Shock Therapy... It's Back
It is unlike any other treatment in psychiatry, a therapy that still
arouses such passionate controversy after 60 years that supporters and
opponents cannot even agree on its name.
Proponents call it electroconvulsive therapy, or ECT. They say it is
an unfairly maligned, poorly understood and remarkably effective treatment
for intractable depression.
Critics call it by its old name: electroshock. They claim that it temporarily
"lifts" depression by causing transient personality changes similar to
those seen in head injury patients: euphoria, confusion and memory loss.
Both camps agree that ECT, which is administered annually to an estimated
100,000 Americans, most of them women, is a simple procedure -- so simple
that an ad for the most widely used shock machine tells doctors they need
only set a dial to a patient's age e and press a button.
Electrodes connected to an ECT machine, which resembles a stereo receiver,
are attached to the scalp of a patient who has received general anesthesia
and a muscle relaxant. With the flip of a switch the machine delivers enough
electricity to power a light bulb for a fraction of a second. The current
causes a brief convulsion, reflected in the involuntary twitching of the
patient's toe. A few minutes later the patient wakes up severely confused
and without any memory of events surrounding the treatment, which is typically
repeated three times a week for about a month.
No one knows how or why ECT works, or what the convulsion, similar to
a grand mal epileptic seizure, does to the brain. But many psychiatrists
and some patients who have undergone ECT say it succeeds when all else
-- drugs, psychotherapy, hospitalization -- have failed. The American Psychiatric
Association (APA) says that about 80 percent of patients who undergo ECT
show substantial improvement. By contrast antidepressant drugs, the cornerstone
of treatment for depression, are effective for 60 to 70 percent of patients.
"ECT is one of God's gifts to mankind," said Max Fink, a professor of
psychiatry at the State University of New York at Stony Brook. "There is
nothing like it, nothing equal to it in efficacy or safety in all of psychiatry,"
declared Fink, who is so committed to the treatment that he remembers the
precise date in 1952 that he first administered it.
There is no doubt that mainstream medicine is solidly behind ECT. The
National Institutes of Health has endorsed it and for years has funded
research into the treatment. The National Alliance for the Mentally Ill,
an influential lobbying group composed of relatives of people with chronic
mental illness, supports the use of ECT as does the National Depressive
and Manic Depressive Association, an organization composed of psychiatric
patients. The APA, the Washington-based trade association that represents
t he nation's psychiatrists, has long battled efforts by lawmakers to regulate
or restrict shock therapy and in recent years has sought to make ECT a
first-line therapy for depression and other mental illnesses, rather than
the treatment of last resort.
And the Food and Drug Administration has proposed relaxing restrictions
on the use of ECT machines, even though the devices have never undergone
the rigorous safety testing that has been required of medical devices for
the past two decades. (Because the machines had been used for years before
the passage of the 1976 Medical Device Act, they were grandfathered in
with the understanding that they would someday undergo testing for safety
and effectiveness.)
Many of the nation's most prestigious teaching hospitals -- Massachusetts
General in Boston, the Mayo Clinic, the University of Iowa, New York's
Columbia Presbyterian, Duke University Medical Center, Chicago's Rush-Presbyterian-St.
Luke's -- regularly administer ECT. In the past three years a few of these
institutions have begun to use the treatment on children, some as young
as 8.
Managed care organizations, which have sharply cut back on reimbursement
for psychiatric treatment, apparently look with favor upon ECT, even though
it is performed in a hospital and typically requires the presence of two
physicians -- a psychiatrist and an anesthesiologist -- and, sometimes,
a cardiologist as well. The cost per treatment ranges from $300 to more
than $1,000 and takes about 15 minutes.
Medicare, the federal government's insurance program for the elderly,
which has become the single biggest source of reimbursement for ECT, pays
psychiatrists more to do ECT than to perform medication checks or psychotherapy.
Increasingly, the treatment is being administered on an outpatient basis.
In the Washington area more than a dozen hospitals perform ECT, according
to Frank Moscarillo, executive director of the Washington Society for ECT
and chief of the ECT service at Sibley Hospital, a private hospital in
Northwest Washington. Moscarillo said that Sibley administers about 1,000
ECT treatments annually, more than all other local hospitals combined.
"With the insurance companies there isn't a limit [for ECT] like there
is for psychotherapy," said Gary Litovitz, medical director of Dominion
Hospital, a private 100-bed psychiatric facility in Falls Church. "That's
because it's a concrete treatment they can get their hands around. We have
not run into a situation where a managed care company cut us off prematurely."
Anecdotal Miracles
Because of the stigma of psychiatric illness in general and of shock
treatment in particular, most patients do not openly discuss their experiences.
Among the few who have is talk show host Dick Cavett, who underwent ECT
in 1980. In a 1992 account of his treatment Cavett told People magazine
that he had suffered from periodic, debilitating depressions since 1959
when he graduated from Yale. In 1975 a psychiatrist prescribed an antidepressant
that worked so well that once Cavett felt better, he simply stopped taking
it.
His worst depression occurred in May 1980 when he became so agitated
that he was taken off a London-bound Concorde jet and driven to Columbia-Presbyterian
Hospital. There he was treated with ECT. "I was so disoriented I couldn't
figure out what they were asking me to sign, but I signed [the release
for treatment] anyway," he wrote.
"In my case ECT was miraculous," he continued. "My wife was dubious,
but when she came into my room afterward, I sat up and said, `Look who's
back among the living.' It was like a magic wand." Cavett, who was in the
hospital for six weeks, said that he has taken antidepressants ever since.
Twice in the past six years writer Martha Manning, who for years practiced
as a clinical psychologist in Northern Virginia, has undergone a series
of ECT treatments. In her 1994 book entitled "Undercurrents," Manning wrote
that months of psychotherapy and numerous antidepressants failed to arrest
her precipitous slide into suicidal depression. When her psychologist Kay
Redfield Jamison suggested shock treatments, Manning was horrified. She
had been trained to regard shock as a risky and barbaric procedure reserved
for those who had exhausted every other option. Ultimately Manning decided
that she had too.
In 1990 she underwent six ECT treatments while a patient at Arlington
Hospital. She said she suffered permanent memory loss for events surrounding
the treatment and was so confused for several weeks that she got lost driving
around her neighborhood and didn't remember her sister's visit 24 hours
after it occurred.
"It is scary, despite anybody's promises to the contrary," Manning said
in an interview. Although some of her memories before and during ECT have
been forever obliterated, Manning said she suffered no other lasting problems.
"I felt I got 30 IQ points back" once the depression lifted.
"I was lucky," said Manning, who says her depression is now controlled
by medication. "ECT was safe for me and very, very helpful. It was a break
in the action, not a cure."
"I'm coming from a position of seeing ECT at its best," added Manning,
who said she would have ECT again if she needed it. "I'm sure there are
other people who've seen it at its worst."
Vanished Memories
Ted Chabasinski is one of those people.
A lawyer in Berkeley, Calif., Chabasinski, 59, says he has spent years
trying to recover from the dozens of ECT treatments he underwent more than
a half-century ago. At age 6, he was taken from a foster family in the
Bronx and sent to New York's Bellevue Hospital to be treated by the late
child psychiatrist Lauretta Bender.
As a child Chabasinski was precocious but very withdrawn, behaviors
that a social worker who regularly visited the foster family believed were
the beginnings of schizophrenia, the same illness from which his mother,
who was poor and unmarried, suffered. " At the time hereditary causes of
mental illness were fashionable," he said.
Chabasinski was one of the first children to receive shock treatments,
which were administered without anesthesia or muscle relaxants. "It made
me want to die," he recalled. "I remember that they would stick a rag in
my mouth so I wouldn't bite through my tongue and that it took three attendants
to hold me down. I knew that in the mornings that I didn't get any breakfast
I was going to get shock treatment." He spent the next 10 years in a state
mental hospital.
Bender, who shocked 100 children, the youngest of whom was 3, abandoned
the use of ECT in the 1950s. She is best known as the co-developer of a
widely used neuropsychological test that bears her name, not as a pioneer
in the use of ECT on children. That work was discredited by researchers
who found that the children she treated either showed no improvement or
got worse.
The experience left Chabasinski with the conviction that ECT was barbaric
and should be outlawed. He convinced residents of his adopted hometown;
in 1982 Berkeley voters overwhelmingly passed a referendum banning the
treatment. That law was overturned by a court after the APA challenged
its constitutionality.
The Old and the New
There is little dispute that ECT administered before the late 1960s,
commonly referred to as "unmodified," was different from later treatment.
When Chabasinski underwent ECT, patients did not routinely receive general
anesthesia and muscle paralyzing drug s to prevent muscle spasms and fractures,
as well as continuous oxygen to protect the brain. Nor was there monitoring
by an electroencephalogram. All of these are standard today. In the old
days shock machines used sine-wave electricity, a different -- and ECT
supporters say riskier -- form of electrical impulse than the brief pulse
current dispensed by contemporary machines.
But critics contend that these changes are largely cosmetic and that
"modified" ECT merely obscures one of the most disturbing manifestations
of earlier treatments -- a patient grimacing and jerking during a convulsion.
Some opponents say that the newer machines are actually more dangerous
because the intensity of the current is greater. Others note that modified
treatment requires that patients undergo repeated general anesthesia, which
carries its own risks.
"The characteristics of the treatment that caused people to be outraged
and shocked are now kind of masked so that the procedure looks rather benign,"
said New York psychiatrist Hugh L. Polk, an ECT opponent who is medical
director of the Glendale Mental Health Clinic in Queens.
"The basic treatment hasn't changed," he added. "It involves passing
a large amount of electricity through people's brains. There's no denying
that ECT is a profound shock to the brain, [an organ that is] enormously
complicated and of which we have only t he barest understanding."
Fifty years after Chabasinski was treated at Bellevue, Theresa E. Adamchik,
a 39-year-old computer technician, underwent ECT as an outpatient at a
hospital in Austin, Tex. Adamchik said that two years of therapy, antidepressants
and repeated hospitalizations had failed to alleviate an unremitting depression
caused in part by the breakup of her second marriage.
Adamchik said she agreed to have the treatments, which were covered
by her health maintenance organization, after doctors assured her "it would
snap me right out of my depression." When she asked about memory loss,
she said, "They told me it would kill as many brain cells as if I went
out and got drunk one night."
But Adamchik said that her memory problems persisted much longer than
her doctors had predicted. "It's very strange. Sometimes there are memories
without emotions and emotions without memories. I have flashes of things
-- bits and pieces," she said. The treatments also erased memories of events
that occurred years earlier, such as the 1978 funeral of her 2-year-old
son, who drowned in a backyard swimming pool.
Adamchik said that although she has returned to work and is no longer
depressed, she would never again consent to shock treatments. "I didn't
have any memory problems before ECT," she said. "I do now. Sometimes I'll
be in the middle of a sentence and I'll just forget what I'm talking about."
Sketchy Data
One of the chief problems in evaluating the effectiveness of ECT, noted
University of Maryland anesthesiologist Beatrice L. Selvin, who reviewed
more than 100 ECT studies conducted since the 1940s, is that "even the
more recent literature is still rife with contradictory findings. . . .
few research papers report well-controlled studies, similar procedures,
measurements, techniques, protocols or data analyses," Selvin concluded
in a 1987 article in the journal Anesthesiology. Her conclusion echoes
a 1985 report by an NIH consensus conference, which cited the poor quality
of ECT research.
A 1993 APA fact sheet said that at least 80 percent of patients with
severe, intractable depression will show substantial improvement after
ECT. Studies have shown that after a course of six to 12 treatments 80
percent of patients have better scores on a commonly used test to measure
depression, usually the Hamilton depression scale.
But what the APA fact sheet does not mention is that improvement is
only temporary and that the relapse rate is high. No study has demonstrated
an effect from ECT longer than four weeks, which is why growing numbers
of psychiatrists are recommending monthly maintenance, or "booster," shock
treatments, even though there is little evidence that these are effective.
Many studies indicate that the relapse rate is high even for patients
who take antidepressant drugs after ECT. A 1993 study by researchers at
Columbia University published in the New England Journal of Medicine, found
that while 79 percent of patients got better after ECT -- one week after
their last treatment they had improved scores on the Hamilton scale --
59 percent were depressed two months later.
Richard D. Weiner, a Duke University psychiatrist who is chairman of
the APA's ECT task force, says that ECT is not a cure for depression. "ECT
is a treatment that's used to bring someone out of an episode," said Weiner,
who compares it to the use of antibiotics to treat pneumonia.
Yet other psychiatrists may not be as convinced of ECT's effectiveness.
An article by researchers at Harvard Medical School published last year
in the American Journal of Psychiatry found such disparities in the use
of ECT in 317 metropolitan areas in the United States that they called
the treatment "among the highest variation procedures in medicine." The
researchers, who attributed the disparities to doubts about ECT, found
that the popularity of the treatment was "strongly associated with the
presence of an academic medical center."
ECT use was highest in several relatively small metropolitan areas:
Rochester, Minn. (Mayo Clinic), Charlottesville (University of Virginia),
Iowa City (University of Iowa Hospitals), Ann Arbor (University of Michigan)
and Raleigh-Durham (Duke University Medical Center).
Another unresolved question about ECT is its mortality rate. According
to the 1990 APA report, one in 10,000 patients dies as a result of modern
ECT. This figure is derived from a study of deaths within 24 hours of ECT
reported to California officials between 1977 and 1983.
But more recent statistics suggest that the death rate may be higher.
Three years ago, Texas became the only state to require doctors to report
deaths of patients that occur within 14 days of shock treatment and one
of only four states to require any reporting of ECT. Officials at the Texas
Department of Mental Health and Mental Retardation report that between
June 1, 1993, and September 1, 1996, they received reports of 21 deaths
among an estimated 2,000 patients.
"Texas collects data no one else collects," said Steven P. Shon, the
department's medical director. The state, however, does not require an
autopsy in these cases. "We need to be very careful" of attributing these
deaths to ECT, he added. "Unless there's an autopsy, there's no way to
make a causal connection."
Records show that four deaths were suicides, all of which occurred less
than one week after ECT. One man died in an automobile accident in which
he was a passenger. In four cases the cause of death was listed as cardiac
arrest or heart attack. One patient died of lung cancer. Two deaths were
complications of general anesthesia. In eight cases there was no information
on the cause of death. At least two-thirds of patients were over 65, and
in nearly every case treatment was funded by Medicare or Medicaid.
Suicide Preventive?
One of the most common reasons cited by doctors for performing ECT is
that it prevents suicide. The report of the 1985 NIH Consensus Conference
states that "the immediate risk of suicide" that can't be managed by other
treatments "is a clear indication for consideration of ECT."
In fact there is no proof that ECT prevents suicide. Some critics suggest
that there is anecdotal evidence that the confusion and memory loss after
treatment may even precipitate suicide in some people. They point to Ernest
Hemingway, who shot himself in July 1961, days after being released from
the Mayo Clinic where he had received more than 20 shock treatments. Before
his death Hemingway complained to his biographer A.E. Hotchner, "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."
A 1986 study by Indiana University researchers of 1,500 psychiatric
patients found that those who committed suicide five to seven years after
hospitalization were somewhat more likely to have had ECT than those who
died from other causes.
The researchers, who also reviewed the literature on ECT and suicide,
concluded that these findings "do not support the commonly held belief
that ECT exerts long-range protective effects against suicide."
"It appears to us that the undeniable efficacy of ECT to dissipate depression
and symptoms of suicidal thinking and behavior has generalized to the belief
that it has long-range protective effects," concluded the researchers in
an article in Convulsive Therapy, a journal for ECT practitioners.
Another factor in ECT's growing popularity is economic, suggests Tampa
psychiatrist Walter E. Afield. It can be summed up in one word: reimbursement.
"Shock is coming back, I think, because of the change in psychiatric
reimbursement," said Afield, former a consultant to Johns Hopkins Hospital
who founded one of the nation's first managed mental health care companies.
"[Insurers] no longer will pay psychiatrists to do psychotherapy, but they
will pay for shock or for medical tests."
"We're being pushed as a specialty to do what's going to pay," said
Afield, who is not opposed to ECT, but to its indiscriminate use. "Finances
are dictating the treatment. In the old days when insurance companies paid
for long-term hospitalization, we had patients who were hospitalized for
a long time. Who pays the bill determines what kind of treatment gets done."
The growing popularity of ECT concerns some psychiatrists. "It's better
than it used to be, but I have grave reservations about it," said Boston
area psychiatrist Daniel B. Fisher, who has never recommended ECT for a
patient. "I see it now being used as a quick and easy and not very lasting
solution and that worries me."
Questions About Memory
Loss Persist
Does ECT cause long-term memory loss?
The model consent form drafted by the American Psychiatric Association
and copied by hospitals says that "perhaps 1 in 200" patients report lasting
memory problems. "The reasons for these rare reports of long-lasting memory
impairment are not fully understood," it concludes.
Critics such as David Oaks, director of the Support Coalition of Eugene,
Ore., an advocacy group composed of former psychiatric patients, say that
the 1 in 200 statistic is a sham. "It's totally fictional and without scientific
justification and is designed to be reassuring," said Oaks. Complaints
about long-term memory loss are widespread among patients, Oaks said. Some
insist that ECT wiped out memories of distant events, such as high school,
or impaired their ability to learn new material.
Harold A. Sackeim, chief of biological psychiatry at the New York State
Psychiatric Institute and a member of the APA's six-member shock therapy
task force, says that the 1 in 200 figure is not derived from any scientific
studies. It is, Sackeim said, "an impressionistic number" provided by New
York psychiatrist and ECT advocate Max Fink in 1979. The figure will likely
be deleted from future APA reports, Sackeim said.
No one knows how many patients suffer from severe memory problems, said
Sackeim, although he believes that the number is quite small.
"I know it happens because I've seen it," he said. He attributes such
cases to improperly performed ECT. Yet even when properly administered,
Sackeim notes that greater memory loss is more likely after bilateral treatment
-- when electrodes are attached t o both sides of the head -- rather than
one side. Because doctors believe bilateral ECT is more effective, it is
administered more often, experts say.
While blaming ECT for memory problems is understandable, it may not
be accurate, noted Larry R. Squire, a neuroscientist at the University
of California at San Diego.
In a series of studies in the 1970s and 1980s Squire, a memory expert
who has spent years studying ECT, compared more than 100 patients who underwent
ECT with those who never had the treatment. He found that memories from
the days shortly before, during and after shock treatments were probably
lost forever. In addition, some patients demonstrated memory problems for
events up to six months before ECT and as long as six months after treatment
ended.
After six months, however, Squire said that ECT patients "perform as
well on new learning tests and on remote memory tests as they performed
before treatment" and as well as a control group of patients who never
had ECT.
The widespread perception that ECT has permanently impaired memory is
"an easy way to explain impairment," Squire said in interview. When patients
are pressured to have ECT, he said, "outrage . . . combined with a sense
of loss or low sense of self-esteem " could account for such a belief,
even if there is no empirical evidence to support it.
Some psychiatrists are skeptical of Squire's hypothesis. They question
the ability of standard tests to detect subtle memory problems and point
to their own clinical experiences with patients.
Daniel B. Fisher, a psychiatrist and director of a community mental
health center near Boston, has "grave reservations" about ECT's effects
on memory and says he has never recommended it to a patient.
"The variability is still there, the unpredictability and uncertainty
about the nature of the side effects," said Fisher, who has a doctorate
in neurochemistry and worked as a neuroscientist at the National Institute
of Mental Health before he went to medical school. "You see these people
who can perform routine functions [after ECT] but have lost some of the
more complex skills." Among them, he said, is a woman he treated who coped
adequately with everyday life but no longer remembered how to play the
piano.
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