A woman in her 40s lies on a hospital bed at AUBMC as technicians set up an IV feed on her wrist. Electrodes are placed on her chest to monitor her vital signs. Blood pressure cuffs are attached to her arm and leg. Its preparations sound unremarkable, but the thought of electroconvulsive therapy (ECT), also known as electroshock therapy, tends to stir visceral horror in the average person.
A friend warned me to prepare myself before observing the procedure, saying he had seen it before on television and found it “very disturbing.” “‘One Flew over the Cuckoo’s Nest’ right?” said Dr. Rabih Chammay, a psychiatrist and head of the Health Ministry’s fledgling mental health department. Set in a psychiatric ward, the 1962 Ken Kesey novel, later turned into a film starring Jack Nicholson, is well-known for depicting the abuse of rebellious patients with ECT and other treatments. “ECT is very stigmatized because of its history and because it was used in a very harsh manner, sometimes in an abusive manner,” Chammay noted. “If you want to talk from a purely medical, scientific perspective, ECT is a treatment modality. It’s never a first-line treatment unless there’s a life-threatening condition. When properly administered medically and psychiatrically … it can have very rapid effects and it doesn’t have long-term effects on the body.” Dr. Ziad Nahas, head of AUBMC’s psychiatry department, insisted, “The field has gone millions of miles away from [the book’s] popular perception.” Inside the procedureConducted in a small room inside AUBMC’s psychiatric ward, ECT is considerably less dramatic than its popular portrayal. All patients are medically cleared before undergoing ECT. A half-dozen staff comprising psychiatric and anesthetic teams are present. Three electrodes are placed on the right side of the patient’s head, connected to an ECT machine that measures the brain’s electrical activity and monitors the seizure that will be induced. Anesthesia and muscle relaxants are administered through the IV, and after the patient falls unconscious, an assistant hands Nahas a larger pair of electrodes attached to the ECT machine. Placing one each on her right vertex and temple, he administers a preset dose of electricity for eight seconds, leading to a 20-second seizure in her brain. A rubber stopper was placed in the patient’s mouth as a precaution, but she does not experience any convulsions. The team carefully monitors her heart rate, blood pressure, respiration and blood oxygen. The anesthesia and muscle relaxants soon begin to wear off, and as she gradually regains consciousness, Nahas asks her, “Ca va?” The patient opens her eyes groggily and nods yes. A few minutes later, he asks her name, birthday, age, present location and the day of the week. After more rest, she leaves the hospital; altogether, she was in and out in 30 minutes. Losing memoriesThese questions are a “good bedside test,” Nahas said. “The quicker she becomes fully orientated, the less likely she’s going to suffer long-term memory loss.” Autobiographical memory loss occurs more often with the classic bilateral approach, he said, which involves placing electrodes on both sides of the head. Losing pockets of autobiographical memories, such as having taken one’s child to Disneyland, can be “quite upsetting” to the patient. At AUBMC, patients undergoing ECT start with the right unilateral ultrabrief pulse approach seen in the session, as research shows that “at six months, there isn’t any autobiographical memory impairment.” Nahas noted that the unilateral approach may cause patients to forget events that occurred around the time of the session, but this was “mainly because the memory has not been laid down properly … rather than true amnesia when the memory was erased.” “I cannot tell the patient you will absolutely not have any memory loss,” Nahas said, but the risk is minimized with the unilateral approach, which he believes is most appropriate in cases of depression. When to use ECT“When you’re using ECT for [agitated] psychosis [which includes some types of schizophrenia] or severe catatonia where you really need to intervene fast because the patient is debilitated, it’s quite the norm to move for bilateral,” he noted. “Cases referred to ECT typically failed other treatments like medication and psychotherapy,” Nahas added, noting that the woman I observed had been suffering from bipolar depression for some 20 years before beginning ECT six months ago. ECT is generally not used a first-line treatment for psychiatric illness, unless the patient poses a risk to himself or others, or shows signs of psychosis, echoed Dr. Jocelyne Azar, a psychiatrist at the Hopital Psychiatrique De La Croix near Beirut. “When we have to make it quick, we start with ECT,” she said. “In general, it’s not a first-line treatment for schizophrenia unless it is a resistant case and we’ve tried all the medications. … Second, when the patient is very agitated, very aggressive, refuses to take any medication … we are obliged to begin with ECT … we need something quick to protect the patient, to protect the family.” ECT is not a first-line treatment for ordinary depression either, she said, but the hospital may use it with depressed patients who are suicidal or delusional. Aside from the risks of anesthesia itself, memory loss is the key side effect of ECT, both psychiatrists said. Azar insisted that “this can resolve in a few days; there is really no major problem with ECT.” In general, De La Croix hospital uses the bilateral approach. While the unilateral has fewer side effects, it may be “less effective or may take more time,” Azar said. Typically, a course of ECT is administered in three sessions spaced out in one week. A bilateral course requires around seven sessions in total, whereas a right unilateral course takes around nine. Shocking foreign maids A study comparing the treatment of foreign domestic workers (FDW) and Lebanese admitted to De La Croix hospital from October 2007 to October 2012 found that 71 percent of FDW were diagnosed with psychotic disorders, compared to 38 percent of the Lebanese control group. Moreover, it found a “striking difference” in almost all aspects of their psychiatric care. Almost all maids were given anti-psychotic medications and their average starting dose was 145 mg higher than that of the Lebanese control group. As well, 51 percent of maids underwent ECT, compared to 17 percent of the Lebanese patients. The average number of days from admission to the start of ECT was 4.6 days for maids, compared to 9.4 for the Lebanese. Overall, it found that FDW were subject to a “rapid escalation in therapeutic measures for quick improvement and discharge.” “Diana,” an Ethiopian maid whose case was recently featured in The Daily Star, was diagnosed with schizophrenia by De La Croix hospital in December and hospitalized for about two weeks before being cleared to fly home. According to her employer, she was treated with psychiatric medication and ECT at the hospital’s recommendation. “A person can have a brief psychotic episode and then be completely back to normal functioning,” said Chammay, who co-authored the study. “Maybe [the maids’] symptoms are not necessarily as psychotic as we think, because maybe in their culture, they express their stress and depression differently.” “I would be very conservative before labeling someone with schizophrenia” he continued, noting that it is a chronic disorder and a diagnosis requires at least six months of continuous symptoms. The study concluded that “pressure is inflicted on the medical team by the employer to lower the costs of hospitalization and accelerate deportation,” as foreigners are not eligible for government-funded psychiatric treatment and private insurance plans in Lebanon never cover mental health. Azar acknowledged the issue and said it was a “matter of finance” as people responsible for the maid “want something very fast and effective so they can take them back to their countries in general.” She argued, however, that perhaps the maids sampled in the study “came very agitated,” requiring more aggressive treatment. She said the hospital would be able to distinguish in 3-4 days if a maid’s agitation was a matter of culture or genuine psychosis, before pursuing ECT. A contrarian hospitalThe Al-Fanar hospital in Tyre, one of three psychiatric hospitals in the country, is staunchly opposed to the practice. Samar Labban, a clinical psychologist and head of the hospital described Al-Fanar more as a “shelter,” noting that patients often stay there long-term, and her family, which runs the hospital, lives on-site. “My father practiced [ECT] at Dar Al-Ajaza [an elderly hospice and a psychiatric hospital near Beirut] and when he came to Al-Fanar, he didn’t want to do it anymore.” “From my experience of 35 years, I have noticed that every patient that [has undergone] electroshock treatment does not respond to any medication,” Labban said. “More than 50 patients in the past 10 years that came from other hospitals, I found they don’t respond to medication after ECT. … Every time I ask [what treatment they had before], they tell me ECT.” She described electroshock therapy as “invasive, annoying and painful … when you are aggressive with a psychiatric patient, they become worse. I rather have the patient come to my office and shout.” Other hospitals, she said, “want to keep patient in bed; we get them outside and in the garden.” Nahas denied that ECT would make patients more unresponsive to medication, noting that those who receive ECT have typically failed other treatments, meaning their cases were difficult to treat in the first place. ECT’s futureBoth Nahas and Azar said their respective hospitals require the consent of the patient – or if the patient is unfit to make a decision, the consent of their family, to perform ECT. Currently, there is no legislation that specifically regulates ECT. The proposedMental Health Act of 2008, if it eventually manages to be passed, will have stringent regulation on its use, Chammay said. Nahas acknowledged “there is a lot of stigma around ECT from 50 years ago but much has been done to safeguard it and it can really be lifesaving.” The days of using unmodified ECT without anesthesia and muscle relaxants are mostly gone, save for anecdotal reports in some countries. He has been spearheading research into FEAST, a “promising” type of ECT in which the electricity is “more focused so you can only tap into the area that regulates mood and avoid any area involved with memory. “There are about 2 million ECTs done worldwide every year, so if we can completely separate the efficacy from the side effects, imagine how much we can help people.” Alexis Lai| The Daily Star