BRAINPOWER
Shock Tactics
Electroconvulsive therapy has a dark past. But by using modern methods and tighter control in the process, psychiatrists are returning to it for the treatment of severe depression. Words KATHY MALHERBE
ELECTRIC SHOCK TREATMENT of any nature has an image issue – courtesy of Josef Mengele’s horrific experiments in the holocaust where high-voltage electric shocks were administered under the guise of testing endurance; the SANDF 1970s aversion therapy to ‘cure’ homosexuals and death-row prisoners being led to the electric chair, strapped down and then fried in front of an audience. Then came the early attempts at electroconvulsive therapy (ECT), also known as shock therapy. Medications, like insulin, were first used to induce seizures in 1938. Insulin causes a sudden drop in glucose, which causes the brain to develop seizures as a sign of distress. That’s because blood glucose is the only ‘fuel’ the brain can use for its energy needs, if deprived of glucose. A year later, electric currents were used to induce seizures. It was a barbaric procedure, with patients suffering unsurprisingly huge amounts of anticipatory anxiety – not to mention frequent bone fractures from arching and thrashing in response to the current. The equally brutal practice of psychosurgery, in the form of lobotomies, was another popular ‘cure’ for mental illness at the time. ECT was abandoned in the 1950s when psychoactive medicines were introduced and reemerged in the 1970s – despite its stigma – to help the mentally ill who were unresponsive to psychoactive medications and psychotherapies. ECT, for the treatment of severe depression, has seen another resurgence in the last 10 years largely due to refinement of the procedure – making it safer and less traumatic. It involves electric currents being passed through the brain.
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These currents trigger a generalised cerebral seizure, which in turn causes changes in brain chemistry that can immediately reverse symptoms of certain mental illnesses. It’s a last-ditch attempt to reboot the brain’s operating system, which gives hope to those who are not responding to any other methods of treatment for mental illness. Dr Gerhard Grobler, President-Elect of the South African Society of Psychiatrists (SASOP) says, ‘Without ECT, at worst, these patients would not survive; at best, lead tragic lives.’ But has ECT entirely overcome its bad reputation? ‘To a certain degree,’ says Dr Grobler, ‘but there are still detractors – some vociferous.’ He says one of the reasons for the stigma is that, until 2002, ‘unmodified ECT treatment’ was still legal. In this procedure, high doses of electricity were administered without anaesthesia or muscle relaxants. However, stringent regulations in the Mental Health Care Act have made it illegal and unmodified treatment hasn’t been practised for the last 15 to 20 years. However, despite a call by WHO for the worldwide banning of unmodified treatment, it is still practised in countries like Japan, India and Nigeria. So what happens during ECT? This account by one patient vividly describes the experience: ‘The doctor presses a button. Electric current shoots through my brain for an instant, causing a grand mal seizure for 20 seconds. My toes curl. It’s over. My brain has been “reset” like a windup toy. I wake up 30 minutes later and think I’m in a hotel room in Acapulco. My head feels as if I’ve just downed a frozen margarita too quickly. My jaw and limbs ache. But I feel elated. On the
anniversary of my first electroshock treatment, I was clearheaded and even-keeled. Two and a half years later, my medication keeps my illness in check, and I’m saner than I’ve ever been. If I could only remember the capital of Chile.’ To the observer, it may initially feel like watching a scene from One Flew over the Cuckoo’s Nest but it is in fact a medical procedure, meticulous in its preparation and execution by an anaesthesiologist, psychiatrist and nurses. An IV is inserted, sensors or electrode pads (each about the size of a 50c coin) are attached on the sides of the head, and an electroencephalogram or EEG measures the electrical activity in the brain. A pulse oximeter allows them to measure the amount of oxygen in the blood. An anaesthetic is injected into the IV and the patient drifts off for five to 10 minutes – all it takes, say fans of ECT, to ‘shock a broken mind into recovery’. A muscle relaxant is injected to help prevent convulsions during the seizure and a mouth guard is sometimes placed between the teeth. The button is pressed and the electrical current passes with a force of from 70 to a maximum of 450 volts (the electric chair uses 2 000 and a wall socket around 250). The current induces a seizure that lasts between 45 and 60 seconds. Doctors monitor the seizure by placing a blood pressure cuff around the forearm or ankle area, preventing the muscle relaxant from paralysing those muscles. Uncontrolled jerking movements of the limb are the only indication the doctor will have that there is a seizure. It’s all over in about 15 minutes. A few minutes later the effects of the short-acting anaesthetic