Shock Value

"ECT is hands-down, for the short term, our most effective treatment for depression," says Harold Sackeim, professor of psychiatry and radiology at Columbia University.

However, only about half of patients remain well even six months after one course, if given no other treatment afterward. "Acutely helping someone out of a period of depression is very important," says Sarah Lisanby, chairperson of the American Psychiatric Association Committee on ECT and Related Treatments. "But it's not the end of the story. The goal is long-term treatment."

That goal is a priority for researchers. The first randomized, controlled study of maintenance treatment following ECT, published in 2001, found that giving patients a combination of an antidepressant and a mood stabilizer significantly increased the chances that they would not relapse into major depression six months after having ECT.

More recently, a research group found that continuing to give ECT once a week to once a month for six months produced results similar to the combination medication treatment.

"We're learning how to keep people well after ECT more than we knew before," said Max Fink, professor emeritus of the Departments of Psychiatry and Neurology at Stony Brook University in New York, who wrote last week's commentary in JAMA. "You can't just stop."

A 20-Minute Procedure

The ECT of today is not the shocking scene depicted in books and movies. The overwhelming majority of patients receive the treatment voluntarily. While I was a clinical psychology intern this year at Western Psychiatric Institute and Clinic in Pittsburgh, the head of the ECT program, Roger Haskett, arranged for my classmates and me to view ECT in action.

At Western, ECT is provided every weekday morning. Patients are wheeled one at a time into the ECT suite, lying on gurneys and in hospital gowns, much like patients about to get any other medical procedure. Many that morning were elderly and female, which is typical of the population that gets ECT, and most appeared calm.

They were given an intravenous anesthesia, which sent them to sleep within minutes. A muscle relaxant coursed through their entire bodies except for one foot, which was wrapped with a blood pressure cuff to keep the muscle relaxant out so the seizure movement could be observed. Five sensors were carefully attached to the patients' foreheads to measure electrical brain activity, and their temples were cleaned and coated with conducting gel. The patients were also given oxygen, and a bite block was inserted into their mouths right before the electrodes were placed on their heads.

The anesthesiologist, psychiatrist and nurse then confirmed which procedure each patient would get -- unilateral (both electrodes on the same side of the head) or bilateral (one electrode on each temple) -- and what dosage of current.

The psychiatrist then placed the electrodes against the patient's head, and the ECT machine sent a jolt of seizure-inducing current. Except for what appears to be a grimace -- an automatic result of stimulation of the muscles that run along the sides of the face -- and a tensing of the total body, ECT patients do not move during the procedure. There is no flailing about, apart from a slight twitching in the cuffed foot. Yet as a new observer, I found watching the experience a little jarring.

The setup is very efficient; each procedure takes about 20 minutes.

The Memory Issue

What bothers many patients afterward -- and is at the core of the continuing controversy about ECT -- is memory loss. Some are confused when they wake up; others complain that they cannot remember past events and have at least temporary trouble forming new memories.