]

You know, Scotti, it takes a real gift to be able to read select parts of a thread and ignore certain key aspects of others.

Evidently choosybeggar has just this gift.

CB, in case you missed where I said so in this thread, and where I’ve said so in multiple other threads, I’ve been suicidal. A cousin of mine died from depression (suicide). I read every week about people committing suicide because of depression.

So don’t give me this shit about not knowing depression can kill. I’ve been down the fucking road several times. I just haven’t taken that left turn yet.

[Tabeitha]

*Originally posted by Morrison’s Lament *
**Sorry, but I’ve known plenty of people with the exact same story as your mom - minus ECT.
I am hesitant to attribute all failures to relapse into depression after discharge to the specific therapy administered, especially on an anecdotal basis.

— G. Raven **

I understand your hesitancy, but unfortunately not everyone can be helped through drugs and therapy, or at least they never found a way with my Mom. IMHO ECT should be used as a last ditch treatment only. I could give you volumes of reasons why I feel it greatly benefited my family, but of course, as I stated earlier, this is only personal opinion based on living with someone whom I watched plummet and stay down for my entire life. I now have the extreme pleasure of knowing the real person who was hidden behind this disease.

Any treatment/drug can be misused, and IMO the less we (the public) hear and know about the treatment/drug the easier it is to abuse.

[choosybeggar]

*Originally posted by iampunha *
**You know, Scotti, it takes a real gift to be able to read select parts of a thread and ignore certain key aspects of others.

Evidently choosybeggar has just this gift.

CB, in case you missed where I said so in this thread, and where I’ve said so in multiple other threads, I’ve been suicidal. A cousin of mine died from depression (suicide). I read every week about people committing suicide because of depression.

So don’t give me this shit about not knowing depression can kill. I’ve been down the fucking road several times. I just haven’t taken that left turn yet. **

Sorry, I missed the line about your history. Had I known that you have personal experience with depression, I would have chosen my words more carefully. And regardless, I apologize for the patronizing tone of my post (Too many days in a row of night float do not a happybeggar make).

But I stand by the the general thesis of my post which was that even high risk therapies are justified in the face of serious illness. And as a corollary, that the common side effects of ECT are mild and temporary and do not merit granting it status as a high risk therapy.