EDITORIAL

The Stigma and the Enigma of ECTDAVID WILKINSON1* AND JANET DAOUD2

1Consultant in Old Age Psychiatry, Thornhill Research Unit, Moorgreen Hospital, Southampton, UK2Honorary Lecturer in Old Age Psychiatry, Western Community Hospital, Southampton, UK

Electroconvulsive therapy (ECT) has experiencedsomething of a renaissance in the last 20 years inthe treatment of late life depression. This has beenfuelled partly by the burgeoning elderly popula-tion and partly by the burgeoning speciality ofgeriatric psychiatry (Benbow, 1987), where apositive approach to managing depression in oldage requires safe, reliable and e�ective treatmentsfor patients who may have many physical pro-blems. ECT predates many of the recent advancesin antidepressant treatments by 50 years, yet stillremains a principal and arguably the most poten-tial treatment for severe depressive psychosis wehave (Godber et al., 1987; Weiner, 1982; Fraser,1981). That it is e�ective in late life depression isnot in doubt (Johnstone et al., 1980; Baldwin,1988; Ottoson, 1985) and those who requireevidence of e�cacy over and above the evidenceof their clinical practice can now ®nd numerouspapers to con®rm this (Wilkinson, 1997). Forexample, in a meta-analysis by Mulsant et al.(1991), ECT was estimated to produce signi®cantimprovement in 83% of cases and cure in 62%.

The current position vis-aÁ-vis ECT, then, is thatit is safe, despite the likelihood in the elderly ofmultiple system disorders and medications (Ray-burn, 1997); well tolerated even in the very old(Casey, 1996); and produces no evidence of thebrain damage (Co�ey et al., 1991; Lippmans et al.,1985) so often postulated by its detractors. It is truethat bilateral ECT is associated with some impair-ment in memory (Peretti et al., 1996; Squire, 1986),but patients receiving brief-pulse unilateral ECTcan expect to recover fully from their depressiveillness without experiencing any short- or long-term memory impairment (Coleman et al., 1996;

Devanand et al., 1991; Weiner et al., 1986), andcertainly no impairment in new learning or intellect.

The enigma of ECT is that there can be fewtreatments that are demonstrably so e�ective thathave been so consistently vili®ed. The ensuingtherapeutic dilemma is that, while the evidencestrongly supports the view that ECT should beconsidered the treatment of choice in every patientwho has either failed to respond to other treat-ments or is so depressed as to be of risk of death byinanition or suicide, it is still regarded by manypatients and the general public as an irrational andunreasonable treatment. It seems we cannot alterthis view by proof of e�cacy owing to the stigmaattached to it, which compounds the stigma asso-ciated with depression and mental illness generally.

The Royal College of Psychiatrists in the UnitedKingdom has adopted the stigma of mental illnessas its new campaign; as an integral part of this, wemust address the public perception of ECT, whichat present is of an archaic and barbaric treatment.Our silent con®dence in its e�cacy is not enough ifwe wish our patients to avail themselves of a fullrange of treatments. The stigmatization that isattached to this treatment must be addressed. Wecan only do this by being honest and open with ourpatients when discussing it. We must acknowledgetheir anxieties and not dismiss their experiences ofconfusion or forgetfulness if they have hadprevious bilateral ECT.

Patients' misconceptions about its use or side-e�ects need to be dealt with as vigorously as itsopponents attack it, and attack it they do inthe most public of arenas. Even the most ineptInternet surfer can ®nd numerous sites dedicated to`ban shock' treatment or to exposing the `lies' thatthose using ECT are purported to promulgate(http://www.gold-coin.com/liesexpose.htm). Alreadythere is a view that data on the World Wide Webare somehow the truth, and yet much of the

CCC 0885±6230/98/120833±03$17.50 Received 6 July 1998# 1998 John Wiley & Sons, Ltd. Accepted 23 July 1998

INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int. J. Geriat. Psychiatry 13, 833±835 (1998)

*Correspondence to: Dr D. G. Wilkinson, Thornhill ResearchUnit, Moorgreen Hospital, Botley Road, West End, South-ampton SO30 3JB, UK.

anti-ECT propaganda is blatant rhetoric, with datasupported by articles cited from as early as the1940s, when ECT was barely understood. Onetypical statement apparently rebutting the `lie' thatECT does not cause brain damage states, `Manynoted experts in the ®elds of psychiatry andneurology have reported brain damage as a resultof shock therapy'. Hardly the stu� of evidence-based medicine.

We as doctors must show our con®dence in ECT,but `Trust me, I am a doctor' is not enough. ECT isone of the few psychiatric treatments that requiressigni®cant medical intervention with general anaes-thesia and, as such, the psychiatrist should have aclear understanding of what he is prescribing andhave regular involvement in its administration. Weshould not relegate it to hidden clinics run byjunior sta�. The same attention should be given toits initial prescription and the adjustment of doseas is given to any other prescription. If bilateralECT is prescribed as a result of poor response tounilateral electrode placement, bland reassurancethat memory loss will not be a problem is foolishand counterproductive. It should also not beforgotten that this is a treatment for a life-threatening illness, which, if it were to remainuntreated, could condemn the patient to anexistence of intolerable distress and anguish andincreased mortality.

If the treatment is successful in patients withresistant relapsing depression, we should considerthe use of continuation and maintenance ECT (onthe premise that the treatment that gets you wellkeeps you well) in any patients who have been non-responders to antidepressant drugs. Thus weshould question the logical inconsistency of treat-ing someone after ECT with the same antidepres-sants that patently failed to treat the depressionbeforehand.

In our attack on the stigma of mental illness andits treatment, we need further research not into thee�cacy of ECT but into its acceptability. Random-ized controlled trials may not move us furtherforward but the use of qualitative research methodsmight (Miller and Crabtree, 1994). It is into areassuch as these that qualitative research is ideallysuited (Pope and Mays, 1995). This could, forexample, include the use of in-depth interviews andfocus groups to explore just what the beliefs andassumptions held by our patients and public are,what these are based on and what in¯uences them.From this baseline information we would then bein a position to formulate strategies to attempt to

alter these beliefs and then monitor their e�ect. Ifwe fail to ground any interventions in evidence-based information, we could end up wasting timeand money on ine�ective strategies. It is easy for usto assume that we know what our patients think,but we might be surprised; likewise, the assumptionthat by being better informed their beliefs oractions will change may not necessarily follow.We must take into account attitudes which may beculturally bound and not always immediatelyobvious to us until we start to explore the situationin depth with the appropriate tools. By taking thisapproach, we may better understand our patients'and their relatives' reluctance to accept ECT as anoption and ®nd ways of reducing their anxieties. Itwould also be helpful to use the media to help thedemysti®cation process, as startling images of theinappropriate use of ECT, as in ®lms like MilosForman's `One Flew Over the Cuckoo's Nest' orJane Campion's `An Angel at my Table', easily ®xthemselves in the public mind if there is nothing tocounteract them.

As in most things, patients' and their relatives'fantasies about ECT are often worse than thereality, and what is clear is that standardizedstrategies like pretreatment information sheets,videos and post treatment discussion groups,while very helpful, do not suit everyone. Patientsrequire di�erent approaches according to theirneeds, and the treatment of depression should beaddressed individually in the same way that asurgeon might discuss outcomes of the manage-ment of breast cancer or peripheral vasculardisease. ECT should be discussed as part of theoverall treatment strategy, not simply left until allelse fails. If we regard ECT as something to bewheeled out at the eleventh hour and quicklyhidden again, it is no wonder our patients treat itwith circumspection. ECT must be seen as part ofan eclectic and pragmatic approach to the treat-ment of severe depressive illness. As part of apositive approach in our search to deal e�ectivelywith this serious disease, it can continue to relievedistress and save lives and may come to be seen as atreatment of choice not simply by psychiatrists butby the public as well.

REFERENCES

Baldwin, R. C. (1988) Delusional and non-delusionaldepression in late life. Evidence of distinct sub-types.Brit. J. Psychiat. 152, 39±44.

# 1998 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 13, 833±835 (1998)

834 EDITORIAL

Benbow, S. M. (1987) The use of electroconvulsivetherapy in old age psychiatry. Int. J. Geriatr. Psychiat.2, 25±30.

Casey, D. A. and Davis, M. H. (1996) Electroconvulsivetherapy in the very old. Gen. Hosp. Psychiat. 18(6),436±439.

Co�ey, C. E., Weiner, R. D. and Djang, W. (1991) Brainanatomic e�ects of ECT. Arch. Gen. Psychiat. 48,1013±1021.

Coleman, E. A., Sackeim, H. A., Prudic, J., Devanand,D. P., McElhinery, M. C. and Moody, B. J. (1996)Subjective memory complaints prior to and followingelectroconvulsive therapy. Biol. Psychiat. 39(5),346±356.

Devanand, D. P., Verma, A. K. and Tirumalesetti, F.(1991) Absence of cognitive impairment after morethan 100 life time ECT treatments. Am. J. Psychiat.148, 929±932.

Fraser, R. M. (1981) ECT and the elderly. In Electro-convulsive TherapyÐAn Appraisal (R. L. Palmer, Ed.).Oxford University Press, Oxford.

Godber, C., Rosenvinge, H., Wilkinson, D. G. andSmithies, J. (1987) Depression in old age: Prognosisafter ECT. Int. J. Geriatr. Psychiat. 2, 19±24.

Johnstone, E. C., Deakins, J. F. and Lawler, P. (1980)The Northwick Park electroconvulsive therapy trial.Lancet 2, 1317±1320.

Lippmans, R., Manshadi, M. andWehry, M. (1985) 1250ECT treatments without evidence of brain injury. Brit.J. Psychiat. 147, 203±204.

Miller, W. L. and Crabtree, B. F. (1994) Clinicalresearch. In Handbook of Qualitative Research.

(N. K. Denzin and Y. S. Lincoln, Eds). Sage,Thousand Oaks, London.

Mulsant, B. H., Rosen, J., Thornton, J. and Zubenko, G.(1991) A prospective naturalistic study of electrocon-vulsive therapy in late life depression. J. Geriatr.Psychiat. Neurol. 4, 3±13.

Ottoson, J. (1985) Use and misuse of electroconvulsivetreatment. Biol. Psychiat. 20, 933±946.

Peretti, C. S., Damian, J. M., Grange , D. and Mobarek,N. (1996) Bilateral ECT and autobiographical mem-ory of subject were experiences related to melancholia:A pilot study. J. A�ect. Disord. 41(1), 9±15.

Pope, C. and Mays, N. (1995) Reaching the partsother methods cannot reach: An introduction toqualitative methods in health and health servicesresearch. Brit. Med. J., 311.

Rayburn, B. K. 1997) Electroconvulsive therapy inpatients with heart failure or valvular heart disease.Convuls. Ther. 13(3), 145±156.

Squire, L. R. (1986) Memory functions as a�ected byelectroconvulsive therapy. Am. NY Acad. Sci. 446,307±314.

Weiner, R. (1982) The role of electroconvulsive therapyin the treatment of depression in the elderly. J. Am.Geriatr. Soc. 30, 701±712.

Weiner, R., Rogers, H. and Davidson, J. (1986) E�ects ofstimulus parameters on cognitive side-e�ects. Am. NYAcad. Sci. 462, 315±325.

Wilkinson, D. G. (1997) ECT in the elderly. In Advancesin Old Age Psychiatry: Chromosomes to CommunityCare (C. Holmes and R. Howard, Eds). Wrightson,Peters®eld, pp. 161±171.

# 1998 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 13, 833±835 (1998)

EDITORIAL 835