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Electroconvulsive Therapy

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Electroconvulsive Therapy

  1. 1. Should ECT be used to treat mental illness? Lecture 1 Dr. Christopher Wilson
  2. 2. Lecture Aims• Describe the procedure and origins of ECT• Discuss changes in perception over time and discuss contributing factors• Describe how the debate incorporates various controversial aspects of psychology• Outline key terms and theoretical perspectives• Define the scope of the debate 2
  3. 3. A COMPLEX HISTORY 3
  4. 4. “a barbaric and destructive process which delayed ouropportunity to deal with the real issues of our distress” 4
  5. 5. “among the safest treatments given under general anesthesia” (RCS, 2005)
  6. 6. The history of ECT has become a metaphor for both advocatesand opponents to explain their vision of psychiatric power andits promise for or threat to society (Hirshbein & Sarvananda, 2008). 6
  7. 7. The ECT debate incorporates manycontroversial aspects.• What is mental illness?• What lengths should we go to to treat somebody with a mental illness?• The power dynamic between health professionals and mentally ill patients.• Various vested interests in the medical profession 7
  8. 8. WHAT IS ECT? 8
  9. 9. Origins of ECT• Convulsive therapies• Disrupted problems in the patient’s thinking and restored some semblance of normality.• Patients became calmer
  10. 10. Origins of ECT• Looking for new ways to cause convulsions (e.g. Insulin Coma)• Cerletti and Bini (1938) – electricity• ECT was easier to administer and better tolerated than metrazol
  11. 11. The procedure• Muscle relaxants & anesthetic• Electrical current is passed through brain• Epileptic seizure• 4-12 individual shocks- a few days apart
  12. 12. How common is its use?• 9,200 people a year (UK) - Decline over 20yrs• Mainly hospitalised patients• Used similarly in USA, Scandinavia, Ireland, Australia and New Zealand• Low, research-based usage in Canada, Germany, Japan, Italy and Netherlands.
  13. 13. Modern research into the technique• Voltage / Current* (0.8-0.9 A)• Vary: pulse width, frequency and the duration• Unilateral / Bilateral
  14. 14. What does it treat?
  15. 15. What has it been used for? alcoholism, anorexia, anxiety disorder, catatonia, drug withdrawal syndrome, homosexuality and hysteria, narcotic addiction, neurosis, obsessive- compulsive disorder, personality disorder, postpartum depression, postpartum psychosis, pseudodementia, psychosis, Alzheimer’s disease, backache, chronic pain, delirium tremens, dementia, epilepsy, neuroleptic malignant syndrome, Parkinson’s disease, and psoriasis. (Frank, 2006)
  16. 16. HOW DOES IT WORK?
  17. 17. Two current theories• ECT Produces a seizure which affects the entire brain.• ECT changes the way brain cells respond to their chemical messengers.• EEG measured during treatment – low interseizure EEG indicates effective treatment (Fink, 1999)
  18. 18. A technical description?“ECT has been compared to kicking amachine to start it up.” (Harvard Mental Health, 2007).
  19. 19. CHANGING VIEWS OVER TIME 19
  20. 20. A marvel of modern medicine - 1940’s• “restore to sanity the ‘living dead’ affected by the dementia praecox form of mental illness.”• In this context, the subsequent risk for vertebral fractures caused by “violent convulsive shocks” appeared entirely reasonable 20
  21. 21. A marvel of modern medicine – 1950’s• In 1952, physicians first used electricity on a patient in order to induce cardiac defibrillation.• Articles in both Time and Newsweek explained that a cardiologist had developed a machine for shocking the heart, based on the principles of shocking patients developed in ECT. 21
  22. 22. Not everyone was convinced – 1950’s• “Some psychiatrists—particularly neuropsychiatrists—think people become severely troubled because something is chemically or glandularly wrong with them”.• “They search for a chemical compound, a form of brain surgery, or a physical process to solve the mystery of emotional illness” 22
  23. 23. An abuse of power? – 1970’s• “Accounts of ECT became more concerned with the power transaction that occurred with the treatment.”• “Commentators increasingly raised questions about psychiatrists’ right to wield this kind of power.” 23
  24. 24. CONTROVERSIAL ASPECTS: THEMEDICAL MODEL 24
  25. 25. The medical model of mental illness• Terminology such as "mental illness,“ "mental disorder," and "biologically based brain disease"• Describe both the putative cause and the nature of disturbing human behavior. 25
  26. 26. Criticism of the medical model • Mental disorders are accorded disease status without meeting the classic Virchowian criteria for disease • In contrast to well- validated medical diagnoses such as cancer and hypertension 26
  27. 27. CONTROVERSIAL ASPECTS: THEDARK HISTORY 27
  28. 28. Opponents of ECT link it to oldertechniques.• ECT was in the tradition of “beating up those labeled insane with methods ranging from torture to lobotomy to psychosurgery”. 28
  29. 29. Proponents describe ECT as anadvance • ECT to illustrates the upward progress of modern science. • The use of a treatment for mental illness directed toward the brain represented a major step forward. 29
  30. 30. CONTROVERSIAL ASPECTS: THEPOWER DYNAMIC 30
  31. 31. An abuse of trust?• ECT was often done without regard to patient consent in its early years• Patients trust doctors to decide the best treatment• In no other psychiatric treatment is a patient as passive—or as unaware of the treatment itself while it is occurring. 31
  32. 32. Trust the experts• Some ECT patients have gone public and insisted that they chose ECT with open minds in order to help treat their severe illnesses.• “Like chemotherapy, ECT is a toxic treatment for a crippling disease.”• “high tech anti-depression therapy” 32
  33. 33. THE SCOPE OF THE DEBATE 33
  34. 34. What are the important features ofany treatment?• How it works• Efficacy• Safety• Comparative utility• Comparative cost Which are the most important? 34
  35. 35. Further ReadingBreggin, P. (2007). ECT damages the brain: Disturbing news for patients and shock doctors alike. Ethical Human Psychology and Psychiatry: An International Journal of Critical Inquiry, 9(2), 83-86.Carney, S., Cowen, P., Geddes, J., Goodwin, G., Rogers, R., Dearness, K., et al. (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders: A systematic review and meta-analysis. The Lancet, 361(9360), 799-808.Esmaili, T., Malek, A. (2007). Electroconvulsive therapy (ECT) in a six-year-old girl suffering from major depressive disorder with catatonic features. European Child Adolescent Psychiatry, 16(1), 58-60.Fink, M. (1982). ECT in anxiety: An appraisal. American Journal of Psychotherapy, 36(3), 371-378. Retrieved from PsycINFO database.Frank, L. (2006). The Electroshock Quotationary. Ethical Human Psychology and Psychiatry: An International Journal of Critical Inquiry, 8(2), 157-177. doi:10.1891/ehpp.8.2.157.
  36. 36. Hirshbein, L., Sarvananda, S. (2008). History, power, and electricity: American popular magazine accounts of electroconvulsive therapy, 1940-2005. Journal of the History of the Behavioral Sciences, 44(1), 1-18. doi:10.1002/jhbs.20283.Johnstone, L. (1999). Adverse psychological effects of ECT. Journal of Mental Health, 8(1), 69-85. doi:10.1080/09638239917652.Johnstone, L., Frith, H. (2005). Discourse analysis and the experience of ECT. Psychology and Psychotherapy: Theory, Research and Practice, 78(2), 189-203. doi:10.1348/147608305X26657.Keltner, N., Boschini, D. (2009). Electroconvulsive therapy. Perspectives in Psychiatric Care, 45(1), 66-70.doi:10.1111/j.1744-6163.2009.00203.x.Maybaum, L., Crockford, D. (1999). Electroconvulsive therapy, personality structure, and suicide. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 44(9), 922-923. Retrieved from PsycINFO database.
  37. 37. Morgan, J., Kellett, J. (1997). Consumer satisfaction and outpatient ECT. International Journal of Geriatric Psychiatry, 12(4), 495-496.Philpot, M., Collins, C., Trivedi, P., Treloar, A., Gallacher, S., Rose, D. (2004). Eliciting users’ views of ECT in two mental health trusts with a user-designed questionnaire. Journal of Mental Health, 13(4), 403-413.Ross, C. (2006). The sham ECT literature: Implications for consent to ECT. Ethical Human Psychology and Psychiatry: An International Journal of Critical Inquiry, 8(1), 17-28.Wilkinson, D., Daoud, J. (1998). The stigma and the enigma of ECT. International Journal of Geriatric Psychiatry, 13(12), 833-835.

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