Carrie Fisher recently talked about her experience of undergoing electroconvulsive therapy (ECT) on the Oprah Winfrey show: “Did you see One Flew Over the Cuckoo’s Nest? Well, it’s not like that.” She went on, apparently, to say she’s put to sleep and given a medication so she doesn’t experience convulsions. I wonder why she felt the need to tell people that she receives an anaesthetic and muscle relaxant when undergoing ECT – a practice that has been routine in US psychiatric hospitals for about half a century and probably the only sort of ECT used in US hospitals for decades? One Flew Over the Cuckoo’s Nest was based on a novel written by Ken Kesey in 1962 and even at that time the treatment depicted in the film – ECT given without anaesthetic to control patients – although not unheard of was not typical of the way ECT was used in US hospitals. Carrie Fisher is not however alone in mentioning One Flew Over the Cuckoo’s Nest when talking about ECT; it is common for journalists and psychiatrists to introduce it into articles about ECT in order to dismiss people’s concerns about ECT as based on a film which showed abuses of the past, and thus side-step concerns about the treatment’s effects on memory and the brain. Typically, Joanna Dowman, Abdul Patel, and Karim Rajput from Birmingham, in an article in the 2005 Journal of ECT entitled Electroconvulsive therapy: attitudes and misconceptions, say:
“It is undeniable that ECT was formerly an inhumane and widely abused treatment, with ECT being performed without the use of anesthesia or handling patients down…. Yet considerable stigma still surrounds ECT, and this probably remains the greatest barrier to public acceptance of this treatment”.
And, writing in the February 2011 edition of Psychiatric Times, American psychiatrist Charles Kellner, has this to say about One Flew Over the Cuckoo’s Nest:
“Made in 1975, it depicts a form of ECT that was already nearly 20 years obsolete in 1975. It was fiction taken literally as medical fact. When ECT was invented in 1938, modern anesthesia had not yet been developed; thus, ECT had to be given in unmodified form”.
This is misleading. Anaesthesia was developed about a century before ECT and even the particular type of anaesthetic used in ECT – a short-acting barbiturate such as thiopentone – was developed at about the same time. The curare-type muscle relaxants which allow the convulsions to be dampened or “modified” followed soon afterwards. So psychiatrists could have used anaesthetics right from the beginning (and a few did); they could have added muscle relaxants and performed modified ECT soon afterwards. But some psychiatrists continued to use unmodified ECT. In some hospitals in large parts of the world that is still how ECT is used – and they are not all hospitals in areas too poor or remote to have access to anaesthesia. There are countries which enter the Eurovision song contest where hospitals using unmodified ECT can be found. And a survey of ECT practice in Asia 2001-2003, an abstract of which was published in European Psychiatry in 2007, found that more than half of ECT was given in unmodified form: “22,194 patients (55.7%) received unmodified ECT totally of 129,906 treatments (54%) at 141 institutions in 14 countries”, out of 257 institutions in 29 countries responding to the survey questionnaire.
The US and the United Kingdom meanwhile are examples of countries where ECT is always, now, given in modified form. But the transition from unmodified to modified was not something that was completed in the 1950s. By the end of that decade, most hospitals were routinely using modified ECT, but there were nevertheless some that were not. I don’t know when the last sighting of unmodified was in the US; in the UK, unmodified ECT continued to be used occasionally into the 1980s.
Thanks to a court case in the 1957 (Bolam v Friern Hospital Management Committee), it is not difficult to trace the switch from modified to unmodified ECT in the UK. John Hector Bolam, who was originally from Gateshead, had served in two world wars. He had worked as a shipping assistant in Singapore and later as a car salesman in London. During the second world war he had been commissioned in the Royal Engineers but was invalided out in 1942 on account of depression. In 1954 he attempted suicide and was admitted to Friern Hospital in London, where he made a good recovery with rest. He was discharged from hospital and returned to work only to become depressed again and be re-admitted to hospital six weeks later. This time he was given, with his consent, ECT. The treatment was performed without muscle relaxant or any form of restraint, and during the convulsion he fractured both hips. This led to Bolam taking legal action against the hospital, arguing that they were negligent in failing to take precautions to prevent injury, especially as the hospital had previously seen six similar, although unilateral, fractures and muscle relaxants had been in widespread use for some years.The case was heard in front of Justice McNair. Doctors called for the defence were Netherne Hospital superintendent Dr Marshall and Friern Hospital consultant J. de Bastarrechea (who both argued that modified ECT carried a higher risk of death than unmodified ECT), Banstead Hospital deputy superintendent A.A. Baker, and Dr L.G.M. Page from the Three Counties Hospital (one of the inventors of the Page-Russell technique of intensive ECT later used by CIA-funded psychiatrist Dr Ewen Cameron in Canada). The judge in summing up told the jury that:
“A doctor is not negligent if he is acting in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art, merely because there is a body of opinion that takes a contrary view.”
The jury found for the defendants, while expressing sympathy for the plaintiff, and the judge’s words became enshrined in law as the Bolam principle or Bolam test which was applied to medico-legal cases for the next fifty years, rather stacking the odds against the patients who had been harmed. It was bad enough to be left horribly injured by treatment and then to lose his bid for compensation, but Bolam had to suffer the further aggravation of having his name associated with the principle which had denied him – and others since – compensation. There have, however, been cases in recent years which have demonstrated a move away from these principles.
The “body of opinion that takes a contrary view” referred to by the judge was already, by the time John Bolam’s case came to court, a hefty one. A survey of 47 hospitals by psychiatrist J.C. Barker from Banstead Hospital in 1957 found that 75 per cent of them usually gave ECT with anaesthetic and muscle relaxants. Five hospitals usually gave ECT with muscle relaxants only, and just four used neither anaesthesia or muscle relaxant. The author concluded that “the choice of technique appeared to depend to a large extent on the personal bias of the doctor concerned”.
By the time an extensive survey of ECT practice in British Hospitals was carried out by John Pippard and Les Ellam in 1980, all hospitals were routinely using modified ECT. But there were a small number of hospitals where unmodified ECT was still occasionally used. As the report of the survey said:
“Q65 If unmodified ECT is ever give, please state your reasons. The answer to Questions 63 and 64 [which asked if a short-acting anaesthetic drug and a muscle relaxant were used before administering ECT] was ‘always’ except in 16 clinics (5%) which refer to rare occasions when relaxants or both relaxants and anaesthesia may be omitted because, for example, there has been slow recovery from relaxant on previous occasions or there is low serum pseudocholinesterase.
Both relaxant and anaesthesia were reported to be sometimes omitted where there is difficulty in finding veins, when the patient prefers unmodified ECT, in emergency or where there has been a lack of response to modified ECT.
We saw ECT given without muscle relaxants at two clinics. In one of these, relaxants are occasionally omitted if there is doubt whether a convulsion is induced; at the other, 3 patients did not have relaxants because recovery was said to have been slow on previous occasions”.
In 1979 it emerged that unmodified ECT was still being used on occasion in Broadmoor to control patients’ behaviour. Sir George Young, Under-Secretary of State for Health and Social Security, defended the practice in Parliament on 26 January 1981 with these words:
“It is not disputed that on a few very exceptional occasions ECT has been administered to patients at Broadmoor hospital without the use of either a muscle relaxant or an anaesthetic. On these rare occasions this treatment has been given because on each occasion it was the clinical judgment of the consultant concerned that this exceptional measure was the best course of treatment at the particular time in the particular circumstances prevailing”.
He went on to quote from a statement on the use of unmodified ECT by the Royal College of Psychiatrists:
“It is conceivable that there could be medical contraindications to the use of anaesthetics and/or muscular relaxants and yet the ECT be urgently needed to control the patient’s behaviour. In these circumstances it would of course need the clinical judgment of the psychiatrist in charge of the case to decide whether to proceed after due consultation. There might also be situations in which anaesthetists are not available at short notice or even a second psychiatrist experienced in anaesthetic techniques. Again it would be a matter for the clinical judgment of the consultant whether in those circumstances he would be justified in going ahead without the modification”.