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Shock Value
Electroconvulsive Therapy Saves Lives. But 70 Years After It First Gained Currency as a Treatment For Major Depression, ECT Continues to Court Controversy.

By Shirley Wang
Special to The Washington Post
Tuesday, July 24, 2007

Anthony Mauger woke up at 5 a.m. one morning nearly 10 years ago and heard a message in his head telling him to kill himself. He wrote a goodbye note to his wife, then jumped off the back deck of their Kensington home, falling the 14 feet hard enough to wake her with the sound of his thud.

The 66-year-old organic chemist succeeded only in smashing his knees and skull. After surgery at Suburban Hospital, he was transferred to Potomac Valley Nursing and Wellness Center in Rockville for intensive psychiatric care.

Mauger had been depressed for about six months, his wife, Inge, remembers. His sleep had been poor, and he was making strange claims that he could not go on vacation or walk. The slew of antidepressants Mauger tried made no difference. After four more months watching her husband deteriorate, Inge Mauger was desperate. "Nothing is happening," she said to his psychiatrist. "Isn't there anything you can do?"

"We can try ECT," he replied.

Better known as shock therapy and seared into our collective consciousness as the involuntary procedure depicted in "One Flew Over the Cuckoo's Nest," electroconvulsive therapy remains a controversial treatment, often used, as in Mauger's case, only after other treatments fail. Its popularity has waxed and waned in its 70-year history, but an estimated 100,000 Americans undergo ECT each year, according to a 1995 survey of more than 17,000 psychiatrists, and its use appears to be steady or increasing since then.

The number of treatments in California -- one of the few states that have mandatory reporting -- increased from about 13,000 to more than 20,000 between 1994 and 2004. Although the District, Maryland and Virginia do not require such reporting, Johns Hopkins Hospital treats about 125 people with ECT annually, a number that has not changed much recently, according to Irving Reti, head of Hopkins's ECT unit; at Sheppard Pratt outside Baltimore, ECT physician Jack Vaeth says his service does about 60 treatments a week, an increase over the past decade.

While no one fully understands why ECT works, many psychiatrists believe that using an electric current to produce a "grand mal" -- or generalized brain -- seizure can "reboot" the brain when medications and psychotherapy fail. Just last week, a commentary in the Journal of the American Medical Association (JAMA) suggested that, despite its demonstrated effectiveness, ECT remains underused, primarily because of its stigmatized history.

The treatment is "miraculous" and "lifesaving," say some patients and doctors, and yet the costs -- primarily memory loss -- can be significant. Many individuals who believe that ECT kept them alive when they were suicidal also urge caution about its use.

Mauger, as an older individual with "treatment-resistant" depression, is a fairly typical patient. Initially scared, he decided to try ECT weeks after his psychiatrist and wife first urged him to. By the seventh of his 12 treatments, he felt his depression lift.

"He sat up and said, 'I'm not depressed anymore,' " his wife said. "I was amazed."

His one relapse years later quickly responded to another course of treatment. "I am terrified of what would have become of me without ECT," Mauger says.

A Long-Term Goal

An acute course of treatment usually comprises eight to 12 sessions, administered two or three times a week at a hospital. Studies show that more than 70 percent of severely depressed patients experience quick improvements. (About 50 to 60 percent respond to antidepressants.)

"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.

Much research has focused on reducing that side effect, but patient experiences vary tremendously, and it is nearly impossible to predict the extent of memory difficulties in individuals, according to Frank Moscarillo, executive director of the Association for Convulsive Therapy, who has conducted ECT at Sibley Hospital since 1968.

Barbara Winkler, 46, of Kennewick, Wash., who had more than 90 sessions of ECT at Yakima Valley Memorial Hospital, cannot recall her wedding, which occurred during the period she was receiving ECT. "It probably saved my life initially," Winkler said. "But the hardest part is probably the memory loss."

Others, like Tom Hempel, 59, from Pittsburgh, see memory lapses as "inconveniences." He jokes about "having an ECT moment." "I know it was worth it," he said.

Many in the ECT field say concentration and memory may also be compromised by depression. But it appears clear now that ECT can affect memory for much longer than the two to three weeks after which many physicians say most patients' ability to remember will return to normal.

Some patients have pointed to inconsistency in information about side effects. Vermont state legislator Anne Donahue, 51, thinks they were not sufficiently emphasized before her first round of treatment in 1995, while the informed-consent form provided to her at a second hospital in 1996 was much more complete and easy to read.

"This is an incredibly vital and valuable treatment, but you have the right to know the risks," Donahue said.

Although the overwhelming majority of ECT patients in the United States consent to the treatment, legislation governing involuntary ECT varies by state. The criteria are generally strict: A patient must be unable to make the decision, and they must be exhibiting dangerous behavior, such as not eating.

Also, there is no special license that a doctor needs to administer ECT in the United States. The American Psychiatric Association has issued practice guidelines, but in most states there is no regulatory body to see that practitioners adhere to those standards or to review the information on consent forms.

Nor is there any firm rule about when ECT is complete. Memory loss tends to get worse with more closely spaced treatments or larger doses of current, so doctors look for a plateau in improvement, when patients say they feel no additional benefit in symptoms.

"The desire to minimize memory loss while maximizing effectiveness is the holy grail," said Steve Seiner, director of the ECT service at McLean Hospital in Belmont, Mass., one of the largest such programs in the country. "The goal of ECT is to get them back to their base line." ยท

Shirley Wang, who is completing an internship at Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center, has a degree in clinical psychology. Comments:health@washpost.com.

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