Hello Friends.

Today is my Sabbath. If you wonder, I’ll briefly explain. If you don’t, skip this :). I get the Sabbath from the Bible. The validity of the Bible as a mostly unchanged book from the original writers isn’t what I’ll comment on. But as all things, I keep the Sabbath because it has shown my selfish short lived self, (call me Blip,) that it is kind to Me. What the Sabbath is about is still my pursuit to know. My understanding influences my activities, and as my learning is plastic, my activities change over the blinking tinsy trail through space and time I traverse.

Because today is Sabbath, it is the day I choose to reengage in writing. Writing about self-care is something I unwrap with many emotions. The gift brings me here today to respond to a person who reached out a few weeks ago. I felt some inner conflict with the question from the Curious, which may have contributed to why I’ve waited to speak.

Here is an abbreviated bit of the person’s points of interest regarding electroconvulsive therapy (ECT):

1. I’m concerned about the suicide epidemic in the military and veterans.  I don’t understand why we are not going to ECT in many of these cases (from a scientific standpoint – I understand stigma and pharma lead to meds first).    
2. Are we in the military and VA missing opportunities to help people by putting ECT as the last resort?

This is how our nurse-ECT specialist responded – (Again I took liberties abbreviating, etc.):

My first exposure to ECT came during my psych rotation in nursing school at the VA in San Diego. I worked with some incredible men struggling  with depression and PTSD and I witnessed some positive results during their treatments. I did notice that ECT was not widely used, and of course had much stigma attached even within the confines of the mental health unit.

A big part of my job here at our center is patient and family education… trying to break down walls, or barriers, that keep people from exploring this treatment as a valuable option. I’ve even visited local psychiatrist’s office to discuss and collaborate – many medical clinicians underutilize it as well… a last resort option for those with “treatment resistant depression/illness.”

I also handle all the insurance authorizations for patients starting ECT, and one of the biggest barriers I come across is the insurance companies asking:

‘How many medications trials has the patient done?’

There have been times that insurances will not authorize the treatments because the patient has not tried ‘enough’ medications or sought out alternate therapies. This is so very frustrating to hear. My response, ‘The patient doesn’t have the luxury of waiting another 2-3 months to try another medication…and suffer any possible side effects!’

What many people don’t understand is that depression and other affective illness is progressive, and it can happen so quickly.

The quicker a patient can have a full treatment response the better… and the success rates lie with ECT as the gold standard… 80-90% success rate.This holds true here at our center.

Patients have come out of some pretty dark places in our small corner of the world with ECT treatment. It is rewarding to watch, to help them, and their families, get their life back.

There’s a study I remember, but can’t quote without looking it up, that unless personal experience is gained in some aspect with ECT, we all will have negative beliefs about it, physicians, medical students, nurses, et al. So, knowing that psychiatry residencies don’t require ECT experience is disheartening. Who do we look to for expert opinions about psychiatric medical treatments, after all? Eventually, those psychiatry residents will become psychiatrists, in a world of underserved mental health care workers. They will become, we might suppose, prejudiced (negative beliefs not based on reason or experience,) and they will act on those beliefs (discrimination.)

One might exhale under the load of it all and reroute. Why do we stay though, dig, and try to grow this poor “fig tree” with water, song, and verse? BECAUSE brain illness is a human condition that kills and destroys and denudes the beloved construct we call, Me. We continue, despite being misunderstood, because each one of us, individually and as a whole, are Loved, valued, and in the end of course, because it serves our selfish desires. Motivation to speak toward the truth about ECT treatment is as complicated as the construction of motivation in any context.

The person who started this dialogue is motivated by “the suicide epidemic in the military and veterans.”

The Curious asked why we wait so long to offer ECT, “from a scientific standpoint,” stating, “I understand stigma and pharma lead to meds first.” Let’s pull on this thread.

• Is there a “scientific standpoint,” or has the alleged algorithm of treating a certain number of medications first before treating with ECT been scientifically studied and/or proven? No and no.

Some years ago during the Q&A of an expensive international well-attended ECT lecture, by those who have much more experience than I, my wobbly legs took my own curious self to the mike. I felt the years, like a bag of gold on a scale, hanging in a plate. And where I stood, my purse felt too light. But I did ask them why we continue to say this? I did even challenge, like a barking puppy, “We need to stop saying this. We need to support our community of practitioners who do offer ECT to anyone (that needs it) who wants it, at any point in their treatment. We need to stop perpetuating this tradition, that has no scientific support, to treat last.” Ruff. Ruff.

Tradition? Yes, tradition.

In medical practice, it is our standard to weigh the benefits of one treatment against the risks of that treatment. And likewise, against the available treatments otherwise known for any illness. For example, many medications may cause dry mouth. Dry mouth, leads to dry gums. Bad breath is there, sure. But do we think of root canals? When we speak about medical treatments, we consider the possible side effect’s along with the hoped for benefits.

• Are the risks of the disease remaining unchecked, untreated, progressing over time, burning and pillaging along the way, etc. more dangerous than the risks of treatment?
• Are the benefits of leaving the disease untreated, more than the potential benefits of the medical treatment?

The standard of one medical practice over time leads to traditions of medical practice. We would like to think that those traditions are based on science. But when they are not, well, here we are.

When I was a kid, I was fortunate to live in the community of FOB’s, (fresh off the boat’ers.) Our boats came from Lebanon. Among the many benefits, like belly dancing, tabouli as a staple, and high volume multi-voiced conversation, I also had to sift through noisy “traditions” not based on science.

Sana, sleep on your back so you don’t get wrinkles in your face.

Sana, pinch your nails so your fingers and nail-beds grow out thin and not flat.

Sana, drink a lot of milk because milk is good for you.

The misconception about when to offer ECT is a tradition that came from a time when many medical treatments were primitive compared to now. For context, imagine that you wanted to know if you were pregnant. You would pee into a cup, (so far so good), and your pee would be injected into a rabbit. (Wait! What!?) In 1935, Portuguese neurologist António Egas Moniz introduced lobotomies. In 1949, he was awarded the Nobel Prize for Medicine. (Clearing throat sounds rattling the air.) This is the company ECT kept.

Have you ever heard the wagging term, “Time will tell”? And it has. We can now leave rabbits perfectly unharmed in our pregnancy tests, and keep drills and saws out of the treatment options for panic attacks. But here, some 80’ish years later, we are still using electricity, a natural process in cell communication, to bring about healing. Why is it still around?

Why is it our tradition to offer ECT so late in the disease? Back in the day of the rabbit test, lobotomy, and when ECT was born, we didn’t have much control in the treatment. It was a wild foal.

• We had ether-gas, or nothing, for anesthesia, rather than the easily tolerated and highly effective intravenously dosed medications we now use to allow our patients not to feel or remember any of the treatment experience.
• We had a sign wave of electricity, comparable to a tsunami dosing; rather than the finely tuned small amount of electrical current we now effectively use.
• We directed the stimulation haphazardly, like a four-year-old playing t-ball as compared to professional baseball. We now place the stimulation more specifically, with deliberation, in areas that are most effective.

The benefits not only stayed through the years, but they have improved. The risks have diminished. Dramatically. This changed the risk-to-benefit ratio, which you remember is our standard to consider in the practice of medicine. But 80-years is a long time. And since anesthesia really wasn’t developed until the 1960’s, fluoxetine was launched in the 1980’s revolutionizing the practice of psychiatry, and the recent changes in the style of practice with ECT have been made now over the last twenty-some years – our traditions have been what traditions are, practices of the old cultures.

This ends my Sabbath writing. Thank you for sharing it with me.

What is the self-care tip? To keep the Sabbath? To get ECT? To change one’s traditions? Laughing. You tell me.

Keep on!