Electroconvulsive therapy endures

MICHELLE COOKE

Margaret Parry cannot remember anything about her childhood. "I used to try desperately to remember, because I didn't want to lose my memory, but you couldn't stop it," she says.

Parry, 74, was 18 when her mother first took her to Porirua Hospital to try to straighten her out.

"I was a troubled teenager and I had a bad home life and I didn't have the love I needed as a child. My mother didn't know what they were going to do with me.

"I did need help, but not that kind of help."

She needed to talk to a therapist, but they weren't really around in the 1950s, so 45 courses of electroconvulsive therapy, or ECT – by which an electric shock, or a stream of electrons, is sent through the brain to evoke a seizure – were forced on her.

She is one of several people to have filed claims against Porirua Hospital for abuse, but says the courts would not look at the use of ECT on her "because it's allowed".

"It handicapped me. Before I had it, I felt normal, like everyone else, and afterwards I didn't feel whole, completely washed out. I was incapable of doing anything and couldn't talk to anybody any more."

Parry, who now lives in Waikato, has recovered enough to marry and have three children, but, since having ECT, she has always struggled with memory and concentration.

"I've never met anybody who said it helped them, and I've met dozens of people who have had it. They all said how terrible it is.

"I can't believe it's still happening today. I'll never be happy until it's banned."

Rae Chalmers, of Wellington, says the treatment she received 20 years ago helped her get over her depression when she was at a critical stage, "but it would only last a day, and then I'd have to have it again".

Chalmers, 75, says it helped her on the road to recovery, but medication had kept her on the steady path.

The women's experiences are reflective of a continuing debate about the need for the treatment, with clinicians and experts also divided over the merits of ECT.

Psychiatrist Pamela Melding and psychologist John Read are on opposite ends of the spectrum when it comes to the therapy.

They do agree on one thing: that clinician inclination (whether your psychiatrist is a fan) plays a big part in who gets the treatment.

Of the 200 people who have an average of between four and 12 courses of ECT each year, between 40 and 60 are in the Canterbury region, with only five from Auckland. Canterbury is followed by Otago, Waikato and Waitemata.

The number of patients has fallen by about a third since consent became compulsory in 2006, but 15 to 20 per cent of those who have ECT are deemed too unwell to consent, so the decision is made on their behalf, with input from psychiatrists, family and the Ethics Committee.

Women receive ECT nearly twice as much as men do, and elderly women receive the most. Reasons for this could include loneliness and isolation, specialists say.

It is given to patients who are suicidal, not eating or drinking, chronically depressed and who have sometimes tried several courses of antidepressants and therapy.

Dr Melding believes the results far outweigh the adverse effects.

ECT is used more often in the South Island because there are more beds and "there's a lot of clinician interest", she said.

Smaller district health boards (DHBs), such as South Canterbury and West Coast, which do not perform ECT, refer patients to the Canterbury DHB.

Melding administers ECT through the Waitemata District Health Board, where she works.

Auckland does less ECT because of a "clinician factor", she says.

Read, an Auckland psychologist and researcher at Auckland University, says the geographic differentiations are important.

"They've been there for a long time and they're huge. So that tells you that in any district health board it only takes one or two psychiatrists who are very keen on ECT.

"Your chances of getting this quite dangerous and ineffective procedure are quite arbitrary."

Auckland DHB confirmed the difference was because of "the prescribing practices of individual clinicians who refer patients to us, rather than any capacity issues".

Dr Richard Potter, of the Canterbury DHB, says it is unfair to compare the rates of ECT use throughout the country.

"Administering ECT is based on clinical needs and patients choosing to have it. It also depends on how often it is offered, which depends on a patient's clinical history."

ECT has survived attempts to have it halted altogether. A petition calling for it to be banned in the late 1990s sparked an independent review which led to the government adopting several recommendations.

THE Health Ministry began to issue annual reports on ECT and decided the treatment would no longer be given to people who did not consent, apart from those deemed too unwell to do so.

"It makes sense, doesn't it?" Melding says. "Why are you going to treat people with ECT when a pill is going to fix it?

"But there are some patients where you're not going to wait, because it's too dangerous to wait. These are patients whose depression is so severe they're catatonic, melancholic – they can't eat or drink or do anything."

It is a short-term solution and is often followed by a course of antidepressants, which can take weeks to work.

A stream of electrons is sent through the brain to evoke a small seizure to shock the patient, a practice that Dr Read says "burns out the brain cells".

Cognitive therapy is the best therapy for depression and it is much safer than ECT, he says.

"None of the follow-up studies [on ECT] that follow people for a week, month or a year show there is any benefit, and that wouldn't matter if there wasn't a horrendous set of adverse effects."

Psychiatrists who administer it acknowledge memory loss is possible, but say it usually comes back.

But others claim they were not advised of the way ECT could affect their memory before they were given it and say whole chunks of their childhood were missing after treatment.

Read says he knows many people, like Parry, who have had ECT, found no benefit from it and then "discovered there are chunks of their lives missing".

"If you tell people there is a pretty good chance you're going to have parts of your life missing, then who is going to sign up for it?"

But Melding says many patients consider it the lesser of two evils. "We have patients who say it's choice really: `If I've got a little bit of a memory problem as opposed to depression, then I'll take the memory problem'.

"It does shake your memory around and it's logical that it does, as ECT releases neuro-transmitters and those neuro-transmitters are not only important in mood, eating and drinking, but they're also important for your concentration and memory. But depression itself knocks those things around."

Memory returns within six weeks after treatment for 95 per cent of patients, but "it might take a bit longer" for the other 5 per cent, she says. The greatest risk was to people with cardiovascular problems, but this was monitored and considered before treatment. Muscle pains, ringing in the ears, headaches and nausea are other adverse effects.

Melding says ECT has changed dramatically since the late 1930s, when it was invented. It was widely used throughout the 1940s and 1950s, when there were few alternatives. Patients weren't given anaesthetic or muscle relaxants and the dose of electricity they were receiving could not be measured.

Patients now sleep during the procedure, which involves sending up to 540 millicoulombs of energy through the brain, and the process is over within minutes.

"In the old days, before we used muscle relaxants, people used to break bones and teeth," she says, "but now they're relaxed."

The treatment is controlled by a computer, as opposed to a machine with dials and wires.

The ministry's acting director of mental health, Susanna Every-Palmer, says there are historical cases of ECT abuse, including it being used as a punishment.

The number of people receiving ECT has declined and it is typically given only to those who consent.

"Someone who wouldn't be able to consent is the type of patient who is mute, unable to communicate and unable to engage. Anybody who can say `Yes, I hear and understand what you're saying' – that person basically has capacity."

Every-Palmer says New Zealand's rate of ECT is relatively low compared with other countries, such as Australia and Britain, which have about five times the amount of use per person.

Melding says the treatment works for 70 per cent of patients, which is "as good as the best treatments in medicine".

The only reason it is still being used is "because it works", she says.

Read disagrees and believes its decline is a signal that it will be gone in 10 to 15 years.

"We will look back on ECT as we now look back on lobotomies."

* Clarification: Due to an editing error, Margaret Parry was referred to as Margaret Perry in an earlier version of this story.

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