electro-shock
Heather Hogan
The proposed new Mental Health Care Bill has one striking omission – it fails to deal with one of the most controversial methods of treatment, electro-shock therapy (ECT).
Experts this week were sharply divided on the therapy, which is used extensively in South Africa. Those in favour claim it is a life-saver; others, including former patients, find the price – in long-lasting effects – much too high.
Used to treat severe depression, suicidal tendencies and schizophrenia, ECT originated in the 1930s. It uses electrical induction to create central nervous system seizures in patients who have failed to respond to other forms of medication and psychotherapy. It is conducted in almost all hospitals dealing with psychiatric patients and some mental institutions.
ECT has come a long way and both the technology and the means of treatment have changed drastically since it was first introduced. Psychiatrists believe it is much safer now.
According to psychiatrists, regulations under the old Mental Health Act regarding the use of ECT are on a par with overseas countries. There is some debate around whether the therapy is safe for pregnant women and children. Although many psychiatrists maintain that it is, and the regulations allow it, Democratic Party national health and HIV/Aids representative Sandy Kalyan, also a trained psychiatrist, says the regulation doesn’t stipulate its potential for harm.
And while some insist that signed and informed consent is needed from either the patient or a guardian, a psychiatrist, whose name is known to the Mail & Guardian, believes differently.
“Signed consent is not necessary. If psychiatrists think the patient needs ECT and the matter is important or is an emergency,” he says, “we don’t need them to sign for it, we can just give it to them.”
“That is not true,” says Dr Sean Kaliski, who works at the Valkenburg mental institution in Cape Town. “If there is nobody available to sign and the patient is going to commit suicide, we can get signed consent from the hospital superintendent on his behalf, but signed consent is always needed.”
The need for consent is confirmed in an article in the Doctors Answers magazine, yet despite this, some patients allege they were treated without their consent or were coerced into signing consent forms while heavily drugged in institutions.
Kalyan confirms that patient consent is covered by the blanket consent form patients sign on their admission to institutions. These forms state that while patients are under the institution’s care, the institution can do whatever it finds necessary. She believes the special ECT consent forms patients sign are there merely to cover the therapist in case of legal action.
Tranquillisers, muscle relaxants and anaesthesia should be given to patients before ECT treatment.
“Prior to the use of these, spinal compression fractures were common,” says Rand Afrikaans University Professor Anita Stuart.
Rumours of side effects abound although, according to Stuart, research indicates ECT is more effective in fighting depression than chemotherapy is in fighting cancer. Kaliski maintains ECT has better results in fighting depression than any other treatment.
“I think ECT has substantial benefits; it has an 80% response rate. If patients are about to kill themselves, it can be a life- saving procedure,” says University of the Witwatersrand Professor Michael Berk. Unfortunately, some patients disagree.
“It’s psychic rape,” claims one angry professional who forcibly underwent ECT in his teens during the 1970s. He says he tried to kill himself repeatedly after treatment and would never have consented to ECT if given a choice. He believes firmly that it was not ECT that saved him, but the realisation that if he didn’t play “mental institution psychiatrists’ games” the treatment would have destroyed him.
“ECT is a blunt instrument for lazy people,” he says. “Of the guys who had it with me, two committed suicide – or so I heard. I don’t think anybody needed it. My impression was that most of those people suffered really bad trauma and they just needed a situation that relieved the pressure, a supportive environment so that they could deal with that trauma and psychotherapy.”
He recalls having split thoughts, headaches, difficulty in speaking, focussing and remembering things after treatment.
“My biggest panic, even now, is wondering what memories and knowledge I lost because of ECT,” he says, claiming he still suffers with a bad memory and poor concentration – contrary to medical opinion, which holds that memory loss is only experienced during treatment and is a temporary side-effect. “This interferes with my home life, my family and my work.”
He is not alone in his pain. Forty-year- old Evelyn Sanyane, once a vibrant and dedicated nurse, is now living with her parents, who will probably have to support her until they die. She doesn’t know what will happen to her then. Sanyane claims she has been unable to work or look after herself since undergoing ECT because she is forgetful. She can’t keep a job.
“I have to keep a cellphone with me at all times so that people can find me because I sometimes forget my way home. I am too afraid to try nursing again because if I forget to give a patient their medicine, I might end up killing them by accident,” she says.
Berk claims there is no “consistent proof” to support allegations that ECT may result in suicidal tendencies, poor concentration, permanent memory loss, depression and the death of brain cells during treatment.
During ECT, 70V to 120V are administered to patients via temporal lobe electrodes for roughly half a second. Treatments are given one to three times per week, lasting for a period of two to four weeks, which add up to the approximate standard eight to nine treatments given to patients. However, this varies with each patient.
Doctors Answers dismisses ECT “scare stories” and says “ECT produces temporary physical changes in the brain by the passage of an electrical current for a very brief time, and no permanent effects result unless the patient has [had] something in the order of 80 or more sessions. Highly intelligent people have frequently had to have treatment and no impairment of their intellectual or other brain functions was found to follow.”
One of ECT’s most notable patients was Nobel Prize-winning author Ernest Hemingway. He apparently had 11 shocks at the Mayo Clinic in Minnesota, in the United States, in 1960 and went for a second series three months later. Hemingway allegedly stated afterwards, “It was a brilliant cure but we lost the patient …”
He committed suicide a month after completing the second series of ECT.
Although authorities claim the treatment is perfectly safe and useful, Erica Chesler, Western Cape director of the Citizens Commission on Human Rights (CCHR) – an organisation founded by but not affiliated to the Church of Scientology – says: “Today psychiatrists promote ECT as safe and effective, yet nothing could be further from the truth.”
In retaliation, psychiatrists have lashed out at the organisation, claiming it is responsible for some American states banning ECT altogether, though whether events or the CCHR played a role in its banning is also debatable.
In 1997, the Dallas Morning News wrote that state records kept during a three-year period ending in September 1996 “show that 17 Texas mental patients died within 14 days of receiving a shock treatment”. The records, which include the death of a 79- year-old Amarillo woman 24 hours after treatment, “do not allege cause and effect between the treatments and death …”
Berk maintains that there is a one-in- 500E00 risk of death resulting from ECT, the same risk as there is in any other procedure where an anaesthetic is used.
Kalyan says: “Although the DP has no official policy on ECT, my personal opinion is that it shouldn’t be used.”
According to Stuart, contra-indications for ECT include increased intracranial pressure, and other effects that need further evaluation are, among others, cardiac disorders, respiratory disease and venous thrombosis. Serious complications such as cardiovascular or respiratory complications arising from ECT occur in fewer than one in 1E000 cases, according to an article in a 1999 Current Medical Diagnosis and Treatment journal published in London.
“Memory loss/confusion is related to the number and frequency of treatments and also proper oxygenation during treatment, and is more severe when bilateral ECT is used,” says Stuart. “Research indicates that unilateral ECT on the left would be more likely to temporarily disturb verbal memories and those on the right non-verbal memories [topographical memories].”
“From surveys of various organisations such as the United Kingdom Advocacy Group,” says Chesler, “it is probable that thousands of South Africans have received irreparable brain damage and other complications from the ECT given to them. This is betrayal in the guise of help. CCHR will continue to oppose ECT until it is banned internationally. The repercussions for psychiatry when this goal is achieved will be enormous.”
“I think that unless somebody can come up with an experimentally and theoretically valid explanation for why ECT is a necessary treatment, it should be banned,” says the former patient. “ECT is the easy way out.”