The Wall Street Journal Gets It Wrong on ECT

A June 30, 2019 Wall Street Journal article by Sumathi Reddy entitled “New Thinking Challenges the Stigma Around ‘Shock Therapy’” argues that modern Electroconvulsive Therapy (ECT) is safer now than it was in the past. That article, however, is inaccurate, in view of the science behind ECT. Below are six quotes from the article along with contradictory citations from the scientific literature.

  1. “Electroconvulsive therapy, its official name, is a brief electrical stimulation of the brain that causes about a minute-long seizure, helping to realign disrupted circuits.”

The mechanism whereby ECT brings about changes in patient behavior is still completely unknown, and saying it “realigns disrupted circuits” is pure nonsense. According to the scientific literature, “…the mechanism of therapeutic action of ECT has not yet been established.”[1] And “ECT is one of the most controversial treatments in medicine, particularly because of still unknown mechanism of action and uncertainty about cognitive side effects.”[1] Also “The efficacy of any medical treatment depends on scientific understanding of the disorder, and how the treatment is applied. But that insight is largely lacking with ECT”[2]

  1. “Experts say ECT is among the most effective treatments for serious depression when medications and talk therapy don’t work. … ECT is typically reserved for patients with the most severe cases where nothing else has worked, although it may be helpful earlier in the course of illness, says Dr. Lisanby.”

This implies that ECT is used very sparingly, but the practice is so profitable that it is, in fact, applied to patients to treat all manner of symptoms. “The cost of ECT runs upwards from $35,000 per series.” And “It is estimated at being a $2-3 billion dollar a year industry.” Also “The attending psychiatrist may charge $300 and up for a session of ECT and may easily perform five to six ECT treatments within one hour ($1,800/hour). The average salary for psychiatrists practicing ECT may be twice that of other psychiatrists.”[3]

  1. “Jerrold Rosenbaum, psychiatrist-in-chief at Massachusetts General Hospital, cautions that ECT is best suited for people with severe depression, particularly those with complicated cases, such as elderly patients. ‘The first line has always been either medication or psychotherapy. ECT is reserved further down the algorithm when things have failed or when someone is seriously suicidal,’ he says.”

The use of ECT is completely unregulated and no such usage limitations are enforced. As a result ECT is used for such “other mental-health conditions” as smoking, obesity, and suicidal thoughts. In one study, “There were 182 different principal diagnoses among patients who received ECT.”[3]

  1. “At McLean, doctors conduct more than 10,000 electroconvulsive therapy treatments a year for patients with depression and other mental-health conditions. ‘The demand here has been steadily increasing and we have continuously expanded to meet that demand,’ said Steve Seiner, McLean’s director of neurotherapeutics program.” And “The University of Michigan does about 3,400 treatments a year. The program has grown about 50% in three years, says Dr. Maixner.”

Once the equipment and personnel are in place, it costs an institution very little to deliver an increased number of ECT treatments. Thus expanding the patient base is highly profitable. One study concludes, “ECT appears to be an important moneymaker for both hospital and psychiatrists in a time when costs are high and reimbursements are scarce.”[3]

  1. “Over the years, techniques have changed. Doctors now deliver shorter pulses of electricity, which reduces the brain’s exposure to the stimulus.”

Modern ECT machines deliver the same total amount of electricity as the older units, just in a burst of brief pulses that batter the brain cells like a jackhammer.[4] The exposure to stimulus is not reduced – it is just made more destructive.

Further, ECT machines deliver a large amount of electric current (900 milliamps) to the patient’s head. From one manufacturer, “… you should upgrade to the 900 mA provided by Thymatron® instruments.”[5] However, this is 90 times the amount of electric current that is considered dangerous to humans. For example, “In medical terms, electrical shocks are usually divided into two categories. Macroshock refers to larger currents (typically more than 10 mA) flowing through a person, which can cause harm or death.”[6]

  1. “Doctors also customize the dose of electricity rather than taking a one-size-fits-all approach.”

The electrical dose level can be tailored to each individual patient, but most often it is not. To do so, one ECT device manufacturer recommends, “This method, termed EMPIRICAL TITRATION, involves administration of subconvulsive intensities in the first treatment, finding the intensity level that produces an adequate seizure in that session, and in subsequent sessions administering an intensity that is a fixed amount above the seizure threshold identified in the first session.” And “In subsequent treatments you plan on delivering a dose that will be approximately 6 times this initial seizure threshold.”[7]

However, more than half of US practitioners don’t spend the time and effort of determining the optimum dose level by trial and error. [7] For them the manufacturers advise using a second method that involves simply picking a number off a chart, “An alternative to the titration method is to … preselect a dosage that on a probabilistic basis is likely to be in the appropriate range relative to seizure threshold.” [7] Notice that this method is more of a gamble than anything precise. But in either case the dose will be at least six times what is required simply to produce a seizure.

But for those who are even less concerned with minimizing patient exposure, one ECT device manufacturer says, “Satisfactory therapeutic results can be obtained with right unilateral ECT by simply setting the PERCENT ENERGY dial to approximate the patient’s age in years (e.g., 75% for a 72 year-old patient). [8] Another manufacturer says “Setting the Thymatron® System IV according to the patient’s age facilitates easy selection of the stimulus charge.” [5] And in a further admonition against using small doses, they advise, “… we do not recommend administering subsequent treatments with progressively lower settings in an attempt to deliver the smallest stimulus that will still induce a seizure.” [8] Thus minimizing the patient’s exposure to dangerous levels of electric current, and the increased risk of side effects, is not a priority.

The scientific literature regarding ECT contradicts the claims made in the WSJ article, and the actual practice of ECT is not as safe and gentle as described. You just can’t put lipstick on this pig and make it pretty. Running electricity through a person’s brain is exactly as brutal as it sounds. Modern ECT devices are no less dangerous, perhaps more so, than those of the past.

REFERENCES

  1. D Kolar, “Current status of electroconvulsive therapy for mood disorders: a clinical review,” Evid Based Mental Health, 20(1), February 2017. <http://ebmh.bmj.com/>
  2. RD Fields, “Beyond the Cuckoo’s Nest: The Quest for Why Shock Therapy Can Work,” Scientific American, November 27, 2017.
  3. AM McKersie, Effects of Funding on Electroconvulsive Therapy in California, Masters Thesis, San Diego State University, 2011. <http://sdsu-dspace.calstate.edu/bitstream/handle/10211.10/1142/McKersie_Anne.pdf>
  4. RC Lee, “Cell Injury by Electric Forces,” (Review Article) Ann. N Y Academy of Sciences, 1066: 85-91, Dec. 2005.
  5. Thymatron® System IV Brochure, Somatics, LLC 2012. <www.thymatron.com>.
  6. S Barker, and J Doyle, “Electrical Safety in the Operating Room: Dry Versus Wet,” Anesthesia & Analgesia, 110(6):1517-1518, June, 2010.
  7. MECTA Corporation, MECTA Instruction Manual, SPECTRUM 5000Q, SPECTRUM 4000Q, SPECTRUM 5000M, SPECTRUM 4000M, Revision 06, November 7, 2008.
  8. R Abrams & CM Swartz, “THYMATRON® System IV Instruction Manual – Twelfth Edition,” UM-TS4, Rev. 12, Somatics LLC, May, 2006.
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