Shock Therapy...IT'S BACK - Shock Therapy

Written by SANDRA G. BOODMAN The Washington Post

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.