Shock therapy makes a quiet comeback
- From: rpautrey2 <rpautrey2@xxxxxxxxx>
- Date: Thu, 7 Aug 2008 08:54:53 -0700 (PDT)
MSNBC.com
Shock therapy makes a quiet comeback
Despite the stigma, 100,000 desperate patients a year now seek
treatment
By Melissa Dahl
Health writer
updated 7:22 a.m. CT, 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
URL: http://www.msnbc.msn.com/id/26044935/
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© 2008 MSNBC.com
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