Electroconvulsive therapy (ECT), where an electric shock of 70 to 450 volts is delivered through the brain of a patient under general anesthesia, has a long and controversial history.
The idea is that the treatment causes a seizure-like fit, to “reset” the faulty circuitry in the brain that causes depressive and psychotic thoughts and behavior – although the biological process for this has never been fully explained.
Each year, around 2,500 people in the UK receive ECT. It is recommended by the treatment oversight body, the National Institute for Health and Care Excellence (NICE), for severe or psychotic depression that is resistant to other treatments such as medications.
But a recently published study suggests that more than a third of these patients do not give their consent to undergo it.
The report, published in the journal Psychology and Psychotherapy: Theory, Research and Practice, is based on Access to Information (FoI) requests sent to the 56 trusts in England that provide mental health services – 37 responded.
Electroconvulsive therapy (ECT), where an electric shock of 70 to 450 volts is delivered through the brain of a patient under general anesthesia, has a long and controversial history (stock image)
John Read, professor of clinical psychology at the University of East London, who led the study, says providing treatment without consent amounts to “people receiving ECT against their will.”
He says the responses indicate that official safeguard procedures, developed to protect patients who do not consent to ECT, are not being followed.
“Our research shows that there is no effective oversight or regulation of ECT in England, due to the inability of the authorities to carry out the required checks,” he told Good Health.
Commenting on the research, Dr Lucy Johnstone, independent clinical psychologist, says receiving ECT without consent can dramatically worsen patients’ mental conditions.
“ECT is very scary,” she says. “My research on the psychological impact of treatment, in the Journal of Mental Health in 1999, shows that it can be very traumatic to go through it without consent.
“Many patients who have received it for severe depression have already suffered trauma from sexual abuse and violence,” she told Good Health. “Being lying on a table beyond your control is a new trauma. “
However, some argue that patients are so sick that they are unable to give consent.
“These are people who are so depressed that they can’t speak; they may very well be hallucinating or having illusions and therefore unable to give their consent, ”explains David Curtis, Honorary Professor at the Center for Psychiatry at Queen Mary University in London.
The idea is that the treatment causes a seizure-like fit, to ‘reset’ the faulty circuitry in the brain that causes depressive and psychotic thoughts and behavior – although the biological process for this has never been fully explained ( stock image)
“They are unable to make decisions about treatment that all of the professionals involved in their care have found to help them.”
In addition, he maintains that ECT is safe and often effective. “It has been well studied for many decades,” he says.
“It is effective for people with severe depressive illness who have not responded adequately to antidepressants. Indeed, given the many documented side effects of antidepressants, I think ECT is safer. ‘
Professor Curtis adds, “We recognize that consent is a problematic area. But often when we conclude that it is better for patients to have ECT than not, a few months later, patients thank us for giving them the treatment. ‘
It may seem strange to think that people who have had such a frightening procedure would be grateful. But Dr Rebecca Lawrence, a consultant psychiatrist working in Scotland, is one of them.
“I have taken several courses over the years to treat psychotic depression,” she says. “The first was when I was pregnant with my first child. The most recent goes back three years. In total, I have had around 70 treatments.
“Without it, I’m not sure I would have recovered to be with my family or to train as a psychiatrist. I would do it again, if I needed to. While the basics – an electric current flowing through your brain, causing you to have a fit – are terrifying, the experience itself was, for me, very easy.
Nonetheless, she concedes that she suffered significant memory loss, which she believes to be a consequence of ECT.
“It’s like there are big holes in my memory before and during treatment. I lost much of my daughter’s first two years, ”she says. Dr Lawrence is particularly concerned that she also has no recollection of ever giving consent to the procedure.
“I always knew I consented but I didn’t remember it happening,” she says. “Fortunately, my husband was with me when I accepted. “
Others might not be so lucky and could never be sure whether they gave or withheld their consent.
The lasting impact of stopping the pandemic
This week: Balance
We appear to have lost our footing slightly during the lockdown, as physiotherapists see an increase in falls among the elderly.
“During the lockdown, many of my clients were only walking about a third of what they used to walk,” says Sammy Margo, a London-based physiotherapist.
“Reduced activity leads to muscle weakness which causes instability, especially in older people,” she explains.
“But I also think that the pandemic has destabilized us. It may sound a little unscientific, but cortisol, the hormone released during stress, affects the vestibular system in the ear which controls balance.
“The good news is that balance is like a muscle and you can retrain it using it. Exercises such as getting up several times from a seated position or standing on one leg with your eyes closed if possible while brushing your teeth will help. Taking walks on less stable surfaces such as grass or sand and walking with confidence can also make a difference.
“As your confidence and strength improve, your balance will improve as well. “
We appear to have lost our footing slightly during the lockdown, as physiotherapists see increased falls among older people (stock image)
This problem can be solved in two ways, explains Dr. Lawrence: “It is important to make sure that someone is with you to discuss it with you later. If treatment is to be administered without consent, “there should always be an appropriate second opinion to determine if it is appropriate,” adds Dr. Lawrence.
Professor Curtis maintains that second opinion checks already exist and are being applied. “The opinion of the patient’s psychiatrist must be approved [under the Mental Health Act] by the Second Opinion Physician (DICO), who is independent and [in] from the outside, ”he said.
By the rules, DICO should talk to the patient and see a nurse and another professional who is not a nurse. If DICO is satisfied, they will sign for the treatment to be given. As with any procedure of this type, this must be recorded.
“In my opinion, ECT is heavily regulated and the guidelines are sufficient,” says Professor Curtis. “If someone received an ECT without the proper procedures, there would be a massive investigation.”
Professor Read’s new research suggests a different picture. He reports that nearly 20% of the 37 trusts that provided information about their screening system for patients who do not consent were not complying with the rules.
This, he says, is because their DICOs did not in turn seek a second opinion from a nurse or other professional.
Additionally, half of all NHS mental health trusts that responded to Professor Read’s FoI requests said they could not easily provide information on the number of patients who received ECT without giving their consent. (Extrapolation of these figures led to the study’s conclusion that more than a third of ECT patients do not give their consent.)
“This suggests that many trusts still don’t consider this issue important enough to even watch it,” says Professor Read.
He adds that the only external monitoring is carried out by the ECT Accreditation Service (ECTAS), which is managed by the Royal College of Psychiatrists.
“But ECTAS also does not monitor this problem in its investigations – and does not have a benchmark or target in its accreditation standards for clinics that administer ECT,” he adds.
ECT is a potentially dangerous procedure, he says, and “requires the strictest monitoring.” “Our study shows that this is not the case in most ECT clinics in England. Control should be transferred to an independent organization.
Regardless of what one thinks of ECT – either as an unnecessary barbaric or effective in severe clinical cases – it certainly seems fair that information about patient consent and professional decision-making is clear. and readily available. This would eliminate at least one controversy from this most controversial treatment.
A spokesperson for the Royal College of Psychiatrists made no comment.