New Look at an Old Therapy / Researcher promotes benefits of electroshock treatments|
By Jamie Talan
DR. MAX FINK'S PHONE rang last week and a patient's father wanted to know why it had taken so long for his teenage son-stuck in a catatonic, psychotic stage for months-to get the proper treatment. He had been put on rounds of medications, but nothing broke through the unrelenting suicidal depression that kept the boy mute.
Fink had taken him off all medications when he was admitted to Long Island Jewish Medical Center, and started the 17-year-old on electroshock therapy.
Within two treatments, the boy's depression was lifting and he smiled for the first time in months.
Fink has focused most of his 50-year career on promoting the benefits of electroshock therapy for depression and schizophrenia. He has remained in the field despite the fact that most of his peers don't understand-and shy away from-the technique that triggers seizures in the brain to fix behavior and thought disorders.
His colleagues try everything before they turn to electroshock therapy. And that is why, he tells this father, it took more than four months for his son to receive this treatment.
It is estimated that 100,000 people in the country receive electroshock therapy-also called electroconvulsive therapy and abbreviated as ECT-each year, a fraction of the 10 million people suffering from serious mental illness.
Some doctors argue that it is a barbaric throwback to a time when there were no drugs available to treat depression and schizophrenia. Many believe delivering high-voltage bursts of electricity is too risky. Other psychiatrists believe that shock therapy is a last resort when medications have failed, or, in rare cases, a first-line treatment for the most troubling, unrelenting cases.
Fink says there are dozens of studies comparing drugs vs. ECT and the shock treatments almost always outshone the medicines.
"If any of us could find a better way to treat patients, we would," he said.
It's been almost a decade since the American Psychiatric Association issued a report concluding that ECT "should not be seen as a 'last resort' therapy" and that to do so "may well deprive patients of effective treatment." 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. Modern-day therapy calls for a series of six to 12 treatments, doctors say, compared to dozens, even hundreds, of sessions decades ago.
But ECT is not an easy solution, nor is it a cure. It provides temporary relief from life-threatening mental illnesses, and recently it has been routine to offer booster ECT to prevent relapse. 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. State hospitals generally rely more on drugs, and don't have ECT machines, Fink said.
Fink agrees that lack of research may prevent psychiatrists from ever understanding why electroshock is beneficial. He thinks that the seizure triggers a slew of neuropeptides that help regulate an imbalance in the patient's endocrine system. He says that many people with serious depression have high cortisol levels, and these stress hormones return to normal following ECT. Fink doesn't think that serotonin or dopamine abnormalities will be key to understanding mental illness. These brain chemicals have been the focus of virtually all studies in depression and schizophrenia.
Despite the controversy over ECT, the technique has remained alive and well, and even quietly flourishing, at Long Island Jewish's Hillside Hospital.
University Hospital at Stony Brook and South Oaks Psychiatric Hospital also provide ECT.
Fink has a new book on the topic: "Electroshock: Restoring the Mind," and a new Web site for people interested in ECT-www.electroshock.org. He's even revved up LIJ's teaching program and he hopes to fit the hospital's ECT suite with the latest device, the Thymatron System IV, later this year.
He said that studies conducted on the brains of psychiatric patients who had undergone ECT have never found any evidence of subsequent brain damage. And he has treated thousands of patients who have broken through their wall of symptoms, and gotten better.
Now, he wants to focus on the future, and on training the next generation of ECT specialists.
"There's a whole group of people who will keep it alive...It's so easy to feel his passion," says Dr. Georgios Petrides, one of Fink's younger proteges. "The results are so dramatic. Our challenge is to use ECT to understand mental illness." But if the psychiatrist has not succeeded in changing the reputation of ECT in the decades since he delivered the first volts to a patient in 1952, Fink's battle will be even more difficult now. The next generation of devices to treat mental illness is already on the horizon, a series of magnets that deliver a different form of electrical current. These devices don't need to target the whole brain. The energy is directed locally, and there's no anesthesia, no side effects.
The developers of these new systems-called transcranial magnetic stimulation or TMS-say that these energy sources are backed by science, and are much safer.
"We are beginning to understand depression and there will be a host of new ways to get into the brain to help people," said Dr. Mark S. George, a psychiatrist at the Medical University of South Carolina.
"ECT got a terrible reputation and it is still struggling to get beyond that," George said. "TMS is totally new and non-invasive. It can be done when people are awake, even reading." "I am betting that we don't need a seizure to treat serious depression," said George. With TMS, patients sit in a chair while doctors deliver magnetized energy over the frontal lobe, directly above the area scientists suspect is involved in depression. The magnets are pulsed on and off for 20 minutes. To patients, it feels like being tapped on the head with a large eraser. By the second week of daily treatment, patients report they are beginning to feel better.
George's latest study of 30 patients-all of whom suffered symptoms of major depression for more than two years-proves the power of the magnetic energy on the brain. Those who received TMS had a 45 percent drop on depression test scores after two weeks, compared to 20 percent of those in a placebo test.
TMS and other modern-day brain devices are wending their way through the federal device regulatory process.
Meanwhile, says Fink, "ECT is alive and well."