Treatment

Electroconvulsive Therapy - ECT

The therapy formerly known as shock treatment is making a comeback.

Nothing in the field of mental health is more apt to get a rise out of people than the subject of shock treatments, or electroconvulsive therapy (ECT) as it is now called. Movies such as "One Flew Over the Cuckoo's Nest" have portrayed the procedure as nothing less than an instrument of torture, and poet Sylvia Plath wrote "with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant."

Yet ECT is fully endorsed by the psychiatric profession as well as patients' groups, is used by the major hospitals, and many patients swear it has saved their lives. Long regarded as a treatment as a last resort - after all attempts at medications therapy have failed - more and more ECT is moving up to front-line status. According to a task force report issued by the American Psychiatric Association, depriving patients from early treatment could "prolong suffering, and may possibly contribute to treatment resistance."

Francis Mondimore MD, in his book, "Bipolar Disorder," asserts that: "ECT is perhaps the most effective treatment there is for severe depression and severe mania, and it often works more quickly than other medications."

With an 80 percent response rate for acute depression, antidepressants don't come close.

And Dr Kay Jamison in "Night Falls Fast" justifies ECT as a first-line treatment for suicidal patients, to stabilize their condition where slow-acting drugs and therapies are not an option.

ECT - What to Expect

ECT, which has been around for some seventy years, works on the principle of an electrically-induced convulsion, similar to a grand mal epileptic seizure. No one knows exactly how this makes a depression lift. Back in the bad old days when ECT was overprescribed - often against a person's will - the patient experienced violent, and sometimes bone-breaking, muscle contractions. Now the patient is given neuromuscular blocking agents which limit muscular activity to an involuntary twitching in the toe.

Immediately prior to the treatment, the patient is injected with a medication that prevents abnormal heart rhythms, then the patient is given an intravenous barbiturate which is used as the general anesthetic, and then the blocking agents. Electrodes are attached to the patient's scalp either on one side of the brain or two - a switch is flipped for a few seconds, the convulsion itself lasts about 30 seconds, and several minutes later the patient wakes up disoriented and groggy, and often with no recollection of the events surrounding the treatment.

ECT and Memory Loss

The most pronounced side effect is short-term memory loss in about two-thirds of the patients. Some patients can also experience longer-term memory loss. The psychiatric profession has reacted defensively to the parade of patients who have come forward with their stories, equating their narratives to Cuckoo's Nest scare tactics, but the truth is psychiatrists have downplayed this rather disturbing invasion of the brain's hard drive. Part of this can be attributed to the politics of ECT, where many of the same people who are against ECT are also against medications and psychiatry in general, including psychiatry's antichrist Peter Breggin and the Church of Scientology.

Only recently has the American Psychiatric Association publicly owned up to the possibility of serious memory problems. A 2003 Institute of Psychiatry (London) review of 35 studies on ECT published in the British Medical Journal found the rate of reported persistent memory loss between 29 and 55 percent, which, unlike the rate of perceived benefit, did not seem to vary between medical or patient-based surveys, but a letter in response to the article noted that "the review is seriously flawed by obsolete information (much of it more than 20 years old) and failure to consider advances in technique that have increased patient satisfaction and reduced cognitive side effects."

At the 2005 APA annual meeting, Harold Sackeim PhD of Columbia University acknowledged that the cognitive side effects that some patients experience can be persistent and profound. On the other hand, ECT is not the same as it was five years ago. "It is changing as we speak," he assured the gathering. This is largely due to changes in the width of the electrical pulse.

A new generation of machines that produce an ultrabrief pulse promises a kinder and gentler era. A very recent unpublished study found virtually no difference in memory loss between those on the new machines and the control group. The briefer pulses permit clinicians to calibrate lower seizure thresholds. Right unilateral ultrabrief ECT, said Dr Sackeim, "appears optimal."

ECT’s effect is generally not long-term, so many psychiatrists recommend an occasional “booster charge,” every six months or so.
Patients disillusioned by psychiatry’s lack of candor in the past are entitled to be skeptical of its claims for an improved ECT. Writes Betsy on my Website:

"Before the ECT, I was a horticulturalist by trade and a botanist by education. I could give complete names, scientific and common, and all the information about any plant I saw. Now, it is ALL GONE. I have also forgotten huge chunks of my former life. I can't remember things from a week ago. Every movie is new to me, because I cannot remember ever seeing it before. Thank god my husband can fill in the missing parts for me, especially about important parts of our children's lives. Please let this stand as a warning

But Sue reports: "The ECT was the smartest thing I could have ever done. It got me out of a downward spiraling depressive episode that saved my life."

An Important ECT Book

In 2006, Kitty Dukakis (with journalist Larry Tye) published Shock: The Healing Power of Electroconvulsive Therapy. Ms Dukakis is the wife of 1988 Democratic Presidential candidate Michael Dukakis. From the time she was old enough to worry about her body image, diet pills were a constant in her life. Ms Dukakis describes her quarter-century love affair with amphetamines as an addiction, though these pills almost certainly did more for her depression than the antidepressants she later took (readers, please don’t get any ideas).

The cure turned out to be worse than her addiction. Once she was off the pills, her depression manifested in full measure, together with a new dependency on the bottle. A steady round of rehabs followed, plus failed trials on antidepressants and mood stabilizers. In a state of emotional unraveling and desperate for a solution, in 2001 Ms Dukakis turned to ECT. As she describes her first treatment:

"They clip to my finger a device that measures the oxygen in my blood. They stick a bunch of electrical leads on my legs, arms, and over my heart, to make sure my heart is okay. They attach a blood pressure cuff to my arm, then insert an IV line into the other arm. The anesthesiologist … says to think of something bright and cheerful. I think about flowers and a field of daisies. I think about Michael and our anniversary."

The Background

The very fact that Ms Dukakis had the option to choose electroconvulsive therapy is something of a miracle. As she and Larry Tye describe in their book, had events played out according to expectations, the plug would have been pulled from ECT years before.

Ironically, ECT's worst enemy has been the psychiatric profession. The over-use of the treatment during the forties and fifties and sixties, often against the patient’s will, under primitive conditions, and on populations upon whom the procedure conferred no benefit, gave rise to strong opposition. Part of the backlash came from the new antipsychiatry movement which got its start from patients who had been abused by ECT and inhumane institution-based practices. The movement found ready allies in other sixties-era groups pressing for political and social reform.

At around the same time, new psychiatric meds, with marketing campaigns heavily bankrolled by the drug industry, promised a new day. The death knell was the release of the 1975 movie, "One Flew Over the Cuckoo’s Nest," that portrayed head nurse Ratchett as Torquemada and ECT as a torture rack with voltage.

Unfortunately, Jack Nicholson’s Oscar-winning performance carried more weight than the facts. Institutions were peremptorily closed, with no community services to fill the vacuum, and ECT machines were mothballed. States such as California passed laws that made getting ECT nearly as difficult to get as abortions in certain states, and virtually impossible for individuals with no access to private hospitals. The number of ECTs dropped precipitously. One expert predicted there would be no more ECTs by the new millennium.

ECT’s Revival

According to the authors of "Shock," Max Fink MD of New York State University, Stonybrook, helped save ECT from extinction. Essentially, he led with the facts – that for depression the response rates were exceptionally high (even in treatment-resistant populations) and offered immediate relief. For most depressed patients, the treatment worked better than antidepressants, and without their troubling side effects. The treatment also worked for mania and for depressive symptoms in schizophrenia.

But there was still the persistent problem of memory loss to contend with. Psychiatry did not help its own cause by repeatedly down-playing and even denying this disturbing invasion to the brain’s hard drive. Ludicrously, psychiatrists picked fights with patients who uncooperatively reported they could no longer remember their own kids’ birthdays. Clinical evidence, anecdotal or otherwise, was difficult to come by, as few clinicians even bothered to follow up on their patients.

Ironically, the authors report, during ECT’s golden era, its champions cited memory loss as an advantage of the treatment. (Economists would call this creative destruction.)

If Dr Fink saved ECT, it was Harold Sackeim who restored its credibility. To the horror of Dr Fink and others, Dr Sackeim freely acknowledged the memory loss. What the old guard saw as giving aid and comfort to the enemy, Dr Sackeim saw as a chance to improve upon technology and technique. Thanks in large part to his efforts, a more sophisticated generation of machines has been introduced and "unilateral" placement (to only one side of the brain) is replacing bilateral placement (though there still may be scope for the latter).

The authors cite Dr Sackeim for the observation that new generation ECT can target specific regions of the brain, thus reducing side effects and memory loss. By contrast, clinicians lack control for how meds are diffused throughout the brain.

During the early nineties, the media began observing that ECT was making a quiet comeback. Lately, the psychiatric profession has been more vocal in advocating ECT as an early treatment option, a development that may frighten some people otherwise prepared to accept the procedure as a last ditch or desperation measure.

One Patient’s Bottom Line

The debate is by no means settled, and moderates tend to get assailed on all fronts by psychiatry and antipsychiatry zealots alike, who unfortunately tend to dominate the discussion (such as it is). As Kitty Dukakis and Larry Tye freely acknowledge, memory loss is still a legitimate concern and needs to be weighed against the promised benefits of treatment. Indeed. Ms Dukakis confesses to not being able to remember important events in her life and to having difficulty recalling names and other details. But she also writes, in relation to her first treatment:

"Next thing I know I am waking up. I am back on the upper floor of Massachusetts General Hospital, in the unit where I slept last night … I am not sure I got the treatment. One clue is a slight headache … Another is the goo on my hair, where they must have attached the electrodes. There is one more sign that I did have my first session of seizure therapy: I feel good – I feel alive."

Yes, Ms Dukakis acknowledges, "I still can’t remember Paris," and that ECT may not be for everyone, but, "as my counselor Corky says, the choice is simple: Would I rather be depressed or be forgetful?"

Making a Choice

The circumstances that force us to make a choice tend to be the very circumstances that cloud our judgment. Not helping is the hysteria and hyperbole that pass for information on the internet. A psychiatric crisis is not the time to carefully weigh ECT’s pros and cons. Making a rational decision is best done well ahead of time, while we have our wits about us. Read "Shock," do further research, and make up your own mind. Then put your intentions in writing, in the form of an advance will or psychiatric directive. There are no right or wrong decisions, only informed and uninformed ones.

NICE Guidelines

The UK’s National Institute for Clinical Excellence, part of the National Health Service, in an April 2003 report recommends that ECT be used to treat severe depression, catatonia, or severe or prolonged mania only after other options have proven ineffective or where the condition is potentially life-threatening. In addition, NICE also advises that treatment should be based on a documented assessment of the risks and potential benefits to the individual, and valid consent should be obtained in all cases where the individual has the ability to grant or refuse consent. Where informed discussion and consent is not possible, advance directives should be taken into account.

NICE further recommends: Clinical status be assessed following each ECT session, and treatment stopped when a response has been achieved, or sooner if there are adverse effects. Cognitive function should be monitored on an ongoing basis. The same criteria for initiating ECT should apply to repeating a course of ECT. ECT is not recommended as maintenance therapy for depression.

Other observations:

Despite the fact that it may be difficult to differentiate the effects of ECT from those of depression, “this should not detract from the fact that a number of individuals find their memory loss extremely damaging and for them this negates any benefit from ECT.”
NICE's interpretation of past studies suggests: "There was little evidence to support the routine prescription of a set number of treatment sessions per course of ECT or of the value of continuation (maintenance) ECT."
ECT achieved better results than antidepressants, but the trials were of "variable quality," often with inadequate doses or durations of drug therapy. Combination meds-ECT was not shown superior to ECT alone.
For mania and catatonia, evidence is from clinical observation rather than trials.
Cognitive impairment is greater in bilateral placement of the electrodes vs unilateral placement, though there is some reduction in efficacy. The Report notes: "There was evidence that the measurement scales used in random controlled trials do not adequately capture the nature and extent of cognitive impairment."
ECT and meds treatment are equally cost effective.

Footnote

In 2007, former Missouri Senator Thomas Eagleton, 77, passed away. Sen Eagleton is best remembered for being dumped as George McGovern’s running mate during the 1972 Presidential campaign when news of his ECT treatments for depression was made public. The stigma of the treatment turned out to be worse than the stigma of his depression. It has been speculated that McGovern might have kept Eagleton as his running mate had only the depression been disclosed.

Ironically, McGovern lost to Richard Nixon, who did not disclose his severe paranoia and other strange behaviors, who exhibited extremely bad judgment, mentally fell apart as the consequences of his actions sheeted home to him, and ultimately resigned in disgrace. By contrast, Missouri voters saw Eagelton fit enough to return him back to the Senate twice more. In 2005, he informed the authors of "Shock" that "I have not had a depression since the mid-1960s."

Updated May 14, 2007, rviewed Feb 10, 2008