He’s held down on a hospital bed by four men in white shirts and skinny black ties. A nurse applies a conductive gel to his temples and jams a leather mouth guard between his teeth.
“This will keep you from biting your tongue,” she says.
A doctor in a black suit turns a dial on a machine beside the bed and the device on his head sends him into convulsions. The camera pans to a close-up on his cringing face.
This Jack Nicholson portrayal in the 1975 film adaptation of Ken Kesey’s One Flew Over the Cuckoo’s Nest, portrays the common misconception about modern usage of Electroconvulsive Therapy (ECT), said Queen’s Psychiatry department head Roumen Milev.
“It’s perceived by laypeople as barbaric treatment and as a method of punishment,” he said. “In reality it’s an exceptionally good and efficacious treatment method for depression.”
Milev said six to eight faculty members from the psychiatry department currently treat an average of 10 to 15 patients with ECT on a regular basis at Providence Care in Kingston.
“The numbers have declined dramatically after antidepressants and other medication were invented in the 1950s and 60s,” Milev said. “But the numbers now are quite stable and we continue to provide a similar number of treatments over the last five, 10 and 20 years.”
He said ECT is used as a treatment for patients with depression who do not react to traditional anti-depressive medication and psychotherapy.
“It’s not a last resort but it’s definitely not a first line treatment,” he said. “Every study has shown the efficacy of the treatment. … It has a higher efficacy than medication.”
A 2009 report from the Canadian Network for Mood and Anxiety Treatments (CANMAT) defines ECT as involving “the induction of a convulsion (seizure) by the application of electrical current to the brain.”
The treatment can be delivered in two ways; either unilaterally on one side of the skull, or bilaterally on both sides.
Milev, who sits on the CANMAT board of directors and co-authored the report, said Queen’s has pioneered several strategies on placing the electrodes delivering the charge.
“When you change the position you can achieve the same efficacy and a lower incidence of the memory problem,” he said, adding that Queen’s faculty primarily administer the treatment bilaterally on the frontal portion of the brain, as suggested by a 1993 in-house study.
He said the major risk associated with ECT is memory loss. The most common memory lost is the 10 to 15 minutes prior to the treatment, but Milev said the risk isn’t confined to that.
“Unfortunately there are some patients which may lose longer term memory,” he said. “It’s a very small portion but there’s no way we can predict in advance who is going to get it.”
Patients are required to sign an informed consent before undergoing the treatment.
“Every treatment known to man has negative possibilities,” Milev said. “The question is … when is it worth [the risk]? The question is not for you and me who are functioning. The question is for someone who has lost their functional capacity.”
The CANMAT report claimed a low mortality rate of 0.2 per 100,000 ECT treatments, which is similar to the mortality rate of general anaesthesia.
Milev offered the following example of an ECT patient.
“Someone is disabled and for five years didn’t leave the house and cannot work, cannot function in the society and family,” he said. “Is it worse to try such treatment in the hopes that he’ll reintegrate back.
“Possible memory loss for five years of his life prior to that would be a deterrent,” he said. “[But] this is what medicine is about. You have to take into consideration the pros and cons and then to do a treatment that will provide the best response for that particular individual.”
Over the summer Nursing Master’s graduate Sarah Xiao shadowed Dr. Regina du Toit as part of her research on ECT.
She said after observing patients receiving ECT at Providence Care, it became obvious that film portrayals of the practice like One Flew Over the Cuckoo’s Nest are misrepresentative.
“It’s basically a blackhole in all of psychiatry,” Xiao said of the movie’s depiction of shock therapy.
She said patients are given a muscle relaxant and general anaesthesia, making for little drama during the four-minute procedure.
Xiao was the 14th recipient of the Margaret Angus Research Fellowship presented by the Museum of Healthcare at Kingston. She spent the summer researching the topic and gave a lecture on her findings last night at Louise D. Acton Hall.
She outlined the history of shock therapy, beginning with ancient methods including the ingestion of electric fish. The first instance of modern ECT, Xiao said, was performed on a man who arrived in Rome on a bus, incoherent and hallucinating in 1938.
Xiao claimed portrayals of ECT in media have shaped public perception of the practice. She said One Flew Over the Cuckoo’s Nest is indicative of an anti-psychiatry trend in the 1960s and 70s, when asylums were suspected of being places of torture and oppression.
“It’s a reoccurring theme,” she said, citing contemporary films like Shutter Island as perpetrators of a negative stereotype for psychiatry. “It’s seen as torturing patients … psychiatry is still very stigmatized.”
The presentation included interviews with the psychiatrist Xiao shadowed, Xiao’s aunt who received shock therapy and several of people citing their limited ECT knowledge.
“I thought it was phased out like lobotomies,” one said.
Among the crowd of 65 crammed into the lecture hall was a local neurologist at Kingston General Hospital who administered shock therapy in the 1960s.
“It was an era where ECT was being used fairly widely used,” Dr. Henry Dinsdale told the Journal after the lecture last night. “The movies were definitely against it.
“[But ECT] is clearly a treatment that’s proven the test of time,” he said. “It saves lives in some cases.”
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