I AM SHOCKED
For many people, even many medical professionals, electroconvulsive therapy (ECT) is shrouded in mystery. This first story is a gentle introduction to ECT and the main concepts around it. It is about a straightforward treatment course, where everything went well, and no difficult decisions needed to be made. While the treatment was standard, the patient’s story was rather more dramatic.
Catherine’s husband was struggling to cope with his wife’s illness. She hadn’t mentioned suicide, but he had been warned to keep an eye on her. Depression was nothing new for Catherine. A few months earlier she had slipped back into another episode - her fourth in the past 10 years. The previous three episodes had all been treated successfully, responding quickly to the same antidepressant. Millions of people experience such episodes, and yet this time it seemed different. After her second bout of depression, Catherine had retired as a medical doctor but had led an active life, going to concerts, taking walks, reading books. But now, there were already signs that her depression was more serious than her previous bouts had been. It soon became evident that her usual antidepressant wasn’t working. Far from it, in fact. Day after day, for nearly six months, she became gradually slower, losing interest in her usual activities, and staying at home practically all the time. She had almost stopped eating, and her weight had dropped by six kilograms. She couldn’t finish anything; in fact, she was incapable of starting anything. Her answers were increasingly vague and confused, and as for questions, she had stopped asking any. Admission to hospital had been discussed, but she had refused.
Alarm bells went off for her psychiatrist who advised her husband to be vigilant. He took heed and one morning, when Catherine seemed to be spending too long in the bathroom, he went upstairs to check that she was all right. The bathroom door was locked and there was no response to his calls. A firm push on the door dislodged the flimsy latch and revealed a scene that filled him with horror: Catherine was lying in the bath, her face just above the water, as white as paper. But the bath wasn’t just full of water. It appeared to be full of blood. Mr Jones rushed to pull her out. This wasn’t that difficult, as she weighed even less now, having lost so much blood. On the inside of her thigh he saw a small trickle of blood. The ambulance arrived quickly. In hospital Catherine was given several litres of blood transfusion. The little cut on her thigh turned out to be quite deep. She had tried to sever her femoral artery with a pair of nail scissors. As a doctor, she knew that cutting a vein isn’t a very efficient way of killing oneself, so she went for an artery, one that carries a lot of blood. She also knew that it passes close under the skin at one point and had probably felt its pulsations on several past patients while assessing the blood supply to their legs. However, Catherine wasn’t a surgeon, wasn’t using an adequate instrument, and probably it hurt too much in any case, so mercifully, she failed to cut it completely. Otherwise, she would have died within minutes. Doctors and farmers are very successful in completing suicides - farmers know how animals are slaughtered and also have dangerous tools to hand, sometimes even firearms. Doctors know what can kill you.
Once stabilised, Catherine was transferred to the psychiatric ward. The team didn’t hesitate too much over which treatment she needed. Although her life had been saved, this patient was clearly in great danger, not just because she could kill herself suddenly and violently, but also because she could simply starve herself - she had lost another three kilograms since her admission. There was no time to wait for a second antidepressant and the added antipsychotic to work, as they could take weeks and might not prove effective anyway. Catherine was referred for ECT. She didn’t consent to it but didn’t object to it either. This wasn’t through apathy, but through sheer incapacity. In fact, she wasn’t even able to reason about her illness and the treatments at this point. Later, she told me that she had felt stupid, weak and confused, and so limited in concentration and focus that she hadn’t been able to listen to the end of a song. She had been unable to think clearly for months.
When I first saw her, her speech was slow and faltering, her eyes wandering aimlessly around the room. She was unable to give clear answers even to simple questions, or to tell me what was wrong with her and when it had started. There was a vague suggestion of something shameful from her past, but her words never finished the thought that was started, her speech disintegrated into muttering, and facts remained absent. I had no doubt whatsoever that all the terrible things that she thought she had done, had happened in her mind only.
‘No, no, that’s wrong,’ she moaned a few times, not always in response to a question. The nurses completed the picture: at times Catherine would pace along the corridor, freeze for a few seconds, and then throw herself on the floor, wringing her hands. She was suspicious of the medication offered to her and would spend minutes looking at the tablets and at the nurses offering them. On one occasion she pointed out that the staff were not real.
The Mental Capacity Act was used to treat her without her consent, as she did not object to having the treatment but had no capacity to make the decision.[1] We set up Catherine’s first treatment as soon as possible. She lay down on the bed without saying anything and vacantly watched the nurses attaching wires to her body: ECG to the chest, EEG to the forehead and behind the ears, a blood pressure cuff to one arm and a pulse/oxygen meter to a finger. When everything was in place, Magdi, our consultant anaesthetist, inserted a needle into a wrist vein, and put an oxygen mask over her face. The monitor soon showed 100% oxygen saturation and Magdi injected 350mg of Thiopental into the vein. After just a few seconds, Catherine’s eyes closed.
‘Open your eyes,’ Magdi said, to make sure she was asleep. Her eyes remained closed and there was no reaction to him stroking her eyelids. She was ready to receive Suxamethonium, a very short-acting muscle relaxant, which would prevent her from contracting her muscles during the seizure, to avoid injuries and muscle aches. During the next minute we kept watching out for the tiny twitches in her muscles that indicated that the muscle relaxant had found its way to the myriads of neuromuscular junctions where the nerves meet the muscles to relay the instructions for movements. After the twitches were over (the correct name is fasciculations), she was ready. Kara, our lead nurse, put a soft mouthguard between Catherine’s teeth, to prevent them from being damaged, as the jaws clench strongly, even with muscle relaxation. The junior doctor placed the two electrodes over Catherine’s temples. ‘Impedance is fine,’ pronounced Kara (the machine had performed a test of the impedance, i.e. the resistance to the electrical current caused by the skin and the skull, and a green light indicated it was within the right range). ‘Happy to proceed?’ she added, checking that I didn’t have any objections to the precise placement of the electrodes over the patient’s temples. Everything was fine, so I nodded encouragingly.
At the first treatment, we want to establish the seizure threshold, i.e. the minimum amount of electricity required to elicit a seizure, so that we don’t give patients an unnecessarily high dose. Today we started with 126mC of electric charge,[2] higher than usual, as we took into account that both her use of Diazepam and her age (over 70) would make her somewhat resistant to seizures. (Diazepam is even used to stop epileptic seizures and always interferes with ECT treatment.) Kara pressed the yellow button on the ECT machine, and a warning noise sounded while the electric charge was delivered. Catherine’s jaws clamped, and tiny muscles convulsed around the eyes, the forehead, and the cheeks, resulting in a grimace. Her fists clenched and the arms were slightly flexed at the elbows. While patients are given muscle relaxants to protect them from convulsions which are too forceful, we do want to see some muscle movement during the seizures, in order to assess the seizure quality, so we ensure the dose is not high enough to completely paralyse the patient. After 1.5 seconds the noise stopped, and Catherine’s face and arms immediately relaxed. The clenching of the muscles during the delivery of the electric stimulus was not a seizure yet. In ECT, the direct effect of the repetitive electric pulses on the neurons in the brain should provoke a seizure, where the neurons start discharging spontaneously and in concert, a few seconds after the stimulation. We were watching intently for the repetitive symmetrical twitching of the muscles that should follow the electric charge. Not a muscle moved. I glanced at the EEG traces. Sometimes the patient’s muscles are too well paralysed, and we can record a seizure only by the electrical activity in the brain. The trace showed a nearly flat line, with minuscule fast see-saw flickers, typically observed in a sleeping person. After about 20 seconds somebody stated, ‘No fit,’ and everybody nodded.
‘Shall we restimulate?’
Kara asked me for approval, having already prepared the machine for another stimulation. Up to two re-stimulations can be administered according to our protocol but only if the patient is safe. The monitor showed an almost unchanged and regular heart rhythm, the oxygen saturation had remained at 100% and Magdi was giving Catherine some extra oxygen, to make sure the level stayed there. There was nothing to worry about, so I said ‘Yes’ in a reassuringly loud voice, to emphasise the lack of any concern. The second stimulation was at 184mC. The initial muscle twitches were much weaker, with the face muscles even more incapable after their feeble attempts to contract at the first stimulation. But after a few seconds the arms and feet started twitching, first almost imperceptibly, like a nervous shaking, then more clearly, in coordinated twitches that continued for 48 seconds. This was a good seizure and it was backed by a clear pattern of generalised tonic-clonic seizure activity on the EEG, which stopped soon after the muscles stopped twitching.
At the second treatment, three days later, we gave Catherine a higher electric dose, 253mC, as we need to treat patients with doses well above their seizure thresholds. Her further treatments were uneventful: she had good seizures throughout, and didn’t need any changes in the electric charge.
After four ECTs, given twice a week over two weeks, Catherine was still depressed but her reasoning had improved to the extent that she was able to think clearly about her illness. At that point she noticed that the treatment was helping her and signed a consent form to continue with ECT.
It was Catherine’s seventh session. I arrived at the department early in the morning. My first action, as usual, was to stick my head into the waiting room for a quick feel of what was going on. An unusual sight presented itself: somebody was reading one of the posters on the wall. It was Catherine. Instead of looking aimlessly around, slumped in a chair, as I remembered her on the previous occasions, she was reading the small typeface of an article that we had displayed proudly in the waiting room. I approached her, trying to hide my joy and surprise. The poster was an article on ECT that had been published in a newspaper. It was one of the rare positive accounts of ECT, even though the central photo showed, as usual in an ECT account, Jack Nicholson on the psychiatric ward in the film One Flew Over the Cuckoo's Nest. Catherine looked back and smiled at me with a soft and charming smile, that suited her face and seemed to be her natural expression.
‘Interesting article, and they mention you.’
I had indeed been interviewed for it - that’s why we had displayed the photocopy in such a prominent place! I was even more stunned by this level of attention and interest from a person who had been unable to think clearly a week earlier. She was feeling well now and agreed that ECT had helped her. The memories of her illness were patchy. She was bemused to hear that her speech and her movements had been slow and that she had insisted that she could not get better. The suicide attempt felt strange and inexplicable to her and she showed no interest in discussing it, beyond admitting that she knew the femoral artery would be the biggest one she could get hold of. She tried to describe how she had felt: ‘Deep despair, depression, sadness, befuddled.’ ‘Befuddled’ was a new word for a non-native speaker like me – ah, the joys of the English language! She was so impressed by her transformation that she was writing notes about her experiences. I wanted to hear the acknowledgment again. Did she appreciate how much she had changed? Did she really attribute this to the ECT?
‘So you are surprised by how well you are responding?’
‘I am shocked!’
The smile confirmed the joke.
I explained that we should now space out the treatments, instead of stopping them suddenly, in order to reduce the risk of relapse. She found the idea very sensible. I mused why a patient who had been psychotic until a week ago found this idea sensible, while so many sane people, and even some professionals, didn’t. Only 15 years ago the official guidelines suggested that ‘treatment should be stopped when a response has been achieved’.
Catherine had four more ECTs. She became so ebullient and full of energy that somebody on the ward worried that she was becoming manic - she was painting her toenails for the first time in many years, for goodness sake! I wasn’t so sure there was anything to worry about, although this can indeed be a side effect of ECT. When you come out of Hell, you can be excused for feeling excited about life. Where does happiness end and mania or illness start? At what point does elation spill over into excess? Mood normally goes up and down in response to events, and it must be a great feeling when the joy of being well again kicks in. Was it abnormal that Catherine wanted to get a car or plan a holiday? No, I argued, this was not mania. She had made a complete recovery, and was back to the bright, happy person she had been previous to her depression. But there was no need to continue with ECT and everybody agreed that it should be stopped.
Catherine started taking Lithium and remained well during our one-year follow-up period. She even volunteered to speak publicly about her experiences with ECT, a brave offer that will be taken up. If every ECT course was so straightforward, and every patient recovered, there would be less controversy over this treatment. And I wouldn’t have much to write about.
[1] Patients who lack capacity to consent, but appear to adhere to the treatment, can receive ECT under the Mental Capacity Act. It is preferred as the less restrictive option, compared to sectioning under the Mental Health Act, in terms of the patient’s freedom.
[2] mC = millicoulombs, a measure of electric charge. ECT machines in the UK are set to deliver between 10 and 1152mC. There will be more discussion on electric charge in this book, so you just need to keep reading.
