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Shock therapy makes a quiet comeback - Article

Posted Aug 06 2008 10:11am
Shock therapy makes a quiet comeback

Despite the stigma, 100,000 desperate patients a year now seek treatment



By Melissa Dahl

Health writer

MSNBC

updated 8:22 a.m. ET, Wed., Aug. 6, 2008



When Bill Russell tells people that his severe depression was relieved by shock therapy, the most common response he gets is: "They're still doing that?"



Most people might be quicker to associate electroshock therapy with torture rather than healing. But since the 1980s, the practice has been quietly making a comeback. The number of patients undergoing electroconvulsive therapy, as it's formally called, has tripled to 100,000 a year, according to the National Mental Health Association.



During an ECT treatment, doctors jolt the unconscious patient's brain with an electrical charge, which triggers a grand mal seizure. It's considered by many psychiatrists to be the most effective way to treat depression especially in patients who haven't responded to antidepressants. One 2006 study at Wake Forest University School of Medicine in North Carolina found that ECT improved the quality of life for nearly 80 percent of patients.



"It's the definitive treatment for depression," says Dr. Kenneth Melman, a psychiatrist at Swedish Medical Center in Seattle who practices ECT. "There aren't any other treatments for depression that have been found to be superior to ECT."



In fact, antidepressants — the most widely used method for treating depression — don't work at all for 30 percent of patients.



But some doctors and past patients say that the risks of shock therapy, such as memory loss, are too high a price to pay for the temporary benefits.



Despite convulsive therapy’s 70-year history, doctors still aren’t sure exactly how ECT works to ease depression. What they do know is that ECT works very quickly, with many patients reporting their depression lifting after just a few sessions — and in patients with severe depression, a fast-acting treatment is considered imperative to prevent a suicide attempt.



Russell, who lives in Mill Creek, Wash., has struggled with depression and obsessive-compulsive disorder since he was in high school. But his depression began to weigh on him like a lead coat in the spring of 2007, after the pace at his job as an electronics technician quickened, and he couldn't keep up and became overwhelmed. Every night that spring, he came home from work and went straight to bed. He was barely eating and dropped 40 pounds in three months. At his lowest point, he formed a plan to kill himself.



As his depression worsened, he was hospitalized, and at one point was on eight different antidepressants and anti-anxiety drugs, but none of them helped. It wasn’t until he tried ECT as a desperate last resort that he was helped. His depression started to lift after the first week of treatments.



A crucial treatment — or brain damage?

But not everyone responds as well as Russell, say critics of the treatment who warn that the cognitive side effects, such as memory loss, are too severe, and that the fuzzy, foggy state of mind that ECT initially causes simply makes patients temporarily forget about their sadness. (Nearly every ECT patient experiences confusion, inability to concentrate and short-term memory loss during the treatment.)



"We talk about cognitive deficits and memory loss — really, that's brain damage," says John Breeding, a psychologist in private practice in Austin, Texas. Breeding has counseled several past ECT patients, who say they’ve suffered long-term cognitive damage as a result of electroshock. He’s working to ban ECT in his state, and he runs the Web site endofshock.com.



Breeding and other skeptics argue that ECT is nothing more than a quick fix: Once the treatments stop, the depression returns. And at least one study backs that claim: In 2001, Columbia University researchers found that without follow-up medications, depression returned in 84 percent of ECT patients within six months.



Most patients are given three treatments a week for a total of six to 12 sessions. After that, once the patient’s mood has reached a plateau, the psychiatrist may stop the ECT sessions and prescribe an antidepressant. If someone hasn’t responded well to antidepressants in the past, ECT won’t do anything to change that. For those patients, a doctor may prescribe a different antidepressant from those that had failed before. Or those patients may need once-a-month follow-up treatments, called maintenance ECT, which can continue for years.



The American Psychiatric Association approves ECT as a “safe and effective” treatment for depression and other mental illnesses, such as schizophrenia and catatonia. Under the APA’s guidelines, an anesthesiologist, a psychiatrist and a recovery nurse must be present during a treatment, and the treatment must be voluntary, unless the patient is unable to provide informed consent. It’s not recommended for the very old, children or those with heart conditions. Insurance covers treatments for most patients.



Despite the APA’s approval, for the general public, shock therapy still conjures images from "One Flew Over the Cuckoo's Nest" — it's Jack Nicholson being electrocuted, making terrible grimaces as his body convulses.



"Quite frankly, the stigma pushes people away from it, and it pushes some psychiatrists away from even recommending ECT," says Dr. William McDonald, an Emory University psychiatrist who reviews the APA’s guidelines on electroconvulsive and electromagnetic therapies. "But most of the stigma related to ECT really is related to misconception."



Psychiatrists readily admit that in the early days, ECT absolutely was a cruel procedure. And because the treatment has lingered in the shadows of psychiatry for decades, many people still associate it with its sketchy past.



Convulsive therapy was introduced in the mid-1930s, when scientists discovered that by triggering a seizure, they were able to shock psychiatric patients back into a functioning state of mind. It was designed to be a treatment for curing schizophrenia, but doctors found it also seemed to benefit patients with depression, bipolar disorder and catatonia.



Convulsions strong enough to break bones

During the '40s and '50s, it was one of the only available methods for treating mental illness, so it was often overused. Even when doctors adhered to the standards of the day, it was a harrowing procedure: As patients were shocked with electricity, they were wide awake, feeling their bodies' convulsions, which were sometimes severe enough to break bones.



At its peak of popularity during the early 1960s, about 300,000 U.S. patients a year received shock therapy.



Treatments both then and now require about the same amount of electricity — somewhere between 3 and 100 joules depending on the patient. (For context, one joule is the amount of energy it takes to lift an apple three feet in the air; 100 joules is enough energy to power a desktop computer.) But in a modern ECT treatment, patients are under anesthesia during the entire process, asleep and unaware of the electrical currents charging through their brains. A muscle relaxant prevents their bodies from jerking around once the seizure is triggered; in fact, the patient hardly moves at all.



When Russell, 43, initially was considering ECT, he and his wife, Sue, did extensive research and had lengthy conversations with his doctor about the realities of the treatment. While he was desperate to find a way out of his depression, he was still terrified of shock therapy. "At first, I thought of Frankenstein," Bill Russell says. “I thought, 'That's drastic, that causes brain damage — there's no way I want to do that.’”



After weighing the risks with the depression he just couldn't shake, he made an appointment with Melman, the doctor at Seattle’s Swedish Medical Center.



The hospital is being renovated, which has shunted the ECT suite to a somewhat unfortunate location: the basement, just down the hall from the emergency room.



"I can remember seeing one person (in the waiting room) that really looked out of it, just like a zombie, sort of," Bill Russell says. "I was just thinking, 'Oh God, no, I don't want to end up like that.'



"We almost got up and felt like saying, 'No way, forget it,'" he remembers.



A quick husband-wife huddle reminded them that they were now down to their last idea for relieving Bill's depression, because psychotherapy, medications and hospitalization hadn't helped. They resolved to give shock therapy a shot.



An anesthesiologist put Russell to sleep as he lay flat on a gurney. After he was out, nurses gave him a muscle relaxant through an IV, paralyzing his body. They placed a blood pressure cuff on his lower right calf, preventing the muscle relaxant from flowing to his right foot, which they would rely on during the treatment to twitch and tell them when a seizure was happening.



Melman placed one handheld electrode at the crown of Russell's head, and the other at his right temple, sending electrical currents through his brain for about 10 seconds while Russell lay perfectly still — only his right foot slightly moving.



During his first month of treatments, Russell's world was like a foggy, fuzzy dream. He was in the thick of ECT’s most common side effect: short-term memory loss. Before his wife left for work each day, she papered their home in Post-Its — Remember to take your pills! Here's my phone number! — and took his keys and license, because if he hopped in the car, he might not remember how to find his way back.



"It was like living with Ozzy Osbourne," Sue Russell remembers. Between July and December 2007, Bill Russell had 20 ECT treatments. He went back to work part-time after the first three months of ECT.



The severity of memory loss varies from patient to patient, and in most cases it’s limited to the weeks before and after. While Russell had a somewhat innocuous experience, Melman recalls a former patient whose relative died during the weeks of her ECT treatments. Her family had to tell her again and again of their loss.



'I was completely devastated'

Some former electroshock patients say that the treatment's side effects don't end with short-term memory loss. Juli Lawrence, who had 12 ECT treatments in 1994, says it caused long-term cognitive damage. She says she now has trouble learning new things, and she still has problems with her memory.



"My family and I were told it would cure the depression and it did not," says Lawrence, who's 46 and lives in Long Island, N.Y. "After holding out all this hope that it would be the final answer, it didn't happen. I was completely devastated. On top of that, I had memory loss, and on top of that, I had cognitive damage."



Lawrence runs a Web site called ect.org, which has a message board filled with hundreds of former ECT patients who call themselves "electroshock survivors." They say they've suffered brain damage as a result of ECT. But as no studies have established a link between ECT and long-term cognitive damage, evidence of long-term harm remains anecdotal.



But for most patients, ECT does provide near-immediate relief, say many psychiatrists. It tends to work best in people who’ve had a hard, fast fall into depression — people like Karen, a current patient of Melman’s. (Because Karen is still going through treatments, she requested that her last name not be used.) Just one month after her first treatment in June, Karen, who is in her early 30s, returned to work part-time.



There were a few awkward exchanges in her first week back, Karen says, when she realized she had forgotten the names of certain co-workers. Her job as a communications liaison for a nonprofit in Seattle involves a lot of international travel, and after returning to work she had trouble recalling the details of some trips. ECT even erased an entire country from her memory — there are pictures of Karen on a trip to Ethiopia that she can’t remember at all.



After 12 treatments, she says she’s 90 percent better. “There’s a little bit of gnawing anxiety … what if this happens again?”



Because ECT has a high relapse rate for depression, doctors prescribe psychotherapy or medications after the final ECT session. For skeptics of ECT like Breeding, the Texas psychologist, that proves that ECT is just a quick fix, and it doesn’t work to relieve depression in the long run.



"Sometimes you need a quick fix," says Dr. Alan Gelenberg, a clinical professor of psychiatry at the University of Wisconsin-Madison. He points out that depression itself has a high relapse rate. And a 2001 Oxford University study found that depression returned in about 40 percent of patients who stopped taking an antidepressant. "But you do need to attend to long term issues in any way you can: medications, talk therapy or periodic readministrations of ECT."



Researchers like Dr. Sarah Lisanby, professor of clinical psychiatry at Columbia University, are working to find new, less traumatic therapies that rival ECT’s efficacy for relieving depression.



Solving the mystery

But part of Lisanby’s research is also devoted to uncovering how ECT works.



“Solving the mystery of how ECT works is going to be important for advancements in the field of psychiatry, because ECT has unparalleled efficacy,” Lisanby says. “Understanding why ECT is so much more effective than medications could help the field develop more effective treatments – and safer treatments.”



Because so much of ECT is still not understood, and because of its stigma, some psychiatrists treat ECT as a dire last resort. Instead of being considered a last option, Melman and other proponents of ECT wish that it was considered a next option.



“It can be considered much earlier than it is for most patients today,” Melman says. “Patients suffer with depression either with no response or partial response (to antidepressants), and for years they limp along with terrible depression.”



For Bill Russell, seven months have passed since his last ECT treatment. He’s now taking antidepressants, and he’s had some bad days that brought him close to scheduling a booster ECT treatment. But both Russells say that their life is essentially back to the way it’s always been in their 12 years of marriage. And they both insist that without ECT, Bill wouldn't be here.



“It was like a kick start, like starting over,” Bill Russell says. “When I was done with the treatments and the fog started to clear, it was like waking up from a bad dream.”

© 2008 MSNBC Interactive



Untreatableonline - There is a video that goes with this article over atMSNBC. I have discussed ECT a bunch of times throughout this blog and I am basically on the fence regarding this procedure. I have seen it make incredible differences in people's lives and I have seen it have no effect at all. Basically if nothing else is working ECT comes into play and it is a gamble. Turns out I have some weird syndrome that caused me to stop breathing after the last session of ECT but this may have more to do with the drugs I was on or the drugs given to me during the procedure then the actual procedure itself. Personally I had no other side effects except a headache and my memory loss was about two hours for each session for I remembered waking up in the morning to go to the procedure and then everything blanks until I woke up in the recovery room. I remember everything else. For the record I had five sessions the first time around and then the one lonely session where my breathing stopped during the second go around. Take care.
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