It is unlike any other treatment in psychiatry, a therapy that still arouses
such passionate controversy after 60 years that supporters and opponents
cannot even agree on its name.
Proponents call it electroconvulsive therapy, or ECT. They say it is an
unfairly maligned, poorly understood and remarkably effective treatment for
Critics call it by its old name: electroshock. They claim that it
temporarily "lifts" depression by causing transient personality changes
similar to those seen in head injury patients: euphoria, confusion and
Both camps agree that ECT, which is administered annually to an estimated
100,000 Americans, most of them women, is a simple procedure -- so simple
that an ad for the most widely used shock machine tells doctors they need
only set a dial to a patient's age e and press a button.
Electrodes connected to an ECT machine, which resembles a stereo receiver,
are attached to the scalp of a patient who has received general anesthesia
and a muscle relaxant. With the flip of a switch the machine delivers enough
electricity to power a light bulb for a fraction of a second. The current
causes a brief convulsion, reflected in the involuntary twitching of the
patient's toe. A few minutes later the patient wakes up severely confused
and without any memory of events surrounding the treatment, which is
typically repeated three times a week for about a month.
No one knows how or why ECT works, or what the convulsion, similar to a
grand mal epileptic seizure, does to the brain. But many psychiatrists and
some patients who have undergone ECT say it succeeds when all else -- drugs,
psychotherapy, hospitalization -- have failed. The American Psychiatric
Association (APA) says that about 80 percent of patients who undergo ECT
show substantial improvement. By contrast antidepressant drugs, the
cornerstone of treatment for depression, are effective for 60 to 70 percent
"ECT is one of God's gifts to mankind," said Max Fink, a professor of
psychiatry at the State University of New York at Stony Brook. "There is
nothing like it, nothing equal to it in efficacy or safety in all of
psychiatry," declared Fink, who is so committed to the treatment that he
remembers the precise date in 1952 that he first administered it.
There is no doubt that mainstream medicine is solidly behind ECT. The
National Institutes of Health has endorsed it and for years has funded
research into the treatment. The National Alliance for the Mentally Ill, an
influential lobbying group composed of relatives of people with chronic
mental illness, supports the use of ECT as does the National Depressive and
Manic Depressive Association, an organization composed of psychiatric
patients. The APA, the Washington-based trade association that represents t
he nation's psychiatrists, has long battled efforts by lawmakers to regulate
or restrict shock therapy and in recent years has sought to make ECT a
first-line therapy for depression and other mental illnesses, rather than
the treatment of last resort.
And the Food and Drug Administration has proposed relaxing restrictions on
the use of ECT machines, even though the devices have never undergone the
rigorous safety testing that has been required of medical devices for the
past two decades. (Because the machines had been used for years before the
passage of the 1976 Medical Device Act, they were grandfathered in with the
understanding that they would someday undergo testing for safety and
Many of the nation's most prestigious teaching hospitals -- Massachusetts
General in Boston, the Mayo Clinic, the University of Iowa, New York's
Columbia Presbyterian, Duke University Medical Center, Chicago's
Rush-Presbyterian-St. Luke's -- regularly administer ECT. In the past three
years a few of these institutions have begun to use the treatment on
children, some as young as 8.
Managed care organizations, which have sharply cut back on reimbursement for
psychiatric treatment, apparently look with favor upon ECT, even though it
is performed in a hospital and typically requires the presence of two
physicians -- a psychiatrist and an anesthesiologist -- and, sometimes, a
cardiologist as well. The cost per treatment ranges from $300 to more than
$1,000 and takes about 15 minutes.
Medicare, the federal government's insurance program for the elderly, which
has become the single biggest source of reimbursement for ECT, pays
psychiatrists more to do ECT than to perform medication checks or
psychotherapy. Increasingly, the treatment is being administered on an
In the Washington area more than a dozen hospitals perform ECT, according to
Frank Moscarillo, executive director of the Washington Society for ECT and
chief of the ECT service at Sibley Hospital, a private hospital in Northwest
Washington. Moscarillo said that Sibley administers about 1,000 ECT
treatments annually, more than all other local hospitals combined.
"With the insurance companies there isn't a limit [for ECT] like there is
for psychotherapy," said Gary Litovitz, medical director of Dominion
Hospital, a private 100-bed psychiatric facility in Falls Church. "That's
because it's a concrete treatment they can get their hands around. We have
not run into a situation where a managed care company cut us off
Because of the stigma of psychiatric illness in general and of shock
treatment in particular, most patients do not openly discuss their
experiences. Among the few who have is talk show host Dick Cavett, who
underwent ECT in 1980. In a 1992 account of his treatment Cavett told People
magazine that he had suffered from periodic, debilitating depressions since
1959 when he graduated from Yale. In 1975 a psychiatrist prescribed an
antidepressant that worked so well that once Cavett felt better, he simply
stopped taking it.
His worst depression occurred in May 1980 when he became so agitated that he
was taken off a London-bound Concorde jet and driven to
Columbia-Presbyterian Hospital. There he was treated with ECT. "I was so
disoriented I couldn't figure out what they were asking me to sign, but I
signed [the release for treatment] anyway," he wrote.
"In my case ECT was miraculous," he continued. "My wife was dubious, but
when she came into my room afterward, I sat up and said, `Look who's back
among the living.' It was like a magic wand." Cavett, who was in the
hospital for six weeks, said that he has taken antidepressants ever since.
Twice in the past six years writer Martha Manning, who for years practiced
as a clinical psychologist in Northern Virginia, has undergone a series of
ECT treatments. In her 1994 book entitled "Undercurrents," Manning wrote
that months of psychotherapy and numerous antidepressants failed to arrest
her precipitous slide into suicidal depression. When her psychologist Kay
Redfield Jamison suggested shock treatments, Manning was horrified. She had
been trained to regard shock as a risky and barbaric procedure reserved for
those who had exhausted every other option. Ultimately Manning decided that
she had too.
In 1990 she underwent six ECT treatments while a patient at Arlington
Hospital. She said she suffered permanent memory loss for events surrounding
the treatment and was so confused for several weeks that she got lost
driving around her neighborhood and didn't remember her sister's visit 24
hours after it occurred.
"It is scary, despite anybody's promises to the contrary," Manning said in
an interview. Although some of her memories before and during ECT have been
forever obliterated, Manning said she suffered no other lasting problems. "I
felt I got 30 IQ points back" once the depression lifted.
"I was lucky," said Manning, who says her depression is now controlled by
medication. "ECT was safe for me and very, very helpful. It was a break in
the action, not a cure."
"I'm coming from a position of seeing ECT at its best," added Manning, who
said she would have ECT again if she needed it. "I'm sure there are other
people who've seen it at its worst."
Ted Chabasinski is one of those people.
A lawyer in Berkeley, Calif., Chabasinski, 59, says he has spent years
trying to recover from the dozens of ECT treatments he underwent more than a
half-century ago. At age 6, he was taken from a foster family in the Bronx
and sent to New York's Bellevue Hospital to be treated by the late child
psychiatrist Lauretta Bender.
As a child Chabasinski was precocious but very withdrawn, behaviors that a
social worker who regularly visited the foster family believed were the
beginnings of schizophrenia, the same illness from which his mother, who was
poor and unmarried, suffered. " At the time hereditary causes of mental
illness were fashionable," he said.
Chabasinski was one of the first children to receive shock treatments, which
were administered without anesthesia or muscle relaxants. "It made me want
to die," he recalled. "I remember that they would stick a rag in my mouth so
I wouldn't bite through my tongue and that it took three attendants to hold
me down. I knew that in the mornings that I didn't get any breakfast I was
going to get shock treatment." He spent the next 10 years in a state mental
Bender, who shocked 100 children, the youngest of whom was 3, abandoned the
use of ECT in the 1950s. She is best known as the co-developer of a widely
used neuropsychological test that bears her name, not as a pioneer in the
use of ECT on children. That work was discredited by researchers who found
that the children she treated either showed no improvement or got worse.
The experience left Chabasinski with the conviction that ECT was barbaric
and should be outlawed. He convinced residents of his adopted hometown; in
1982 Berkeley voters overwhelmingly passed a referendum banning the
treatment. That law was overturned by a court after the APA challenged its
The Old and the New
There is little dispute that ECT administered before the late 1960s,
commonly referred to as "unmodified," was different from later treatment.
When Chabasinski underwent ECT, patients did not routinely receive general
anesthesia and muscle paralyzing drug s to prevent muscle spasms and
fractures, as well as continuous oxygen to protect the brain. Nor was there
monitoring by an electroencephalogram. All of these are standard today. In
the old days shock machines used sine-wave electricity, a different -- and
ECT supporters say riskier -- form of electrical impulse than the brief
pulse current dispensed by contemporary machines.
But critics contend that these changes are largely cosmetic and that
"modified" ECT merely obscures one of the most disturbing manifestations of
earlier treatments -- a patient grimacing and jerking during a convulsion.
Some opponents say that the newer machines are actually more dangerous
because the intensity of the current is greater. Others note that modified
treatment requires that patients undergo repeated general anesthesia, which
carries its own risks.
"The characteristics of the treatment that caused people to be outraged and
shocked are now kind of masked so that the procedure looks rather benign,"
said New York psychiatrist Hugh L. Polk, an ECT opponent who is medical
director of the Glendale Mental Health Clinic in Queens.
"The basic treatment hasn't changed," he added. "It involves passing a large
amount of electricity through people's brains. There's no denying that ECT
is a profound shock to the brain, [an organ that is] enormously complicated
and of which we have only t he barest understanding."
Fifty years after Chabasinski was treated at Bellevue, Theresa E. Adamchik,
a 39-year-old computer technician, underwent ECT as an outpatient at a
hospital in Austin, Tex. Adamchik said that two years of therapy,
antidepressants and repeated hospitalizations had failed to alleviate an
unremitting depression caused in part by the breakup of her second marriage.
Adamchik said she agreed to have the treatments, which were covered by her
health maintenance organization, after doctors assured her "it would snap me
right out of my depression." When she asked about memory loss, she said,
"They told me it would kill as many brain cells as if I went out and got
drunk one night."
But Adamchik said that her memory problems persisted much longer than her
doctors had predicted. "It's very strange. Sometimes there are memories
without emotions and emotions without memories. I have flashes of things --
bits and pieces," she said. The treatments also erased memories of events
that occurred years earlier, such as the 1978 funeral of her 2-year-old son,
who drowned in a backyard swimming pool.
Adamchik said that although she has returned to work and is no longer
depressed, she would never again consent to shock treatments. "I didn't have
any memory problems before ECT," she said. "I do now. Sometimes I'll be in
the middle of a sentence and I'll just forget what I'm talking about."
One of the chief problems in evaluating the effectiveness of ECT, noted
University of Maryland anesthesiologist Beatrice L. Selvin, who reviewed
more than 100 ECT studies conducted since the 1940s, is that "even the more
recent literature is still rife with contradictory findings. . . . few
research papers report well-controlled studies, similar procedures,
measurements, techniques, protocols or data analyses," Selvin concluded in a
1987 article in the journal Anesthesiology. Her conclusion echoes a 1985
report by an NIH consensus conference, which cited the poor quality of ECT
A 1993 APA fact sheet said that at least 80 percent of patients with severe,
intractable depression will show substantial improvement after ECT. Studies
have shown that after a course of six to 12 treatments 80 percent of
patients have better scores on a commonly used test to measure depression,
usually the Hamilton depression scale.
But what the APA fact sheet does not mention is that improvement is only
temporary and that the relapse rate is high. No study has demonstrated an
effect from ECT longer than four weeks, which is why growing numbers of
psychiatrists are recommending monthly maintenance, or "booster," shock
treatments, even though there is little evidence that these are effective.
Many studies indicate that the relapse rate is high even for patients who
take antidepressant drugs after ECT. A 1993 study by researchers at Columbia
University published in the New England Journal of Medicine, found that
while 79 percent of patients got better after ECT -- one week after their
last treatment they had improved scores on the Hamilton scale -- 59 percent
were depressed two months later.
Richard D. Weiner, a Duke University psychiatrist who is chairman of the
APA's ECT task force, says that ECT is not a cure for depression. "ECT is a
treatment that's used to bring someone out of an episode," said Weiner, who
compares it to the use of antibiotics to treat pneumonia.
Yet other psychiatrists may not be as convinced of ECT's effectiveness. An
article by researchers at Harvard Medical School published last year in the
American Journal of Psychiatry found such disparities in the use of ECT in
317 metropolitan areas in the United States that they called the treatment
"among the highest variation procedures in medicine." The researchers, who
attributed the disparities to doubts about ECT, found that the popularity of
the treatment was "strongly associated with the presence of an academic
ECT use was highest in several relatively small metropolitan areas:
Rochester, Minn. (Mayo Clinic), Charlottesville (University of Virginia),
Iowa City (University of Iowa Hospitals), Ann Arbor (University of Michigan)
and Raleigh-Durham (Duke University Medical Center).
Another unresolved question about ECT is its mortality rate. According to
the 1990 APA report, one in 10,000 patients dies as a result of modern ECT.
This figure is derived from a study of deaths within 24 hours of ECT
reported to California officials between 1977 and 1983.
But more recent statistics suggest that the death rate may be higher. Three
years ago, Texas became the only state to require doctors to report deaths
of patients that occur within 14 days of shock treatment and one of only
four states to require any reporting of ECT. Officials at the Texas
Department of Mental Health and Mental Retardation report that between June
1, 1993, and September 1, 1996, they received reports of 21 deaths among an
estimated 2,000 patients.
"Texas collects data no one else collects," said Steven P. Shon, the
department's medical director. The state, however, does not require an
autopsy in these cases. "We need to be very careful" of attributing these
deaths to ECT, he added. "Unless there's an autopsy, there's no way to make
a causal connection."
Records show that four deaths were suicides, all of which occurred less than
one week after ECT. One man died in an automobile accident in which he was a
passenger. In four cases the cause of death was listed as cardiac arrest or
heart attack. One patient died of lung cancer. Two deaths were complications
of general anesthesia. In eight cases there was no information on the cause
of death. At least two-thirds of patients were over 65, and in nearly every
case treatment was funded by Medicare or Medicaid.
One of the most common reasons cited by doctors for performing ECT is that
it prevents suicide. The report of the 1985 NIH Consensus Conference states
that "the immediate risk of suicide" that can't be managed by other
treatments "is a clear indication for consideration of ECT."
In fact there is no proof that ECT prevents suicide. Some critics suggest
that there is anecdotal evidence that the confusion and memory loss after
treatment may even precipitate suicide in some people. They point to Ernest
Hemingway, who shot himself in July 1961, days after being released from the
Mayo Clinic where he had received more than 20 shock treatments. Before his
death Hemingway complained to his biographer A.E. Hotchner, "What is the
sense of ruining my head and erasing my memory, which is my capital, and
putting me out of business? It was a brilliant cure, but we lost the
A 1986 study by Indiana University researchers of 1,500 psychiatric patients
found that those who committed suicide five to seven years after
hospitalization were somewhat more likely to have had ECT than those who
died from other causes.
The researchers, who also reviewed the literature on ECT and suicide,
concluded that these findings "do not support the commonly held belief that
ECT exerts long-range protective effects against suicide."
"It appears to us that the undeniable efficacy of ECT to dissipate
depression and symptoms of suicidal thinking and behavior has generalized to
the belief that it has long-range protective effects," concluded the
researchers in an article in Convulsive Therapy, a journal for ECT
Another factor in ECT's growing popularity is economic, suggests Tampa
psychiatrist Walter E. Afield. It can be summed up in one word:
"Shock is coming back, I think, because of the change in psychiatric
reimbursement," said Afield, former a consultant to Johns Hopkins Hospital
who founded one of the nation's first managed mental health care companies.
"[Insurers] no longer will pay psychiatrists to do psychotherapy, but they
will pay for shock or for medical tests."
"We're being pushed as a specialty to do what's going to pay," said Afield,
who is not opposed to ECT, but to its indiscriminate use. "Finances are
dictating the treatment. In the old days when insurance companies paid for
long-term hospitalization, we had patients who were hospitalized for a long
time. Who pays the bill determines what kind of treatment gets done."
The growing popularity of ECT concerns some psychiatrists. "It's better than
it used to be, but I have grave reservations about it," said Boston area
psychiatrist Daniel B. Fisher, who has never recommended ECT for a patient.
"I see it now being used as a quick and easy and not very lasting solution
and that worries me."
Questions About Memory Loss Persist
Does ECT cause long-term memory loss?
The model consent form drafted by the American Psychiatric Association and
copied by hospitals says that "perhaps 1 in 200" patients report lasting
memory problems. "The reasons for these rare reports of long-lasting memory
impairment are not fully understood," it concludes.
Critics such as David Oaks, director of the Support Coalition of Eugene,
Ore., an advocacy group composed of former psychiatric patients, say that
the 1 in 200 statistic is a sham. "It's totally fictional and without
scientific justification and is designed to be reassuring," said Oaks.
Complaints about long-term memory loss are widespread among patients, Oaks
said. Some insist that ECT wiped out memories of distant events, such as
high school, or impaired their ability to learn new material.
Harold A. Sackeim, chief of biological psychiatry at the New York State
Psychiatric Institute and a member of the APA's six-member shock therapy
task force, says that the 1 in 200 figure is not derived from any scientific
studies. It is, Sackeim said, "an impressionistic number" provided by New
York psychiatrist and ECT advocate Max Fink in 1979. The figure will likely
be deleted from future APA reports, Sackeim said.
No one knows how many patients suffer from severe memory problems, said
Sackeim, although he believes that the number is quite small.
"I know it happens because I've seen it," he said. He attributes such cases
to improperly performed ECT. Yet even when properly administered, Sackeim
notes that greater memory loss is more likely after bilateral treatment --
when electrodes are attached t o both sides of the head -- rather than one
side. Because doctors believe bilateral ECT is more effective, it is
administered more often, experts say.
While blaming ECT for memory problems is understandable, it may not be
accurate, noted Larry R. Squire, a neuroscientist at the University of
California at San Diego.
In a series of studies in the 1970s and 1980s Squire, a memory expert who
has spent years studying ECT, compared more than 100 patients who underwent
ECT with those who never had the treatment. He found that memories from the
days shortly before, during and after shock treatments were probably lost
forever. In addition, some patients demonstrated memory problems for events
up to six months before ECT and as long as six months after treatment ended.
After six months, however, Squire said that ECT patients "perform as well on
new learning tests and on remote memory tests as they performed before
treatment" and as well as a control group of patients who never had ECT.
The widespread perception that ECT has permanently impaired memory is "an
easy way to explain impairment," Squire said in interview. When patients are
pressured to have ECT, he said, "outrage . . . combined with a sense of loss
or low sense of self-esteem " could account for such a belief, even if there
is no empirical evidence to support it.
Some psychiatrists are skeptical of Squire's hypothesis. They question the
ability of standard tests to detect subtle memory problems and point to
their own clinical experiences with patients.
Daniel B. Fisher, a psychiatrist and director of a community mental health
center near Boston, has "grave reservations" about ECT's effects on memory
and says he has never recommended it to a patient.
"The variability is still there, the unpredictability and uncertainty about
the nature of the side effects," said Fisher, who has a doctorate in
neurochemistry and worked as a neuroscientist at the National Institute of
Mental Health before he went to medical school. "You see these people who
can perform routine functions [after ECT] but have lost some of the more
complex skills." Among them, he said, is a woman he treated who coped
adequately with everyday life but no longer remembered how to play the piano.