A Kinder, Gentler ECT|
by the Riverfront Times
"Something bent down and took hold of me and shook me like the end of the world," wrote Sylvia Plath in The Bell Jar. "Whee-ee-ee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt drubbed me until I thought my bones would break and the sap fly out of me like a split plant."
That's what shock therapy used to be. Today, anesthesia, muscle relaxants, re-engineered machines and repositioned electrodes buffer the jolt, and insights about the biochemistry of depression ease the stigma. As a result, electroconvulsion therapy (ECT) is being used more readily and more successfully, even on older adults once considered high risk. Not only does ECT work when drugs can't, but it efficiently short-circuits psychiatric-hospital stays, making it a natural in a cost-conscious managed-care climate.
The improvements are dramatic -- but not everything has changed. Patients still complain of permanent, significant memory loss, and psychiatrists still say they're wrong. Researchers still don't know exactly how ECT works or what it might do to a child's developing brain. Ethicists still don't know how to tell if a patient's consent was really "informed." And the Food and Drug Administration (FDA) still hasn't asked for clinical trials showing that individual ECT machines are safe.
Used to people recoiling at the very notion of electrically induced brain seizures, ECT experts tend to minimize concerns, afraid another swing of the pendulum could deprive patients of their last alternative. But after struggling so valiantly to reclaim ECT's reputation, psychiatrists' own memories may have grown a little spotty when it comes to the need for caution.
Ugo Cerletti and Lucio Bini first used shock therapy in Italy in 1938, convinced the body manufactured a "vitalizing substance" during an epileptic convulsion. They watched breathlessly, Cerletti wrote later, "overwhelmed during the apnea as we watched the cadaverous cyanosis of the patient's face." No substance oozed, but the shock did snap the man into lucidity.
In the bedlam of the '40s and '50s, shock was the only tool psychiatrists had, and they administered it with abandon. The typical recipient was a 40-ish male, impoverished and rebellious, living in a public institution. By the end of the '50s, enough asylums had zapped patients with a rainbow of disorders into monochrome docility, and public outrage grounded ECT. Just in time, miraculous new anti-psychotic and anti-depressant medications took over.
It took another few decades to realize the drugs' less than miraculous side effects -- cardiac risks and mobility disorders -- and the plain fact that they didn't help everyone. Meanwhile, ECT had been significantly improved. Learning that seizure thresholds varied enormously, psychiatrists found they needed only a fraction of the standard voltage for many women and young people. Sedatives and muscle relaxants removed the pain, the need for restraints, the physical danger of broken limbs and the horrific twitching spasms. Patients were thoroughly monitored, and physical resistance (some people do have thicker skulls) was measured ahead of time to avoid electrical burns.
When Malcolm Bliss closed, Dr. John Csernansky, medical director of the Metropolitan Psychiatric Center that replaced it, retrieved a little black box from the basement -- a shock machine from the 1940s. Now, holding it in one hand, he presses its silver button urgently, demonstrating how the psychiatrist controlled the electrical pulse's duration. Crudely measured, those pulses lasted one or two seconds apiece, and continued as long as the doctor chose. In today's machines, the electricity is produced from a different kind of wave, the duration of each shock is computerized, each pulse lasts perhaps 0.5 milliseconds, and the entire train of impulses cannot last longer than eight seconds.
An American Psychiatric Association (APA) task force issued guidelines in 1990 suggesting that hospitals "insulate the waiting patient from auditory and visual contact with the treatment and recovery areas" -- so he no longer has to watch peers emerge from treatment, their eyes deadened. The guidelines also note that "immediate side effects from ECT are rare except for headaches, muscle ache or soreness, nausea and confusion."
Compared to the old days, it's a picnic.
Almost all St. Louis hospitals provide ECT treatment. "We do maybe 10 a day," says one anesthesiologist. "Everybody's doing them. It's very well accepted in the medical community." St. John's Mercy Hospital counted more than 2,000 treatments given in the last fiscal year (compared to 1,500 five years ago). Dr. Donald Hay, director of the mood-disorders program at St. Louis University, says they do 10 treatments a week on average. BJC Inc., known as the local ECT headquarters, declined to provide a count. But even satisfied patients call Barnes "Jiffy Jolt" because it speeds so many of them through its ECT assembly line.
The nickname isn't surprising: Harvard researchers announced last year that ECT's popularity increases around academic medical centers. Universities are supposed to take the lead, after all, and depression is the disease of the decade. In 1990, the National Institute of Mental Health estimated a startling 9.5 percent of American adults (17.5 million people) suffering from depressive disorders. Now that we know depression is often biological, there's less shame, more determination to get relief. And after successful ECT, improvement's intuitively obvious.
"Somehow I just knew that I was better," people say, "and that I did not have to be in the hospital anymore." Major depression isn't the blues, they add; it's hell, eroding love, joy, energy, will, clarity and the very instinct for life. When Anne Simpson (a pseudonym) sank into deep depression, "it went on for months, and the part of me that was willing to continue on felt as though it were getting smaller and smaller." Doctors tried a buffet line of drugs; none worked. But after her third course of ECT, Simpson renewed friendships, changed jobs, re-entered the world. Fran Scott has had ECT twice in her life, when manic-depression hit a wall no drug could penetrate, and she'd do it again. "A lot of people just go in the hospital and sit there while doctors play games with drugs," she explains, "and they are still miserable. And it's scary to be depressed."
Scientists still don't know exactly why ECT works -- except that it has less to do with electrical jolts than with the seizure they induce. Electricity runs through our brains already; that's what causes the neurons to fire and discharge neurotransmitters, which then carry the impulse across the great divide to the next cell. "Brain cells are set up in oscillating circuits that are firing regularly," explains Csernansky. "What you are trying to do when you induce a seizure is get them all to fire in synchrony."
Many psychiatrists believe an ECT seizure increases the brain's sensitivity to the neurotransmitter serotonin, which meshes perfectly with the theory that low levels of serotonin cause depression. Another theory is that ECT, which, paradoxically, raises the brain's seizure threshold, causes an anti-convulsive effect that may also involve serotonin.
ECT can temporarily help catatonic, manic and other psychotic states, but it's used most often for severe depression whose cause is biological. "What ECT cannot do," underscores Metropolitan's new ECT director, Dr. Omar Quadri, "is change the real-life situation of the person." Psychiatrists say patients who respond best to ECT have depression that shows up physically, in disrupted sleep, appetite, energy, sex drive, etc. But Debbie Kuhn, a social worker who co-founded the Women's Counseling Collective, points out that biological and situational depression aren't that easy to divide. Emotional problems often bubble up as physical symptoms, and what looks biological can have complex underlying causes. Misdiagnose, and you're needlessly subjecting someone to the anesthesia, expense, disorientation, stigma and possible memory loss of ECT -- not to mention the despair that hits when the "treatment of last resort" has failed.
Or keeps failing. "I've seen people who were not responding to medication," says a former psychiatric patient, "and the ECT didn't work, and they'd just keep giving it and giving it." There's more than sadism at work; apparently the seizures have to reach some critical unknown number. "There was actually a movement at one time to do multiple seizures within a single treatment," Csernansky recalls. "In principle, it sounded like a good idea."
ECT machines, in use long before the 1976 Medical Device Act, were grandfathered into FDA approval without rigorous review. They are Class III, and normally manufacturers would have had to submit clinical trials documenting their safety by now. Instead, they applied for a reclassification to Class II, explains FDA physiologist Steve Hinckley. "We are trying to decide how we want to approach the reclassification," he adds, "and that should be addressed in the near future." Currently, manufacturers need provide only a technical comparison of their machine to a similar product. No ongoing inspections are required; a hospital could be using an ancient high-voltage machine without violating a single rule. Hinckley says the FDA would only look twice if a pattern started showing up, "like suddenly a lot of Chevys with the brakes failing."
Rep. Peter DeFazio (D-Ore.) has repeatedly demanded governmental review of ECT; the federal Department of Health and Human Services (HHS) finally acceded, but DeFazio was recently informed that they have subcontracted that review to a private nonprofit organization. David Oaks, director of the Support Coalition (an alliance of 44 groups working for human rights in psychiatry), says the review proposal is so vague it doesn't even mention ECT.
Dr. Harold Sackeim, professor of psychiatry at Columbia University and consultant to the APA's task force on ECT, calls U.S. machines markedly superior in safety. He says, "At a purely technical level, there's been a misunderstanding or misrepresentation. ECT's opponents claim that, because anesthesia is used, more electricity is required. What isn't appreciated is that the nature of the wave form used now is far more efficient, so on average you need about a third less electricity."
The debate blurs into a general lack of consensus -- a Harvard study in the June 1995 American Journal of Psychiatry reported "marked disagreement" among clinicians about the value, proper use and timing of ECT. The research is rife with contradictory results and conflicts of interest. The standard textbook on ECT was written by Dr. Richard Abrams, who happens to co-own Somatics Inc., one of the world's largest ECT-machine companies. One of ECT's strongest advocates is APA task-force member Dr. Max Fink, a paid consultant on ECT lawsuits who's been receiving video royalties from an ECT-machine company. Csernansky isn't worried about such conflicts -- an ECT machine is hardly an "impulse purchase," he points out. Still, the experts do stand to gain.
According to the APA's model consent form, perhaps one in 200 patients reports devastating memory losses. That stat has been vigorously challenged by activists, and APA consultant Sackeim admits "it's hard to defend quantitatively." What was accurate, he says, was the intent, which was to emphasize the infrequency of severe memory problems with today's ECT.
Anne Simpson had three courses of ECT last year, and a lot of memory loss. "The standard line I would get from my psychiatrist was, `That isn't in the literature,'" she says wryly. "But everyone I know who's had ECT has had problems with memory. I think psychiatrists really underplay the side effects. I had cognitive problems, I was physically wasted, exhausted all the time. And most of 1995 is gone.
"After you recover from depression, people encourage you to rebuild your life," she adds. "But frankly, I couldn't even remember what my life was. I run into people I met in '95 and have no recollection of who they are. Journals I kept at the time are completely unfamiliar. And I'm still finding clothes I don't recognize." She'd been depressed before, she says, but never experienced this kind of memory problem. "I consider myself a proponent of ECT, but I strongly feel people are not given full information."
In lawsuit after lawsuit, psychiatrists have blamed the mental illness itself -- and not the ECT -- for the memory loss. Neuropsychological deterioration results from some of the disorders for which ECT is used, they say, and as for mood disorders, mood is the best predictor of how anyone evaluates his or her memory. If we're sad, we feel like we're forgetting more.
In patients' accounts, though, memory problems don't explain themselves away that readily. "The nurse kidded me because I kept asking her, `Why am I getting a divorce?'" laughs Ellen Fein, "but it was brand new to me." Scott doesn't remember "going to the doctor, going in the hospital, the treatments, the day in between. Except smoking -- I remember being out on the smoking porch! But I don't remember the month of May." She's told her depression started after she found a sofa and couldn't get it to her home. "I don't even know why I was looking for a sofa," she chuckles, "or where I got the money."
Psychiatrists make much of the shift to unilateral ECT, which is given only on the "nondominant" side of the brain and thus leaves verbal memory unscathed. Unilateral ECT is recommended whenever possible (although clinicians do murmur that bilateral still causes a better seizure). In Toxic Psychiatry, Dr. Peter Breggin names the downside of the improvement: "It's relatively easier for doctors to overlook harm done to the nonverbal side, because the patient can't speak about it."
Maybe people who feel they were pressured into ECT have such a sense of loss and outrage, they cling to illusions of impaired memory. But there are other possibilities: That it's easier to call someone with mental illness "treatment-resistant" than to credit her claims. That standardized tests can fail to detect subtle memory problems. That psychiatrists don't want to emphasize the memory problems of an 80-percent-effective treatment that's often used as a last resort.
Sackeim does admit, "If you are engaged in a physical treatment that is altering neuropsychological function, there will be exceptional, very rare cases where there are untoward effects." Even a generally favorable National Institute of Health consensus report (1985) conceded the risk of permanent memory loss with ECT. But Quadri, about to head a new ECT program, insists that "the memory loss is not permanent. If it happens at all, it's usually transient and very minor. Not major chunks of their life -- that does not happen."
Tell that to the psychiatrist who drove round and round her own neighborhood, the woman who didn't remember being president of a self-help center, the woman who couldn't find her shower. "She probably remembered it that night," remarks a St. Louis anesthesiologist who asked not to be named. "I don't think the memory problems are that profound." His dismissal sounds cavalier until he continues, his voice taut: "You have to know what these people look like. Usually they are chronically depressed, they have the flattest affect (emotional expression) you have ever seen, and they're leading pretty dysfunctional lives. To see them starting to come in and actually have a conversation ..." To a witness, that change is worth a few memories.
Today's typical ECT patient is a privately hospitalized older white woman who's clinically depressed, can't be helped by medication and has insurance. That shift alone worries ECT's opponents. "An older woman who is sad, isolated and pressured by her family will sign almost anything," Oaks warns. "It's not consent, it's elder abuse! If we were dealing with gutter repair and how the elderly are being ripped off, 60 Minutes would be there in a flash."
Psychiatrists counter with the benefits: ECT is fast, it works when drugs can't and at least 80 percent of the time it breaks the impasse. Would you deny healing to someone you love just because, at the point of decision, she's too sick to say yes? In ECT cases, logical guidelines for informed consent spin into paradox: How do you set criteria when, in Hay's wry summary, "The organ that makes the decision is the organ affected"?
Missouri law allows a guardian or court to order ECT for someone who is too deluded to decide or too depressed to think anything could help. "We have to have a lot of paperwork to back up a request for court order," notes Dr. Peggy Szwabo, assistant professor of psychiatry at St. Louis University. "Anytime we go to court, all of us get nervous. But if someone is a danger to themselves or others, you are going to do the hard work."
The law presumes every individual competent until proven otherwise, and the APA guidelines say that "the presence of psychosis, irrational thinking, or involuntary hospitalization do not in themselves constitute proof of lack of capacity." To a layperson, the statement sounds ludicrous: Since when do psychosis and irrationality make for good decisions? Quadri offers a crisp reminder that "psychosis is not global. A patient may believe someone is coming to kill them, but they don't stop knowing food is good." (If a patient consented saying, "Great, the electricity will suck the evil spirits from my mind," their capacity would be questioned; psychosis twisted its way into the decision.)
The APA guidelines warn that "threats of involuntary hospitalization or precipitous discharge" violate someone's informed consent. Then they say patients have the right to know the consequences of their decisions, and physicians have the right to transfer a patient if they disagree with the chosen course of treatment. So how do you, nonthreateningly, tell someone who's severely depressed that she may kill herself without ECT, and if she refuses ECT you will have to stop treating her and she will have to leave the hospital?
"We always try to be matter-of-fact," comments Csernansky. "We say, `Well, we think you would benefit from ECT. Yes, there are alternatives, we could try drug therapy, but it would take longer.' We're not threatening them, but we are advising them." Unfortunately, whether someone hears threat or advice will depend on their mood, past experiences and hundreds of other unknowable variables. Private hospitals have an even tougher scenario because money dictates the time frame. "We're in a relatively cleaner position," notes Csernansky, "because we can continue treating patients whether they can pay or not."
Most of the ECT recipients The Riverfront Times spoke with did give consent -- sort of. "Really, I didn't know it was up to the person," confides Scott. "I mean, I realize I probably signed a consent form, but I didn't realize it was up to me." Ellen Fein, normally her own sharpest advocate, says, "I don't really remember giving an OK. I was at a point where I felt like I'd tried everything, and I trusted my doctors."
Short of telepathy, there's no way to clarify consent proceedings. So maybe we need to be a little franker about their limitations.
"If someone is ill enough to be admitted to the hospital," notes Csernansky, "which is getting harder and harder to prove, there is tremendous pressure to treat their illness as quickly as possible." ECT can cost as much as $800 per treatment; it requires six to eight treatments on average, and lasts two or three weeks. But drug and/or psychotherapy treatment can take considerably longer, and the least expensive psychiatric hospital, the state-funded Metropolitan, costs about $400 a day. "If ECT decreases length of stay," sums up Quadri, "they will promote it."
As for outpatient ECT, when Dr. Michael J. Bennett, vice president of Merit Behavioral Care, attended a meeting of the APA's new task force on ECT, he found medicine and insurance in rare agreement. At St. John's Mercy, outpatients and inpatients are already split 60-40, and the trend's increasing everywhere. It's great for patients with supportive families to sleep in their own bed -- but what about people who live alone, or who drive in from a rural area three days a week, exhausted and disoriented?
The allegation that doctors make money off ECT is more flurry than fact, although it's true that insurance companies reimburse at a higher rate for ECT than for psychotherapy or drug checks. "ECT tends to be self-regulated," says Csernansky, "because people who do it, do a lot of it. They pay higher insurance premiums, so ..." We'll say it: They need to justify the expense.
At the Women's Counseling Collective, Kuhn says she had six patients hospitalized last year, and every one was offered ECT. "I've had clients actually told, `This is the only treatment that will help you,'" she adds. "Or given ECT without the therapist or (primary-care) physician being consulted. My concern is the increase: For a while, hospitals began to offer more comprehensive treatment, with chemical-dependency and sexual-trauma units, family programs, therapy, medications. Now, with the rise of managed care, we help people by giving them a pill or shocking them. Heaven forbid we talk to them about their lives."
Last December, Dennis Cauchon wrote a cover story for USA Today quoting an assertion that in Texas (one of only four states with ECT reporting laws), 65-year-olds got 360 percent more shock therapy than 64-year-olds. There, Medicare made the difference. In St. Louis, there's no way to know. Our Medicare B carrier, General American, also reimburses for ECT, but it doesn't track the number of treatments separately, and neither does the state of Missouri.
Activists warn that, based on Texas' stats, the elderly's rate of death after ECT could be 50 times higher than the 1 in 10,000 estimated on the APA model consent form. But Hay points out that elderly patients are often referred very late (people expect the old to be depressed) and have serious medical conditions (often that's why they're receiving ECT instead of drugs with cardiac side effects).
Researchers do agree that the risk of severe confusion and heart and lung problems after ECT increases with age. So does the seizure threshold, which means it's harder to induce a seizure long enough to have the desired effect. So why is ECT being used more and more with older patients? Because medication risks also increase with age, as does the vulnerability to severe depression. Older people's psychic reserves are depleted from all sides -- by physical aging, by decreases in neurotransmitter levels, by losses and loneliness.
At the other end of life's spectrum, children carry even higher risk. Precious little is known about mood disorders in a developing brain. (Psychiatrists used to think children couldn't get depressed because they weren't mature enough to feel guilt. Biochemical discoveries exploded that cozy notion, but insight hasn't filled the void.) Dr. Tony Baker published an article in the British medical journal Lancet last year recommending a halt to treatments of children, whose skulls have lower electrical resistance. In the U.S., only Texas and California prohibit ECT on children younger than 16. What's most frightening is the inescapable logic: We won't know how to do it safely until we do it more often.
The paradoxes continue: As the World Association of Electroshock Survivors fights to ban ECT, the National Association of Mental Illness pushes to make it accessible to lower-income and minority patients. In a 1986 National Institute of Mental Health survey, 23 percent of patients -- but only 1.5 percent of ECT recipients -- were African-American.
Higher-income recipients -- mostly white and two-thirds female -- will be receiving even more ECT in the future. Since no ECT study has shown an effect lasting longer than a month, and since drugs didn't work in the first place, more psychiatrists are now recommending "maintenance ECT," which continues treatments for many weeks at a decreasing frequency. "Certain patients respond only to ECT," explains Quadri. "Maintenance ECT is like a miracle to them."
It had better be a well-administered miracle, though, and the APA guidelines are streaked with uncertainty. "Criteria for capacity to consent are vague," they admit, and "formal `tests' of capacity do not exist." How do you know when to use ECT? "At present no accepted standards exist." There's also no central tracking and no licensing; each hospital is responsible for "privileging" psychiatrists who, hopefully, have had specialized training. "Unfortunately," the guidelines note, "in many departments training in ECT has fallen behind training in other treatment modalities."
Going futuristic, there are frightening potential applications for ECT, especially since, as Quadri notes, "low levels of serotonin are linked also to impulsivity. Impulsive suicides, aggressive homicides." Last year, a study published in the Journal of Forensic Sciences examined a case of involuntary ECT that had been court-ordered in New York for a prisoner before his trial.
The simpler future lies with alternatives. Researchers in Spain, Israel and New York are experimenting with magnetic currents, which don't require anesthesia, don't cause pain or externally obvious seizures, and can be focused precisely. So far, benefits last only two weeks. But as Fein points out, "There's still no cure for mental illness."
Until there is, manipulating
electromagnetic forces and chemicals will
continue -- probably should continue -- to make
us uneasy. "Despite everything we can do, there
is something sacred about the human mind,"
Csernansky says softly. "My own view is that
there will always be a certain mystery about it
-- and some discomfort about whether it's right
to treat the mind like it's just another organ
of the body." After this sudden rush of words,
he pauses, then gestures with an open palm.
"It's a little closer to God than the liver."