Is electrocompulsive therapy inhumane?

“Open your mouth?”

“What’s that?”

“To keep you from biting your tongue.”

“No! No!”

It’s a Friday night in 1975. You decide to hit up the cinema and see the latest Jack Nicholson flick that’s been pegged as Absolutely Maddening! One Flew Over the Cuckoo’s Nest, based on the 1962 book written by Ken Kesey, went on to become one of the most popular and absolutely terrifying psychological thrillers of it’s time.

It’s also caused significant damage to the field of psychiatry that remains felt today.

There are a number of disconcerting features of the movie, with inpatients being locked in straight jackets and handcuffs serving as just one example (this never actually happened except in certain cases of very dangerous, high-risk people, which I agree is still inhumane; it’s not practiced whatsoever any longer). One of the most significant and gruesome scenes featured in the movie is a scene featuring electrocompulsive therapy (ECT).

The main character Randle McMurphy is played by Jack Nicholson. In the scene, Nicholson is brought into a room by security, and is met by another twelve men, who proceed to man-handle him onto a stretcher. They paint him with “conductive,” and shove a mouth guard in his mouth. They proceed to shock him, featuring loud screams, huge convulsions, and best of all, all while he is still completely awake. Gruesome. But come on.

ECT remains a procedure of mystery in the public realm and sadly that has resulted in people disproportionately and incorrectly being informed on the nature of ECT by modern media. In the 1970’s, at a time when media was limited to movies, and television, productions like One Flew Over had a tremendous impact that still hurts the field of psychiatry, and most importantly, patients.

What am I talking about?

“My recommendation is a short course of elctrocompulsive therapy, also known as ECT.”

“No, no way I want that. I don’t want to be electrocuted man.”

“In my experience, ECT is the treatment that would work best for your condition.”

“There’s no God damn way.”

ECT remains today one of the most under-utilized therapies in medicine. That’s because ECT actually has a tremendous amount of evidence for a number of different psychiatric disorders, and in many cases, works significantly better than medications. Yet due to patient and provider stigma, ECT is often left aside because people “don’t feel comfortable” with it. Movies like One Flew Over popularized what can only be described as torture in the movie, and called it ECT, which is actually an extremely safe and effective procedure.

What are some advantages of ECT?

• Electrocompulsive therapy is unique in it’s ability to treat a number of different illnesses. I have routinely used ECT to treat depression, depression with psychosis, mania, and behavioural/psychiatric symptoms of dementia.
• ECT is the most effective treatment for unipolar depression (also known as Major Depressive Disorder). Remission rates have been estimated as high as 90%.
• ECT is the most effective treatment for bipolar depression and mania. Remission rates have been recorded as high as 80%.
• ECT, in many cases, works more quickly than medications.
• ECT is safe in pregnancy whereas many psychiatric medications for bipolar disorder are not.
• No medication side effects.
• ECT is performed under anaesthetic.
• ECT is performed with muscle relaxants; usually, the only convulsion seen happens in the big toe.
• ECT is one of the only treatments approved for suicidality.

What are some disadvantages of ECT?

• ECT requires a hospital, an anaesthesiologist, and a psychiatrist to administer. This costs money and resources (arguably, the cost saved by the quick and larger effect mitigates this).
• ECT does have some side effects, most notoriously memory and thinking problems on the day of the treatments (a typical course involves three treatments a week for a month, and then tapering that down).
• ECT can require maintenance treatments once a month for a few years or longer after you complete the acute course.

The conclusion? ECT remains one of the most effective and safest treatments in medicine. It has the ability to help people, and I’ve seen it. What’s inhumane is how little access there is to this treatment around the country.

Editor’s note: Working in Toronto, ECT was a relatively accessible service. I’ve worked at three hospitals, at least, with the ability to do ECT. This is not the case everywhere. I’ve worked in centres acorss the country where there is no access to ECT, and sick, unwell people, who deserve to have this excellent treatment, are left to go and suffer without. Improving ECT access and education is part of ending the stigma!

Stay tuned for “How does ECT work?”

Dr. Travis Barron is a resident physician in Toronto, Canada.