Shock Value

Electroconvulsive Therapy Saves Lives. But 70 Years After It First Gained Currency as a Treatment For Major Depression, ECT Continues to Court Controversy.

By Shirley Wang
Special to The Washington Post
Tuesday, July 24, 2007; HE01

Anthony Mauger woke up at 5 a.m. one morning nearly 10 years ago and heard a message in his head telling him to kill himself. He wrote a goodbye note to his wife, then jumped off the back deck of their Kensington home, falling the 14 feet hard enough to wake her with the sound of his thud.

The 66-year-old organic chemist succeeded only in smashing his knees and skull. After surgery at Suburban Hospital, he was transferred to Potomac Valley Nursing and Wellness Center in Rockville for intensive psychiatric care.

Mauger had been depressed for about six months, his wife, Inge, remembers. His sleep had been poor, and he was making strange claims that he could not go on vacation or walk. The slew of antidepressants Mauger tried made no difference. After four more months watching her husband deteriorate, Inge Mauger was desperate. “Nothing is happening,” she said to his psychiatrist. “Isn’t there anything you can do?”

“We can try ECT,” he replied.

Better known as shock therapy and seared into our collective consciousness as the involuntary procedure depicted in “One Flew Over the Cuckoo’s Nest,” electroconvulsive therapy remains a controversial treatment, often used, as in Mauger’s case, only after other treatments fail. Its popularity has waxed and waned in its 70-year history, but an estimated 100,000 Americans undergo ECT each year, according to a 1995 survey of more than 17,000 psychiatrists, and its use appears to be steady or increasing since then.

The number of treatments in California — one of the few states that have mandatory reporting — increased from about 13,000 to more than 20,000 between 1994 and 2004. Although the District, Maryland and Virginia do not require such reporting, Johns Hopkins Hospital treats about 125 people with ECT annually, a number that has not changed much recently, according to Irving Reti, head of Hopkins’s ECT unit; at Sheppard Pratt outside Baltimore, ECT physician Jack Vaeth says his service does about 60 treatments a week, an increase over the past decade.

While no one fully understands why ECT works, many psychiatrists believe that using an electric current to produce a “grand mal” — or generalized brain — seizure can “reboot” the brain when medications and psychotherapy fail. Just last week, a commentary in the Journal of the American Medical Association (JAMA) suggested that, despite its demonstrated effectiveness, ECT remains underused, primarily because of its stigmatized history.

The treatment is “miraculous” and “lifesaving,” say some patients and doctors, and yet the costs — primarily memory loss — can be significant. Many individuals who believe that ECT kept them alive when they were suicidal also urge caution about its use.

Mauger, as an older individual with “treatment-resistant” depression, is a fairly typical patient. Initially scared, he decided to try ECT weeks after his psychiatrist and wife first urged him to. By the seventh of his 12 treatments, he felt his depression lift.

“He sat up and said, ‘I’m not depressed anymore,’ ” his wife said. “I was amazed.”

His one relapse years later quickly responded to another course of treatment. “I am terrified of what would have become of me without ECT,” Mauger says.
A Long-Term Goal

An acute course of treatment usually comprises eight to 12 sessions, administered two or three times a week at a hospital. Studies show that more than 70 percent of severely depressed patients experience quick improvements. (About 50 to 60 percent respond to antidepressants.)

“ECT is hands-down, for the short term, our most effective treatment for depression,” says Harold Sackeim, professor of psychiatry and radiology at Columbia University.

However, only about half of patients remain well even six months after one course, if given no other treatment afterward. “Acutely helping someone out of a period of depression is very important,” says Sarah Lisanby, chairperson of the American Psychiatric Association Committee on ECT and Related Treatments. “But it’s not the end of the story. The goal is long-term treatment.”

That goal is a priority for researchers. The first randomized, controlled study of maintenance treatment following ECT, published in 2001, found that giving patients a combination of an antidepressant and a mood stabilizer significantly increased the chances that they would not relapse into major depression six months after having ECT.

More recently, a research group found that continuing to give ECT once a week to once a month for six months produced results similar to the combination medication treatment.

“We’re learning how to keep people well after ECT more than we knew before,” said Max Fink, professor emeritus of the Departments of Psychiatry and Neurology at Stony Brook University in New York, who wrote last week’s commentary in JAMA. “You can’t just stop.”
A 20-Minute Procedure

The ECT of today is not the shocking scene depicted in books and movies. The overwhelming majority of patients receive the treatment voluntarily. While I was a clinical psychology intern this year at Western Psychiatric Institute and Clinic in Pittsburgh, the head of the ECT program, Roger Haskett, arranged for my classmates and me to view ECT in action.

At Western, ECT is provided every weekday morning. Patients are wheeled one at a time into the ECT suite, lying on gurneys and in hospital gowns, much like patients about to get any other medical procedure. Many that morning were elderly and female, which is typical of the population that gets ECT, and most appeared calm.

They were given an intravenous anesthesia, which sent them to sleep within minutes. A muscle relaxant coursed through their entire bodies except for one foot, which was wrapped with a blood pressure cuff to keep the muscle relaxant out so the seizure movement could be observed. Five sensors were carefully attached to the patients’ foreheads to measure electrical brain activity, and their temples were cleaned and coated with conducting gel. The patients were also given oxygen, and a bite block was inserted into their mouths right before the electrodes were placed on their heads.

The anesthesiologist, psychiatrist and nurse then confirmed which procedure each patient would get — unilateral (both electrodes on the same side of the head) or bilateral (one electrode on each temple) — and what dosage of current.

The psychiatrist then placed the electrodes against the patient’s head, and the ECT machine sent a jolt of seizure-inducing current. Except for what appears to be a grimace — an automatic result of stimulation of the muscles that run along the sides of the face — and a tensing of the total body, ECT patients do not move during the procedure. There is no flailing about, apart from a slight twitching in the cuffed foot. Yet as a new observer, I found watching the experience a little jarring.

The setup is very efficient; each procedure takes about 20 minutes.
The Memory Issue

What bothers many patients afterward — and is at the core of the continuing controversy about ECT — is memory loss. Some are confused when they wake up; others complain that they cannot remember past events and have at least temporary trouble forming new memories.

Much research has focused on reducing that side effect, but patient experiences vary tremendously, and it is nearly impossible to predict the extent of memory difficulties in individuals, according to Frank Moscarillo, executive director of the Association for Convulsive Therapy, who has conducted ECT at Sibley Hospital since 1968.

Barbara Winkler, 46, of Kennewick, Wash., who had more than 90 sessions of ECT at Yakima Valley Memorial Hospital, cannot recall her wedding, which occurred during the period she was receiving ECT. “It probably saved my life initially,” Winkler said. “But the hardest part is probably the memory loss.”

Others, like Tom Hempel, 59, from Pittsburgh, see memory lapses as “inconveniences.” He jokes about “having an ECT moment.” “I know it was worth it,” he said.

Many in the ECT field say concentration and memory may also be compromised by depression. But it appears clear now that ECT can affect memory for much longer than the two to three weeks after which many physicians say most patients’ ability to remember will return to normal.

Some patients have pointed to inconsistency in information about side effects. Vermont state legislator Anne Donahue, 51, thinks they were not sufficiently emphasized before her first round of treatment in 1995, while the informed-consent form provided to her at a second hospital in 1996 was much more complete and easy to read.

“This is an incredibly vital and valuable treatment, but you have the right to know the risks,” Donahue said.

Although the overwhelming majority of ECT patients in the United States consent to the treatment, legislation governing involuntary ECT varies by state. The criteria are generally strict: A patient must be unable to make the decision, and they must be exhibiting dangerous behavior, such as not eating.

Also, there is no special license that a doctor needs to administer ECT in the United States. The American Psychiatric Association has issued practice guidelines, but in most states there is no regulatory body to see that practitioners adhere to those standards or to review the information on consent forms.

Nor is there any firm rule about when ECT is complete. Memory loss tends to get worse with more closely spaced treatments or larger doses of current, so doctors look for a plateau in improvement, when patients say they feel no additional benefit in symptoms.

“The desire to minimize memory loss while maximizing effectiveness is the holy grail,” said Steve Seiner, director of the ECT service at McLean Hospital in Belmont, Mass., one of the largest such programs in the country. “The goal of ECT is to get them back to their base line.” ยท

Shirley Wang, who is completing an internship at Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center, has a degree in clinical psychology

Comments (10)

marilynJune 10th, 2008 at 7:18 pm

i was diagnoised with depression in 1995 and have 8 rounds of ect.

yes. my depressions eased up. and yes with medication it was better.
but not with out a very big price to pay. my long term memory had disapated. i have no memory of my children growing up.

every now and then i remember something but not much. my girls would always say and still do . “you remember when” no honey i dont . i dont remember when. when you took your first walk. your first word. your dance or your parties…

along with that i have short term memory has gotton worse.

i am unable to maintain a job because of my memory comeing and going at the moment i need it most being a nurse.

i am irate at the fact that my whole life is ruined . and no one could explain to me the facts of what could be later on down the road.

i lost my marriage because of this. and my second one is in trouble because no one understands the effects of ect on your everyday memory.
so if you are considering ECT for you family member. besure you know the out will be. because no one knows for sure what happpens next, only when it begins.

sign a unhappy mother who lost her childrens most precious moments and her own childhood. to which i cant remember either..
be safe , be sure do your home work. marilyn stephens

NikkiApril 23rd, 2009 at 9:03 pm

I was very upset to read your story marylin how you must feel loosing such valuable memories. My pop is having his first treatment today. We stopped doctors from doin the procedure 20 yrs ago but have agreed to do the course this time around as his condition is so much worse. My biggest fear is that he will forget us (me) and loose all those memories so valuable and dear. I will keep you infomed on his treatment and let you know the outcome and any side affects he has incurred.

NancyApril 29th, 2009 at 2:26 pm

but what about those of us who NEED the side effect of memory loss? is it guaranteed? is it permanent? i NEED to forget my childhood as it has been haunting me my entire life. i’m thinking ECT might be my last shot…i really dont have anything left to lose.

Catherine HerrmanMay 3rd, 2009 at 9:17 pm

Nancy, Memory comes back eventually. No, ECT should not be used for that purpose. I hardly think a doctor would consider it. It’s rather unethical. ECT is used when depression leaves no other option other than perhaps suicide. There are other ways to deal with PTSD. I’m sure you have tried many. Keep researching it.

Brett S.July 2nd, 2009 at 4:19 am

Any HELP via Comments / Replies would be GREATLY APPRECIATED!
I have become the ultimate treatment-resistant patient. (I have tried everything there is and in many combinations.) I am between 45-55, and I have had, basically, a life-long (since puberty) usually moderate, high functioning until recently, although, at times, quite painful, atypical unipolar depression. For the last two years, I seem to have more “typical” major depression symptoms that have been layered on top of my atypical depression symptoms. The new symptoms include more sedentary problems such as lethargy, lack of motivation, great difficulty paying bills, getting out of the house, etc.
I have had psych. consultations for both ECT and rTMS. Both seem like disasters. The ECT doctor said that, in his experience, he could say that I have an 80% probability of a “good response” (not quite sure what that means). He said that, in his unit’s experience, the lowest 1 to 3 to 6 month relapse rate is if a patient starts using, and responds to, Parnate (MAOI), during the treatments. This, he says, lowers relapse rate to 20% over those same time periods. If a different drug works, the relapse rate is around 50%; if no drug works, the relapse rate is 40%. After tapering off continuation treatments, he has recently starting recommending now 1 treatment per month in perpetuity to prevent relapse.
The rTMS doctor offered me a 50% response rate, and he said that a valid try with rTMS required 5 x week treatments for 6 weeks. But, no side effects. But, if it works, maintenance treatments of either 1 x week or 2 x week are required in perpetuity.

Penny W.July 15th, 2009 at 1:33 pm

Brett…I am suffering from the same major depression symptoms + some. I have been seeking relief for the last 8 years and am too treatment resistant. I now am on my 35+ ECT treatment and so far they have been mildly effective. I did try only one medication that helped and was told this med will tend to work when so many have failed. It is a skin patch called Emsam, an MAOI. I can no longer used it because of bad skin sight reactions from the patch itself. It worked really well for me from the first day, and if you take the low dose there are no diet restrictions as other MAOI’s. I did try to take another MAOI during the course of my ECT treatments (I can’t remember it’s name) but it had no effect. I long for someone to make the Emsam in another form. I’m really not sure that I ever should have taken it because now I know what it feels like to have treatment that works.

janetJuly 26th, 2009 at 12:12 pm

Just started with two treatments last week. Scheduled for 3x’s this week (today is Sunday). I am having a really hard time with it, esp. thinking about it today. I am just so tired and feel this is a freakish thing for me to be doing. The last treatment I lost bowel control during treatment which only added to my humilitation. It feels hard to even want to try. Hearing the machine go off for another person’s treatment was also very hard to hear. I feel like we are all experiments. Only 100,000 people have it a year. In the general population, that is VERY few! My memory is already shot so that is not so much of a concern. Not sure really what is except that when I think about what I am really doing, going in there, it seems too unnatural for me. Something is just not right about the whole thing. What else is left to do? Is it even worth trying this or that? To live like this is so not worth it. Sleeping most of three day a week and the other nights still up until all hours. No function, effort to go or do anything that you then beat yourself up over things said or done while in the company of others. Does anyone have any answers? Does anyone even understand?

Anthony MaugerAugust 7th, 2009 at 3:10 pm

I am the person first referred to in Shirley Wang’s article in the Washington Post in 2007. ECT in 1998 produced a miraculous cure of my major depression (which included a suicide attempt). I was taken right back to normal and went back to work soon thereafter. I had another, shorter course of ECT in 2004. This is a follow-up.

Since then I have had no return of depression. I take a mood-stabilizing drug (lamictal) which may have helped with that.

This is important: in view of varied accounts of memory loss: For me, it was no problem. It was only short term and rather than being a problem, it was a blessing. I can’t remember the events that lead up to my ECT. I CAN”T EVEN REMEMBER WHAT IT WAS LIKE TO BE DEPRESSED.

Of course, I can only report my own experience. I cannot generalize.

Anthony Mauger

TomNovember 14th, 2009 at 8:45 am

I am relating somewhat to Brett’s description of a new layer of sedentary, lower motivation symptomology having been layered on top of a high functioning atypical unipolar depression. I am experiencing the same thing to some extent, although I am not completely sure whether the lowered motivation with respect to certain behaviors should be considered linked to “depression” per se, or whether the lowered motivation may reflect the unstructured time I experienced after I was originally laid off (for economic reasons; before most of this developed) and the fact that, unlike the day to day to demands and necessary behaviors during the several decades I worked, certain things can feel like a treat not to have to do; and, those tasks/chores have come to be considered by me somewhat as chores.

At any rate, has anyone out there had any similar lower-motivation symptomology that did not fully react as he or she thought in might to numerous unilateral ECT treatments. Has such a person tried one or more bilateral treatments with a hope of finding that such treatments change the way these tasks feel, present themselves, etc., in terms of motivation and desire. Given that I do not “feel” depressed anymore (other symptoms have responded well to the types of unilateral ECT I have had), is it worth taking the increased temporary, and permanent, risk of memory impairment, in order to try to find myself with a changed motivation level and attitute toward these tasks? The alternative is to try and push through it; try and DO these tasks despite lower motivation, and try to weaken any underlying beliefs and increase appropriate desire and motivation that way, althgough one never knows if that is possible. Thank you in advance to anyone who is able to Reply with any shared experiences or other help, advice or other thoughts for me.

nicoleJanuary 23rd, 2010 at 10:11 pm

my dad is about to undergo ect recently his ilness has become much worse i know this is the best thing for him and there are no other options available at the moment as we have tried several lots of medications ect is our only hope iam just scared that he wont be the same and he will suffer from severe memory loss. but at the same time i just want my dad back.


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