ECT Strikes Again.

Time to strike back

In a surprising turn, the ABC has just published an article on involuntary ECT which actually includes critical comments by patients. It starts with the story of Rebecca, a patient who strenuously objected to ECT but got it anyway and was left with significant side effects. The article then quotes the RANZCP:

ECT was one of the most effective treatments for severe depression and other serious mental illnesses … "For people who are suffering and where nothing else has worked, ECT can quite literally save a life.”

Where nothing else has worked. Rebecca’s story continues: “Shortly after admission, she was placed under a treatment order and told she would receive ECT.” It tends to suggest that nothing else had worked as they hadn’t tried anything else which, strictly speaking, is not an outright lie. Later, the reporter quoted Dr Colleen Loo, of Sydney’s University of NSW, whom we met last week in connection with using ketamine for depression. She is a former president of the International Society for ECT and Neurostimulation, so she is not exactly neutral on the topic:

Dr Loo said ECT was more beneficial for patients who lack capacity, pointing to a Singaporean study of 175 recipients … those lacking capacity showed greater improvements in mood, functioning, and cognition, although patients were only monitored one to two days after treatment. Similar studies had not been conducted in Australia, Loo said, because research on those unable to consent would "be a nightmare to get any ethics committee to ever agree".

There are no accurate figures for this country but at least 1,700 people are subjected to involuntary ECT each year, with the actual figure probably much higher. Each state has its own mental health act but they all now require psychiatrists to apply to a mental health review tribunal (MHRT) for approval to give involuntary ECT. Tribunals have three members, a lawyer as chair, a “qualified” lay person and a psychiatrist. The lawyers know nothing about mental disorder or psychiatry and are only there to see all the legal boxes are ticked. They don’t consider things like “Does this psychiatrist know how to take a proper history? Has s/he asked the important questions?” They don’t ask how the psychiatrist arrived at the diagnosis or, indeed, whether it’s correct, only that a diagnosis has been reached. The community member is somebody who has an interest in mental disorder, usually because a close relative is/was disturbed or had a bad outcome. Again, they only know what they’re told. In particular, the psychiatrist members are committed to the idea that involuntary treatment is good, and ECT is good, so patients who object are obviously severely mentally ill and require more treatment, not less.

As a result of this inbuilt bias, tribunals rarely refuse applications for involuntary ECT. Even if patients knew they could appeal that decision, and had the resources and awareness, there is very little chance of an approval being overturned. The reason for this unanimity is simple: the system looks after itself. In the first place, critics of mainstream psychiatry will never get a seat on the tribunal, and secondly, tribunal members only ever hear one point of view, the mainstream narrative. We saw this a couple of years ago. While reading a Queensland MHRT annual report, I saw that its members had been given an educational talk on ECT. Curious as to who had said what, I asked for a copy of the lecture. No way, said the president of the tribunal, you can’t have that, it’s secret. Now that’s rubbish: everything the speaker said has to be in the public domain. They’re not allowed to say anything that hasn’t been verified a thousand times over.

However, we don’t need to see the lecture to know who said what about ECT. With a warm and benevolent smile, one of the city’s many shock-jockeys, who makes a fortune from it, said: “ECT is the most wonderful, essential, life-saving treatment and patients are always grateful for it so nobody should be denied it, especially when they don’t want it.” What the devoted members of the tribunal weren’t told was this: There are places in the world where ECT is banned, and plenty of places where it’s severely restricted or simply not available, yet all those places manage to cope without it. Even where it is used, rates vary enormously from one city to the next, and even within cities. The main factor that decides whether patients will get ECT is financial: can they afford it? BTW, over the past 30 years of so, ECT usage in the England division of UK’s NHS has declined by 90%. Just thought I’d mention it (all figures are in [2]).

Finally, the psychiatrist told the reporter: “…where nothing else has worked, ECT can quite literally save a life.” In the first place, I don’t believe it. Even working alone under the most trying conditions in remote regions, I never used ECT. If I could manage without it, so can all these clever psychiatrists in their luxury offices in the cities. Second, why did it get to the point where the patient is on death’s doorstep? The answer is they didn’t try anything else just because they didn’t know anything else. Psychiatrists who use ECT don’t start with the notion that mental disorder can be fixed by talking, they are ideologically committed to the idea that it’s all biological. What they mean is: “We’ve spent several years trying her on different tablets and they haven’t worked so we’d better give her ECT before she tops herself.” They don’t say: “Hmm, looks as though our drugs have failed, why don’t we ask a psychotherapist?” The idea that their “treatment” could fail simply does not occur to them, it’s outside their comprehension.

We see this in the report from Singapore that Dr Loo quoted (I’ve emailed her for the reference but don’t expect a reply). She said the patients were followed up for one to two days. Is she real? Does she expect people to be impressed by that “evidence”? That soon after ECT, patients are still wandering around stunned, what they say has no weight. If one of them rang to order a new car, the hospital would immediately say s/he was in no fit state to make that decision. But more to the point, what does she expect them to say? “No, I don’t feel any better but you’ve left me with a huge headache and messed with my memory.” A patient who says that will be stuck in hospital indefinitely and will almost certainly get more.

Dr Loo is an associate professor at UNSW. She knows perfectly well you cannot put any weight on a study that had only 1-2 days follow-up. More importantly, she also knows that any form of treatment must be studied properly, and this applies a fortiori to involuntary treatment. Her claim that it hasn’t been studied in Australia because it wouldn’t be possible to get ethical approval is rubbish: if nobody knows how effective it is, then why is it used? It hasn’t been studied because the people who give ECT have made up their minds and don’t want facts to get in the way. Most emphatically, they don’t want the opposite view to get any air time so, instead of hard facts, what you get is unjustified opinion: “ECT can quite literally save a life.” So can talking to the patient but, in fact, ECT doesn’t save anything. Apart from running up costs, it has no effect.

ECT was invented in Italy in about 1938 and spread rapidly from there. In the 1960s, psychiatry in Italy was in a scandalous state so, after considerable research and public debate, the ancient mental hospitals were gradually closed and replaced with community and local services. The main law was passed in 1978, known as the Basaglia Law after its prime mover, and part of it said that ECT had to be phased out. In 1999, private ECT was banned, which immediately led to predictions of disaster:

[In Italy, ECT] may now be administered only as an emergency procedure in government hospitals after other treatments have failed and if the patient is in a “life-threatening” situation. Because of politically based conflicts, the use of ECT in Italy was already among the lowest in the European community; the new regulations now threaten the very existence of this truly indispensable treatment in the land of its birth [1].

In 2014, 91 hospitals in Italy (population 59million) were authorised to use ECT but only 14 actually did. The great bulk of Italians do not have access to this indispensable, life-saving treatment. Perhaps that’s why, during the Covid lockdowns, Italians spent their time singing to each other from their balconies, apparently unaware that they should have been throwing themselves off them.

There is no evidence whatsoever to say that ECT saves lives, or is indispensable, or even effective [2]. End of story. What should be a scientific question has become a matter of ideology where people who are paid to give us the right scientific answers simply dish up propaganda that suits their interests. But times are changing. The UN Convention on the Rights of People with Disability (CRPD, from 2006, which Australia has signed but the US has still not ratified) specifically states: “Article 15(1): No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment” [3]. It goes further, as the recent WHO Guidance on Mental Health Policy makes absolutely clear:

… over the past fifteen years, new perspectives have been emerging, encompassing a shift from a primarily biomedical focus toward approaches that are more person-centred, recovery-oriented, and grounded in human rights (p1) … Coercive practices such as involuntary admission, involuntary treatment, seclusion, and the use of physical, mechanical, or chemical restraints are widespread in mental health services globally. However, there is no evidence that these practices offer any benefits, while significant evidence shows they cause physical and psychological harm, dehumanization, trauma, and worsening mental health, as well as eroding trust in services [4, p4, emphasis added].

No evidence. There is no evidence to show that depriving people of practically the whole of their human rights by locking them away indefinitely, stripping them of their clothes and identity, and forcing them to take drugs or treatment they don’t want and often regard as torture and that shorten their lives, no evidence that this actually works. Nobody has ever shown that the benefit to the individual and to the larger society outweighs the (immense) cost in both dollar and moral terms. Anyway, it has to end. According to the same rules-based international order that our governments are always braying about, all coercive treatment is to be phased out.

We can, however, be sure that the transition to a “humane, person-centred, recovery-oriented” psychiatry will not be led by psychiatrists. History leaves no doubt that any change which seems to threaten the profession’s status, power or incomes will be resisted fiercely [5, 6], not least because psychiatrists won’t be fighting alone. Behind them, urging them on and handing them all the resources they need, stands Big Pharma, fighting a battle to survive. When society realises that endlessly pouring ever larger doses of ever more powerful drugs into our mouths is actually producing the surge in mental disorder, then the drug companies will all have to get honest jobs, like developing vaccines before they’re needed. A quarter of the world’s children go to bed hungry, yet today’s biggest selling drugs are for losing weight.

The issue of involuntary treatment has to be moved from the shadows to centre-stage. Do we, as a society, have the right to take people who have broken no laws, lock them in terrible places, deny them practically every human right, and force them to take dangerous and seriously unpleasant “treatment” against their will? All the so-called hard-headed researchers will say: “We only look at the science, we don’t impose any moral values on practice.” First, that is in fact a moral decision. Choosing to avoid the complex moral issues is a moral choice, which they have never justified – and can’t. Second, there is no hard evidence to show that this process achieves the goals people imagine it should. My view is that in the absence of any valid scientific and moral arguments, the practice cannot continue, its only justification is tradition, as in: “That’s how it’s always been.” That argument, however, carries no weight. It doesn’t work for countries that practice female genital mutilation, or duelling, or child labour, or suttee, or stoning gay people, or torturing animals and so on, and it doesn’t work for treating our most miserable and vulnerable citizens as though they’re dangerous animals.

We should all, however, be grateful that the ABC actually carried this article. It wouldn’t have happened a few years ago, and I’ll bet they’ve had lots of complaints from “concerned psychiatrists” about publishing “hostile antipsychiatry” material. The last thing mainstream psychiatry wants is to lose control of the narrative. That means now is the time to push back.

References:

1. Abrams, R. (2000). Use of ECT in Italy [Letter]. American Journal of Psychiatry, 157, 840.

2. McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104. DOI: 10.1891/1559-4343.19.2.91

3. UN OHCHR (2006) Convention on the Rights of Persons with Disabilities. 12 December 2006, Sixty-first session of the General Assembly by resolution A/RES/61/106. https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-rights-persons-disabilities

4. UN OHCHR/WHO (2023): Mental health, human rights and legislation: guidance and practice. Geneva: WHO/UNHCR. https://www.who.int/publications/i/item/9789240080737

5. Scull A (2022) Desperate Remedies: Psychiatry and the mysteries of mental illness. London: Penguin.

6. Harrington A (2020). Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness. New York: Norton.

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