Psychiatry is an easy field to demonize. Psychiatrists treat inexplicable, malevolent illnesses that often have no physical appearance: Depression is not facial disfigurement, mania is not a rash. Sometimes our treatments also seem inexplicable, and then it's easy to feel that they are malevolent too. The most highly feared treatment that a psychiatrist can recommend is electroconvulsive therapy, or ECT.
Last month, I recommended ECT for an elderly patient. He is a frail man, but feisty; usually he requires a nurse's help to walk down the hall, but in the grip of mania he can unhinge a television set from a hospital wall and hurl it out of the room. He has failed medication after medication and has not left the ward for months.
ECT is often recommended for patients considered most vulnerable -- the elderly, the medically ill, pregnant women -- and for those who have been medication-resistant. It can break mania and depression faster than drugs and with fewer side effects. In this way, it is a triumph of therapeutics, with high rates of success and low rates of risk. It probably should be used more often.
I spoke to my patient's daughter, who is his legal guardian. I said "electroconvulsive therapy." But she heard "shock treatment." I think she thought I was condemning him to a gulag.
As for the treatment, absolutely not, she said. She was readying for a righteous battle. He's an old man. His bones could break. He might have brain damage. He'll lose his memory. It's like that movie, she said.
She meant "One Flew Over the Cuckoo's Nest," the 1975 movie in which Jack Nicholson, playing Randall McMurphy, a patient at a mental institution, is stranded on a gurney with a tongue depressor between his teeth, waiting for the bolt of electricity that will diminish him forever. On the screen, psychiatry had transformed a healthy contemptuous rebel into a lobotomized being.
The movie made a permanent impression on almost everyone who saw it. Personally, I vowed never to let a psychiatrist lay a finger on me. You took your life in your hands just lying on the shrink's couch.
My patient's daughter and I began again on common ground. Her father was a prisoner to his illness; we agreed on this. Mania is not only an irrational state, it can be a medically dangerous one; the body is literally overloaded with excitement. I tried to present some facts. She tried, much to her credit, to listen.
Before any ECT trial, I told her, blood tests, electrocardiograms, X-rays and MRIs are taken and reviewed. Then, usually in an operating room, a seizure is induced electrically and specifically. Placement of electrodes predicts the severity and type of side effects. The patient is always anesthetized (no pain) and given muscle relaxants (no broken bones). Throughout the seizure, which can last up to about a minute, cardiac function is monitored by continuous electrocardiogram and brain waves by continuous electroencephalogram. There is no lasting brain damage and no lobes are missing afterward, though there can be nausea, headaches and memory loss that nearly always passes. In life, nothing -- especially illness and relief -- is free.
My patient's daughter had many questions. She was horrified at first, then amazed and even shy. While she asked them, a pair of famous teeth flashed over her shoulder: Randall McMurphy was hovering. "Who are you going to believe?" he seemed to say in his mocking tone. "This stuff is Satan. Look what it did to me ... and that was just in the movies." Fear, myth and film memories trump logic. She wanted to listen to me. She had to hear him. In the end, she signed the consent form, but her signature wavered. It is brave to argue with an Oscar-worthy performance and hard to submit a relative to the most infamous symbol in psychiatry. She was filled with guilt. She will probably continue to feel that way until her father improves.
Elissa Ely is a psychiatrist at a state hospital in Massachusetts.