“The Horror, the Horror”

     Marlon Brando’s final words from the movie Apocalypse Now immediately echo in one’s mind when reading a recent article in Psychiatry and Clinical Neurosciences which tells of Japanese psychiatrist Shimpei Hanaoka using ECT in order to force a patient to agree to take clozapine long term to treat her mental illness.

     Hanaoka and his team view the case as an unparalleled success. The journal of the Japanese Society of Psychiatry and Neurology which published this case study apparently does not disagree.

     The female patient had been forcibly hospitalized in her late thirties and administered an antipsychotic, which in Japan can be given without a patient’s consent. Hanaoka saw no improvement in her psychotic symptoms so he prescribed her clozapine, but in Japan taking clozapine must be consented to by a patient because the drug may cause potentially fatal side effects.

     The woman initially consented to take clozapine, but then she refused. “If I take this, I will die,” she said.

     Hanaoka announced that her refusal to take it was a symptom of her “reduced insight” and her inability to make a decision that was a survival one for herself. He ordered two ECT treatments a week for her, because in Japan, barbarically enough, a patient need not consent to receiving electroshock therapy.

     After her third ECT session, the symptoms of her psychosis apparently “subsided” enough that she “voluntarily” consented to take clozapine. However, she still needed to consent to taking a continuous dosage of clozapine, so she was prescribed another twelve session of ECT. Her “insight and decision making capacity gradually returned,” per Hanaoka, and she finally consented to taking clozapine regularly.

     The authors of this case study highlighted the treatment that this woman received as one of “ethical care.”

     “The horror, the horror.”