Racism in Canada traces both historical and contemporary racist
community attitudes, as well as governmental negligence and political
non-compliance with United Nations human rights standards and incidents
in Canada. Contemporary Canada is the product of indigenous First Nations combined with multiple waves of immigration, predominantly from Europe and in modern times, from Asia.
Overview
In a 2013 survey of 80 countries by the World Values Survey, Canada was ranked among the most racially tolerant societies in the world. In 2021, the Social Progress Index ranked Canada 6th in the world for overall tolerance and inclusion.
Canadian author and journalist Terry Glavin claims that white Canadians consider themselves to be mostly free of racial prejudice, perceiving the country to be a "more inclusive society" than its direct neighbor the United States, a notion that has come under criticism. For instance, Galvin cites the treatment of the Aboriginal population in Canada as evidence of Canada's own racist tendencies. These perceptions of inclusion and "colour-blindness" have also been challenged in recent years by scholars such as Constance Backhouse
stating that white supremacy is still prevalent in the country's legal
system, with blatant racism created and enforced through the law. According to one commentator, Canadian "racism contributes to a self-perpetuating cycle of criminalization and imprisonment".
In addition, throughout Canada's history there have been laws and
regulations that have negatively affected a wide variety of races,
religions, and groups of persons.
Canadian law uses the term "visible minority" to refer to people of colour (but not aboriginal Canadians), introduced by the Employment Equity Act of 1995.
However, the UN Committee on the Elimination of Racial Discrimination
stated this term may be considered objectionable by certain minorities
and recommended an evaluation of this term.
Canada's treatment of First Nations people is governed by the Indian Act. The Canadian Indian Act helped inspire South Africa's apartheid policies.
Many Indigenous people were forced into assimilation through the Canadian Indian residential school system. From 1928 to the mid-1990s, Indigenous girls in the residential school system
were subject to forced sterilization once they reached puberty. The
number of sterilized girls is not known because the records were
destroyed. European colonizers assumed the Indigenous peoples needed saving, a form of "charitable racism". However, this attitude is not absent from modern Canada, for example, in August 2008, McGill University's Chancellor and International Olympic Committee representative Richard Pound told La Presse: "We must not forget that 400 years ago, Canada was a land of savages,
with scarcely 10,000 inhabitants of European origin, while in China,
we're talking about a 5,000-year-old civilization", implying that the
First Nations people were "uncivilized".
In 1999 the Canadian government created an autonomous territory, Nunavut,
for the Inuit living in the Arctic and northernmost parts of the
country. The Inuit compose 85% of the population of Nunavut, which
represents a new level of self-determination for the Indigenous peoples of Canada.
Slavery of Aboriginals and Black Canadians
Ku Klux Klan members, on foot and horseback, by a cross erected in a field near Kingston, Ontario, in 1927
Canada had also practiced segregation, and a Canadian Ku Klux Klan also exists. Racial profiling occurs in cities such as Halifax, Toronto and Montreal.
Black people made up 3% of the Canadian population in 2016, and 9% of
the population of Toronto (which has the largest communities of
Caribbean and African immigrants). They disproportionately lived in poverty, they were three times as likely to be carded
in Toronto than Whites were, and incarceration rates among Blacks were
climbing faster than they were among any other demographic. A Black Lives Matter protest was staged at Toronto Police Headquarters in March 2016.
On August 12, 1911, the Governor General in Council approved a one-year prohibition of black immigration to Canada because, according to the Order-in-Council, "the Negro race" was "unsuitable to the climate and requirements of Canada." It was tabled on June 2, 1911, by the Minister of the Interior, Frank Oliver,
following mounting pressure from white prairie farmers who were
discontented with an influx in the immigration of black farmers from the
United States. It was never officially enforced or added to the Immigration Act, likely because the government—led by Prime MinisterWilfrid Laurier—was hesitant to alienate black voters ahead of the 1911 federal election. It was repealed later that year.
In Nova Scotia, a community which mainly consisted of Black Canadians were forcibly removed and eventually razed between 1964 and 1967 after years of intentional neglect by the government in Halifax.
The 1918 Toronto anti-Greek riot was a three-day race riot in
Toronto, Ontario, Canada, targeting Greek immigrants during August 2–4,
1918. It was the largest riot in the city's history and one of the
largest anti-Greek riots in the world.
Jewish students were prohibited from studying at Canadian universities. Canada had imposed restrictive policies on Jewish immigration. In 1939, Jewish refugees who were escaping from WWII in Europe by traveling aboard the MS St Louis were not allowed to enter Canada due to racist immigration policies.
The government's policies have changed, however, antisemitism
remains problematic. Jews are a tiny-and therefore a more
vulnerable-minority in Canada, in 2018, they only comprised 1.1% of
Canada's entire population.
Partially due to the small size of the community, hate crimes against
Jews (also referred to as "violent antisemitism") is the highest
per-capita form of race-based violence reported in Canada.
In 1914, Indians arriving in Canada were not allowed to enter despite being British subjects, leading to the deaths of dozens of immigrants in the Komagata Maru incident.
Chinese Canadians
Boarded windows and storefronts on Pender Street in Chinatown after the September 1907 riots
Starting in 1858, Chinese "coolies" were brought to Canada to work in British Columbia in the mines and on the Canadian Pacific Railway. After anti-Chinese riots broke out in 1886, a "Chinese head tax" was implemented to curtail immigration from China. In 1907, the Anti-Oriental Riots in Vancouver
targeted Chinese and Japanese-owned businesses, and the Asiatic
Exclusion League was formed to drive Asians out of the province. League
members attacked Asians, resulting in numerous riots. In 1923, the federal government passed the Chinese Immigration Act, commonly known as the Exclusion Act, prohibiting most Chinese immigration. The Act was repealed in 1947,
but discrimination limiting non-European immigrants continued until
1967 when a points-based system was introduced to assess immigrants
regardless of origin.
Japanese Canadians
A Royal Canadian Navy officer questions Canadian fishermen of Japanese descent as their boats were confiscated.
Although a British–Japanese treaty guaranteed Japanese citizens
freedom of travel, they were nevertheless subject to anti-Asian racism
in Canada, though a slightly lesser degree at the time than the Chinese
before World War II, as an informal agreement between the Japanese and
Canadian governments limited Japanese immigration in the wake of the Vancouver anti-Asian riots.
In 1942, during World War II, many Canadians of Japanese heritage—even those born in Canada— were forcibly moved to internment camps under the authority of the War Measures Act. At first, many men were separated from their families and sent to road camps in Ontario and on the British Columbia–Alberta border. Small towns in the BC interior such as Greenwood, Sandon, New Denver and Slocan
became internment camps for women, children and the aged. To stay
together, Japanese–Canadian families chose to work in farms in Alberta and Manitoba. Those who resisted and challenged the orders of the Canadian government were rounded up by the Royal Canadian Mounted Police and incarcerated in a barbed-wire prisoner-of-war camp in Angler, Ontario.
Japanese–Canadians fishing boats were also seized, with plans to
drastically reduce fishing licenses from them and forcibly redistribute
them for white Canadians.
With government promises to return the land and properties seized
during that time period, Japanese Canadians left their homes. This
turned out to be untrue, as the seized possessions were resold and never
returned to the Japanese Canadians. Unlike prisoners of war, who were
protected by the Geneva Convention, Japanese–Canadians were forced to pay for their own internment.
COVID-19 pandemic
In the midst of the COVID-19 pandemic, Asian Canadians reported increased incidents of violent assaults, especially against women of Asian descent.
According to an Angus Reid survey from 22 June 2020, up to 50% of
Chinese-Canadians had experienced verbal abuse, and 29% had been made to
feel feared, as if they posed a threat to public safety. Another survey of 1,600 adults conducted by ResearchCo and obtained by the Agence France-Presse
revealed one in four Canadians of Asian descent (70% of whom were of
Chinese descent) who lived in British Columbia knew someone within their
household who had faced discrimination. The survey also revealed 24 percent of Canadians of South Asian descent reported racist insults. Canadians of Indigenous origin had also reported discrimination.
Anti-Sikh sentiment in Canada has a historical and contemporary
presence marked by several key events and ongoing issues. Early
instances include the 1907 Bellingham Race Riot, where South East Asian and South Asian immigrants, mostly Sikhs, were violently targeted by white mobs in Washington (state), spilling over into Canadian anti-immigrant sentiments and the Pacific Northwest.
The 1914 Komagata Maru incident incident further highlighted
institutional racism when 376 Indian passengers, mostly Sikhs, were
denied entry into Canada and forced to return to India, where many faced
persecution.
Post September 11 attacks,
Sikhs in Canada experienced increased xenophobia and hate crimes, often
being mistaken for Muslims due to their turbans and beards.
The representation of murdered Indigenous women in crime statistics is not proportionate to the general population. In 2006, Amnesty International researched racism specific to Indigenous women in Canada.
They reported on the lack of basic human rights, discrimination, and
violence against Indigenous women. The Amnesty report found that First Nations women (age 25–44) with status under the Indian Act were five times more likely than other women of the same age to die as a result of violence. In 2006, the documentary filmFinding Dawn looked into the many missing and murdered Aboriginal women in Canada over the past three decades.
In September 2016, in response to repeated calls from Indigenous groups,
activists, and non-governmental organizations, the Government of Canada
under Prime Minister Justin Trudeau, jointly with all provincial and territorial governments, established a national public inquiry into Missing and Murdered Indigenous Women and Girls.
Indigenous people still have to deal with racism within Canada and the challenges that the communities face are often ignored. There are still negative stereotypes associated with Indigenous people such as being freeloaders, drug addicts or dumb. Indigenous people are more likely to feel depression due to several factors such as poverty, loss of cultural identity, inadequate health care and more.
In 2020, the staff at a hospital in the Quebec city of Joliette were shown on video mocking and making racist remarks at an Atikamekw woman who eventually died.
Indigenous leaders say the video exposes the grim realities of systemic
racism that have long gone ignored or suppressed throughout Canada.
Electroconvulsive therapy (ECT) or electroshock therapy (EST) is a psychiatric treatment during which a generalized seizure (without muscular convulsions) is electrically induced to manage refractory mental disorders. Typically, 70 to 120 volts are applied externally to the patient's head, resulting in approximately 800 milliamperes of direct current passing between the electrodes, for a duration of 100 milliseconds
to 6 seconds, either from temple to temple (bilateral ECT) or from
front to back of one side of the head (unilateral ECT). However, only
about 1% of the electrical current crosses the bony skull into the brain
because skull impedance is about 100 times higher than skin impedance.
Aside from effects on the brain, the general physical risks of ECT are similar to those of brief general anesthesia. Immediately following treatment, the most common adverse effects are confusion and transient memory loss. Among treatments for severely depressed pregnant women, ECT is one of the least harmful to the fetus.
ECT is often used as an intervention for major depressive disorder, mania, autism, and catatonia.
The usual course of ECT involves multiple administrations, typically
given two or three times per week until the patient no longer has
symptoms. ECT is administered under anesthesia with a muscle relaxant.
ECT can differ in its application in three ways: electrode placement,
treatment frequency, and the electrical waveform of the stimulus. These
treatment parameters can pose significant differences in both adverse
side effects and symptom remission in the treated patient.
Placement can be bilateral, where the electric current is passed
from one side of the brain to the other, or unilateral, in which the
current is solely passed across one hemisphere
of the brain. High-dose unilateral ECT has some cognitive advantages
compared to moderate-dose bilateral ECT while showing no difference in
antidepressant efficacy.
History
A Bergonic chair,
a device "for giving general electric treatment for psychological
effect, in psycho-neurotic cases", according to original photo
description. World War I era.
As early as the 16th century, agents to induce seizures were used to
treat psychiatric conditions. In 1785, the therapeutic use of seizure
induction was documented in the London Medical and Surgical Journal.
As to its earliest antecedents one doctor claims 1744 as the dawn of
electricity's therapeutic use, as documented in the first issue of Electricity and Medicine. Treatment and cure of hysterical blindness was documented eleven years later. Benjamin Franklin wrote that an electrostatic machine cured "a woman of hysterical fits." By 1801, James Lind as well as Giovanni Aldini had used galvanism to treat patients with various mental disorders. G.B.C. Duchenne, the mid-19th century "Father of Electrotherapy", said its use was integral to a neurological practice.
In the second half of the 19th century, such efforts were frequent enough in British asylums as to make it notable.
Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then metrazol (cardiazol). Meduna is thought to be the father of convulsive therapy.
In 1937, the first international meeting on schizophrenia and convulsive therapy was held in Switzerland by the Swiss psychiatrist Max Müller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide.
The ECT procedure was first conducted in 1938 by Italian neuro-psychiatrist Ugo Cerletti and rapidly replaced less safe and effective forms of biological treatments in use at the time. Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his assistant Lucio Bini at Sapienza University of Rome developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1938, experimented for the first time on a person affected by delusions.
It was believed early on that inducing convulsions aided in helping those with severe schizophrenia but later found to be most useful with affective disorders such as depression.
Cerletti had noted a shock to the head produced convulsions in dogs.
The idea to use electroshock on humans came to Cerletti when he saw how
pigs were given an electric shock before being butchered to put them in
an anesthetized state.
Cerletti and Bini practiced until they felt they had the right
parameters needed to have a successful human trial. Once they started
trials on patients, they found that after 10–20 treatments the results
were significant. Patients had much improved.
A positive side effect to the treatment was retrograde amnesia. It was because of this side effect that patients could not remember the treatments and had no ill feelings toward it.
ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening and more convenient. Cerletti and Bini were nominated for a Nobel Prize
but did not receive one. By 1940, the procedure was introduced to both
England and the US. In Germany and Austria, it was promoted by Friedrich Meggendorfer.
Through the 1940s and 1950s, the use of ECT became widespread. At the
time the ECT device was patented and commercialized abroad, the two
Italian inventors had competitive tensions that damaged their
relationship.
In the 1960s, despite a climate of condemnation, the original
Cerletti-Bini ECT apparatus prototype was contended by scientific
museums between Italy and the US. The ECT apparatus prototype is now owned and displayed by the Sapienza Museum of the History of Medicine in Rome.
In the early 1940s, in an attempt to reduce the memory
disturbance and confusion associated with treatment, two modifications
were introduced: the use of unilateral electrode placement and the
replacement of sinusoidal current with brief pulse. It took many years for brief-pulse equipment to be widely adopted.
In the 1940s and early 1950s, ECT was usually given in an
"unmodified" form, without muscle relaxants, and the seizure resulted in
a full-scale convulsion. A rare but serious complication of unmodified
ECT was fracture or dislocation of the long bones. In the 1940s,
psychiatrists began to experiment with curare, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction of suxamethonium
(succinylcholine), a safer synthetic alternative to curare, in 1951 led
to the more widespread use of "modified" ECT. A short-acting anesthetic
was usually given in addition to the muscle relaxant in order to spare
patients the terrifying feeling of suffocation that can be experienced
with muscle relaxants.
The steady growth of antidepressant
use along with negative depictions of ECT in the mass media led to a
marked decline in the use of ECT during the 1950s to the 1970s. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia
was routinely given, and that "these now-antiquated practices
contributed to the negative portrayal of ECT in the popular media." The New York Times described the public's negative perception of ECT as being caused mainly by one movie: "For Big Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and, in the public mind, shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".
In 1976, Dr. Blatchley demonstrated the effectiveness of his
constant current, brief pulse device ECT. This device eventually largely
replaced earlier devices because of the reduction in cognitive side
effects, although as of 2012 some ECT clinics still were using sine-wave
devices.
The 1970s saw the publication of the first American Psychiatric Association
(APA) task force report on electroconvulsive therapy (to be followed by
further reports in 1990 and 2001). The report endorsed the use of ECT
in the treatment of depression. The decade also saw criticism of ECT.
Specifically, critics pointed to shortcomings such as noted side
effects, the procedure being used as a form of abuse, and uneven
application of ECT. The use of ECT declined until the 1980s, "when use
began to increase amid growing awareness of its benefits and
cost-effectiveness for treating severe depression". In 1985, the National Institute of Mental Health and National Institutes of Health
convened a consensus development conference on ECT and concluded that,
while ECT was the most controversial treatment in psychiatry and had
significant side-effects, it had been shown to be effective for a narrow
range of severe psychiatric disorders.
Because of the backlash noted previously, national institutions
reviewed past practices and set new standards. In 1978, the American
Psychiatric Association released its first task force report in which
new standards for consent
were introduced and the use of unilateral electrode placement was
recommended. The 1985 NIMH Consensus Conference confirmed the
therapeutic role of ECT in certain circumstances. The American
Psychiatric Association released its second task force report in 1990
where specific details on the delivery, education, and training of ECT
were documented. Finally, in 2001 the American Psychiatric Association
released its latest task force report. This report emphasizes the importance of informed consent,
and the expanded role that the procedure has in modern medicine. By
2017, ECT was routinely covered by insurance companies for providing the
"biggest bang for the buck" for otherwise intractable cases of severe mental illness, was receiving favorable media coverage, and was being provided in regional medical centers.
Though ECT use declined with the advent of modern
antidepressants, there has been a resurgence of ECT with new modern
technologies and techniques. Modern shock voltage is given for a shorter duration of 0.5 milliseconds where conventional brief pulse is 1.5 milliseconds.
In a review from 2022 of neuroimaging
studies based on a global data collaboration ECT was suggested to work
via a temporary disruption of neural circuits followed by augmented neuroplasticity and rewiring.
Modern use
ECT is used, where possible, with informed consent in treatment-resistant major depressive disorder, bipolar depression, treatment-resistant catatonia, prolonged or severe mania,
and in conditions where "there is a need for rapid, definitive response
because of the severity of a psychiatric or medical condition (e.g.,
when illness is characterized by suicidality, psychosis, stupor, marked psychomotor retardation, depressive delusions or hallucinations, or life-threatening physical exhaustion associated with mania)." It has also been used to treat autism in adults with an intellectual disability, yet findings from a systematic review found this an unestablished intervention.
A meta-analysis on the effectiveness of ECT in unipolar and bipolar depression indicated that although patients with unipolar depression and bipolar depression responded to other medical treatments very differently, both groups responded equally well to ECT. Overall remission
rate for patients given a round of ECT treatment was 50.9% for those
with unipolar depression and 53.2% for those with bipolar depression.
Most severely depressed patients respond to ECT.
In 2004, a meta-analysis found in terms of efficacy, "a
significant superiority of ECT in all comparisons: ECT versus simulated
ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus tricyclics and ECT versus monoamine oxidase inhibitors."
In 2003, The UK ECT Review Group published a systematic review and meta-analysis comparing ECT to placebo
and antidepressant drugs. This meta-analysis demonstrated a large
effect size (high efficacy relative to the mean in terms of the standard deviation) for ECT versus placebo, and versus antidepressant drugs.
Other estimates regarding the response rate in treatment
resistant depression vary between 60–80%, with a remission rate of
50–60%.
In addition to reducing symptoms of depression and inducing relapse,
ECT has also been shown to reduce the risk of suicide, improve
functional outcomes and quality of life as well as reduce the risk of
re-hospitalization. Efficacy does not depend on depression subtype. With regards to treatment resistant schizophrenia, the response rate is 40–70%.
Follow-up
There is little agreement on the most appropriate follow-up to ECT for people with major depressive disorder.
The initial course of ECT is then transitioned to maintenance ECT,
pharmacotherapy or both. When ECT is stopped abruptly, without a bridge
to maintenance ECT or medications (usually antidepressants and Lithium), it is associated with a relapse rate of 84%.
There is no defined schedule for maintenance ECT, however it is usually
started weekly with intervals extended permissibly with the goal of
maintaining remission. When ECT is followed by treatment with antidepressants,
about 50% of people relapsed by 12 months following successful initial
treatment with ECT, with about 37% relapsing within the first 6 months.
About twice as many relapsed with no antidepressants. Most of the
evidence for continuation therapy is with tricyclic antidepressants; evidence for relapse prevention with newer antidepressants is lacking. Adjunct maintenance ECT paired with cognitive behavioral therapy has also been shown to reduce relapse rates. Maintenance ECT may safely continue indefinitely, with no set maximum treatment interval established.
Lithium has also been found to reduce the risk of relapse, especially in younger patients.
Catatonia
ECT is generally a second-line treatment for people with catatonia who do not respond to other treatments, but is a first-line treatment for severe or life-threatening catatonia.
There is a plethora of evidence for its efficacy, notwithstanding a
lack of randomised controlled trials, such that "the excellent efficacy
of ECT in catatonia is generally acknowledged". For people with autism spectrum disorders who have catatonia, there is little published evidence about the efficacy of ECT.
Mania
ECT is used to treat people who have severe or prolonged mania; NICE recommends it only in life-threatening situations or when other treatments have failed and as a second-line treatment for bipolar mania.
Schizophrenia
ECT is widely used worldwide in the treatment of schizophrenia, but in North America and Western Europe it is invariably used only in treatment resistant schizophrenia when symptoms show little response to antipsychotics; there is comprehensive research evidence for such practice. It is useful in the case of severe exacerbations of catatonic schizophrenia, whether excited or stuporous. There are also case reports of ECT improving persistent psychotic symptoms associated with stimulant-induced psychosis.
Effects
Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia; the US Surgeon General's report says that there are "no absolute health contraindications" to its use. Immediately following treatment, the most common adverse effects are confusion and memory loss. Some patients experience muscle soreness
after ECT. Other common adverse effects after ECT include headache, jaw
soreness, nausea, vomiting and fatigue. These side effects are
transient and respond to treatment. There is evidence and rationale to support giving low doses of benzodiazepines or otherwise low doses of general anesthetics, which induce sedation but not anesthesia, to patients to reduce adverse effects of ECT.
While there are no absolute contraindications for ECT, there is
increased risk for patients who have unstable or severe cardiovascular
conditions or aneurysms; who have recently had a stroke; who have increased intracranial pressure (for instance, due to a solid brain tumor), or who have severe pulmonary conditions, or who are generally at high risk for receiving anesthesia.
In adolescents, ECT is highly efficient for several psychiatric disorders, with few and relatively benign adverse effects.
Risk of death
A meta-analysis from 2017 found that the death rate of ECT was around 2.1 per 100,000 procedures. A review from 2011 reported an estimate of the mortality rate associated with ECT as less than 1 death per 73,440 treatments.
Cognitive impairment
Cognitive impairment sometimes occurs after ECT. The American Psychiatric Association (APA) report in 2001 acknowledges: "In some patients the recovery from retrograde amnesia will be incomplete, and evidence has shown that ECT can result in persistent or permanent memory loss". It is the purported effects of ECT on long-term memory that give rise to much of the concern surrounding its use.
However, the methods used to measure memory loss are non-specific, and
their application to people with depressive disorders, who have cognitive deficits related to the depression, including problems with memory, may further limit their utility.
The acute effects of ECT can include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment).
Memory loss and confusion are more pronounced with bilateral electrode
placement rather than unilateral, and with outdated sine-wave rather
than brief-pulse currents. The use of either constant or pulsing
electrical impulses also varied the memory loss results in patients.
Patients who received pulsing electrical impulses, as opposed to a
steady flow, seemed to incur less memory loss. The vast majority of
modern treatment uses brief pulse currents.
A greater number of treatments and higher electrical charges (stimulus
charges) have also been associated with a greater risk of memory
impairment.
Retrograde amnesia is most marked for events occurring in the weeks or months before treatment. Anterograde memory loss
usually resolves 2–4 weeks after treatment, whereas retrograde amnesia
(which develops gradually after repeated treatments in the initial
course) usually takes weeks to months to resolve, and amnesia rarely
persist for more than 1 year. Retrograde amnesia after ECT usually affects autobiographical memory, rather than semantic memory.
One published review summarizing the results of questionnaires about
subjective memory loss found that between 29% and 55% of respondents
believed they experienced long-lasting or permanent memory changes. In 2000, American psychiatrist Sarah Lisanby
and colleagues found that bilateral ECT left patients with more
persistently impaired memory of public events as compared to right
unilateral ECT. However, bilateral ECT may be more efficacious than unilateral in the treatment of mood disorders.
ECT has not been found to increase the risk of dementia nor cause structural brain damage.
Effects on brain structure
Considerable
controversy exists over the effects of ECT on brain tissue, although a
number of mental health associations—including the APA—have concluded
that there is no evidence that ECT causes structural brain damage.
A 1999 report by the US Surgeon General states: "The fears that ECT
causes gross structural brain pathology have not been supported by
decades of methodologically sound research in both humans and animals."
Many expert proponents of ECT maintain that the procedure is safe
and does not cause brain damage. Dr. Charles Kellner, a prominent ECT
researcher and former chief editor of the Journal of ECT, stated
in a 2007 interview that, "There are a number of well-designed studies
that show ECT does not cause brain damage and numerous reports of
patients who have received a large number of treatments over their
lifetime and have suffered no significant problems due to ECT."
Kellner cites a study purporting to show an absence of cognitive
impairment in eight subjects after more than 100 lifetime ECT
treatments.
Kellner stated "Rather than cause brain damage, there is evidence that
ECT may reverse some of the damaging effects of serious psychiatric
illness." Two meta-analyses find that ECT is associated with brain
matter growth.
Effects in pregnancy
If
steps are taken to decrease potential risks, ECT is generally accepted
to be relatively safe during all trimesters of pregnancy, particularly
when compared to pharmacological treatments. Suggested preparation for ECT during pregnancy includes a pelvic examination, discontinuation of nonessential anticholinergic medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate antacid. During ECT, elevation of the pregnant woman's right hip, external fetal cardiac monitoring, intubation, and avoidance of excessive hyperventilation are recommended.
In many instances of active mood disorder during pregnancy, the risks
of untreated symptoms may outweigh the risks of ECT. Potential
complications of ECT during pregnancy can be minimized by modifications
in technique. The use of ECT during pregnancy requires thorough
evaluation of the patient's capacity for informed consent.
Effects on the heart
ECT can cause a lack of blood flow and oxygen to the heart, heart arrhythmia, and "persistent asystole". A 2019 systematic review and meta-analysis
of 82 studies found that the rate of major adverse cardiac events with
ECT was 1 in 39 patients or about 1 in 200 to 500 procedures. The risk of death with ECT however is low. If death does occur, cardiovascular complications are considered as causal in about 30% of individuals.
Procedure
Electroconvulsive therapy machine on display at Glenside Museum in Bristol, EnglandECT device produced by Siemens and used for example at the Asyl psychiatric hospital in Kristiansand, Norway from the 1960s to the 1980s
The placement of electrodes, as well as the dose and duration of the stimulation is determined on a per-patient basis.
In unilateral ECT, both electrodes are placed on the same side of
the patient's head. Unilateral ECT may be used first to minimize side
effects such as memory loss.
In bilateral ECT, the two electrodes are placed on opposite sides
of the head. Usually bitemporal placement is used, whereby the
electrodes are placed on the temples. Uncommonly bifrontal placement is
used; this involves positioning the electrodes on the patient's
forehead, roughly above each eye.
Unilateral ECT is thought to cause fewer cognitive effects than
bilateral treatment, but is less effective unless administered at higher
doses. Most patients in the US and almost all in the UK receive bilateral ECT.
The electrodes deliver an electrical stimulus. The stimulus
levels recommended for ECT are in excess of an individual's seizure
threshold: about one and a half times seizure threshold for bilateral
ECT and up to 12 times for unilateral ECT.
Below these levels treatment may not be effective in spite of a
seizure, while doses massively above threshold level, especially with
bilateral ECT, expose patients to the risk of more severe cognitive
impairment without additional therapeutic gains. Seizure threshold is determined by trial and error ("dose titration").
Some psychiatrists use dose titration, some still use "fixed dose"
(that is, all patients are given the same dose) and others compromise by
roughly estimating a patient's threshold according to age and sex.
Older men tend to have higher thresholds than younger women, but it is
not a hard and fast rule, and other factors, for example drugs, affect
seizure threshold.
Immediately prior to treatment, a patient is given a short-acting anesthetic such as methohexital, propofol, etomidate, or thiopental, a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation. In a minority of countries such as Japan, India, and Nigeria,
ECT may be used without anesthesia. The Union Health Ministry of India
recommended a ban on ECT without anesthesia in India's Mental Health
Care Bill of 2010 and the Mental Health Care Bill of 2013. The practice was abolished in Turkey's largest psychiatric hospital in 2008.
ECT is usually administered three times a week, on alternate days, over a course of two to four weeks.
An illustration depicting electroconvulsive therapy
Neuroimaging prior to ECT
Neuroimaging
prior to ECT may be useful for detecting intracranial pressure or mass
given that patients respond less when one of these conditions exist.
Nonetheless, it is not indicated due to high cost and low prevalence of
these conditions in patients needing ECT.
Concurrent pharmacotherapy
Whether psychiatric medications are terminated prior to treatment or maintained, varies.However, drugs that are known to cause toxicity in combination with ECT, such as lithium, are discontinued, and benzodiazepines, which increase the seizure threshold,
are either discontinued, a benzodiazepine antagonist is administered at
each ECT session, or the ECT treatment is adjusted accordingly.
A 2009 RCT provides some evidence indicating that concurrent use of some antidepressant improves ECT efficacy.
Course
ECT is usually done from 6 to 12 times in 2 to 4 weeks but can sometimes exceed 12 rounds. It is also recommended to not do ECT more than 3 times per week. Evidence suggest that ECTs for depression may be stopped if there is no improvement during the first six sessions.
Treatment team
In
the US, the medical team performing the procedure typically consists of
a psychiatrist, an anesthetist, an ECT treatment nurse or qualified
assistant, and one or more recovery nurses. Medical trainees may assist, but only under the direct supervision of credentialed attending physicians and staff.
Devices
Vintage ECT machine from before 1960Modern ECT machine
Most modern ECT devices deliver a brief-pulse current, which is
thought to cause fewer cognitive effects than the sine-wave currents
which were originally used in ECT. A small minority of psychiatrists in the US still use sine-wave stimuli. Sine-wave is no longer used in the UK or Ireland.
Typically, the electrical stimulus used in ECT is about 800 milliamps and has up to several hundred watts, and the current flows for between one and six seconds.
In the US, ECT devices are manufactured by two companies,
Somatics, which is owned by psychiatrists Richard Abrams and Conrad
Swartz, and Mecta. In the UK, the market for ECT devices was long monopolized by Ectron Ltd, which was set up by psychiatrist Robert Russell.
Mechanism of action
Despite decades of research, the exact mechanism of action of ECT remains elusive. A review from 2022 of neuroimaging
studies based on a global data collaboration resulted in a model of
temporary disruption of neural circuits followed by augmented
neuroplasticity and rewiring. Other brain changes observed after ECT include increased gray matter volume in the frontolimbic areas including the hippocampus and amygdala, increased white matter tracts in the frontal and temporal lobes, increased monoamine neurotransmitters and increased neurogenesis in the dentate gyrus. Changes in sleep architecture due to the induced seizures have also been hypothesized as a mechanism of action.
Use
As of 2001, it was estimated that about one million people received ECT annually.
There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists.
International practice varies considerably from widespread use of the
therapy in many Western countries to a small minority of countries that
do not use ECT at all, such as Slovenia.
About 70 percent of ECT patients are women. This may be because women are more likely to be diagnosed with depression. Older and more affluent patients are also more likely to receive ECT. The use of ECT is not as common in ethnic minorities.
In Sweden, which has a complete register of all ECT treatments in
the country, in 2013 the rate of persons treated in that year per
100,000 inhabitants was 41. Almost the same rate had already been
present in 1975 with 42 patients per 100,000 inhabitants.
United States
ECT
became popular in the US in the 1940s. At the time, psychiatric
hospitals were overrun with patients whom doctors were desperate to
treat and cure. Whereas lobotomies
would reduce a patient to a more manageable submissive state, ECT
helped to improve mood in those with severe depression. A survey of
psychiatric practice in the late 1980s found that an estimated 100,000
people received ECT annually, with wide variation between metropolitan
statistical areas.
Accurate statistics about the frequency, context and
circumstances of ECT in the US are difficult to obtain because only a
few states have reporting laws that require the treating facility to
supply state authorities with this information. In 13 of the 50 states, the practice of ECT is regulated by law.
In the mid-1990s in Texas, ECT was used in about one third of psychiatric facilities and given to about 1,650 people annually.
Usage of ECT has since declined slightly; in 2000–01 ECT was given to
about 1,500 people aged from 16 to 97 (in Texas it is illegal to give
ECT to anyone under sixteen).
ECT is more commonly used in private psychiatric hospitals than in
public hospitals, and minority patients are underrepresented in the ECT
statistics.
In the United States, ECT is usually given three times a week; in the United Kingdom, it is usually given twice a week. Occasionally it is given on a daily basis.
A course usually consists of 6–12 treatments, but may be more or fewer.
Following a course of ECT some patients may be given continuation or
maintenance ECT with further treatments at weekly, fortnightly or
monthly intervals.
A few psychiatrists in the US use multiple-monitored ECT (MMECT), where
patients receive more than one treatment per anesthetic.
Electroconvulsive therapy is not a required subject in US medical
schools and not a required skill in psychiatric residency training.
Privileging for ECT practice at institutions is a local option: no
national certification standards are established, and no ECT-specific
continuing training experiences are required of ECT practitioners.
United Kingdom
In the UK in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then to about 12,000 per annum in 2002.
It is still used in nearly all psychiatric hospitals, with a survey of
ECT use from 2002 finding that 71 percent of patients were women and 46
percent were over 65 years of age. Eighty-one percent had a diagnosis of
mood disorder; schizophrenia was the next most common diagnosis. Sixteen percent were treated without their consent. In 2003, the National Institute for Health and Care Excellence, a government body which was set up to standardize treatment throughout the National Health Service
in England and Wales, issued guidance on the use of ECT. Its use was
recommended "only to achieve rapid and short-term improvement of severe
symptoms after an adequate trial of treatment options has proven
ineffective and/or when the condition is considered to be potentially
life-threatening in individuals with severe depressive illness,
catatonia or a prolonged manic episode".
The guidance received a mixed reception. It was welcomed by an editorial in the British Medical Journal but the Royal College of Psychiatrists launched an unsuccessful appeal. The NICE guidance, as the British Medical Journal
editorial points out, is only a policy statement and psychiatrists may
deviate from it if they see fit. Adherence to standards has not been
universal in the past. A survey of ECT use in 1980 found that more than
half of ECT clinics failed to meet minimum standards set by the Royal
College of Psychiatrists, with a later survey in 1998 finding that
minimum standards were largely adhered to, but that two-thirds of
clinics still fell short of current guidelines, particularly in the
training and supervision of junior doctors involved in the procedure. A voluntary accreditation scheme, ECTAS, was set up in 2004 by the Royal College, and as of 2017 the vast majority of ECT clinics in England, Wales, Northern Ireland and the Republic of Ireland have signed up.
The Mental Health Act 2007
allows people to be treated against their will. This law has extra
protections regarding ECT. A patient capable of making the decision can
decline the treatment, and in that case treatment cannot be given unless
it will save that patient's life or is immediately necessary to prevent
deterioration of the patient's condition. A patient may not be capable
of making the decision (they "lack capacity"), and in that situation ECT
can be given if it is appropriate and also if there are no advance
directives that prevent the use of ECT.
China
ECT
was introduced in China in the early 1950s and while it was originally
practiced without anesthesia, as of 2012 almost all procedures were
conducted with it. As of 2012, there are approximately 400 ECT machines
in China, and 150,000 ECT treatments are performed each year.
Chinese national practice guidelines recommend ECT for the treatment of
schizophrenia, depressive disorders, and bipolar disorder and in the
Chinese literature, ECT is an effective treatment for schizophrenia and
mood disorders.
Although the Chinese government stopped classifying homosexuality
as an illness in 2001, electroconvulsive therapy is still used by some
establishments as a form of "conversion therapy". Alleged Internet addiction (or general unruliness) in adolescents is also known to have been treated with ECT, sometimes without anestheia, most notably by Yang Yongxin. The practice was banned in 2009 after news on Yang broke out.
Society and culture
Controversy
Surveys
of public opinion, the testimony of former patients, legal restrictions
on the use of ECT and disputes as to the efficacy, ethics and adverse
effects of ECT within the psychiatric and wider medical community
indicate that the use of ECT remains controversial.
This is reflected in the January 2011 vote by the FDA's Neurological
Devices Advisory Panel to recommend that FDA maintain ECT devices in the
Class III device category for high risk devices, except for patients
with catatonia, major depressive disorder, and bipolar disorder.
This may result in the manufacturers of such devices having to do
controlled trials on their safety and efficacy for the first time. In justifying their position, panelists referred to the memory loss associated with ECT and the lack of long-term data.
Legal status
Informed consent
The World Health Organization
(2005) advises that ECT should be used only with the informed consent
of the patient (or their guardian if their incapacity to consent has
been established).
In the US, this doctrine places a legal obligation on a doctor to
make a patient aware of the reason for treatment, the risks and
benefits of a proposed treatment, the risks and benefits of alternative
treatment, and the risks and benefits of receiving no treatment. The
patient is then given the opportunity to accept or reject the treatment.
The form states how many treatments are recommended and also makes the
patient aware that consent may be revoked and treatment discontinued at
any time during a course of ECT.
The US Surgeon General's Report on Mental Health states that patients
should be warned that the benefits of ECT are short-lived without active
continuation treatment in the form of drugs or further ECT, and that
there may be some risk of permanent, severe memory loss after ECT.
The report advises psychiatrists to involve patients in discussion,
possibly with the aid of leaflets or videos, both before and during a
course of ECT.
According to the US Surgeon General, involuntary treatment is
uncommon in the US and is typically used only in cases of great
extremity, and only when all other treatment options have been
exhausted. The use of ECT is believed to be a potentially life-saving
treatment.
In one of the few jurisdictions where recent statistics on ECT
usage are available, a national audit of ECT by the Scottish ECT
Accreditation Network indicated that 77% of patients who received the
treatment in 2008 were capable of giving informed consent.
In the UK, in order for consent to be valid it requires an
explanation in "broad terms" of the nature of the procedure and its
likely effects.
One review from 2005 found that only about half of patients felt they
were given sufficient information about ECT and its adverse effects and another survey found that about fifty percent of psychiatrists and nurses agreed with them.
A 2005 study published in the British Journal of Psychiatry described patients' perspectives on the adequacy of informed consent before ECT.
The study found that "About half (45–55%) of patients reported they
were given an adequate explanation of ECT, implying a similar percentage
felt they were not." The authors also stated:
Approximately a third did not feel
they had freely consented to ECT even when they had signed a consent
form. The proportion who feel they did not freely choose the treatment
has actually increased over time. The same themes arise whether the
patient had received treatment a year ago or 30 years ago. Neither
current nor proposed safeguards for patients are sufficient to ensure
informed consent with respect to ECT, at least in England and Wales.
Involuntary ECT
Procedures for involuntary ECT vary from country to country depending on local mental health laws.
United States
In
most states in the US, a judicial order following a formal hearing is
needed before a patient can be forced to undergo involuntary ECT.
However, ECT can also be involuntarily administered in situations with
less immediate danger. Suicidal intent is a common justification for its
involuntary use, especially when other treatments are ineffective.
United Kingdom
Until 2007 in England and Wales, the Mental Health Act 1983 allowed the use of ECT on detained patients whether or not they had capacity to consent to it. However, following amendments
which took effect in 2007, ECT may not generally be given to a patient
who has capacity and refuses it, irrespective of his or her detention
under the Act. In fact, even if a patient is deemed to lack capacity, if they made a valid advance decision
refusing ECT then they should not be given it; and even if they do not
have an advance decision, the psychiatrist must obtain an independent
second opinion (which is also the case if the patient is under age of
consent).
However, there is an exception regardless of consent and capacity;
under Section 62 of the Act, if the treating psychiatrist says the need
for treatment is urgent they may start a course of ECT without
authorization.
From 2003 to 2005, about 2,000 people a year in England and Wales were
treated without their consent under the Mental Health Act.
Concerns have been raised by the official regulator that psychiatrists
are too readily assuming that patients have the capacity to consent to
their treatments, and that there is a worrying lack of independent advocacy.
In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 2003
also gives patients with capacity the right to refuse ECT.
Regulation
In the US, ECT devices came into existence prior to medical devices being regulated by the Food and Drug Administration. In 1976, the Medical Device Regulation Act
required the FDA to retrospectively review already existing devices,
classify them, and determine whether clinical trials were needed to
prove efficacy and safety. The FDA initially classified the devices used
to administer ECT as Class III medical devices. In 2014, the American Psychiatric Association
petitioned the FDA to reclassify ECT devices from Class III (high-risk)
to Class II (medium-risk). A similar reclassification proposal in 2010
did not pass.
In 2018, the FDA re-classified ECT devices as Class II devices when
used to treat catatonia or a severe major depressive episode associated
with major depressive disorder or bipolar disorder.
By country
Australia
In Western Australia,
ECT has been heavily restricted since 2014, after a bill passed with
bipartisan support introducing restrictions on ECT, which were welcomed
by mental health experts. Children under 14 are prohibited from
receiving ECT, while those aged 14 to 18 must have informed consent
approval from the Mental Health Tribunal. The law imposes a $15,000 fine
on anyone who performs ECT on a child under the age of 14.
Many mental health facilities offer ECT for specific diagnoses, such as chronic depression, mania, catatonia and schizophrenia. However, ECT is often only used as a treatment of last resort.
To be considered for ECT, often testing such as an EKG and lab tests
are required, in addition to a physical and neurological exam. Certain
medications and conditions, such as cardiac conditions or hypertension,
may disqualify a patient from ECT. Patients should give proper informed
consent before ECT is performed. In the United States, ECT is performed
under general anesthesia. Both trained health professionals with
experience in ECT administration as well as a specifically trained and
certified anesthesiologist should administer the procedure and
anesthesia respectively.
Judge Rotenberg Center
In 2020 the Food and Drug Administration
(FDA) implemented a rule previously drafted in 2016 banning the use of
ECT to treat disabilities. This ban specifically had major complications
for the controversial Judge Rotenberg Center (JRC) in Canton, Massachusetts,
which uses various methods of ECT. Specifically, it is believed by many
that most of the cases at JRC do not require the use of ECT.
Public perception
A questionnaire survey of 379 members of the general public in Australia
indicated that more than 60% of respondents had some knowledge about
the main aspects of ECT. Participants were generally opposed to the use
of ECT on depressed individuals with psychosocial issues, on children,
and on involuntary patients. Public perceptions of ECT were found to be
mainly negative. A sample of the general public, medical students, and psychiatry trainees in the United Kingdom found that the psychiatry trainees were more knowledgeable and had more favorable opinions of ECT than did the other groups.
More members of the general public believed that ECT was used for
control or punishment purposes than medical students or psychiatry
trainees.
Ernest Hemingway, an American author, died by suicide in 1961 half a year after ECT treatment at the Mayo Clinic in 1960.
He is reported to have said to his biographer, "Well, what is the sense
of ruining my head and erasing my memory, which is my capital, and
putting me out of business? It was a brilliant cure but we lost the
patient." However, the same biographer (Hotchner, 1966) and also a second biographer (Lynn,
1987) emphasized - according to a review from 2008 - "that Hemingway’s
serious mental illness and plans for suicide significantly predated his
ECT treatments."
Robert Pirsig had a nervous breakdown and spent time in and out of psychiatric hospitals between 1961 and 1963.
He was diagnosed with paranoid schizophrenia and clinical depression as
a result of an evaluation conducted by psychoanalysts, and was treated
with electroconvulsive therapy on numerous occasions, a treatment he discusses in his novel, Zen and the Art of Motorcycle Maintenance.
American surgeon and award-winning author Sherwin B. Nuland is another notable person who has undergone ECT.
In his 40s, his depression became so severe that he had to be
institutionalized. After exhausting all treatment options, a young
resident assigned to his case suggested ECT, which ended up being
successful.
Author David Foster Wallace also received ECT for many years, beginning as a teenager, before his suicide at age 46.
New Zealand author Janet Frame experienced both insulin coma therapy and ECT (but without the use of anesthesia or muscle relaxants). She wrote about this in her autobiography, An Angel at My Table (1984), which was later adapted into a film (1990).
American actor Carrie Fisher wrote about her experience with memory loss after ECT treatments in her memoir Wishful Drinking.
Lou Reed had ECT as a teenager to "cure" his homosexuality. He later claimed it had induced multiple personality disorder, and resulted in his hatred of psychiatrists.
After Reed's death, his sister denied the ECT treatments were intended
to suppress his "homosexual urges", asserting that their parents were
not homophobic but had been told by his doctors that ECT was necessary to treat Reed's mental and behavioral issues.
Fictional examples
Electroconvulsive
therapy has been depicted in fiction, including fictional works partly
based on true experiences. These include Sylvia Plath's semi-autobiographical novel, The Bell Jar, Ken Loach's film Family Life, and Ken Kesey's novel One Flew Over the Cuckoo's Nest; Kesey's novel is a direct product of his time working the graveyard shift as an orderly at a mental health facility in Menlo Park, California.
Two analyses of large numbers of films using ECT scenes found
that almost all presented fictional settings that were unrelated to real
treatment routines and were apparently aimed at stigmatizing ECT as a
tool of repression and of mind and behavior control - having effects of
memory-erosion, pain and damage.
The song “The Mind Electric” by Miracle Musical is typically interpreted as depicting someone undergoing ECT.
In the television series "Mr Bates vs The Post Office", which is based on true events, the character of Saman Kaur receives ECT following a deep depression and attempted suicide.
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