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SHOCK THERAPY...IT'S BACK By SANDRA G. BOODMAN The Washington Post September 24 1996, Page Z14 |
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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 intractable depression. 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 memory loss. 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 of patients. "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 effectiveness.) 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 outpatient basis. 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 prematurely." Anecdotal Miracles 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." Vanished Memories 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 hospital. 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 constitutionality. 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." Sketchy Data 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 research. 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 medical center." 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. Suicide Preventive? 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 patient." 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 practitioners. Another factor in ECT's growing popularity is economic, suggests Tampa psychiatrist Walter E. Afield. It can be summed up in one word: reimbursement. "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. continued |