Last Resort Therapy

Last Resort Therapy

The Record (Bergen County, NJ)

Jennifer Hughes

CORRECTION: An article about electroshock treatments that appeared in the Oct. 25 Health section incorrectly reported the name of the founder of the Committee for Truth in Psychiatry. The group was founded by Marilyn Rice. (PUBLISHED THURSDAY, NOVEMBER 10, 2005, PAGE A02.)

When most people think of electroshock therapy, they picture Jack Nicholson writhing in agony on a gurney in “One Flew Over the Cuckoo’s Nest,” but “Jane” has never seen the film.

The 52-year-old doctor from Morris County, reluctantly agreed to ECT (the procedure is now called electroconvulsive therapy) in February after her 30-year battle with manic depression had reached its terrible crescendo.

Medications no longer worked and the cocktail of drugs brought nighttime insomnia and daytime drowsiness. Tremors shook her hands, she gained 50 pounds, and her sex life evaporated.

“I don’t like to think about it, but I was really suicidal,” said Jane, whose mother is institutionalized with severe depression. Since then, she has had 16 treatments at University Hospital in Newark and said her lifelong depression has lifted.

“It basically saved my life,” she said.

ECT, which causes a grand mal seizure, has changed since its early days, when even proponents agree it was used on too many patients, in painful procedures. Now, patients who receive ECT are given anesthesia and muscle relaxants, which prevent broken bones and muscle injuries. The amount of electricity in most ECT treatments is about 800 milliamps, about one-fifth the power you would feel if you were shocked through your wall socket, doctors said.

Many psychiatrists admit memory loss is a serious potential side effect of ECT, but the treatment is often the last resort, when medications don’t work, for people who are severely depressed.

“ECT is the gold standard by which all anti-depression treatments are judged,” said Dr. Charles Kellner, who treated Jane. “It works better and faster than any other treatment.”

At Englewood Hospital and Medical Center, Dr. Charles Blackinton said those referred for ECT often can’t take drugs because of medical conditions or can’t tolerate the side effects.

“People are no longer willing to put up with partially remitted depression,” said Blackinton, who has been doing ECT at the hospital since 1964.

But while ads for anti-depressants are commonplace on TV, ECT has not escaped its association with psychiatry’s dark ages. Jane asked to remain anonymous because of the stigma.

ECT also has not shed its vocal critics, who insist success rates are overblown, that memory loss from ECT is more widespread than reported and that it is often irreversible.

“Neurologists are trying to prevent seizures because of the bad things that they do to the brain, while psychiatrists go out of their way to produce seizures,” said Dr. Peter Sterling, professor of neuroscience at the University of Pennsylvania School of Medicine. “It doesn’t make any sense to me.”

Despite the fact that ECT has been used in the United States for more than 50 years, no one knows exactly how it works or how many patients receive it each year.

The American Psychiatric Association estimates 100,000 patients get ECT annually – but doctors admit the figure is merely a guess because no government agency or outside group monitors or tracks ECT nationwide.

Englewood Hospital has seen a rise in ECT patients; from 142 in 2003 to 168 for the first eight months of 2005. At the University Hospital, which has had an ECT program for 2 1/2 years, about 26 patients have undergone ECT each year, including some who came from as far away as California.

While several states have laws that require reporting information on ECT patients, New Jersey does not.

Linda Andre, a freelance writer in New York City, founded the Committee for Truth in Psychiatry in 1984 to cope with her negative reaction to ECT.

She said she was coerced into ECT by family members. She said she has no memory of ever being depressed and that the treatment wiped out five years of memories.

“Your life is erased like it never happened. … It can be very difficult to live your life after that,” she said. Andre said her group has about 500 members nationwide, and all of them have experienced severe side effects from ECT.

She said she often hears former patients say doctors don’t adequately explain side effects and push people into the treatment.

One of the biggest hurdles Jane had to overcome before she agreed to ECT was the fact that her doctor couldn’t explain how it worked.

“I’m a scientist,” she said. “That was very hard for me to accept.”

It is not the electricity but rather the seizure caused by ECT’s current that is believed to be the key, said Kellner. One theory is that when the body releases neurotransmitters to “turn off” the seizure, those are the same brain chemicals that naturally help alleviate depression.

Backing up that theory is the fact that many of the most recent and most effective anti-depression drugs were first developed as anti-convulsants, Kellner said.

Dozens of studies have been done on ECT’s effectiveness with a wide range of success rates.

* In a 2005 study, 85 percent of patients reported a remission in their depression during ECT treatments and within a week of the course’s conclusion.

* Another study, from 2004, reported between 30 and 46 percent of patients interviewed within days of ECT reported that their depression had lifted.

* A 2001 study found that without follow-up medication, depression returned in 85 percent of patients within six months. Only 39 percent reported a relapse if they had medications.

ECT is a short-term solution, said researcher Dr. Vaughn McCall, editor of the Journal of ECT and the president of the Association for Convulsive Therapy, which has about 400 members worldwide.

“The first thing you have to do with a patient is disabuse them of the idea that this is a cure,” McCall said.

Just because ECT helps only in the short term does not mean it should be discounted, argued Kellner.

“If someone kills themselves because they couldn’t get well in the short term, then it doesn’t matter what would have worked in the long term,” he said.

ECT can pull a patient from the depths of a life-threatening depression quickly and long enough to allow time for medications to work, to find a proper cocktail, or to allow for a natural lifting of depression, McCall said. In some cases, patients rely on a “maintenance” ECT – having the treatments spread out for years.

“There’s no good answer for why drugs sometimes work after ECT when they didn’t work before,” said Englewood’s Blackinton.

Dr. Peter Breggin, author of the book “Toxic Psychiatry,” is likely the most well-known critic of ECT. He said the reason some patients show an improvement after ECT is precisely because of the damage caused to the brain.

“Patients are too numb, bewildered and confused to be anything, let alone depressed,” he said.

The other major hot button issue of ECT is memory loss. Supporters of ECT say memory loss is usually not permanent or extensive and generally involves impersonal memories like names of places.

“There are some reports of people with much more profound memory loss … we don’t understand why this happens, but it is quite rare,” said Kellner.

Critics say studies are tailored to weed out severe cases, and there is not enough follow-up on patients to give a real understanding of effects.

“All the studies are done by shock docs,” said Breggin. “I’d discount anything they have to say.”

In one study from 1986, patients wrote down an inventory of personal information and memories before ECT treatment and were asked the same questions again post-ECT.

Those with bilateral ECT – when electrodes are placed on both sides of the head – had forgotten about 30 to 40 percent of the information. Patients in a control group who did not have ECT forgot about 15 to 20 percent of the information.

Because of the problems with memory loss, researchers are looking for ways to induce seizures, or create similar brain chemistry, without electricity.

One way is through magnetic stimulation, which produces seizures in a more localized, specific part of the brain, said Dr. Sarah Lisanby, a researcher and practicing physician at Columbia University. Another technique is called Vargus Nerve Stimulation, which uses a small device implanted in the body that stimulates a nerve running through the neck to the brain.

One of Sterling’s arguments against ECT comes from how researchers are trying to promote these new treatments.

“In order to promote them, they’re pointing out the damage caused by ECT, the fact that it is safer than ECT, even though they had denied for years that ECT caused damage,” he said.

Lisanby noted that while ECT can have serious side effects, so do psychiatric medications.

“I’d like to see us as a field do a better job of communicating more accurate information about the benefits and risks of ECT as compared to other treatments,” she said. “I think that could help combat some of the stigma and lack of information on what ECT is.”

(SIDEBAR, page F01)

What the procedure entails

Most patients who have ECT have a course of therapy that includes six to 12 treatments, starting with three times a week.

* A patient who is referred for ECT undergoes a physical exam to ensure there is no neurological problem that could be causing depressive symptoms. Blood tests and spinal X-rays are taken to ensure the patient can tolerate the anesthesia and seizure caused by ECT.

* Doctors explain to the patient and family members side effects, including memory loss and cognitive difficulties. They are advised to have someone help at home after treatments, to refrain from driving, and to avoid major decisions.

* At the hospital, monitors are placed on the patient to track blood pressure, heart rate, oxygen content and brain waves. Gauze is inserted into the person’s mouth to prevent tooth damage. A general anesthetic is administered, and the ECT electrodes are placed on the scalp. In bilateral ECT, one is placed on each temple; in unilateral ECT, the electrode is placed on the top of the head near the right side.

* The electrical pulse lasts from half a second to eight seconds, and the patient undergoes a grand mal seizure, which can last from 25 seconds to 90 seconds. In many cases, because of the muscle relaxant given, the patient’s body barely moves.

* Once the patients awaken, usually after less than 10 minutes, they remain in a recovery area until they can be driven home or return to a psychiatric unit of a hospital.

Source: Dr. Charles Blackinton, Englewood Hospital

Comments (2)

anjie robertsSeptember 17th, 2006 at 10:37 pm

I have had ECT series on two different occasions. both times it was absolutely the last resort. I had severe medication resistant depression and was extremely suicidal (came very close to suceeding by overdosing on a whole bottle of R insulin) and on both cases it worked very well. I survived to finally find the proper psychiatrist who has finally discovered my proper diagnoses and is treating me with proper medications and therapies. I am happier and feel better than I have in many years. If I had not had the ECT I dont believe I would be here to tell this story. To all of the naysayer of ECT, please relax, find a new cause. I’ve been thru it. I was well advised of the exact procedure and the exact possible side effects and willingly took the treatment and am very glad that I did and would again if I needed to. Yes, I did have memory disturbances during the inital month after treatment which is normal and just about all of it went away. I am not displeased in any way with the treatment. As for the few patients who do have a less than favorable outcome, the same can be said of any medical procedure. Some people may not react as well as others.

mICHELE pEREZJanuary 8th, 2007 at 2:14 pm

I was interested in the psychiatric care that “Anjie roberts” received specifically, the physician who treated her after her ECT treatments. Please respond asap.

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