Electroshock therapy revised
Although tamed down from its days in the 1940s, the practice of using electricity to treat psychological disorders still has its critics.
Minneapolis Star Tribune
Staff Writer 11-17-1999
Sherrie always wears screaming-yellow Tweety Bird socks when she comes to Abbott Northwestern Hospital for electroconvulsive therapy (ECT). After dozens of sessions during the last year, she knows that she'll be fast asleep when her doctors run a current of electricity through her brain to initiate a grand mal seizure, and she won't feel or remember a thing about it.
But still, as she lays on the gurney and a doctor starts an intravenous line for the anesthesia and muscle relaxants, Sherrie, who asked that her full name not be used, admits that she gets nervous, and her lucky socks bring her comfort.
ECT is a far cry from the violent and punishing images of what used to be called electroshock therapy that have been imprinted on the public's mind - for example, by the film ``One Flew Over the Cuckoo' s Nest'' or by its subliminal parallels to Frankenstein's monster and the electric chair.
Despite its negative image, ECT is a common treatment for mental illnesses, primarily severe depression. Use of anesthetics and muscle relaxants makes it far more humane today than it was at its sometimes bone-breaking inception in the 1940s.
Next month, the U.S. Surgeon General's Office is expected to approve ECT as a safe and effective treatment when it issues the Surgeon's General's Annual Report, which this year focuses on mental illness.
ECT long has been accepted by the medical establishment as a treatment that works when all else fails. But its dark history, public image and the fact that to this day no one knows why it works make ECT a natural focus not only for misunderstanding and fear, but for conflict and controversy as well.
Advance notice of the preliminary report's endorsement of ECT already has set off a flurry of sparks. Some groups say that the report does not adequately reflect the risks associated with ECT, primarily memory loss.
Objections to the Surgeon General's Report were voiced by the National Mental Health Consumers' Self-Help Clearinghouse, based in Philadelphia. The four-paragraph section of the report describing ECT was given to the group for advance review.
The clearinghouse and others who question the procedure said that the preliminary version of the section downplayed the degree and frequency of memory loss. ``I had five years of memory loss, and to this day, I can't tell you what happened,'' said Linda Andre, director of the New York group Committee for Truth in Psychiatry, which claims 500 members nationally. Andre, now 39, had shock treatment when she was 25, she said.
The report said that permanent memory loss remains a legitimate topic for careful, long-term study. Yet psychiatrists and their patients have said that memory loss is by far a better choice than the agony of severe depression and the risk of suicide.
Sherrie, who is 37, is a classic example. She started her slide into depression somewhere in her 30s. She has lost her job as a nurse, lost her house and lives with her parents. She has struggled against suicide and has tried many antidepressants, none of which have been effective. Her psychiatrist, Dr. Doug Nemecek, gives her a series of ECT sessions once every two weeks.
Each session lasts only a few minutes. The anesthetic puts her to sleep in seconds, and machines monitor her heart rate and breathing. An oxygen mask is used to make sure that her brain is not deprived during the seizure. Nemecek places a rubber strap across her head, with electrodes at her temples, and puts a bite guard between her teeth. The ECT machine at his side delivers a burst of electricity that's less than what it would take to light a 40-watt bulb for one second. Sherrie grimaces, and it's over. She's wheeled to the recovery room, where an hour later she wakes confused and with a headache.
``It's been effective enough to keep her from being suicidal, '' Nemecek said. ``But not effective enough to get her back to work.' '
Sherrie falls into the surprisingly large group of people for whom antidepressants don't work, or at least not for long.
Anywhere from six to 10 percent of the population will suffer from severe depression at some point in their lives, said Dr. Teri Rummans, a psychiatrist at the Mayo Clinic in Rochester, Minn. Of those, 50 to 70 percent respond to medications. Those who don't are candidates for ECT, and it works on about 80 percent of them, she said. But it's not a one-shot deal, so to speak. Many patients need to repeat ECT periodically as well as combine it with medication, psychiatrists said.
Long, disturbing past
Electricity in one form or another has been used to treat mental and physical illnesses for centuries, starting with the Romans, who placed electric torpedo fish on the head as a cure for headaches. In the 1800s, when it became technically feasible to store static electricity, elaborate machines were devised to run electricity through patients to treat paralysis, ``nervous disorders'' and other ailments.
The first recorded therapeutic seizures were actually induced by chemicals - with drugs such as insulin - inspired by the incorrect belief at the time that people who suffered from epilepsy did not suffer from schizophrenia. So, physicians deduced, perhaps inducing a seizure would cure mental illness.
Italian psychiatrist Ugo Cerletti was the first to try electricity to induce grand mal seizures after seeing how slaughterhouses stunned pigs into unconsciousness before turning them into pork.
In 1938 he tried it on a clearly psychotic man who talked only in gibberish.
``The third time was the charm,'' said Timothy Kneeland, a history professor at Greenville College in Greenville, Ill., who has just completed a book on the history of ECT. ``He snapped out of it and asked where he was. But the cure was short-term.'' It caught on very fast, Kneeland said, quickly replacing chemically induced shock treatments in England and the United States. It became popular in part because there were no other treatments. But it was also appealing, Kneeland said, because it was fast and simple.
Doctors - general practitioners and psychiatrists alike - even made house calls with their electroshock machines.
But the treatment, a terrifying and painful procedure at the time, was overused and misused. Powerful voltages coursed through the body, sometimes breaking bones or causing burns or even death. As ``One Flew Over the Cuckoo's Nest'' pointed out so graphically, it was sometimes used to punish and control inmates in mental institutions.
Making it milder, easier
With the advent of antipsychotic drugs, such as thorazine, in the 1960s and the closing of state mental hospitals in the following decades, use of ECT began to wane. And because of its past, use on patients in public institutions required court supervision.
Those legal restrictions remain to this day, said Dr. Alan Radke, medical director at the Minnesota Department of Human Services. The department only can administer ECT on a patient who is competent, or it must obtain two physician opinions and a court order, he said. As a result, ``we do not give ECT in an emergency.''
ECT was revived in the early 1980s, primarily because of the support of the American Psychiatric Assocation. Its use has climbed steadily, but it's no clearer now than it was in Cerletti's day why it works. Theories abound: Electricity may flood the brain with its chemical messengers, called neurotransmitters, which may alleviate depression; electricity has some affect on the glands, such as the hypothalamus, which control hormones that affect mood, or the brain' s effort to resist seizures dampens abnormally active brain activity, stabilizing mood.
Despite the still-unsolved mystery, Kneeland said that he, like thousands of others, would choose ECT for himself or a family member over depression or suicide. ``If history is any predictor,'' he suggested, ``ECT is here to stay.'' But his endorsement is lukewarm. He worries that blanket acceptance of ECT simply legitimizes ``push-button psychiatry,'' which is also the name of his book.
We live in a time of rising mental illnesses, he said. Suicide rates for teenagers and young adults are increasing. Depression among the elderly is at epidemic proportions.
It is popular to assume that all emotional and mental problems can be reduced to their molecular level, he said, and be treated in a physical way. But that may be oversimplified. ``We are avoiding some interesting questions. If it's just biological, why has [mental illness] risen so dramatically in our culture? Can our thoughts, or life itself, be the cause of our mental illness? Can our behavior be the cause of mental illness? And if your behavior and thoughts make you ill, can't they also make you well?'' In other words, perhaps medicine has given short shrift to talk therapy and to other efforts that help people change their lives, and experts may find it easier instead to give them treatment at the push of a button.
The mystery of ECT
Although electroconvulsive therapy (ECT) has been used since 1938, no one knows why it alleviates depression and other mental illnesses. The treatment consists of running a small amount of electrical current through a patient's brain, initiating a grand mal seizure, similar to that in epilepsy.
- Treatments usually consist of six to 12 sessions over several weeks.
- The patient receives general anesthesia and muscle relaxants, making the procedure painless.
- After the patient is unconscious, two electrodes are placed on the patient's head. A series of approximately 90-volt electric impulses - the amount needed to run a 40 watt bulb - run through the brain for about 50 seconds, causing the seizure.
- The patients' vital signs - heart rate, breathing rate and blood pressure - are monitored throughout. An oxygen mask ensures the brain is not deprived of oxygen.
- The patient awakens an hour or so later, confused and often with a headache and short-term memory loss about events around the time of the treatment.
Because scientists don't understand the metabolism of depression, they can't understand why ECT relieves it. But current theories revolve around how the therapy affects two kinds of brain chemicals.
- Neurotransmitters. Scientists believe that depression is caused by the malfunction in the chemical messengers called neurotransmitters that regulate emotion and mood - serotonin, dopamine, neurepinephrine and others. One theory is that ECT causes neurotransmitters to flood the brain, temporarily bringing their levels back to normal, or another theory speculates that it changes the way brain cells receive the neurotransmitters.
- Neuroendocrine. Just as neurotransmitters are believed to affect mood and emotion, so do some hormones. One theory is that ECT affects the function of the hypothalamus, a gland deep in the brain that, among other things, releases chemicals that affect mood.
In 46 A.D., Scribonius Largus, a physician to the Roman emperor Claudius, discovered that the torpedo fish, also known as the electric ray, cured headaches. Scientists later learned that the fish stuns its prey by producing small pulses of electricity in its muscles.
An illustration from the 1871 book ``A Practical Treatise on the Medical and Surgical Uses of Electricity'' depicts a procedure known as the electric hand. The doctor conducts electricity through himself and into the patient suffering from nervous exhaustion.