FEBRUARY 26, 2001
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."