The fifty-something woman was ready for her treatment. In a room at Duke University Medical Center, North Carolina, she bantered with five nurses, a psychiatrist and an anaesthetist, joking that her shock of white hair made it hard to place the electrodes. Then, oxygen mask on, an intravenous tube to pump fast-acting barbiturates and muscle relaxants into a vein in her hand, she was out. Her right toes began a jerky dance as if they were keeping time with the erratic tracings of the heart and brain monitors nearby.
Thirty-four seconds later her brain seizure stopped and her second toe stayed coiled around the big one, like crossed fingers hoping she would stay well. Several months earlier, a course of 10 shock treatments over a three-week period had stopped her severe depression in its tracks; she was now in for a ‘maintenance’ session to prevent a relapse.
Buying time
Like tens of thousands of people in the US, she took a chance that a burst of electricity lasting only a few seconds, at less than half the power it takes to burn a 40-watt light bulb, would stave off deep depression, buying her time from thoughts of suicide. Electroconvulsive therapy (ECT) is casting off its past image to become the treatment of choice for many severely depressed Americans. To so-called ‘shock doctors’ at private US hospitals, and to most of their patients, ECT in its new and improved form is a neat and clean medical procedure, with few complications apart from some initial memory loss and confusion in the hours following the treatment.
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With the American Psychiatric Association saying that ECT can work for more than 80 per cent of severely depressed patients, the treatment is increasingly being accepted as the most effective treatment available when all other therapies have failed. In 1986, the last year for which national data for psychiatric treatment are available, some 36 500 people received ECT, more than a 15 per cent increase over 1980. Researchers estimate that figure to be much higher now.
‘There’s no question that ECT is making a comeback, despite its terrible image,’ says Richard Weiner, the psychiatrist at Duke who treated the depressed woman, and an international leader in ECT research. ‘For the first time, people have come to me specifically asking for ECT, when before it was always the doctors who convinced the patients they needed it.’
Deborah Norris, a 38-year-old missionary nurse, didn’t take long to decide to use ECT when her doctor recommended it. Suffering from severe depression brought on by post-traumatic stress disorder from her years at the Gaza Strip, she tried a variety of antidepressants that left her sleeping for 22 hours a day. ‘I tried ECT because I couldn’t live like that. I was nervous, but after the first treatment there was nothing to it,’ she says. Twelve treatments later, Norris says ‘I am just about back to my old self. If I had a depression again, I’d go right back to ECT.’
Seizure crucial
It is the seizure, not the shock, that is the ‘healing’ agent in ECT. The origins of the treatment date back to the early part of the century, when the erroneous belief that epilepsy and schizophrenia could not exist in the same patient led doctors to induce seizures as a cure for schizophrenia.
In 1938, the first ‘electroshock’ was administered, and it quickly became the main medical treatment for the mentally ill; there was little else available. But its efficacy in treating depressive diseases led the to excessive, sometimes abusive, use of ECT in a wide range of mental illnesses for which it was ineffective.
When the first generation of antidepressant drugs came on the market in the 1960s, ECT fell out of favour and was restricted to the disorders it treats best – severe depression and catatonic and affective schizophrenia disorders. But during the lull of the 1960s and 1970s, researchers found ways to mitigate many of the worst side effects of the therapy, such as broken bones in patients and severe loss of memory. Now psychiatrists tell patients that there may be some temporary memory impairment; rarely is there severe, persistent memory loss.
Today’s treatment little resembles the whammy delivered to conscious patients by Big Nurse in Ken Kesey’s book One Flew Over The Cuckoo’s Nest. Modern ECT therapy uses anaesthetists to deliver intravenous fast-acting barbiturates to put the patient to sleep, muscle relaxants to stop muscle spasms and broken bones, and masks to make sure the patient gets enough oxygen. The procedure has moved from the bedside to a more elaborate treatment room, using heart and brain monitors. In all, the treatment takes about 15 minutes from the time patients lie down on the treatment table to when they start to wake up.
Less juice
Physicians also calibrate the electrical dose to suit each patient: they deliver low doses initially and gradually build up to just the current that will produce a seizure. There is enormous variation in the seizure threshold between patients because there are big differences in the geometry of skulls and scalps, the relative thickness of the subdural spaces between the skull and brain, and the excitability of the underlying nerve cells. The typical seizure threshold varies between 30 and 100 milliampere seconds; the previous generation of machines delivered at least twice as much juice.
The way the current is delivered to the patients has also changed. Doctors now prefer to mimic the spiky, rhythmic activity of the nerve cells by sending short pulses of electricity, between 80 and 180 in a second. The original method of sending the current in a continuous sine wave produced too big a seizure for too long, and this probably also affected memory.
Psychiatrists are still debating the best position for the electrodes to produce maximum benefit with minimum side effects. Some favour placing one electrode on the temple of the nondominant side of the brain and the other on the top of the head. This produces a bilateral seizure, but the seizure will be less intense on the dominant side and, therefore, less likely to affect memory. Others believe the traditional method of placing electrodes on both temples is more effective.
A study published in the New England Journal of Medicine in March 1993 found that the position of the electrodes and the amount of electricity delivered strongly influences clinical outcome: a low current to one side of the brain has little effect in reducing depression, whereas current applied bilaterally, at any dose, is effective but results in greater memory loss.
In pace with clinical advances, researchers are still trying to find out why ECT works. One theory – for which there is some evidence – is that ECT alters the volume of neurotransmitting signals that pass between nerve cells. Although they cannot pinpoint which neurotransmitters are affected – options include gamma aminobutric acid, noradrenaline and serotonin – scientists think that brain chemistry is ‘reset’ following an ECT seizure, correcting abnormal production of signals that control affective behaviour.
While such clinical refinements and laboratory investigations steadily improved the practice of ECT, the ineffectiveness as well as the side effects of some drugs to treat depression have become clearer. Some patients using Thorazine, for example, developed tardive dyskinesia – twitches in the mouth and tongue – due to brain damage.
Firm support
In 1978, the American Psychiatric Association published the report of its task force on ECT, which came down firmly in support of ECT to treat depression. That same year, six teams of British researchers started conducting a landmark series of experiments to compare two groups of patients: one group were given ECT, and the other believed they had ECT, but did not actually receive a shock. All real ECT treatments demonstrated a clinical advantage. Then in 1985, the US National Institutes of Health in Maryland concluded that the treatment was ‘demonstrably effective for a narrow range of severe psychiatric disorders, including depression, mania and schizophrenia’.
ECT is certainly enjoying a new acceptance in the US, aided by testimonies from entertainers such as Dick Cavett – one of the more erudite of the talk show hosts – that ECT saved his life. At the same time, the treatment is still a topic of controversy.
Linda Andre is one of many worried about the increasing use of the therapy. She says that ECT ‘wiped out five years of memory and brought my IQ down 40 points’. Andre, who had ECT in 1984, sued the manufacturer of the ECT machine and New York Hospital three years after her treatment. She has now set up the Committee for Truth in Psychiatry, which has 500 members. The group is lobbying for ECT machines to be investigated for safety and for stronger warnings in patient consent forms about the possibility of memory loss.
A second grass-roots organisation, the 182-member World Association of Electroshock Survivors, has also hit the headlines. Its founder, Dianna Loper, claimed on the Oprah Winfrey Show last December that ECT, used to treat her depression without her consent, had ‘fried’ her brain, bringing on recurrent bouts of epilepsy.
Lee Coleman, a psychiatrist practising in Berkeley, California, describes ECT as producing ‘the kind of acute brain injury that you would expect when you put electricity in your brain. It’s like what happens from a blow on the head – confusion, loss of memory, inability to retain new information.’
Coleman maintains that ECT’s side effect is the treatment itself: ‘Patients can’t remember what was upsetting them. It’s interesting that when you use less treatment, such as with unilateral electrode placement, you get less memory loss. That’s exactly what you would suspect if the treatment works by brain injury.’ Psychiatrists, patients and their families who allow the use of ECT are copping out, he says. ‘It’s a quick fix. Everyone is avoiding the real cause why people are depressed, and that is because life is not going in such a good way.’
Shocks for the rich
Although statistics are hard to come by, ECT appears to be more widely used in some other parts of the world than in the US. In Britain, for example, patients are three times more likely to receive ECT . According to Allen Scott, a consultant psychiatrist at the Royal Edinburgh Hospital, this is partly because ECT is used differently in Britain. First, it is often the first treatment given to severely depressed, suicidal patients rather than a last-ditch solution as in the US. Secondly, Scott says that the people who receive ECT in Britain are ‘representative of people who get depressed, rather than people who can afford it’.
According to Scott, the debate that is not being heard in the US, and that should be, is that ECT is mostly used on patients who can pay for treatments, which can cost up to $1000 a treatment or $12 000 for a full series over two weeks. While ECT may have become the treatment of choice, it is only within reach of depressed Americans with private medical insurance. It is not available to everyone who gets depressed, he says, only those who can afford it.
‘This criticism is, unfortunately, true,’ says Harold Sackheim, chief of biological psychiatry at New York State Psychiatric Institute. ‘In the 1980s, there wasn’t a single nonwhite to receive ECT in a state facility in America.’ According to James Thompson, a psychiatrist and epidemiologist at the University of Maryland, 71 per cent of ECT recipients in 1986 were women, mostly elderly and medically insured. Whites were also eleven times more likely to receive ECT than blacks.
Government funding for ECT treatments in public hospitals plummeted when ECT’s image took a nose dive, and has never recovered. But, according to Sackheim, ECT was still accepted in private or teaching hospitals. Recently, however, several public hospitals in New York City, including the Bronx Lebanon and the Harlem, have begun to reverse that trend by starting ECT programmes.
‘The public has a visceral reaction to ECT and that’s why it has always been controversial and will probably remain so,’ says Sackheim. ‘No one would ever rationally think that inducing a seizure by applying electricity would be a therapy. It can be seen as a grotesque drama.
Renee Twombly is a freelance health and science reporter based in Durham, North Carolina.
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Britain’s shock story
America’s love-hate relationship with electroconvulsive therapy has not played itself out with quite such emotion in Britain. Allen Scott, a consultant psychiatrist at Royal Edinburgh Hospital and a member of the Royal College of Psychiatry’s committee on ECT, says it never fell from favour in Britain, although its use did decline with the arrival of antidepressant drugs.
John Pippard, a senior researcher at the Royal College of Psychiatry and a leading British authority on the use of the therapy, maintains that the use, per capita, is up to three times higher in Britain as in the US, with up to 20 000 people in England and Wales receiving treatment in 1991.
ECT is also used differently in Britain in that it is generally more low-technology: there is less monitoring, and fewer nurses in attendance. It is also available in public and private hospitals, and tends to be the first rather than last therapy offered to deeply depressed individuals, especially those who are suicidal.
But that does not mean that problems do not exist in administering ECT in Britain. In a survey of health regions in 1992, Pippard found that physicians giving ECT had no hands-on training and the treatment was unregulated. ‘It means that perhaps 20 per cent of those patients were not getting adequate treatments,’ he says. Additionally, half of ECT machines being used may be inadequately powered to trigger a full seizure, says Pippard.
New guidelines expected this spring by the Royal College of Psychiatry will specify that clinics should upgrade to newer, more efficient machines that deliver the electricity in brief bursts and that psychiatrists receive more intensive hands-on training in administering the treatment.