Despite Infamy, Shock Therapy Makes a Comeback


March 12, 1995

LEBANON, N.H.--Susan Lacey's deepening depression began casting its shadow over her husband and teen-age son late last summer. But her 9-year-old daughter, whose artistic personality so resembled her own, had been affected the most.

"I kept trying to reassure her," Susan said. "Yet by October, I was no longer sure, and I couldn't lie to her. I've never lied to her.

"And I finally found myself saying to my husband, 'I can't tell her anymore that things are going to be OK.' I said, 'I never could understand how this could happen before, but I'm very suicidal right now and I know that if I kill myself, how could you ever say to her that things are OK again?'

"And I said to him, 'I think I have to kill her first. Then I'd kill myself.' And I was barely able to breathe as I was saying these things, and yet I believed that was the course I was going to have to follow."

That was what brought 41-year-old Susan Lacey to Dartmouth-Hitchcock Medical Center in Lebanon, N.H., two days later to undergo the most feared and reviled treatment in psychiatry: electroconvulsive therapy.

Shock treatment.

It sounds like something out of psychiatry's Dark Ages, reminiscent of leeches and lobotomies. Never more so than in this era of Prozac, when pills can change personalities overnight.

But for reasons that have eluded scientists for 60 years, there remains no faster, safer way to yank people out of deadly depressions than by placing electrodes on their temples and zapping their brains with enough electricity to trigger convulsions.

As a result, ECT--psychiatry's oldest continuously used procedure--is quietly making a comeback as the treatment of choice for the dangerously depressed. This year, an estimated 60,000 Americans will undergo a total of a million ECT sessions, the most since the mid-'70s. Nearly all will get better, at least for a while.

Most will be white, middle-class people, a growing number of whom will be treated in the morning and sent home in time for lunch. A few will be given ECT for schizophrenia or catatonia. But the vast majority will be severely depressed men and women for whom antidepressant drugs work too slowly or not at all. Some can't take them for other reasons--heart conditions or pregnancy.

In 10 years of battling depression, ECT was the one treatment Susan Lacey hadn't tried. She'd been through psychotherapy, bright lights, mood stabilizers, antidepressants. And she'd suffered through countless side effects: weight gains, headaches, appetite loss, sexual dysfunction, insomnia.

An award-winning author of scholarly magazine articles and books, Susan once described herself as "a high-energy perfectionist with a great sense of humor, physically active, very engaged with my children and various organizations, an irrepressible reader, and a highly motivated writer."

That was the old Susan, before the illness had crowded everything else from her life. She resigned the boards she had served on--the arts council, the historical society. Last year, unable to meet her own exacting standards, she'd given up even trying to write.

Winters were the worst. The short, cold days and long, dark nights heightened her feelings of despair. But last summer, in place of the usual respite, Susan felt herself going further downhill.

Her migraines got worse and her crying jags lasted longer. Her head hurt so much she could no longer listen to her daughter's piano playing. She stopped helping her son with his homework when she realized she could no longer read.

"I mostly asked my children just to leave me alone. I left most of the housework to my husband, who now had to make all the dinners and do all the laundry."

Her blue eyes turned red and swollen from crying and lack of sleep, and her face grew slack, as though the muscles no longer worked. No longer eloquent, she spoke in a weary monotone that seemed to come from far away, groping for words like someone speaking a foreign language.

She began showing up for therapy sessions with questions about bullets and guns. Sleep topped a growing list of things she'd forgotten how to do. At night, while her family slept, she sat in the bathroom and cried.

Mornings, she sat by the river that flows past her house, immersed in thoughts of slicing her throat with her penknife and throwing herself in the water. It wouldn't be hard. "There was virtually nothing left of me."

Still, when her doctor recommended ECT, Susan was horrified.

"I knew that the illness was killing me," she said. Yet she was afraid of ECT's effect on her brain, that while "it might save my life physically, it might not return me to the person I'd been."

Such fears are common in light of ECT's history, said Dr. Matthew Rudorfer, assistant chief of the Clinical Treatment Research Branch of the National Institute of Mental Health in Bethesda, Md.

Shock therapy began in the 1930s, when an Italian scientist used electricity to induce a seizure, refining a concept that goes back to the 19th Century, when one approach was to put electric eels on patients' heads.

In 1939, the New York State Psychiatric Institute at Columbia-Presbyterian Medical Center introduced shock therapy to America. It soon became psychiatry's biggest fad, used to treat virtually everything.

There was, after all, nothing else.

"This was the era of the large state hospital, where people stayed sometimes for their lives," Rudorfer said. "What else were they offered? Ten types of water treatments or massages."

Unlike water treatments or massages, shock therapy often had positive effects, particularly on the delusional and depressed. Bedridden patients who hadn't spoken in years suddenly sat up and talked. Suicidal patients were no longer in danger of harming themselves. But the benefits, however dramatic, were often fleeting, and often came at the expense of the patient's memory.

There were other problems. Up to 40% suffered broken bones or other injuries during seizures. Some had heart attacks. One in a thousand died.

In 1975, when the movie based on Ken Kesey's novel "One Flew Over the Cuckoo's Nest" gave the public its first look at the "wonder treatment," shock therapy was already a generation out of date, having suffered a dramatic reversal of fortune with the rise of psychopharmacology in the 1960s.

But at a handful of hospitals, ECT never went away. Instead, anesthesia, muscle relaxants and sophisticated new equipment turned it from the assaultive punishment of the past to a treatment about as dramatic as a dental procedure.

It's almost as safe. The mortality rate is now one in 20,000, the same as for the anesthesia alone. By comparison, 15 of every 100 people with severe depressions like Susan's ultimately commit suicide.

Eighty percent of those who have undergone the new ECT say they would do it again. Undoubtedly, some will. Even with antidepressant drugs, at least 20% will have relapses, often within six months. Mood disorders, said Rudorfer, "tend to be recurrent and relapsing illnesses, with episodes that come with increasing frequency as people go along."

The average patient hospitalized for depression at Columbia-Presbyterian Medical Center today is in his or her mid-50s and has already had four previous episodes, according to Dr. Harold Sackeim, chief of biological psychiatry.

Although ECT is remarkably effective as a treatment for depression, Sackeim said, it isn't a cure. It doesn't permanently affect underlying biological problems. Some hospitals now use additional treatments at regular intervals to ward off relapses. Studies of so-called "maintenance" ECT have yet to be done, but researchers say the idea makes sense.

"ECT is the only treatment we have in psychiatry that, once it works, we stop it," Sackeim said. "We don't do that with drugs." People who do stop taking antidepressant medicines relapse at similar rates, he said.

Of course, to most people, there's a big difference between an extra pill and an additional shock treatment. The social stigma that cost former Missouri Sen. Thomas Eagleton a shot at the Democratic vice presidency in 1972 lives on.

Dissatisfied former patients picket hospitals and lobby legislatures to limit access to ECT. Some blame their treatments for large, permanent gaps in their memories, and contend patients aren't adequately warned of the risks.

The movement has had some success. Berkeley, Calif., banned ECT in 1982, though a court overturned the ban six months later. Last year, Texas lawmakers made ECT off-limits to anyone under 16.

On the other side of the issue are the New England Journal of Medicine, the National Alliance for the Mentally Ill, the American Psychiatric Assn., and the doctors who study and administer ECT.

All maintain that state-of-the-art equipment has greatly reduced the impact on memory, limiting losses to the weeks right around the time of treatment. Though some gaps may be permanent, studies show most missing memories return within six months. Either way, they're the result not of any permanent brain damage but of temporary impairment in mechanisms that store short-term memory.

Understandably, people who have had ECT may be highly sensitized to normal forgetting, said Dr. Richard Weiner, director of the ECT program at Duke University Medical Center and chief of psychiatry at the Durham, N.C., Veterans Administration Medical Center.

"You and I forget things, but we don't worry about it. But if you had an acute period of organic amnesia, your perception and concern regarding your memory function might change."

Weiner also notes that some patients may have an unconscious need to forget, as evidenced by one highly educated woman who believed ECT had destroyed her mind. Under hypnosis, her abilities were proven intact.

For all that, Sackeim said, "The field has been way too defensive. Many in the anti-psychiatry movement were treated in the '40s and '50s. Some were treated badly, given high-intensity treatments and not careful enough monitoring of their cognitive states."

To minimize risks, most doctors limit patients to three treatments a week. And instead of a long wave of current, today's machines give only brief pulses.

Still, on the eve of her first treatment, Susan hardly slept.

Inside the brightly lit ECT suite the next morning, she prayed silently as the anesthesiologist inserted an IV needle in her arm and a nurse attached blood pressure, oxygen and heart monitors.

The doctor positioned electrodes on either side of her head, 1 inch up from the halfway point between the eye and ear. (Some doctors place both on the same side of the head, usually the right. Studies have shown this placement reduces memory loss, although it's also considered less effective.)

The anesthesiologist put Susan to sleep with a fast-acting barbiturate.

After placing a bite block in her mouth and an oxygen mask over her face, he gave her a powerful muscle relaxant to immobilize her body during the seizure. He also took over her breathing, since her diaphragm would be paralyzed by the drug.

The doctor pressed a button on a machine resembling a stereo receiver, releasing tiny bursts of electrical current. The amount required depends on the thickness of the skull and the electrical properties of the scalp and brain, which vary greatly from person to person. But even the machine's highest setting is barely enough to produce a flicker in a 100-watt light bulb.

Most of it passes from one electrode to the other. But a minuscule amount found its way through thin spots in Susan's skull to her brain--enough to trigger a seizure lasting less than a minute.

Jagged spikes on the heart monitor, a rise in blood pressure and the slight, rhythmic twitching of her toes, in sync with the discharge of electricity in her brain, were the only visible signs of the seizure. But within her skull, far more dramatic events were taking place: the firing of billions of nerve cells and the release of massive amounts of chemicals.

There's no way of knowing which were responsible for alleviating Susan's depression.

Regardless, after 3 1/2 weeks and 11 trips to the ECT suite, Susan realized something remarkable: She no longer wanted to die.

Dr. C. Lewis Ravaris, professor of psychiatry at Dartmouth College and director of Mood Disorder Services at Dartmouth-Hitchcock Medical Center, noticed the changes in Susan before she did. She slept better. Her face lost its stiffness, and her pallor disappeared. "We saw almost a steady progression as we moved along," Ravaris said.

She has mixed feelings about the treatment that saved her life. "It may be benign in that it doesn't leave scars, and you can more or less get up and walk away from it."

Susan Lacey's name has been changed to protect her privacy. Details of her battle with depression, and the electroconvulsive therapy that saved her life, have been confirmed by her doctor, C. Lewis Ravaris, director of Mood Disorder Services at Dartmouth-Hitchcock Medical Center.