Mental Health: Restorative Electroshocks
Electroconvulsive treatment has been used in psychiatry since the 1930s, but it remains shrouded in mystery and taboos. Contrary to popular belief, electroconvulsive therapy is still routinely given in hospitals across the country to treatment-resistant severe depressive or bipolar patients. The controversial method has greatly evolved and saves lives.
Psychiatrist Valérie Tourjman holds electrodes that are applied to patients' temples for electroshock treatment.
The University Institute of Mental Health of Montreal (IUSMM) stands in the east of town. Behind the wide columns of the Bourget Pavilion, patients make their way to the top floor to receive electroconvulsive therapy, or ECT, electroshock treatments.
In the sanitized corridors of the pavilion, Colette is well settled on her stretcher. The woman, in her late 50s, has been going to the Institute every week for a year and a half to receive her treatment. She has lived with severe bipolar disorder since adolescence.
Colette goes to IUSMM every week for a electroconvulsive therapy.
I took all the medications you can imagine, she says, before listing the many molecules she tried to control her disorder, without success. In addition, the medication for bipolarity interacted with his other health problems.
In an impasse, the IUSMM team offered him ECT, a treatment of last resort unknown to the general population which comes with its share of prejudices.
At first, I didn't want to, because I thought we should shave our heads. People have a bad idea of ECT, admits Colette, laughing. A year and a half later, she doesn't regret her choice at all.
“It's like I'm 17 , before the onset of my illness. »
— Colette, IUSMM patient
Each year, 150 to 200 patients pass through the Institut universitaire en santé maladie de Montréal to undergo ECT treatments. Some, like Colette, return weekly, or monthly, for maintenance sessions.
The effects of the treatment are usually felt after 6 to 12 sessions. Some patients will use it for a longer period. The benefits are great, but are not permanent; they must be maintained with medication, psychotherapy, or even new ECT sessions.
The procedure, which has been modified since its invention, no longer has anything to do with what is depicted in certain works of fiction.
At IUSMM, electroshocks are given in an operating theatre, in the presence of nurses, a psychiatrist and an anesthesiologist. Colette is connected to various devices that monitor her state of health, including her heart rate. The team secures their consent until the very last minute.
The vital signs of the patient, who will be under general anesthesia, are monitored throughout the session.
The patient is placed under general anesthesia, the time of the session, which lasts about ten minutes. He is also given a muscle relaxant, to prevent injury, except in the right arm, so that the psychiatrist can observe the duration of the convulsion.
The medical team then applies the electrodes to Colette's temples. The stimulus parameters are calibrated, according to each patient. When everything is in place, the psychiatrist presses a button on the ECT machine, which sends an electric shock through the brain.
A member of the medical team applies the electrodes to the patient. The electrical stimulation and resulting convulsion lasts a few seconds
The stimulation only lasts a few seconds. Colette's pulse will increase, and her convulsion will last about forty seconds. Did it come down to the level of the heart?, asks psychiatrist Valérie Tourjman, head of the ECT department at the Institute. Colette's pulse slowly returns to normal.
The psychiatrist studies the trace of the electroencephalogram printed on a long sheet of paper. Valérie Tourjman scrutinizes the signs that indicate that the convulsion went well.
ECT is that we activate the brain simultaneously to produce a convulsion that will be very short, and we know that this event will lead to an improvement in psychiatric condition,” says Dr. Tourjman.
Colette, meanwhile, is transferred to a recovery room until the anesthesia wears off. She can go home in a few hours.
In Quebec, RAMQ data counted more than 9,000 electroconvulsive therapy sessions in 2021. The prevalence of the practice had dropped by 30% between 2002 and 2013. It was increasing constant since, until the arrival of the pandemic, before resuming the momentum.
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ECT is reserved for patients with depression or bipolar disorder who do not respond to standard treatments. It can also be administered to schizophrenic patients. According to the Institut national de santé publique du Québec (INSPQ), approximately 0.09% of patients treated each year in the province for mental disorders receive this treatment.
Its effectiveness for depression is impressive. According to studies, psychiatrists see an improvement in depressive symptoms in 50 to 80% of cases treated with ECT.
A study published last spring in the journal The Lancet found that people hospitalized with severe depression, and who received ECT treatment at a Toronto hospital, were 47% less likely to commit suicide within the following year than those who did not.
However, we do not yet understand all the mechanisms that explain its effectiveness. It does a lot of things at the same time, so it's hard to say if it's this effect that makes the change, explains psychiatrist Valérie Tourjman.
The psychiatrist and head of the ECT department at IUSMM, Valérie Tourjman
ECT causes the same changes in receptors as antidepressants, but faster and more markedly, says Dr. Tourjman.
The treatment also brings about other changes in the brain that are not necessarily seen with first-line treatments. Depression leads in many cases to atrophy of the cerebral volume; ECT allows a significant recovery of this loss.
Electroconvulsive therapy is still stigmatized, predated by its 1950s reputation, long conveyed in works of fiction, such as in One Flew Over the Cuckoo's Nest , a 1975 film.
One scene shows the main character, played by Jack Nicholson, writhing in pain as he undergoes forceful electroshocks without anesthesia.
The character of R.P. McMurphy (Jack Nicholson) undergoes electric shocks against his will in the film Flight over a cuckoo's nest.
The prejudices concerning this practice come, among other things, from the abuses recorded at the time when ECT was one of the only effective treatments for psychiatric illnesses, believes psychiatrist Valérie Tourjman.
It was used too widely, in indications for which it was not an appropriate treatment, she admits.
Since then, the practice of electroconvulsive therapy has greatly changed. Less electrical current is used, which reduces side effects. There are guidelines that frame which patients can get the treatment. Free and informed consent is required.
Even so, the fear of permanent brain damage remains strong.
There is no evidence that neurons are destroyed by ECT. There have been autopsy studies, imaging studies, neuropsychological testing studies, and there has never been evidence of permanent brain damage, Dr. Tourjman insists.
This treatment does have undesirable side effects. Patients report memory loss surrounding the moments before and after treatment. Others mention loss of autobiographical memory. However, studies report that these effects are transient, in the vast majority of cases.
Patients also report effects such as muscle aches, nausea and headaches, but these may be attributable to the general anesthetic.
A stone's throw from the Botanical Garden in Montreal, a former residence for nuns houses the offices of Action Autonomie, a community organization dedicated to defending mental health rights.< /p>
The handful of employees respond to requests from citizens who claim to be victims of abuse of rights related to their mental state. They assist them in situations of confinement in an establishment, or judicial authorization of care, for example.
We try to ensure that the rights of these people are known to those who care for them and are also respected by those who care for them, which is not always obvious, says Action Autonomie's case and communications officer, Jean-François Plouffe.
The Action Autonomie team does not want to take the place of doctors or lawyers, but they believe that the solutions to people's psychiatric problems are not only found in pharmaceutical treatments or ECT.
When you give 10 sessions of psychotherapy, you will tell me, it's better than nothing, but it's not always enough. These are the scales of the Ministry of Health. It is very difficult to get more than that number. But maybe after 20 or 30 sessions, and we've gone over the issue, maybe we could have avoided this last resort treatment that is electroshock.
Electroconvulsive therapy remains a practice charged in the popular imagination. Additional efforts must therefore be made by the medical community to clearly and precisely inform patients about how it works and its side effects, believes Jean-François Plouffe.
“It is still a question of inducing in people a state of convulsion which is similar to an epileptic seizure. It's not nothing. »
— Jean-François Plouffe, spokesperson for Action Autonomie
Consent is required for this type of processing, but Action Autonomie wonders how of which it is made. Jean-François Plouffe recounts having several testimonials from patients who feel that they did not obtain all the information necessary for free and informed consent before being immersed in the process.
Jean-François Plouffe pleads for better monitoring of the practice of electroconvulsive therapy in the province.
And then it happens that a patient is not considered capable of consenting, and the case ends up in court to authorize treatment against his will.
As recently as September, the CISSS de Laval obtained a judgment from the Superior Court for around sixty ECT sessions to be given to a schizophrenic patient. His mother and guardian, whom we spoke to, fears that the treatments have made her son's condition worse.
In psychiatry in particular […] the fact of refusing a treatment is considered as a deterioration of the mental state, and as an additional proof of the fact that the person needs the treatment, deplores Jean-François Plouffe.
The annual data on individuals who receive electroshock therapy in Quebec also raise eyebrows at Action Autonomie.
Women and the elderly are overrepresented among patients who receive ECT. While the gender difference in use of this treatment has narrowed over time, the increase in the number of sessions has mostly been seen in people over the age of 65.
To this, psychiatrists respond that these are the groups most likely to suffer from depression. And in the case of the elderly, their condition is more difficult to treat, and their depression can more quickly precarious their physical health.
There is also a significant regional disparity in the number of treatments, year after year. In 2021, seven times more ECT sessions were given in Mauricie-Centre-du-Québec than in Saguenay–Lac-St-Jean… and five times more than in the Laurentians.
Are people in Mauricie-Centre-du-Québec 10 times more depressed than people in the Laurentians or Saguenay–Lac-Saint-Jean? We don't think. We think that it is simply a particular, professional interest that certain doctors have in this treatment and that they use it routinely, worries Mr. Plouffe.
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Moreover, this regional disparity was noted in a report by the National Institute of Public Health in 2020, which raises questions about the optimal use of treatment.
The report called for continuing the in-depth examination of the use of ECT in Quebec. But the Center of Excellence in Electroconvulsive Therapy of Quebec, which aimed to implement best practices, no longer exists, confirms the INSPQ.
The Ministry of Health did not respond to our questions on the subject.
Myreille Bédard is convinced that electroshocks saved her life. The artist and broadcaster went through a major depression in the early 2000s. She was hospitalized against her will for almost a year, before being offered ECT treatments.
Myreille, like many others, had a lot of prejudices about this treatment. But his condition worsened, without improvement. I felt that I had reached a turning point. I had nothing to lose, I wanted to die, I was going to die. It gave me almost a resurrection, she says.
Myreille Bédard experienced another depressive episode in 2018. She received electroshock again, a treatment that is still effective in her case.
Myreille Bédard experienced two severe depressions which did not respond to the usual treatments and which were cured by ECT sessions.
Even today, mental health care remains the poor relations of the system, deplores the artist. And the taboos surrounding it persist, even in the medical community.
I think that in physical health, in general, we inform people better, we infantilize them less, observes Ms. Bédard. She would like better support for patients who will have to go through the same path as her.
Today, Myreille is doing better. She wrote a book to tell her story to break down the stigma surrounding mental health issues. She urges people who are suffering to consult, despite the barriers that may arise.View larger
Myreille Bédard has published a book about her experience with depression, in order to break taboos concerning mental health.
And to those who could benefit from ECT, she says this: Educate yourself and stay open. Because me, if I had said no-no-no, it's out of the question, I don't do ECT, I don't think I would be talking to you today, she concludes.
Nahila Bendali's report is broadcast on the show Désautels on Sunday on Sunday from 10 a.m. to noon and in rebroadcast on Monday at 3 a.m. on HERE First.