Called `barbaric' by some, a `miracle' cure by others,
it is being used more and more to treat depression
By Jamie Talan
SUSAN WITTE remembers looking at her children and wondering when they grew up. She recalls looking at pictures from a fun-filled vacation and wondering when she was away. And she still wonders about her husband . . . has it really been 23 years of marriage?
Susan Witte has lost six years of her life.
The 42-year-old North Valley Stream woman says the memories, both good and bad, were wiped out when psychiatrists passed electric currents through her brain to pull her from the depths of a depression.
"The doctors said that my memory would return in four weeks," Witte said of her treatment with electroconvulsive therapy (ECT). "It just kept getting worse. It never came back." And, she says, the treatments did not alleviate her depression.
Thousands of patients who receive what is popularly known as shock therapy complain of its problems, such as loss of memory. But thousands of others swear by the treatment that has rapidly expanded to an estimated 100,000 people a year.
Since it was discovered more than 50 years ago, ECT has split the psychiatric community. Some doctors argue that it is a barbaric throwback to a time when there were no drugs available to treat depression and radical surgery, even lobotomies, were mistakenly believed to be the only cure. Other psychiatrists contend that using quick, high-voltage bursts of electricity is usually safer, faster and more effective in treating suicidal depression than are most drugs.
"Some of my colleagues would rather spend years, even decades, administering mind-altering drugs, most with disturbing side effects, even though studies have shown that thirty percent of patients do not respond to medications," said Dr. Max Fink of the Health Science Center at the State University of New York at Stony Brook. An ECT expert, Fink edits the only journal devoted to research on shock therapy.
"They still believe that there are no alternatives," the psychiatrist said. "If any of us could find a better way to treat patients, we would. At the present time, there is nothing that beats ECT."
But there are equally outspoken doctors who have built their careers on fighting shock therapy. They are armed with decades of studies that they say prove the dangerousness of the technique.
"ECT is a barbaric assault on the brain," said Dr. Peter Breggin, a Maryland psychiatrist who opposes the treatment. Breggin is often called as a witness in ECT malpractice cases. "It damages the brain. ECT patients don't know whether they are coming or going." Animal studies clearly show that zapping the brain with electricity damages cells, he argues.
Breggin is also one of the leading opponents of a recent task force report by the American Psychiatric Association that backs ECT as a primary therapy for some cases of severe depression and mania.
The report, released in December, recommends that the 29,000 U.S. psychiatrists learn the technique and offer it as an alternative to drug therapy. The six researchers who worked on the report concluded that ECT was safe and effective when used appropriately. ECT, the report concluded, "should not be seen as a `last resort' therapy. Such a view may well deprive patients of effective treatment."
Perhaps the only thing both sides agree on is that the technology of ECT has steadily improved.
ECT dates from 1938 when psychiatrist Ugo Cerletti, practicing in Italy, applied electrified tongs to the temples of a schizophrenic patient. He and others argued that epileptics had seizures but were free of schizophrenia, so perhaps inducing seizures in non-epileptics would relieve the symptoms of schizophrenia.
European psychiatrists began inducing seizures by giving toxic doses of camphor or Metrazol. Cerletti's electric technique was convenient and seemingly safer. By 1948, about 85 percent of U.S. hospitals surveyed said they used chemically or electrically induced shock on mental patients. In time, psychiatrists began to see that the electric technique worked best for people seriously depressed and on the verge of suicide.
NO ONE REALLY knows how ECT works, only that it causes a seizure in the brain that seems to alleviate many of the symptoms of severe depression and mania. It is also being used experimentally to treat schizophrenia, Alzheimer's and Parkinson's diseases. Psychiatrists agree that modern ECT, administered with muscle relaxants and anesthesia, has come a long way from the days when an electric shock jarred the whole body into convulsions, often resulting in broken bones.
Researchers at the National Institute of Mental Health estimate that during any six-month period about 10 million people suffer depression. An episode can last weeks or months, and the likelihood of a future bout is high. Researchers now suspect that some forms of depression are caused by brain chemicals gone awry.
Drug therapy is still considered the best treatment for most people with depression. Some people can't tolerate the side effects, which can include blurred vision, dry mouth, urinary retention, constipation, rapid heart beat, hypotension, sedation and sexual difficulty.
Researchers say that 70 percent of patients respond to antidepressant medications, but it may take several weeks, even months, for people to begin to feel better. ECT, which is saved for only the most severe cases of depression or mania, is said to work quickly, often after the first treatment. Dr. Herbert Fox of Gracie Square Hospital in Manhattan said that studies have shown that it is effective 80 to 90 percent of the time.
Some doctors estimate that 100,000 Americans a year receive ECT treatments. Modern-day therapy calls for a series of six to 12 treatments, doctors say, compared to dozens, even hundreds, of shock sessions decades ago.
But ECT is not an easy solution, nor is it a cure. It provides temporary relief from life-threatening mental illnesses, Fox said. It is a type of surgery, and any surgery has its limits and dangers. During the procedure, electrodes are placed on the head and chest to record changes in heart rate and brain waves. Electrodes are also placed on the scalp to elicit a seizure.
Before electricity surges through the brain, patients are given an IV barbiturate to sleep and a relaxant to calm the body's hundreds of muscles. The bolt of electricity lasts seconds, just long enough to produce a seizure. The anesthetic wears off in minutes, and the patient resumes normal activity within two hours of treatment.
The majority of ECT cases are carried out in a hospital, but more and more patients are receiving shock treatments on an out-patient basis.
Julie, 32, of Queens, has spent most of her adult life fighting severe bouts of depression. She has seen six doctors in as many years. She was given antidepressants, antipsychotics, even lithium, but the side effects were always so harsh that she was forced to stop. She was falling so deep into her sadness that she felt that it would only be a matter of time before she was evicted from her apartment.
"I was so emotionally dull that I was unable to connect with other people," said Julie, who asked that her last name not be used. "I felt so weak that I did not have the strength to look for yet another doctor." So Julie, who was working her way through a master's degree in social work, decided to look into electroshock therapy. Her mother also suffered from severe depressions and found relief from shocks to her brain.
"I read about all the side effects, and they did not sound as bad as the ones I was experiencing on the medications," Julie said. Some of her complaints: severe dry mouth, dulled thinking and concentration, and anxiety. Lithium left her with disfiguring acne. She was a persistent patient. She worked at a psychiatric hospital and did not want to take time off to get better. She found the answer at an out-patient clinic at Gracie Square.
There she worked with psychiatrists on a treatment schedule that would allow her to continue work and college. She travels to the hospital once a month for ECT treatment.
"It's a miracle. Years ago, I would have been institutionalized for a couple of years," Julie said, pointing out that her depression has lifted. "I am doing a lot better than most people who have never suffered depression."
Fox and others say they worry that ECT is fast becoming a treatment for the rich or, like Julie, at least the adequately insured. Private hospitals are buying up ECT machines, Fox said, while state hospitals are relying more heavily on drugs to treat their patients.
New York State, which operates 33 hospitals, is looking into whether it should provide more ECT. According to Dr. John Oldham, the acting chief of the state's Office of Mental Health, "We can't be sure whether it should be used more or less. I would say that there are a few state facilities where it is not readily available and that it can be a problem for patients."
But making it available may also cause problems. Dr. Richard Frances, a professor of clinical psychiatry at the University of Medicine and Dentistry of New Jersey, said that patients' most common complaints are confusion and memory lapses.
"These problems can be very frightening to people," Frances said. "There is a temporary period of memory loss during the time people are getting ECT."
While some patients complain of lifelong memory lapses, studies on the structure of the brain have not shown any evidence of such permanent memory loss. Dr. Matthew Rudorfer of the National Institute of Mental Health says that he has done PET (positron emission tomography) scans on a few patients and so far has found no brain chemical differences between those who received ECT and those who did not. In other studies, researchers have induced repeated seizures in rats and were unable to detect any damage to the stimulated area. Other animal studies conducted using MRI (magnetic resonance imaging) scans - these devices reveal structural abnormalities - also found no changes before or after ECT.
IN ADDITION to memory problems, some patients complain of side effects including headaches, nausea, muscle aches or soreness, weakness, drowsiness, anorexia and missed menstrual periods, said Harold Sackeim, an ECT researcher at Columbia University College of Physicians and Surgeons.
More than two years after Long Island's Witte had ECT to treat her chronic sadness, she says she is still having problems. While some of her memories returned after her shock treatment, others from several years before the therapy have not. After her hospital stay, she says, she had no idea how to find her own house. She did not know the neighborhood foodstore where she had shopped for a decade. Family vacations were snapshots of empty weeks.
Friends, family and a long-time psychologist have helped Witte put the pieces of her lost life back together.
"The treatment has profoundly changed her," husband William said. "She has had to get to know me and the children all over again."