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- 1. MythbustersJill BonacciLuchelleLacambraRisha RajECT (Electroconvulsive Therapy) is a barbaric and unsafe procedure.Myth or Fact?
- 2. Case StudyECT is being considered; however, Raman has been hesitant to provide consent because she views the prospect of ECT with “horror” due to “barbaric” depictions of the procedure in films she has seen, such as One Flew Over the Cuckoo’s Nest (1975) and Requiem for a Dream (2000). Raman’s family is very supportive of all treatment modalities as they would like her condition to improve. Though, like Raman, they are concerned about the “brutal” nature of ECT and would appreciate staff taking the time to ensure they are adequately informed. Indeed, it is crucial that we educated others so that inaccurate stigmas do not overshadow the empirical evidence for ECT`s effectiveness.Raman is a 40 year old female of South Asian descent, diagnosed with treatment resistant major depressive disorder. She is currently admitted to a psychiatric inpatient unit at Canuck Hospital. Raman has no family history of mental illness. Many adjunctive therapies have been utilized previously (Acupuncture; CBT; St. John’s Wort), along with antidepressant medications with little improvement on her condition.
- 3. Neuman’s System Model-Raman, 40 years old, femaleSouth AsianBasic coreEffects on Flexible Lines of Defense:-unhealthy diet-sedentary lifestyle-unable to work fulltime-low socioeconomic statusStrengths:-family support-Utilizing different adjunctive therapies and medications-devoted to cultureEffects on Normal Line of Defense:-easily angered -irritable-anxietyPrimary Prevention:-stress management activities-diet-exercise-more education on ECTStressors:Being in psychiatric inpatient unit -Low incomeLoss of meaningful relationshipsSecondary Prevention:Antidepressants
- 4. Adjunctive Therapies (Acupuncture, St. John’s Wort, CBT)
- 5. ECT (currently being considered)ATTITUDES and MISCONCEPTIONSConsiderable stigma still surrounds ECT, and this probably remains the greatest barrier to public acceptance.ECT is viewed as barbaric, a primitive form of medical practice; it’s associated with the electric chair, with fears of brutality and punishment; patients fear being conscious during shocks; fear pain, brain damage, and memory loss; hold fears involving general anaesthesia, personality changes, zombie-like behaviour and death (Dowman et al., 2005).Those with less personal or clinical experience with ECT are more likely to have relied on films as a source of knowledge, and as a result attitudes tend to be more negative and inaccurate (McFarquhar & Thompson, 2008; Abbas, Mashrai & Mohanna, 2007).These findings and beliefs hold true internationally—in Pakistan, Britain, and India (Arshad et al., 2007; Euba & Crugel, 2009; Andrade et al., 2010). This is significant considering our patient is of South Asian descent.
- 6. ”It’s just like any operation thing you know . . .so you still get the same nerves”“To this day I still dream about it. Bolt upright, sweating in bed. They’ve actually zapped me before I went to sleep”“I wasn’t scared of what was going to go on, I was scared of what it would do to my brain”(Koopowitz et al., 2003)
- 7. ECT in the MediaPassionshttp://www.youtube.com/watch?v=2wM_cTaBMfEOne Flew Over the Cuckoo’s Nesthttp://www.youtube.com/watch?v=DCUmINGae44Requiem for a Dreamhttp://www.youtube.com/watch?v=TtX-2-YoXPs
- 8. MEDIA PORTRAYALMuch of the media over the years has represented ECT as a brutal and inhumane treatment in which unwilling patients are forcibly held down while electricity is applied to their head and a violent grand mal convulsion ensues (McDonald & Walter, 2009). McDonald & Walter (2001) concluded that ECT has been increasingly depicted as a cruel and negative treatment; there has been minimal focus on therapeutic benefits, and instead its portrayal as a dangerous, and abusive practice.ECTs distorted projection by the Pakistani media is responsible for the majority of this particular population’s adverse attitudes (Arshad et al., 2007). In this study, the most popular sources of information for patients were electronic and print media, films, relatives and friends; only 23 % identified doctors as a source.In India, Andrade et al. (2010) discovered that Hindi cinema is another source of public misinformation about ECT. Thirteen Hindi movies contained inaccurate, distorted, and dramatized depictions; it was administered to punish, obliterate identity, and/or induce insanity.Euba & Crugel (2009) examined the depiction of ECT in the British press and found there to be predominantly either a neutral or negative tone; the two main semantic domains were “cruelty” and “ECT as a tool for repression” (p. 265).
- 9. TREATMENT PROCEDUREA general anaesthetic is administered followed by a muscle relaxant (to prevent injuries and minimize discomfort). Brief electric currents are then passed through electrodes on the scalp to stimulate the brain which causes a mild seizure that is very brief in duration. Oxygen is administered until the treatment ends, the anaesthesia wears off and the patient resumes breathing independently. The patient remains in the recovery room where nursing staff continue to monitor the patient`s status (BC Ministry of Health Services, 2002).Patients receive a thorough evaluation prior to the procedure; this includes a psychiatric and medical history, review of all body systems, physical examination, lab tests, ECG, as well as a consultation with an internist. Subspecialty consults (e.g., cardiologist) and other diagnostic tests (e.g., cardiac or brain imaging) are ordered as indicated (BC Ministry of Health Services, 2002).In truth, the patient is NOT awake during the procedure; therefore they do NOT experience any pain or discomfort. They are carefully screened and monitored before, during, and after the procedure.
- 10. Although most memory problems are transitory, patients may still complain of memory problems years after treatment. Modifications in treatment procedures have helped to decrease the extent of cognitive impairment related to ECT (Trevino et al., 2010); patients generally have fewer memory problems with unilateral compared to bilateral ECT.COGNITIVE FUNCTIONINGThere is no known occurrence of brain damage associated with ECT; research conducted by Reisner (2003), found some problems with anterograde and retrograde amnesia for ECT patients. Initially there can be some difficulty in retaining newly learned information. However, as early as a few weeks to 6 or 7 months post-ECT, this sort of memory deficit is unlikely to exist. Patients may experience a range of cognitive adverse effects which can vary in severity (Gardner & O’Connor, 2008). Acute confusion or general disorientation in the immediate post-ictal phase is a common but self-limiting episode (Sienaert, 2011).
- 11. SAFETY OF ECTECT, like all medical treatments, has side effects. Given the risks entailed in the illness for which ECT is indicated, these effects are relatively minor. Typical transient adverse effects include: hypertension, headache, muscle aches and stiffness, nausea—usually mild and well tolerated by patients (American Psychiatric Association, 2001); some of these can be treated prophylactically with analgesic and antiemetic drugs. Reported mortality rates include:2:100,000 (BC Ministry of Health Services, 2002)2-10:100,000 which is comparable to the death rate for general anaesthesia (Shiwach et al., 2001)10:100,000 (American Psychiatric Association, 2001)16:100,000 (Scaranto & Frelthous, 2000)
- 12. ECT’s mortality rate is comparable to, or lower than universally accepted antidepressant medication (Abrams, 1993).Nuttall et al., (2004) found no deaths in 17,394 ECT treatments scheduled in a single hospital between 1999-2003. Only 0.92% of the sample experienced a complication – mostly cardiac arrhythmias. However, no permanent injury resulted. The authors concluded that “ECT is an extremely safe procedure” with low morbidity and mortality (p. 237). Even so, complications can occur, typically in the setting of pre-existing medical conditions.For the last 30 years substantial improvements in both anaesthesiology safety and ECT technique have occurred resulting in a lower rate of mortality. Reported adverse events are rare and typically minor in severity (Watts et al., 2011).
- 13. IS ECT EFFECTIVE?In the past decade, several large-scale studies have confirmed the significant superiority of ECT (Sienaert, 2011). Unfortunately, it is often reserved as a last resort. Although it is a highly effective treatment for various psychiatric disorders (MDD; bipolar disorder; catatonia), a major limitation involves the significant rate in which some patients relapse after a short-term course; continuation or maintenance ECT may be implemented. Overall, recent research has revealed that most patients show high degrees of satisfaction (Trevino et al., 2010).
- 14. “Must have done some good for me . . . because I’m not as paranoid as I was . . . I’m a bit more normal . . . it really brought me back to reality”.(Koopowitz et al., 2003)“I basically believe it saved my life – without ECT I would not be here, sitting talking to you today”. (Koopowitz et al., 2003)“I still suffer from some memory loss, but it is nothing compared to my condition prior to ECT”. (Rayner et al., 2009)
- 15. NURSING IMPLICATIONSExplain the treatment; educate the client and correct any misconceptions. Ensure they have all the relevant information at hand to make rational treatment decisions. Ensure informed consent is obtained. It is imperative that the patient make an informed decision based on factual information, and not on preconceived ideas from negative media portrayal or other unreliable sources.Psychiatry professionals have the responsibility to promote ECT as a modern and effective intervention, by asserting its valuable therapeutic role in treatment, as well as improvements in ECT practice, while also acknowledging its potential risks and side effects.(Kavanagh & McLoughlin, 2009)
- 16. LIMITATIONS of RESEARCHNuttall et al., (2004) acknowledged that some adverse events may not have been reported in their study due to a limited computerized database collection. In addition, a much larger sample size would be favourable to determine the mortality rate, such as the sample used in the Shiwach et al., (2001) study.Watts et al., (2011) relied on hospital staff to self-report adverse events; therefore, it is possible that their reports do not represent the full collection of actual events.Unfortunately, non-randomized evidence forms a large part of the studies on ECT. Sample heterogeneity and the presence of concomitant psychotropic meds may have confounded the study outcomes. Considering the disadvantages in the interpretation of this type of evidence, some caution must be taken in generalizing the findings to daily practice (Trevino et al., 2010).
- 17. YOU Decide…Fear of the procedure and resulting side effects are certainly factors explaining the reluctance of patients to accept this highly effective treatment. However, as we have presented, recent studies have demonstrated that cognitive side effects are generally transient, that effective ECT can be achieved with minimal cognitive consequence, and that it is a low-risk, safe procedure.Psychiatric nurses must assist in providing accurate and comprehensive information about ECT, as an understanding of this material is a requirement for making an informed decision.