Master Gangxiao: ECT Therapy for Difficult and Intractable Conditions — Chapter 7: ECT Therapy

Chapter 7: ECT Therapy

All of the therapeutic approaches discussed above come with considerable drawbacks. Morita therapy is a fundamental treatment that works across a broad range of conditions, but the course is far too long — typically requiring around forty days of hospitalization, if not more. Religion is even less viable; most Chinese people would scoff at it and stamp it underfoot, and having written that chapter, I may well have invited a round of attacks for my trouble. Insulin coma therapy is expensive and technically complex to administer. Artificial hibernation therapy carries high risks. Traditional Chinese medicine yields uncertain results while producing significant toxic side effects. This doesn't only hinder the treatment of psychiatric illnesses themselves — it also obstructs treatment of the somatic symptoms that accompany them. What we genuinely need is a therapy that is fast, safe, and inexpensive. By comparison, ECT meets these three requirements quite well. And so, although ECT belongs among the scientific therapies discussed in the previous chapter, I've singled it out and given it a chapter of its own.

ECT — also known as electroshock or electroconvulsive therapy — involves passing a brief, measured electrical current through the brain to induce loss of consciousness and a seizure, as a means of treating psychiatric disorders. Today, no psychiatric hospital can do without an ECT machine, and every textbook of psychiatry covers this therapy. Yet the very words "electricity" and "shock" strike fear into people's hearts. Hospitals that use this therapy strictly control access, making sure other patients and family members don't witness the procedure. In truth, this is a misunderstanding born of rumor and hearsay. Electroconvulsive therapy is in fact quite safe — even safer than taking antipsychotic medication. To dispel this misunderstanding, I'll address its safety first.

In the 1980s, a task force of the American Psychiatric Association surveyed four thousand of its members: 72% considered ECT safe, economical, and effective, while only 7% advocated abolishing it. Among patients surveyed, 30% expressed dislike for ECT, but 78% found it helpful. Later, others surveyed psychiatrists, nurses, psychological workers, and social workers across four tiers of familiarity. The results: different professional groups showed markedly different levels of understanding. Psychiatrists had the highest, followed in order by nurses, psychological workers, and social workers. As clinical experience increased, scores on the ECT awareness scale rose accordingly. Psychological workers were an exception — they regarded ECT as a form of mechanical intervention rather than a psychological treatment modality, and they remained skeptical. The more experienced they were in psychotherapy and the more skilled their techniques, the more they leaned toward psychological therapies and the less they endorsed ECT.

That conclusion speaks for itself: people reject ECT when they know and have experienced the least of it, and trust it more the more experience they gain. Our worry about ECT comes down to knowing too little about it.

The mortality rate for electroconvulsive therapy is approximately 1 in 70,000 — comparable to minor surgical procedures such as tonsillectomy. The cause of death is usually cardiac, though it's difficult to attribute definitively to the treatment itself. In 1959, one analysis put the mortality rate at roughly 3–4 per 100,000 treatments. A Danish study recorded 22,210 treatments with only a single death. Another researcher reported a mortality rate of 0.2 per 10,000, documenting that among 18,627 ECT sessions, not even a single fracture occurred. In China, the Shanghai Mental Health Center performed hundreds of thousands of treatments from 1958 to 1986, with only 3 deaths. The Jining Psychiatric Hospital in Shandong performed approximately 200,000 treatments from 1952 to 1990 without a single fatality. That makes ECT no more dangerous than taking metamizole for a cold. ECT is safe. Its current intensity and duration are designed and controlled, and can be kept entirely within safe parameters.

As for the biological mechanisms of ECT, plenty of research has been done. My focus here is primarily on the psychological mechanism. As I proposed and demonstrated earlier, near-death experiences and ordeals can cure illness. ECT allows a person to complete the ordeal of "dying once" in an instant — and through that ordeal, achieve therapeutic results for both psychiatric and psychological disorders and the many somatic illnesses attached to them, as revealed in Chapter 3. Compared with the forty-plus days of hospitalization that Morita therapy requires, this is far more rapid: each session involves only a momentary passage of current, causing the person to lose consciousness in an instant — to "nearly die" once. Compared with a lifetime of religious cultivation, it's faster still. Compared with shamanism, it's more civilized and progressive. Compared with certain drug therapies, it's more economical — the electricity it consumes costs mere fractions of a cent, while some medications are extremely expensive.

If we honestly confront the fact that roughly four-fifths of the world's population practices religion — and that people in developed nations hold religious beliefs too — and if we accept that religious cultivation benefits physical and mental health (including the improvement of social adaptability), then even a person without illness, in the narrow sense of somatic symptoms, might reasonably undergo ECT a few times as an equivalent form of cultivation: experiencing "death" firsthand, broadening the heart, treating life with kindness, loving life, and bringing one's outlook toward a more rational frame. There's nothing objectionable in this. ECT is a biological therapy and a mechanical therapy, but it's also a psychological therapy. It constitutes an ordeal, and it combines the effects of both biological and psychological treatment. If four-fifths of humanity can devote a lifetime to religious cultivation, why not advocate that four-fifths undergo ECT? At the very least, why shouldn't the one-fifth who don't practice religion use ECT to make up for the mind-body cultivation they lack?

Of course, ECT doesn't appear as humane as Morita therapy — after all, the person loses consciousness and "dies once." But it should be said that the recipient feels no suffering. They lose consciousness at once and have no awareness of the process.

ECT produces minimal side effects, though the following situations may arise:

First, confusion. This manifests as an acute organic syndrome accompanied by disorientation and behavioral disturbances. It generally doesn't exceed thirty minutes. Suspending or discontinuing treatment allows spontaneous recovery.

Second, memory impairment. Its characteristic features are reduced short-term memory capacity (anterograde amnesia) and difficulty recalling recent events. Clinically, patients often complain of being unable to remember certain names. This impairment is reversible, generally recovering within three to six weeks. The more treatments administered, the longer the recovery time. After recovery, memory function may be slightly poorer than before treatment.

Third, epilepsy. In a small number of patients, ECT may trigger epileptic seizures, though it's also possible the epilepsy bears no causal relationship to the treatment. If there is no organic basis, such epilepsy resolves on its own within a year of discontinuing ECT.

These side effects are generally not severe. In reality, every form of treatment carries some adverse reactions to a greater or lesser degree. Let me cite two of the most commonly used medications to illustrate what adverse reactions look like. Since these medications are so widely used and still produce these side effects, the minor side effects of ECT are hardly worth mentioning.

Adverse reactions of penicillin potassium (cited from the New Handbook of Commonly Used Medications, 1992 Jindun edition):

(1) Allergic reactions. Incidence rate approximately 5–10%, with the most severe being anaphylactic shock, which can be life-threatening if not treated promptly. Next are cutaneous allergic reactions and organ-specific allergic reactions, with some neurotoxicity as well. In patients with impaired renal function or in elderly patients, high-dose injections may also produce hallucinations, muscle fasciculations, and grand mal–type seizures.

(2) Superinfection may occur during treatment. Large doses of the sodium salt may produce hypokalemia, metabolic alkalosis, and hypernatremia. Large-dose intravenous drip of the potassium salt may cause hyperkalemia, with even the risk of cardiac arrest.

Enough — no need to cite further. These two points alone would alarm anyone who isn't a physician. Let me also cite the most commonly used antipyretic and analgesic, metamizole, which can: (1) cause collapse; (2) produce allergic skin rashes and drug-induced fever that can lead to death; (3) cause pain and swelling at injection sites, with some patients developing systemic toxemic symptoms; (4) with prolonged use, cause granulocytopenia, thrombocytopenia, and aplastic anemia, also with fatal outcomes; (5) occasionally produce anaphylactic shock resulting in respiratory and circulatory failure.

Every medicine carries some toxicity. Every therapeutic method has side effects. The side effects of ECT are not particularly severe.

Indications for ECT:

1. Depression. Severe depression is the foremost indication for ECT. It is effective for recurrent unipolar depression, depression in bipolar affective disorder, involutional depression, postpartum depression, and severe late-onset depression. ECT may be selected for agitated depression, and is especially effective for those with intense suicidal ideation or suicidal behavior. It is somewhat less effective for depressive neurosis.

2. Mania. ECT is effective in controlling or improving extreme excitement, agitation, and aggressive behavior. It can therefore be beneficial to use ECT first, before lithium salts take effect.

3. Schizophrenia. ECT yields good results for patients with marked guilt and self-blame, food refusal, difficulty in nursing care, and catatonic stupor. It is also effective for schizophrenia accompanied by depression and for depressive-type schizoaffective disorder.

4. Reactive psychosis. Reactive psychosis accompanied by depression, guilt, food refusal, or suicidal attempts.

5. Hysteria. For hysterical psychiatric episodes.

6. Others. Neuroleptic malignant syndrome induced by antipsychotic medications, Peck's syndrome, tardive dyskinesia, and psychiatric patients with concurrent somatic illnesses, such as depression combined with cardiovascular disease.

ECT can also ameliorate certain signs and symptoms of non-psychiatric and psychiatric conditions, such as the hypokinesia of pellagra, the psychiatric symptoms of general paresis, severe trigeminal neuralgia, and thalamic pain.

We already know that the somatic symptoms attached to the categories of psychiatric illness listed above are exceedingly numerous. Depression alone involves a host of somatic symptoms, and may even present exclusively as somatic symptoms without any psychiatric manifestations — what's known as masked depression.

Of course, ECT has its contraindications as well, primarily cardiovascular disease.

ECT machines come in two types. One uses sinusoidal alternating voltage, typically 70–120V, with a current duration of 0.5–0.6 seconds. The other uses pulsed current, generally at 40 mA, with a duration of 1–2 seconds. The procedure is performed by a specially trained physician, and I won't elaborate further here.

Course of treatment: 6–12 sessions constitute one course. Treatment begins with one session daily, then is reduced to every other day or 2–3 times per week. By the end of the course, sessions may be down to once per week.

Modified ECT therapy: ECT without induced seizures.

Conventional ECT, because of the convulsions, appears "brutal" on the surface and provokes fear in patients and their families. Bennett began injecting muscle relaxants before the procedure in 1940 to prevent seizures. With subsequent advances in muscle relaxant pharmacology, highly effective relaxant drugs are now available. But since no seizure occurs, how does the practitioner determine that a treatment has been effective? Generally, pupil dilation, piloerection, and slight twitching of the muscles around the eyes and nose are taken as signs of an effective response, corresponding to the convulsions observed before the modified technique.

In actual practice, due to the practitioner's excessive caution and also to individual tolerance, 1–2% of patients have difficulty achieving a seizure response at the standard treatment current. If the current is insufficient, the voltage too low, or the duration too short — falling below the seizure threshold — therapeutic efficacy is compromised. In such cases, the current should be increased.

One point worth noting: during modified ECT without seizures, antibiotics and muscle relaxants have a synergistic effect. Before the procedure, one should ask whether the patient has recently received antibiotics such as kanamycin. Excessive muscle relaxation can mask the achievement of the seizure threshold — meaning that the failure to achieve piloerection or twitching around the eyes and nose may go unnoticed.

This booklet can be brought to a close here. To summarize the viewpoint I've been elaborating: for biomedicine, certain diseases that recur repeatedly or become chronic, intractable conditions may be caused by non-biological factors — that is, psychological and social ones. Therapies involving moderate physical and mental tribulation are effective, and the best among them is ECT.