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FEBRUARY 26, 2001
Time Magazine
New Sparks over electroshock
The old treatment has come a long way since
Cuckoo's Nest. But some still question its safety
By JOHN CLOUD WESTFIELD
On some gut level, the whole idea of electroshock therapy is
absurd. At a time when people with mental illnesses can
choose from a pharmacological cornucopia, why would they
have electricity run through their brain instead? Didn't
electroshock disappear around the same time as three-martini
lunches?
Actually, electroconvulsive therapy, as psychiatrists call it,
has remained a common treatment for those who are severely
depressed and who don't respond to (or can't tolerate) drugs.
Its use in the U.S. has been quietly on the rise in the past two
decades. Because most states don't require reporting on
electroshock, there are no hard figures, but many people in
the electroshock world agree that at least 100,000 Americans
receive the treatment annually, up from a 1980 federal
estimate of 33,000. Research on electroshock has also
surged. Just last month the American Psychiatric Association
released a second edition of its report on electroconvulsive
therapy; it lists more than 1,000 citations.
Why all the interest? One reason is that electroshock remains
a nagging scientific puzzle: it works a little bit like banging the
side of a fuzzy TV--it just works, except when it doesn't.
Second, a small but persistent group of advocates wants to
ban it--they say it causes brain damage--and a larger, more
mainstream group of activists wants more research before the
treatment spreads any further. Many of these folks are former
patients (or survivors, to use a term of choice), and they have
helped persuade a handful of state legislatures to consider a
ban. No states have agreed, though at least four have
enacted restrictions.
Psychiatrists and some former patients who found the
treatment beneficial are rushing to try to prove the dissenters
wrong. An ugly war of words has erupted. Dr. Peter Breggin,
a psychiatrist who has written four books critical of
electroshock and who favors therapy and human services
instead, told Time that shock is used by "cold, aloof guys who
seem to feel more comfortable with machines than patients."
Dr. Harold Sackeim, who runs the department of biological
psychiatry at the New York State Psychiatric Institute,
responds that caregivers who forgo the use of electroshock
and other biological methods to treat the suicidally depressed
"are going to end up with a lot of dead patients."
If you are a filmgoer of a certain age, your image of
electroshock was shaped by such movies as The Snake Pit or
One Flew Over the Cuckoo's Nest. In the latter, a small army
of orderlies and nurses restrain Randle Patrick McMurphy
(Jack Nicholson) as he is connected to the electrodes. The
treatment is agonizing because McMurphy isn't given
anesthesia, which has been routine for years.
But even today, when the worst pain is usually a headache
after patients awaken, some say they are coerced into
electroshock and lied to about it. "The doctor told my family it
was an absolute cure for depression," says Juli Lawrence,
who underwent electroshock in 1994. But the following week
she attempted suicide. She says her doctor also failed to
warn her about the memory loss usually associated with
electroshock, which can range from forgetting where you
parked your car to forgetting that you own a car at all. The
memory loss is often temporary, but not always. (A 1999
Surgeon General's report says there are "no reliable data" on
the incidence of severe memory impairment.) Lawrence says
she can't recall any events from nearly two years before and
from several months after her treatment. She now runs
ect.org, a website critical of electroshock that works to stop
the treatment from being forced on people. (Roughly 1% of
those who undergo electroshock are ordered by a judge to
do so, according to state figures published on ect.org.)
Of course, uninformed medical consent is a problem not
exclusive to electroshock, and judges can force other kinds of
treatment as well. But electroshock is an unusually retro
procedure, one that some psychiatrists avoid. According to
the Surgeon General, the response rate for electroshock is
an impressive 60% to 70%--about the same as today's
superpills, including Prozac and its kin. But that fact itself
embarrasses some psychiatrists, who would rather not think of
themselves as well-educated electricians. Not all psychiatric
residents learn electroshock. Younger psychiatrists are more
ambivalent about it than older ones, according to a 1999
survey. After all, even the latest electroshock devices look
something like Led Zeppelin-era stereo equipment. They are
based on technology so old the U.S Food and Drug
Administration says they predate its regulatory authority (the
agency has classified the devices in the category it uses for
equipment whose risks are high or unknown). The website for
the Thymatron, the Cadillac of electroshock devices, still
features an outdated page on how to test the device for Y2K
compliance.
But when performed properly, psychiatrists say, electroshock
is simple, safe and looks a lot more boring than its cinematic
counterpart. Curtis Hartmann, 47, a Westfield, Mass., lawyer
who has received about 100 electroshocks since 1976 to
help control his bipolar illness, knows the procedure well.
Hartmann fasts the night before, a routine practice before
general anesthesia. He leaves his home around 4 a.m. and
drives to nearby Holyoke Hospital. He goes to the second
floor and turns left toward the short-stay surgery unit. His
body is prepared for electroshock in three ways: an
anesthesiologist puts him to sleep; a chemical relaxes his
muscles; a respirator helps him breathe.
All these steps are taken to protect him from the physical
side effects of having a seizure, which is what happens when
the electrodes are attached to Hartmann's head and
electricity courses into him. For reasons no one quite
understands--just as no one is precisely sure how all
antidepressants work or why some people improve with good
old-fashioned talk therapy and others don't--the seizure is
key. Hartmann explains it this way: "The seizure just kind of
dynamites the depression out of my brain somehow."
Before Italian researchers first tried electricity in 1938,
doctors used chemicals to induce the frightening, painful
seizures. Electricity worked faster, but the pain of uncontrolled
convulsions remained. Patients fractured their spine, bit their
tongue, broke bones. Consequently, the devils who ran some
asylums used electroshock as punishment. In many circles, it
retains a frisson of barbarity. Writers such as Ernest
Hemingway and Sylvia Plath reinforced the image. "It was a
brilliant cure," Hemingway wrote sarcastically in the days after
his electroshock and before shooting himself, "but we lost the
patient."
Hartmann quotes that line in his fascinating, not yet
published memoir, Life as Death. He knows some people
don't respond to electroshock, and he understands the risk
he takes when he undergoes it (his most recent treatment
was mid-2000; he currently takes medications). A tiny number
of patients die: the U.S. National Institute of Mental Health
says the figure is 1 in 10,000, about the same as any
procedure involving anesthesia. Antishock activists cite Texas
statistics from the mid-'90s, saying about 1 in 320
electroshock patients died in the two weeks after treatment,
though the deaths weren't necessarily caused by
electroshock. The activists also say electroshock causes brain
damage. Dr. Breggin says the damage produces delirium so
severe that patients can't fully experience depression or other
higher mental functions during the several weeks after
electroshock.
Yet a 1999 Surgeon General's report argues that "there are
virtually no absolute health contraindications" for
electroshock. It notes that psychiatrists have revised their
technique for delivering the electricity in the past generation
so that less power is needed and, consequently, fewer side
effects result. For his part, Hartmann says he has often gone
to work around noon after morning electroshock sessions.
"The people in the office are just agog that you can add two
and two, that you're not drooling," he says. "But my
concentration was actually improved, and I felt so much
better." Hartmann says the memory problems he has
experienced have been minor--getting confused about what
he ordered from the hospital menu, for instance.
More important to Hartmann is the fact that since he first
experienced depression at 15, electroshock has been "the
only thing that has ever let me feel 100% ... Depression is like
being a corpse with a pulse. I tried everything else. I had a
loving family, thousands of hours of good psychotherapy, and
none of it ever helped." Hartmann believes he would have
killed himself--perhaps by starving himself, as he tried once--if
not for electroshock.
It's no panacea, of course. Electroshock's effects are short
term, lasting weeks or months before depression can
descend again. At $2,500 a treatment, it's also expensive,
though insurance usually covers it. Antishock activists say it's
just a cash cow for hospitals and that the response rates
cited by the Surgeon General are inflated. In 1996, Lawrence
of ect.org surveyed 41 former electroshock patients and
found that 70% said the treatment had no effect on their
depression. Joseph Rogers, executive director of the National
Mental Health Consumers' Self-Help Clearinghouse, says 3
out of 4 of the electroshock patients he speaks with had
negative experiences: coercion by psychiatrists, confusion,
memory loss. Rogers and Lawrence don't want the treatment
banned, but they believe few would undergo it if they knew all
the risks beforehand.
It's hard to know what steps people will take when despair
rules. Novelist William Styron has long battled depression; his
1990 memoir about it, Darkness Visible, inspired Hartmann
and millions of others. Last summer Styron underwent
electroshock for the first time. He had asked several
prominent psychiatrists about the option, and they agreed it
could help. It didn't, though he says he didn't suffer any
negative side effects. "Anyone who would ban it is ridiculously
off base," he says.
A ban seems unlikely--the psychiatric establishment uses its
clout to quash the idea wherever it can--but more states could
require more complete and open records on who gets
electroshock. "The problem is it's a roll of the dice," says Brian
Coopper, senior director of consumer advocacy for the
National Mental Health Association. "Electroconvulsive
therapy can be a quick fix, but you can't tell who's going to
come out of it with part of his life missing."
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