The thriller Homeland reached its denouement in the UK at the weekend – in an Electroconvulsive Therapy (ECT) scene. Claire Danes, a Homeland security agent supposedly taking Clozapine to contain her paranoia has to distinguish reality from psychosis to save the United States (see Homeland Security). Quite obviously to anyone who knows anything about Clozapine, she was not taking it. She is having ECT, which you are expected to think will wipe her memory, when she solves the plot. Quite obviously to anyone who knows anything about ECT, this is not a reliable way to wipe her memory – giving a benzodiazepine at the key moments would have been much more reliable.
A true story?
Homeland adds to a growing list of psychiatric treatments featured as characters in plots. While inaccurate it does not portray ECT as horrifically as Clint Eastwood’s The Changeling, which starts with a clip saying it is a true story – not just based on a true story. The Changeling portrays the horrors of psychiatry as they have been since One Flew over the Cuckoo’s Nest – through involuntary ECT – even though the heroine’s incarceration happened 10 years before ECT was invented.
The only explanation for getting the history so wrong in a “true” story is that ECT inflicted in this way clearly epitomizes fears about psychiatry. But forced treatment with ECT is vanishingly rare. In practice insiders, staff and patients, are more likely to fear forcible and indefinite medication with long-acting antipsychotic injections – a treatment that is more clearly brain damaging, memory disturbing and likely to turn a person into a zombie than ECT.
Pharmacological abuse
In terms of the greatest amount of damage done to the greatest number of people, the real abuses, the real dramas, lie in primary care treatment with prescription only drugs like the antidepressants, statins, asthma inhalers and other drugs. Where ECT given punitively, as has happened in the past, might be compared to rape, something closer to sexual abuse or sexual harassment happens with prescription drugs (see Pharmacological Abuse).
The psychiatric detention or treatment papers aren’t in evidence when we are prescribed a prescription drug. We are free to walk out the door after a consultation, and we think as a consequence that there is nothing to worry about.
But prescription links us inescapably to a prescriber. For most of us, going to the doctor is like going to the bank manager or the head teacher – we feel a few inches tall, absurdly grateful for the smallest signs of favor, and often completely forget what we had meant to say. If things begin to go wrong after treatment starts, the doctor may quickly seem like our only way out. We become ever more dependent on him, and grateful.
Stockholm syndrome
We head into a medical version of Stockholm syndrome – the puzzling state where hostages are often close to being in love with those who have taken them hostage. If the difficulties we develop are caused by the treatment and the doctor doesn’t recognise that what he is doing is wrong for us, we become hostages to fate.
It can be extraordinarily difficult to distinguish between the anxieties, insomnias, and morbid thoughts that treatments can cause even in healthy volunteers and the anxieties, insomnias and morbid thoughts stemming from the problem we took to the doctor in the first instance. It is effortless for the doctor to blame any worsening on our original problem, rather than his treatment. With much less going for them, surgeons blamed the victim faced with the evidence of memory problems after cardiac surgery, and psychiatrists routinely blame patients hooked on antidepressants or tranquilizers or who get diabetes from antipsychotics.
From stigma to reprisal
We can become isolated astonishingly quickly. If we approach someone for help in the case of an antidepressant, we have to risk the stigma of being seen to have a mental problem and then also risk being stigmatised as a loser. We risk incomprehension – even if we approach mental health professionals, none of whom are likely to side with us rather than the doctor. We risk having our next prescription increased to treat our illogical thinking. No one will call this a reprisal. If for some reason, we are listened to and treatment stops and we get worse, no-one is likely to counsel patience to help see us through what might well be a withdrawal syndrome.
Our questions will be put in the weighing scales… and found wanting
Our questions will be put in the weighing scales against the scientific answers and found wanting. There is no-one on our side who is likely to point out that the so-called scientific evidence has been carefully constructed by companies, who suppress trials that don’t suit their interests, and who selectively publish data from trials so that even a trial that has shown a drug fails to work and can trigger suicide can be transformed into a trial that shows unparalleled evidence of efficacy. No one to point out that pretty well all the trials published in even the best journals are likely to be ghostwritten. No-one to point out that lawyers and others looking after the interests of pharmaceutical companies regularly take advantage of medical innumeracy to hide even more dead bodies by constructing trials so the results will not be statistically significant.
As in other areas of abuse, if we wait for the abusers to recognise the problem we are likely to wait for ever. As in so many other areas from Enron to sexual abuse, it is likely to be women who will blow the whistle.
Dying for a cure
Rebekah Beddoe’s 2007 book Dying for a Cure does this. Following a post-partum depression, Beddoe outlines a drama of seduction, increasing personal confusion, family bewilderment and finally survival against the odds.
Dying for a Cure calls out for a movie to be made of it – but we are likely to be waiting a long time for Clint Eastwood or a future episode of Homeland to take on this challenge. What stops them? In contrast to The Changeling, the problems found in Dying for a Cure are ones in which we are all complicit.
If directors are not prepared to take on the challenge, as a matter of honor they should desist from making movies like The Changeling, which by picking out the wrong villain play a part in perpetuating the kinds of abuse that makes medicine induced death possibly the leading cause of death in the Western world today.
Dr Healy,
You write: “But forced treatment with ECT is vanishingly rare.” I wish I could agree. The young man I wrote of elsewhere, who eventually committed suicide was given, against his parents’ wishes, as a first treatment, eight or nine ECT treatments that served only to worsen his condition. My theory about this particular case is that the young, inexperienced psychiatrist who “treated” him, to my certain knowledge, did her residency under an individual who seldom prescribes anything for young in-patients other than ECT. This type modeling/teaching is probably the principal cause of styles of prescribing.
In the case I described, this was followed by forcible “treatment” with antipsychotics although he never displayed the slightest sign or symptom of psychosis.
How many physicians can be expected to acknowledge that their treatment is causing harm when the prescription pad has become the primary treatment modality and the psychiatrist’s raison d’etre? It is the rare psychiatrist who remembers that, first and foremost, he/she is a physician and, while respecting the art of medicine, it is fundamentally a science. As scientists, we are obliged to seek evidence to disprove our null hypotheses not look to manufacturers’ “data” to lend support to an already shaky construct.
You write: “As in so many other areas from Enron to sexual abuse, it is likely to be women who will blow the whistle.” I would agree but let’s not forget the source of the word “hysteria” and the power it still has to shut women up. I have known two young, female physicians commit suicide, one with her baby, in the throes of post-partum depression, and the dreaded “hysterical” was used even by their colleagues. I am so opposed to the continued use of this term that I insist on referring to “uterectomy” rather than the procedure’s commonly used name.
I had a friend who was misdiagnosed as schizophrenic as a young man in London many years ago and was subjected to insulin shock therapy. His description of being brought close to death by insulin injection then shocked back to life was harrowing and he told the story only after sitting down to breakfast with my family, catching sight of a box of corn flakes and having to rush off to vomit. When he came back, white and shaking, he apologized and explained that he couldn’t bear even the sight of corn flakes because after the insulin shock,performed always first thing in the morning, breakfast was always – you guessed it.
“Dying for a Cure calls out for a movie to be made of it” – but where does the money to make movies come from? And are we so naïve that we can’t recognize product placement in books and films?
“Medicine induced death (is) possibly the leading cause of death in the Western world today.” I agree and although suicide is the most obvious, the greater number of deaths is due to serious physiological damage to the most vulnerable – the very young and the very old.
It is my sincere hope that one of these days, and may it be soon, we will look back on the current situation with the same horror that insulin shock evokes. But, I’m not holding my breath.
I am hearing here and there from patients whose doctors, stumped by their prolonged antidepressant withdrawal symptoms, suggest ECT, apparently in what we in the States would call a Hail-Mary play, a wild throw hoping to score.
So apparently it’s still there for any US doctor who wants to experiment with it on a patient.
I agree in Homeland the ECT sequence was used for maximal Gothic effect to heighten Carrie’s victimization by “the system.” The script also did not address the consequences of her taking clozapine inconsistently, which might trigger bizarre symptoms, mania, and even violence in the most stolid of patients.
But that might have been realistic — not many psychiatrists would have recognized the possibility of withdrawal symptoms. Many people with adverse drug reactions are escalated to ever-more aggressive treatment until they are reduced to a proper state of acquiescence.
(I have the same problem with Homeland as I had with Silence of the Lambs. I simply do not believe intelligence services would hire those trembling, delicate flowers as agents.)
Dr. Healey,
You write “But forced treatment with ECT is vanishingly rare. In practice insiders, staff and patients, are more likely to fear forcible and indefinite medication with long-acting antipsychotic injections – a treatment that is more clearly brain damaging, memory disturbing and likely to turn a person into a zombie than ECT.”
I know you are a proponent of ECT, but like everyhing else to do with psychiatry, there may be more going on with ECT than pointing to Hollywood caricatures of forced treatment to show people how naive we are. You say it isn’t forced, but what if, like meds, there is not full disclosure when ECT is being urged as a treatment? Certainly, my experience at CAMH in Toronto, hints at this. My son was admitted to the hospital at the age of 19, put on Rispirdal, and a mere month later fell into a deep depression, which lasted about a week. The doctors told me that if he didn’t snap out of his depression, they were going to administer ECT. My son and my husband and I were treatment naive – what did we know about the drugs let alone any controversies concerning ECT. One might say we were being taken advantage of for the benefits of a teaching hospital. Naive parents will sign anything, won’t they, when the doctors are fear mongering (to quote another of your posts)? There are enough people who claim that their memories have been wiped out to some extent or another that their claims should be taken seriously, and brought up in the course of any suggestion of electroshock treatment. I also was under the impression that ECT is given as a last resort after continuous and severe depression. In my opinion, the doctors did not try a first resort (no drug empathy) and someone of 19 years of age who has not had a history of continuous and severe depression, but had understandable situational depression, should not have been considered a candidate for electroshock, no matter how innocuous you claim it is. As it happens, his university chaplain visited him, held his hand and empathized, which I believe lifted his depression in time to avoid ECT.
Rossa
I am a proponent of nothing except people’s ability to get a treatment that might help them when they need it. I wish no-one needed any of these treatments, but in practice we do need them.
There is almost certainly greater disclosure with ECT than with the meds, but still there will be abuses with ECT. Whatever about the abuses, there are roughly 10 people per 250,000 people in this region who get ECT per year (1 without consent – 9 with what may or may not be reasonable consent). There are between 10,000 and 20,000 on psychotropic drugs per 250,000 – almost none of whom can have given proper consent. The issue isn’t does ECT cause harm; its whether ECT or drugs are a better symbol of the problems we are faced with in terms of disclosure and the sheer volume of people affected. These problems extend to other prescription drugs also.
Nope. There is no “greater disclosure” and, given that electroshock trauma/terror ALWAYS causes brain damage, it is not an “option” or something anyone human “needs”.
Because doctors like you minimize the injuries produced by shock (blame it on those benzos even when every survivor testifies to the stupidity and invalid nature of that red herring; gee, why did I have a perfectly fine memory before ECT, even with some benzo use causing the odd blip) people believe the propaganda and lies about “safety and efficacy”.
I would rather eat benzos for a year or take a few months of anti psychotic meds
than destroy my memory and cognitive abilities by having some clueless and indifferent doctor supply me with multiple closed head injuries and call it a “healing option”.
So only 9 or 10 people were assaulted? That makes it better? Shouldn’t all forms of definitive harm be banned.
Alto is correct in stating that most victims of ECT
(most of them women, often without an advocate who is truly informed)
become “victims” of unrecognized iatrogenic insanity or subsequent drug withdrawal. This makes the situation even more frightening because of the huge numbers of people on these neurotoxic drugs.
ECT is a barbaric assault/human rights violation. No one is told or “informed” that the procedure produces brain damage before they “sign”.
Take a break from the drug education; the message is getting out there big time.
Focus on some real research on the damage inflicted on innocent people through ECT. Read the science. Believe the victims. If you hear a story about a victim of psych drug poisoning, do you challenge them and tell them they are mistaken or lying?? Why not approach ECT survivors stories with the same amount of credulity??
It is time to ban ECT. The risk outweighs any minor transient and short lived benefit. And, if there is still some need to pretend to “do something”, apply “sham” ECT. Same efficacy and recovery rates, but zero the brain damage.
I would really appreciate a response, even late as this post is.
Diane
Its great if we can treat people without intervening. When we do intervene medically then its with poisons and mutilation and often just the doctor can be toxic and dangerous. The art is to bring some good out of the use of a poison or mutilation and to ensure the relationship is not dangerous. The key thing is the relationship not the poison or the mutilation. I have never called for any drugs or procedures to be banned. As regards ECT, I tell people of the risks and when people outline problems afterwards I confirm that there are problems but lay out the fact that the meds they are on may be contributing to those problems. ECT almost certainly causes some problems – even some problems that people aren’t clearly aware of and don’t complain about – but many of the problems people are aware of are more clearly linked to their meds than to ECT. Psychiatry can be very damaging but surgery and cardiology can be too – the best bet anyone has of achieving the benefits that can come from these sources is if they are in a relationship with a doctor who is vigilant about the risks and very aware of the harm that can be done. There are many many people who have been terribly damaged by ECT but a great part of the damage comes from the system not the treatment. Its the system that assaults us not the treatment. Sherwin Nuland’s TED talk on ECT makes a good case why as things still stand today its better have the possibility of ECT than not.
David
I fear the problem keeps on coming back to the wetware — the clueless humans who are running the machines as well as the prescription pads.
As Albert Einstein said “It has become appallingly obvious that our technology has surpassed our humanity.”
Let me also say that “treatment-resistant depression,” which supposedly justifies resorting to ECT, these days is often an iatrogenic result of overmedication and withdrawal syndrome.
While Googling for something I remembered about ECT machines having inconsistent voltage and being poorly maintained, I found a review in Clinical Psychiatry News about this very episode of Homeland http://www.clinicalpsychiatrynews.com/index.php?id=2407&cHash=071010&tx_ttnews%5Btt_news%5D=94452
I have seen remarkable improvements after ECT but my experience has been mostly limited to the elderly and I must acknowledge that my experience with ECT in adolescents and young adults is limited. The American Association of Child and Adolescent Psychiatry states the following: “ECT may be considered when there is a lack of response to two or more trials of pharmacotherapy or when the severity of symptoms precludes waiting for a response to pharmacological treatment. Consent of the adolescent’s legal guardian is mandatory, and the patient’s consent or assent should be obtained.”
(I find this remarkable in light of the black box warnings on antidepressants.)
I have previously commented on the issue of consent. In Canada, the Supreme Court (based on the Charter of Rights and Freedoms) has been quite explicit on the right of any competent individual to give informed refusal for any medical intervention including medications. A surrogate decision maker, standing in place of the patient, has the same right. (See Supreme Court of Canada: Swayze.)
The important issue is “informed”. “Assent” is not sufficient as it contains no requirement for the provision of information about the proposed treatment. If one meekly ingests a drug, one is “assenting.” To impose any intervention without the patient’s informed consent is medical battery but how many individuals, when at a most vulnerable point in their lives are even aware of their rights or have the energy to demand that these be respected? Should we not be advocating the same procedure for obtaining consent for medications as is required before surgery – disclosure of all known effects and possible adverse effects up to and including death, written on the form by the physician in plain language, non-jargon terms? I believe that it can be argued that, in Canada at least, this is already a legal requirement as the Swayze case shows. The respondent in that case was a man with a well established psychotic disorder for whom the lower courts had tried to enforce antipsychotic medication. The Supreme Court said that, as he had shown a good understanding of the nature of his disorder and the effects of medications, he had the right to refuse. Competent surrogate decision makers have the same right.
I can understand peoples anger where doctor’s playing God are concerned and especially with the forced treatment of patients. The mental health services in Ireland are appalling and people are still being treated like second class citizens where informed consent is sadly rare. A prime example is Irish psychiatry denying all side-effects of antidepressants. What? Cause suicide? Never! 100% certainty.
I was reading ‘Pharmacological abuse’ which you posted today…http://t.co/3Z2Ye3Jf It’s very interesting and seems to tie in with the opinions in this post here.
In Ireland there was an important case with findings which may be useful for mental health patients:Dunne v The National Maternity Hospital [1989] IR 91
This was a tragic case involving a Wicklow woman who gave birth to twins. One twin died and the other was seriously injured. At that time the ‘common practice’ in the National Maternity Hospital, in the case of twins, was to monitor only one baby. Seems ridiculous now!
Finlay C.J. in his decision, among other things, stated:
“If a medical practitioner charged with negligence defends his conduct by establishing that he followed a practice which was general, and which was approved of by his colleagues of similar specialisation and skill, he cannot escape liability if in reply the plaintiff establishes that such practice has inherent defects which ought to be obvious to any person giving the matter due consideration.”
This means that under Irish Law a doctor or psychiatrist can be held liable, whether or not he/she is doing what every other doctor is doing, if that practice is flawed or ‘inherently defective’. Seems to me to be only a matter of time before a patient in the ‘mental health’ services will take an action.
Leonie