I just saw ECT for the first time...

[235750]

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I just saw my first ECT a little while ago ago. I'm a little disturbed by the experience, and I'd like to get your perspective on the treatment.

I know that ECT is relatively rare (ratio of procedures to psychiatrists is low), and I don't want anyone to work out who I am or where I went, so I will leave the details as vague as possible.

The procedure itself was executed well and seemed very sterile/humane. I didn't see an indication of pain, and with the patient anesthetized, his or her feet seemed to be the only thing that moved. The psychiatrist-- who was extremely kind of letting me follow him/her around-- said that ECT was wonderful because it was so effective. In addiition, he or she enjoyed the "great" compensation of ECT...he/she mentioned that, as the only procedure psychiatrists can do, it is a wonderful way to get paid. He or she recommended that I integrate ECT into my future practice because of this feature.

I understand that the treatment is effective for certain conditions. That part is not debatable. What disturbs me is that we don't know why it works. While medicine/science often discovers things by accident (antibiotics, etc) we seem to find a mechanism at some point. If we don't know how it works, how can we refine the technique or justify its continued use?

The lack of mechanism, along with the fact that ECT pays well, really concerns me. The doctor acted very nonclant and said the machanism was only an issue if one were a researcher: the evidence for the clinical application is there already there, so why would we care? I thought if I had that attitude I'd have become a mid-leveler and saved myself some time.

My question is: to those doctors out there who use ECT, how do you reconcile this gap in knowledge? Or is recent research that perhaps those doctors didn't know about that suggest a mechanism?

 

[whopper]

The doctor you mentioned was being practical, though not academic. Several doctors do things, and don't know why it works, they just do it. Kinda like driving a car to work. How many people truly know how their car works to the point where they can isolate the mechanisms, take the car apart, and put it back together again?

If we don't know how it works, how can we refine the technique or justify its continued use?

There are several things in medicine where at best we only have theories, though in replicatable studies, the results remain consistent. ECT is one of them. So too is the data that smoking causes cancer. Where has one truly gathered the smoking gun data where one actually recorded the tobacco actually altering the DNA in a manner that created a cancerous cell? Until then its only a theory.

Same goes with seizure meds. The exact mechanism for several of them are theoretical. Until they are exactly discovered, shall we doctors stop seizure medications in those with epilepsy? I think not.

That doesn't mean we should rest on our laurels and not care about obtaining more information. We would greatly advance our field and improve people's lives if we could find the exact mechanism.

In the meantime, people do need these treatments, and we do have enough data to justify their use. The person can also refuse the treatment.

 

[Superpsyched]

Though I am not a psychiatrist yet, I was taught that their is a proposed mechanism about how ECT works. The geriatric psychiatrist I worked with said that it basically like a giant dose of an antidepressant- lots of neurotransmitters were released and kind of "reset" the brain. This, in turn, helps the patient regulate their serotonin, NorE, and dopamine levels (which all play a part in depression to varying degrees).

Also, I don't think just b/c a mechanism isn't known it makes it immoral. We know patients have a great response. It seems that scientific theory is often behind the results!

 

[OldPsychDoc]

Though I am not a psychiatrist yet, I was taught that their is a proposed mechanism about how ECT works. The geriatric psychiatrist I worked with said that it basically like a giant dose of an antidepressant- lots of neurotransmitters were released and kind of "reset" the brain. This, in turn, helps the patient regulate their serotonin, NorE, and dopamine levels (which all play a part in depression to varying degrees).

Also, I don't think just b/c a mechanism isn't known it makes it immoral. We know patients have a great response. It seems that scientific theory is often behind the results!

I don't think that a "hand wave" theory like that is any better than saying "I don't know how it works--but clinical evidence shows that it does work, works rapidly, and works more effectively than medications."
I could (and do 😳) say that "It's like pressing CTRL-ALT-DELETE for your brain"--but that has no better or worse explanatory value than saying "It sends out lots of neurotransmitters".

Take home: be honest about your ignorance.

 

[Doc Samson]

While medicine/science often discovers things by accident (antibiotics, etc) we seem to find a mechanism at some point.

Right... the key part being "at some point." We're just not at that point with ECT yet. To me, this is what makes psychiatry so interesting - there's a lot we don't yet know. It's like practicing Neurology 50 years ago - you know a lot, you rely on your bedside exam skills, and you have the sense that the field is on the verge of making huge break-throughs in a bunch of different areas.

As I often tell my patients, if I had the choice between a treatment working and not knowing why, or not working and knowing exactly why, I'd take the former every time.

 

[235750]

So too is the data that smoking causes cancer. Where has one truly gathered the smoking gun data where one actually recorded the tobacco actually altering the DNA in a manner that created a cancerous cell? Until then its only a theory.

I agree that all we have are theories, but some are much better than others, and in this case I think the rationale behind ECT is poor. With your example of smoking, I think we have some pretty convincing mechanisms as to why and how it causes cancer on a molecular level. We do understand the biochemical actions of benzene, carbon monoxide, etc, and we can quanitfy a general amount for each cigeratte. We know these compounds are bad (ie carcinogens), so the proposed mechanism (while not perfect) is pretty convincing.

With your example of cars, you're right, I know nothing about cars, and that goes for most people. But that's becuase we are consumers of cars: if the designers over at Toyota added more space for oil in the engine, I'd expect them to have a reason why. To me, what makes an expert an expert is understanding the theories and reasons behind concepts in their respective field. Anyone can memorize preconstructed algorythms, but it takes time and thought to understand why things work they way they do. Medicine, I think, is no different.

Right... the key part being "at some point." We're just not at that point with ECT yet. To me, this is what makes psychiatry so interesting - there's a lot we don't yet know.

I understand that we don't know everything there is to know about the human body. That mystery is very alluring, no matter the field you are in. And I'm ok with reveling in that mystery. Its just, from what I've seen in medicine, we usually don't create invasive tests arbitrarily from nothing.

The test for me is this: Let's say for a second that ECT doesn't exist. If we got to keep our current knowledge of the brain, would we have ample evidence to get an NIH grant to start animal testing? Do you think you'd ever get to human testing without a proposed mechanism besides 'i think it reboots the brain'? It seems the burden of proof for the researcher is quite high since ECT is such a radical procedure. You put an electric current through someone's brain for goodness sake! I feel like you better have a damn good reason to do it besides "well, the psychiatrist before me did it, and his pts were ok". And I also think that after over 70 years, we'd have some sort of idea besides the CRTL-ALT-DEL analogy. In contrast, we still preform trepanning (sp?) in one way or another, but we certainly know the reasons behind that

Look, I'm sorry for my ranting, I truly am on your side. I knew we had gaps in our knowledge, but I was ignorant of our ignorance which I get is part of the educational process. I think psychiatry is wonderful and ECT obviously helps some people lead better lives. I was just hoping that someone out there knew the exact mechanism. This is just me being frustrated with reality! 🙂

I also should add that we saw a few patients who had the ECT months ago and they were significantly improved. So again, I think this technique works well

I will take OldPsychDoc's advice to heart. Thanks for everyone's replies

 

[billypilgrim37]

"It's like pressing CTRL-ALT-DELETE for your brain"

I bet your paranoid patients with working memory deficiencies love when you tell them you are going to DELETE THEIR BRAINS!!!

ZombieOPD...

 

[whopper]

Fair enough, and any good doctor should question, and demand for a better understanding than our current level of knowledge.

An example a professor of mine once said...he likened it to defibrillation, another treatment where the theory of the mechanism is also in a similar state of explanation (at least as far as he and I knew.) He said there's a theory that the application of an electrical current to nerves or neurons resets them. Why? He didn't know, just that the theory fit the results in ECT just like it does with defibrillation.

I did a search on defibrillation when I mentioned this a few years ago, and for that treatment, the mechanisms are also theoretical and not well explained. (Unless someone came out with recent data showing how it exactly works).

Until then, we are at our current state--with only theories, but with measurable results on the efficacy of the procedure.

While we should get more data, that is also one of the reasons why this field is so interesting. Maybe you could do some research on this, or this mystery will motivate others to do so.

(Hmm--perhaps a PET scan right before and after ECT?)

 

[OldPsychDoc]

I bet your paranoid patients with working memory deficiencies love when you tell them you are going to DELETE THEIR BRAINS!!!

ZombieOPD...

Someone that paranoid would never get through the informed consent process--but clearly, it's not a description I use with the seriously impaired...

 

[Doc Samson]

The test for me is this: Let's say for a second that ECT doesn't exist. If we got to keep our current knowledge of the brain, would we have ample evidence to get an NIH grant to start animal testing?

Almost all of the time-tested treatments we have for pretty much anything would fail this test. A bunch of very useful meds pre-date FDA approval (lithium, barbiturates) - we have only figured out their mechanism of action after decades of using them. Without knowing the MOA, we can definitvely identify clinical efficacy and risk of adverse effects and then carefully apply this knowledge in clinical decision making.

 

[Anasazi23]

I agree that all we have are theories, but some are much better than others, and in this case I think the rationale behind ECT is poor. With your example of smoking, I think we have some pretty convincing mechanisms as to why and how it causes cancer on a molecular level. We do understand the biochemical actions of benzene, carbon monoxide, etc, and we can quanitfy a general amount for each cigeratte. We know these compounds are bad (ie carcinogens), so the proposed mechanism (while not perfect) is pretty convincing.
Thanks for everyone's replies

There are lots of credible theories regarding the mechanism of action of ECT. The same could be said of even lithium treatment. The mechanism is known, but its relation to clinical efficacy is less sound.

http://www.gjpsy.uni-goettingen.de/gjp-article-grover2-ECT.pdf

 

[235750]

The mechanism is known, but its relation to clinical efficacy is less sound.http://www.gjpsy.uni-goettingen.de/gjp-article-grover2-ECT.pdf

Thanks for the article! That was a great paper on ECT.

The articles does end by saying, "There is no single theory that satisfactorily explains the MOA of ECT". So, it does seem to confirm what I was saying earlier.

Thanks again for posting that link!

 

[RGMSU]

I just saw my first ECT a little while ago ago. I'm a little disturbed by the experience, and I'd like to get your perspective on the treatment.

I know that ECT is relatively rare (ratio of procedures to psychiatrists is low), and I don't want anyone to work out who I am or where I went, so I will leave the details as vague as possible.

The procedure itself was executed well and seemed very sterile/humane. I didn't see an indication of pain, and with the patient anesthetized, his or her feet seemed to be the only thing that moved. The psychiatrist-- who was extremely kind of letting me follow him/her around-- said that ECT was wonderful because it was so effective. In addiition, he or she enjoyed the "great" compensation of ECT...he/she mentioned that, as the only procedure psychiatrists can do, it is a wonderful way to get paid. He or she recommended that I integrate ECT into my future practice because of this feature.

I understand that the treatment is effective for certain conditions. That part is not debatable. What disturbs me is that we don't know why it works. While medicine/science often discovers things by accident (antibiotics, etc) we seem to find a mechanism at some point. If we don't know how it works, how can we refine the technique or justify its continued use?

The lack of mechanism, along with the fact that ECT pays well, really concerns me. The doctor acted very nonclant and said the machanism was only an issue if one were a researcher: the evidence for the clinical application is there already there, so why would we care? I thought if I had that attitude I'd have become a mid-leveler and saved myself some time.

My question is: to those doctors out there who use ECT, how do you reconcile this gap in knowledge? Or is recent research that perhaps those doctors didn't know about that suggest a mechanism?

The bigger concern to me would be the long term effects of it. I have seen some studies calling this into question. As far as mechanism, much of the neurochemical/neurophysical mechanisms are only vaguely understood.

 

[stn2006]

Psychiatry is still in its infancy, including ECT. Probably there is know exact mechanism is know but who is to say that the brain, and people are simple. During the time of Leonardo, doctors diagnose people using their birthday. I would rather have my family member alive with some memory lost than death or have to worry about he/she committed suicide.

 

[RGMSU]

Psychiatry is still in its infancy, including ECT. Probably there is know exact mechanism is know but who is to say that the brain, and people are simple. During the time of Leonardo, doctors diagnose people using their birthday. I would rather have my family member alive with some memory lost than death or have to worry about he/she committed suicide.

The memory loss is definitely what I was referring to. I don't necessarily disagree that the benefits might outweigh the risks in some cases.

 

[worriedwell]

You are fooling yourself if you think any MOA in psychiatry is well understood...this includes SSRIs. So be humble about mechanisms when talking about something as complex as neurotransmission and the behavioral and cognitive manifestations of mental disorders. It is very NOT simple.

It makes me sick when people actually act confident about a chemical imbalance being corrected by adding Serotonin. Your search for a mode of action is more for your own peace of mind (to reduce your anxiety) than it is an ethical concern. It would be unethical to withhold ECT from a catatonic or a severely psychotically depressed patient.

I do agree with the search however, as that is being a scientist, which then likely will give you a chance to improve treatments. But science and clinical medicine are not at all the same thing. It is faulty logic to reason that because a mechanism is not exactly known, then one should withhold treatment.

 

[Thorazine]

You are fooling yourself if you think any MOA in psychiatry is well understood...this includes SSRIs. So be humble about mechanisms when talking about something as complex as neurotransmission and the behavioral and cognitive manifestations of mental disorders. It is very NOT simple.

It makes me sick when people actually act confident about a chemical imbalance being corrected by adding Serotonin. Your search for a mode of action is more for your own peace of mind (to reduce your anxiety) than it is an ethical concern. It would be unethical to withhold ECT from a catatonic or a severely psychotically depressed patient.

I do agree with the search however, as that is being a scientist, which then likely will give you a chance to improve treatments. But science and clinical medicine are not at all the same thing. It is faulty logic to reason that because a mechanism is not exactly known, then one should withhold treatment.

👍👍👍 very well said

 

[RGMSU]

You are fooling yourself if you think any MOA in psychiatry is well understood...this includes SSRIs. So be humble about mechanisms when talking about something as complex as neurotransmission and the behavioral and cognitive manifestations of mental disorders. It is very NOT simple.

It makes me sick when people actually act confident about a chemical imbalance being corrected by adding Serotonin. Your search for a mode of action is more for your own peace of mind (to reduce your anxiety) than it is an ethical concern. It would be unethical to withhold ECT from a catatonic or a severely psychotically depressed patient.

I do agree with the search however, as that is being a scientist, which then likely will give you a chance to improve treatments. But science and clinical medicine are not at all the same thing. It is faulty logic to reason that because a mechanism is not exactly known, then one should withhold treatment.

Consideration of mechanism is not irrelevant though. Offering something that is potentially risky without clear evidence of why it works is not without its ethical questions either. So, this mentality can't be taken to the extreme. The patient or the patient's caretaker should be well-informed of risks and evidence and make their own decision, if possible.

 

[whopper]

Consideration of mechanism is not irrelevant though. Offering something that is potentially risky without clear evidence of why it works is not without its ethical questions either

True, and its not like you can just tell a patient to do a treatment without explaining to them what the treatment is, what it's about, the risks and benefits.

At least doctors are supposed to do that. As I'm sure many of you finding out if you're doing your C&L consult rotation in the hospital.

 

[BabyPsychDoc]

I just saw my first ECT a little while ago ago. I'm a little disturbed by the experience, and I'd like to get your perspective on the treatment.

I know that ECT is relatively rare (ratio of procedures to psychiatrists is low), and I don't want anyone to work out who I am or where I went, so I will leave the details as vague as possible.

The procedure itself was executed well and seemed very sterile/humane. I didn't see an indication of pain, and with the patient anesthetized, his or her feet seemed to be the only thing that moved. The psychiatrist-- who was extremely kind of letting me follow him/her around-- said that ECT was wonderful because it was so effective. In addiition, he or she enjoyed the "great" compensation of ECT...he/she mentioned that, as the only procedure psychiatrists can do, it is a wonderful way to get paid. He or she recommended that I integrate ECT into my future practice because of this feature.

I understand that the treatment is effective for certain conditions. That part is not debatable. What disturbs me is that we don't know why it works. While medicine/science often discovers things by accident (antibiotics, etc) we seem to find a mechanism at some point. If we don't know how it works, how can we refine the technique or justify its continued use?

The lack of mechanism, along with the fact that ECT pays well, really concerns me. The doctor acted very nonclant and said the machanism was only an issue if one were a researcher: the evidence for the clinical application is there already there, so why would we care? I thought if I had that attitude I'd have become a mid-leveler and saved myself some time.

My question is: to those doctors out there who use ECT, how do you reconcile this gap in knowledge? Or is recent research that perhaps those doctors didn't know about that suggest a mechanism?

Bayer had no idea how and why aspirin worked when they discovered it. Fleming could not explain the mechanism of action of penicillin with the tools available to him. Ditto for fox glove, St Johns wart, belladonna, etc. Mankind enjoyed the benefits of these drugs for decades, even though at the time they were no more than "magic pills".

To me, the main reason people are uncomfortable with the idea of using ECT "just because it works" is the book by a drugged-up beatnik and the organization founded by a controversial psychiatrist supported by a copyrighted religion.

I am not saying that you are a troll, a Scientologist or whatever. I am saying that it is difficult to discuss these issues without being affected by the anti-psychiatry arguments - whether the influence is conscious or unconscious. I kind of gather that you are feeling conflicted about this issue, and most likely the conflict is down to your intellectual part (medical student) struggling to come to terms with your emotional distress at "frying someone's brain".

I sound like an analyst now, though, so time to close my post.

 

[Thorazine]

explaining the risks and benefits of a procedure is quite different from explaining WHY the procedure should work.
as many have already said, there are plenty of things in medicine we use because we know it works although we dont know why.

the first time i saw ect i was disturbed too. it was just strange, the room was so quiet and calm, and it was no big deal to just electrocute someones head and make them seize. it was a little horrifying to be honest. especially when your perception of a seizure is that its such a violent and bad thing that needs to be stopped, you wonder why you would MAKE someone seize.

but when you see your patient after a couple of treatments, smiling, making jokes, so thrilled that a little seizure has pretty much saved their life...
how can you NOT offer this to patients that clearly need it?

ect is often a last resort, as it should be. its an invasive procedure with risks. but it shouldnt be withheld for our discomfort.

 

[BabyPsychDoc]

explaining the risks and benefits of a procedure is quite different from explaining WHY the procedure should work.
as many have already said, there are plenty of things in medicine we use because we know it works although we dont know why.

the first time i saw ect i was disturbed too. it was just strange, the room was so quiet and calm, and it was no big deal to just electrocute someones head and make them seize. it was a little horrifying to be honest. especially when your perception of a seizure is that its such a violent and bad thing that needs to be stopped, you wonder why you would MAKE someone seize.

but when you see your patient after a couple of treatments, smiling, making jokes, so thrilled that a little seizure has pretty much saved their life...
how can you NOT offer this to patients that clearly need it?

ect is often a last resort, as it should be. its an invasive procedure with risks. but it shouldnt be withheld for our discomfort.

👍 The only thing I would disagree with is the "ect is the last resort" statement. ECT, like any other procedure, has its indications: and severe depressive episode (esp with psychotic features, or where rapid improvement is essential), is an indication to use it as 1st line rx.

 

[235750]

To me, the main reason people are uncomfortable with the idea of using ECT "just because it works" is the book by a drugged-up beatnik and the organization founded by a controversial psychiatrist supported by a copyrighted religion.

Wow.

I think you should reread my posts. My objection to ECT was that we don't understand the mechanism. I have no idea what you're talking about regarding a drugged-up beatnik.

I am not saying that you are a troll, a Scientologist or whatever.

Thank you...I think?

I am saying that it is difficult to discuss these issues without being affected by the anti-psychiatry arguments - whether the influence is conscious or unconscious.

I think it is very easy to talk about our ignorance of the natural world without having to resort to scientology, intelligent design, or some other non-science theory. Again, if you reread all of the previous posts, I think you'll find that everyone conducted themselves in a constructive manner and I personally found this thread to be quite helpful.

I kind of gather that you are feeling conflicted about this issue, and most likely the conflict is down to your intellectual part (medical student) struggling to come to terms with your emotional distress at "frying someone's brain".

Again, my dilemma is not having a MOA for ECT. It is as simple as that.

I was and am in no way emotionally distressed with the procedure in of itself. I mentioned the procedure was painless/sterile. Also, I said that trepanning (ie craniotomy) is still preformed, which is fine as we understand how it works.

Re: your example of other medical treatments, we already discussed this.