ELECTROCONVULSIVE THERAPY SHEDS ITS SHOCKING PAST
As I walked into the room adjacent to the electroconvulsive therapy (ECT) suite, images of a strapped down, fully awake Jack Nicholson jolting flashed in my mind. Since watching unmodified ECT in “One Flew Over the Cuckoo’s Nest” and “Requiem for a Dream,” educational materials of modified ECT (i.e., where the patient is under anesthesia and receives muscle relaxants to counteract the electrical stimulus in the body) had largely replaced these archaic accounts of the procedure in my mind.
Still, visceral images from fiction persisted in my consciousness as I — a fourth-year medical student planning to enter psychiatry — awaited my first experience observing the procedure. The patient I’d been working with had treatment-resistant depression, which means that her depressive episode endured despite months-long trials of different antidepressant medications. I helped push the patient’s bed into the ECT suite, where the medical team greeted the patient.
The patient quickly fell asleep under general anesthesia and, working with the anesthesiologist and nurse, the psychiatrist administered a weak current to one side of the patient’s scalp using a handheld electrode, resulting in a brief seizure. The anesthesia and muscle relaxants prevented pronounced muscular contractions, and the resultant seizure lasted 29 seconds.
This medically induced activity seizure shuts the physiologic lights in brain cells “off” and then back “on,” leading to changes in chemical transmitters, hormones, growth factors, and neural connections in the brain. Together, these changes alleviate symptoms of depression and other mental illnesses. In seven minutes, the entire procedure was complete; the patient was awake and being wheeled out of the room.
Like most patients, the patient who I was working with had undergone a series of ECT sessions over the course of weeks, (eight to 12 treatments over three to four weeks is typical), while the severity of her depression and any potential short-term cognitive side effects were monitored using standardized tests. This patient’s depression improved and the only side effect she had was difficulty remembering the 20-minute period surrounding the ECT procedure.
I wish more medical students could see what I experienced. It was the final step I needed to abandon my inaccurate perception and solidify my confidence in recommending and counseling patients on the treatment.
As a future psychiatrist, I was thankful that I had the opportunity to see how innocuous the procedure was and how well the patients did afterward. However, many potential ECT patients — and the people in their support systems from whom they seek guidance — will not have had an experience like mine. They are more likely to be left with blockbuster scenes, such as the recent one in “Don’t Worry Darling.” In the movie (warning, spoiler alert ahead), Florence Pugh’s character is held as a psychological captive to Harry Styles’ character and electrified into amnesia to continue her ignorant existence in the dystopic virtual reality-based town, Victory. Virtual reality or not, the scene amounts to torture and could not be further from the reality of ECT.
Despite its controversial history, ECT is safe and highly effective. Among physicians and researchers, ECT is shedding its complicated and harmful past, including as a threat to control psychiatric patients in state psychiatric hospitals and for conversion therapy as a “treatment” for LGBTQ individuals in the 1950s, and is settling into its place in modern medicine. It is now widely recognized as the first-line treatment for treatment-refractory depression or depression with other specific clinical situations (e.g., pregnancy, acute suicidality, rapidly deteriorating physical state, etc.)
ECT leads to a 62% remission rate in depression, with a substantial improvement in 80% to 90% of patients and minor side effects (e.g., nausea, headache, fatigue, confusion, and short-term memory effects, which may last minutes to hours and appears to improve over time). For reference, around 30% of patients taking common antidepressants, also known as selective serotonin reuptake inhibitors, or SSRIs, achieve remission. I have seen firsthand patients’ depressive symptoms improve over the weeks of ECT treatment — and hear them laugh for the first time.
Many stand to benefit from ECT: almost one in every three patients with depression presents with treatment-refractory depression. Yet, ECT is still underutilized. A 2018 study found that among nearly one million patients with depression, only 0.25% of these patients received ECT. Crucially, ECT’s underutilization is not universal across patient populations. As a practitioner striving to promote health justice in medicine — cautious as to not re-perpetuate medical racism at the cusp of medical advances — I am concerned.
Stark racial/ethnic disparities in ECT access and referral exist amongst low-income, Black, and Latinx patients and are potentially worsening. ECT use is steadily growing by 1.6% each year among white patients, whereas uptake is not increasing amongst other racial/ethnic groups.
How can we close this gap and expand
the benefits of this efficacious procedure? First, there must be wider access to ECT, where questions regarding insurance coverage at ECT-capable facilities become relevant. Second, physicians must (correctly) diagnose patients with disorders where ECT is indicated and refer them.
Within the U.S., ECT is not offered everywhere. ECT is primarily administered at large academic medical centers or private health care facilities. As a result, low-income patients are less likely to receive ECT. Although the lack of ECT in public facilities may contribute to racial disparities, it cannot fully explain the disparate numbers. Even when access to ECT-capable facilities is equal, Black and Latinx patients are nearly half as likely as white patients to receive ECT.
The predominant theory on this treatment gap is that clinicians’ racial/ethnic diagnostic biases may be limiting the reach of this incredibly effective treatment. Like others in society, physicians experience implicit, or unconscious, bias. Research demonstrates that these biases impact differences in rates of diagnosis, treatment, and, in turn, health outcomes.
Clinically, ECT is most indicated for severe mood disorders (e.g., major depressive disorder), versus psychotic disorders (e.g., schizophrenia). Despite population data that shows psychotic disorders affect all racial/ethnic groups equally, studies show that Black and Latinx patients are three to four times more likely than white patients to be diagnosed with a psychotic illness, even when all other demographic variables are controlled. In contrast, Black patients are significantly less likely than white patients to receive mood disorder diagnoses. Such diagnostic bias likely results in misdiagnosing mood disorders as psychotic disorders, leading to fewer ECT referrals.
Symptom attribution — when doctors’ perceptual biases shape their impression of a patient’s diagnosis — is thought to be the main driver of clinicians’ overdiagnosis of Black and Latinx patients with psychotic illnesses. One way this manifests is that providers are more likely to identify so-called “negative symptoms” of psychosis (i.e., apathy, lack of emotionality, paucity of speech, social withdrawal, and lethargy) for
Black patients compared to white patients.
Also, given past harms, mistrust of the medical establishment rightfully exists for many racial/ethnic groups. To medicine’s further detriment, research shows that clinicians take Black patients’ expressions of mistrust and misattribute them as paranoia — a hallmark symptom of psychotic disorders.
History offers important context: starting in the 1960s, research papers increasingly described schizophrenia as a disorder of racialized aggression. Articles conflated symptoms of schizophrenia with Black patients’ involvement in the civil rights protests organized by the Black Panthers, Nation of Islam, and other Black Power activist groups. Around this time, an ad for Haldol, an antipsychotic drug, depicted a Black man who appeared enraged and with a clenched, Black Power fist, conveying that the man’s social belligerence necessitated chemical control.
But for whatever the cause, doctors (who remain predominantly white in the U.S.) are misperceiving symptoms of patients. Although they may be well-intentioned and without explicit bias, their implicit biases — which may be influenced by historical racism — and resultant diagnostic fallacies limit their ability to accurately diagnose patients with mood disorders and refer them to ECT.
The factors contributing to minimal ECT use span access, referral, and informed consent conversations, in which addressing ECT’s noxious history is crucial given understandable medical mistrust. Physicians (perhaps working with the media) will have to do a lot of work to shift society’s perspective and rebuild trust in this modern procedure, which is encumbered by a history of coercive psychiatric care and horrific cameos in pop culture.
To counter the lack of access amongst low-income patients, who are disproportionately treated at public hospitals, requires increased funding for government facilities to offer ECT (and hiring the necessary nursing and anesthesia staff to assist) and work to repair historical narratives around its violent use.
As medicine seeks to address long-standing racial health disparities, medical trainees and clinicians should be educated on physician bias in the diagnosis of psychotic disorders and ECT referral. Further, the field of psychiatry could move to utilize standardized interview scripts to assess symptoms, codify an evidence-based ECT treatment screening protocol, and conduct more research on factors contributing to observed disparities.
Medical institutions must also continue to increase representation, support, and retention of people with backgrounds that are underrepresented in the profession to reflect the population served and hopefully decrease widespread bias.
One of the greatest medical injustices in the U.S. is that some of the best innovations in care exist, yet many Americans cannot access them. As we rewrite ECT’s story and capitalize on its medical promise, let’s center our efforts on the people historically left out.