Shock Therapy Leaves the Cuckoo's Nest

The treatment is gaining acceptance, but controversy lingers

Ann Renee Hansard's daily cocktail of depression and anxiety pills was losing its power to lift her spirits. Although spring was bursting out around her home in Thomasville, Ga., life seemed to grow darker and duller with each day. In May, the unemployed teacher decided she needed something more to help her appreciate life again. So Hansard, 41, headed to Emory University Hospital in Atlanta for a series of electric shocks to her brain.

Electroconvulsive therapy, once seen as a barbaric practice because it induces brain seizures and was sometimes used against the patient's will, has emerged from the dark ages. While its effects on the brain are still not fully understood and it doesn't help all who try it, ECT is once again a widely accepted treatment for cases of severe depression, some types of psychoses, and catatonia. But gone are the days when patients writhed and bucked on the treatment table as teams of doctors and nurses fought to hold them down after electricity coursed through their brains. Anesthesia and muscle relaxants have eliminated the kinds of convulsions that were gruesomely enacted by Jack Nicholson in One Flew Over the Cuckoo's Nest.

Instead, in today's hospitals and clinics, patients are more likely to wake up wondering whether they've even had the procedure. Compared with the 1970s and '80s, when ECT was generally frowned on, the procedure is "clearly accepted as an effective treatment, and in some cases, a life-saving treatment," says Dr. Paul S. Appelbaum, chair of the psychiatry department at the University of Massachusetts Medical School and president of the American Psychiatric Assn. (APA) for the year to May, 2003. As a treatment for depression, ECT now has the imprimatur of the National Institute of Mental Health, the American Medical Assn., the U.S. Surgeon General, and the National Mental Health Assn., a patient-advocacy group, as well as the APA.

The fact that ECT is helping at least some patients in the short term is good news. But it also highlights the enduring challenges of treating depression by less drastic means. At least 20% of depressed patients don't respond to medication, says the NIMH, despite major advances in drug therapies during the past decade. And many more respond only temporarily. So psychiatrists continue to search for alternatives. For all its merits, ECT benefits appear to fade with time, too, requiring follow-up treatment. Among the other promising therapies under study are electromagnetic stimulation, which causes seizures like ECT, and vagus nerve stimulation, which involves implanting a device like a pacemaker to stimulate a nerve linked to the brain -- and which has already been approved for treating epilepsy. "Some think these can even replace ECT," says Dr. Richard D. Weiner, a professor of psychiatry and director of the ECT program at Duke University Medical Center -- but that is still several years away.

Although firm case numbers are hard to come by, anecdotal evidence suggests ECT treatments are on the rise. McLean Hospital, a psychiatric center in Belmont, Mass., that's affiliated with Harvard Medical School, says it gives about 3,000 treatments a year to 300 patients, up from about 1,800 for 180 patients in 1996. And some high-profile patients are helping to erase the stigma that dogged ECT. Kitty Dukakis, the wife of former Democratic Presidential candidate Michael S. Dukakis, said through a spokesperson that ECT has helped relieve her depression. She's now writing a book about her experiences.

Despite the progress in shock administration, ECT is not likely to become as common as medication for treating depression. For one, it's more complex and more dangerous to administer. It requires full anesthesia and oxygen. And because its effect on the brain remains a mystery, even supporters like the editors at the Journal of the American Medical Association acknowledge that "producing convulsions with electric current seems like a strange way to treat illness." Psychiatrists generally recommend ECT if medication fails or a patient needs help fast, or for elderly patients who can't tolerate multiple medications. "It's a second-line treatment, when people need a definitive response," says Dr. Michael Henry, director of ECT at McLean.

Still, controversy lingers around ECT. Some patient-advocacy groups say patients suffer severe memory loss -- and they are backed by a report in the June 21 British Medical Journal. Researchers at London University's Institute of Psychiatry analyzed 18 earlier studies in which patients were asked how they fared with ECT. This report repudiated a claim by Britain's Royal College of Physicians that 80% of patients were satisfied with the treatment, and that memory loss was not "clinically important." It found that at least one-third of patients report significant memory loss after treatment.

Doctors acknowledge the impact on memory but say it's limited and usually temporary. And the potential benefits of ECT, they say, are significant. Patients tend to feel better almost immediately. Medication can take anywhere from 4 to 12 weeks to have an impact -- and a process of trial and error can stretch that out longer. Advocates also point to a study in the Mar. 8 issue of The Lancet deeming ECT an effective, short-term treatment for depression.

One of the challenges is to prevent relapses that seem to affect many patients. Some doctors recommend follow-up treatment with medication or a regimen of "maintenance" or occasional ECT, starting with once a week, but growing less frequent over a six-month period.

The treatment's history and shortcomings have not stopped thousands every year from seeking ECT -- many as outpatients. At McLean, the procedure takes about 20 minutes, patients wake up from anesthesia shortly after, and they leave within an hour or two. The regimen generally calls for 6 to 12 "doses," administered every other day. Each dose is about 30 jules of electricity, or enough charge to light a 30-watt light bulb for one second, says Dr. C. Edward Coffey, chairman of the department of psychiatry at the Henry Ford Health System in Detroit.

Hansard says she felt better after her six treatments at Emory in May. But she suffered more memory loss than after a previous round in early 2001. She's considering maintenance ECT, but she would like to see more research on it. The NIMH is funding studies that address exactly that question. Its spending for research on major depression rose 60%, to $206 million, between 2000 and 2002. Within a few years, doctors may have even stronger weapons in their depression-fighting arsenal.

By Faith Arner in Boston

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