The shocking facts about shock treatment.

Have you ever heard a medical war story?
I died on the table, and they brought me back twice. Broke two of my left ribs. The doc said it was a miracle.

You probably have. How about a psychiatric war story?
I was so depressed I wanted to kill myself; they gave me shock treatments and I got all better. Look at me now.

You probably haven’t. The reason is not that stories about ECT, electro-convulsive therapy, don’t exist*; it is because there is still a huge amount of stigma about mental illness in general and about ECT in particular. It is not something you talk about when you run into an old friend at the grocery store.

We’re all familiar with the horror stories, though, the images burned into our minds from years of TV and cinema. A feisty, likeable young man strapped down on the gurney, shocked with naked wires till his hair singes, turned into a zombie staring into space.  Our hearts turn with indignation. How dare they?

I ran into some of that recently, on Twitter. A simple comment about the effectiveness of ECT brought on the wrath of the antipsychiatry folks.

You’re mixing electricity with water!
Doctors just love to strap people down and shock them don’t they?
Have you had ECT yourself? You seem to have very strong feelings about it.

The wrath has persisted – even when I and two other psychiatrists clearly stated that yes, if severely depressed, we would choose ECT as a treatment for ourselves. It’s no surprise; there is little knowledge and plenty of misinformation about ECT amongst both patients and doctors.
Let’s talk about ECT, then.

What is ECT?
During ECT, a small electric current, smaller than a Taser or a cardiac defibrillator, is applied to the person’s temple to induce a generalized seizure, lasting 15-45 seconds.

How does it work?
*Edited. There is no definitive answer to exactly how ECT works, but there are several well documented changes in the brain. The small seizure releases several neuro-chemicals in the brain. It also modulates the activity of several brain centers, such as the frontal cortex, prefrontal cortex, and cingulate cortex.

What is it used for?
The main use of ECT is in people who are severely depressed, often with strong suicidal thoughts, psychosis, catatonia, or severe malnutrition due to refusal of food.

ECT is not a first line treatment. It is usually considered in patients who have failed multiple treatments with several different medications and psychotherapies.

Is it better than other therapies?
Meta-analyses (collecting and analyzing multiple studies done over years) show that ECT is more effective than any other treatment used for severe major depression**. Significant improvement occurs in 70 to 90 percent of patients who receive ECT, compared with approximately 30 percent for medication.

In 2011, the FDA conducted its own systematic review and meta-analyses** with the following findings:
– An analysis of 5 randomized trials estimated that improvement on the depression rating scale was about 7.1 points greater in patients who received ECT compared with sham ECT.
– A review of 3 randomized trials found that ECT was more effective than placebo.
– An analysis of 8 randomized trials estimated that improvement on the depression rating scale was about 5.0 points greater in patients who received ECT compared with antidepressant medication.

Is it painful?
No. ECT is performed under anesthesia. Along with anesthetic, a muscle relaxant is usually administered so that the body does not shake, unlike a regular generalized seizure. This prevents accidental injuries during the convulsion.

There are two movements commonly seen during ECT- the initial facial grimace, which happens because electrodes directly placed on the temples cause the facial muscles to contract- it is often scary to students watching the procedure, but the patient does not feel a thing.
Second, a blood pressure cuff is placed on one ankle to prevent the muscle relaxant from reaching one foot. This allows the doctors to observe the seizure in the toes of one foot, to corroborate with the EEG.

What EEG?
An EEG- brain wave monitoring – is done during ECT. This allows the doctors to ensure an adequate seizure time, 15-45 seconds. This also allows them to use medication to terminate the seizure if it goes on longer than intended. An EKG-cardiac monitoring- is also commonly done.

What are the side effects? Can it kill the patient?
The death rate of ECT is 2 to 4 deaths per 100,000 treatments, making it one of the safest procedures performed under anesthesia. Death is mostly related to heart-related side effects. All patients must undergo a medical evaluation for clearance prior to receiving ECT, and a cardiac consultation is indicated for those with heart problems. Other side effects include aspiration pneumonia, fractures, injuries to the tongue or teeth, headache, and nausea.

What about the brain damage?
ECT causes three types of brain side effects:
– Acute confusion- this is a result of the seizure and anesthesia. It resolves in half an hour.
– Anterograde amnesia- decreased ability to retain new information. This usually resolves in 1-2 weeks after treatment.
– Retrograde amnesia- forgetting recent memories, for events that occur during the course of ECT and a few weeks- months prior to that. The deficits are greatest for knowledge about public events, rather than personal information. Some of the lost memories may return, while others may not. In one systematic review, 30-55% of patients reported persistent memory loss.***

The typical ECT patient is severely depressed and accepts some degree of memory loss as a reasonable tradeoff for improvement in depression.

Can someone be given ECT against their will?
ECT should be done with informed consent- a discussion of risks and benefits with the patient. It often involves patients watching videos of the procedure to assuage their anxiety, and they are given plenty of time to ask questions and decide if they want to proceed with treatment. Under rare circumstances, if a patient is too sick to give an adequate informed consent, the doctor may petition the court for a treatment order. ****

The trope of a poor, mentally ill person being given ECT against their will is just that, a trope. The typical ECT patient today is relatively affluent and receives ECT in a private center. State hospitals rarely offer the treatment.

For further information, please visit:
The National Institute of Mental Health. http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml
JAMA. http://jama.jamanetwork.com/article.aspx?articleid=193642
UpToDate basics. http://www.uptodate.com/contents/electroconvulsive-therapy-ect-the-basics?source=see_link
UpToDate beyond the basics. http://www.uptodate.com/contents/electroconvulsive-therapy-ect-beyond-the-basics?source=see_link

* Surgeon/writer Sherwin Nuland gave this wonderful TED talk about the history of ECT and his own experience as an ECT patient. Please watch this video for a patient perspective. http://www.youtube.com/watch?v=oEZrAGdZ1i8

** FDA Executive Summary: Prepared for the January 27-28, 2011 meeting of the Neurological Devices Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices (ECT). http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/NeurologicalDevicesPanel/UCM240933.pdf

**UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361:799.

*** Rose D, Fleischmann P, Wykes T, et al. Patients’ perspectives on electroconvulsive therapy: systematic review. BMJ 2003; 326:1363.

****The only time I saw a court ordered ECT in 6 years of training was an elderly patient, depressed to the point of zero communication. He was completely immobile, could not eat, could not use the restroom. He stayed so still for such a long time that contractures developed in all 4 limbs. Since he could not communicate his wishes, the doctors petitioned the court. After 6 ECT treatments, he started communicating enough to be able to work with physical therapy, and eventually became mobile enough to walk short distances with a walker. I will never forget the first day he smiled at me.

About these ads

About purplesque

Psychiatrist, cook, bookworm, photographer. Not necessarily in that order.
This entry was posted in Psychiatry and tagged , . Bookmark the permalink.

49 Responses to The shocking facts about shock treatment.

  1. Rob Lindeman says:

    Nena, you lost me at the mechanism of action section. What you wrote is speculation bordering on fantasy. If the brain pathways involved in depression were known, I could accept, for the sake of argument, that ECT alters them. But these putative pathways are not known.

    Like resetting an electrochemical circuit? This is fantasy. I hope you don’t use such phrases with patients. If there is actually a therapeutic effect of ECT, as opposed to a large placebo effect as with SSRIs, the best you could say is you don’t know how it works.

    • purplesque says:

      Hi, Rob. Comparison with SSRIs, sham ECTs and placebo show a significantly larger effect with ECT. How would you explain that?

      As far as MOA, there is a reasonable amount of information out there on the effect of ECT on GABA, BDNF and other neurotransmitters. You may want to look up the UpToDate article on MOA of ECT.

      • Rob Lindeman says:

        Nena, of course you and I know that the mechanism of action of ECT is unknown, but your readers don’t know it because you didn’t tell them. So neurotransmitters are released? So what? This is not a mechanism of action. And I’ve read the same reviews you have.

        The problem with sham ECT as a placebo control is that it is just that: a sham. The subject wakes up and is not confused and has no memory loss. A proper control would do both. Similarly with SSRI trials, the controls do not experience any of the anti-cholinergic effects such as dry mouth or inability to achieve orgasm. And yet the so-called therapeutic effect is minimal to clinically-insignificant.

        Properly constructed trials would include “active” placebos. Without the side-effects, you have no placebo effect.

        • Rob Lindeman says:

          I should have said that without active controls you don’t have a TRUE placebo effect. And the comparison to SSRI trials was only meant to illustrate that even the small therapeutic effect may be due to absence of active placebo.

          With ECT, with general anesthesia, the potential for placebo effect is much larger. Incidentally, fascinating studies of sham surgeries also show large placebo effects. Go ahead, explain THAT one using neurchemicals if you like!

          • Rob Lindeman says:

            http://www.nejm.org/doi/full/10.1056/NEJM195905282602204
            An Evaluation of Internal-Mammary-Artery Ligation by a Double-Blind Technic
            Leonard A. Cobb, M.D.†, George I. Thomas, M.D.‡, David H. Dillard, M.D.§, K. Alvin Merendino, M.D.¶, and Robert A. Bruce, M.D.
            N Engl J Med 1959; 260:1115-1118May 28, 1959

          • Rob Lindeman says:

            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888585/
            Randomized Surgical Trials and “Sham” Surgery: Relevance to Modern Orthopaedics and Minimally Invasive Surgery

            Brian R Wolf, MD and Joseph A Buckwalter, MD
            Author information ► Copyright and License information ►

            • Rob Lindeman says:

              http://www.ncbi.nlm.nih.gov/pmc/articles/PMC321223/
              Relation between Depression and Intractability of Seizures
              Attarian H, Vahle V, Carter J, Hykes E, Gilliam F

              Epilepsy Behav 2003;4:298–301

              Patients with epilepsy have a higher prevalence of depressive disorders than the general population, but the relation between seizure rates and depression has not been adequately studied. We used the Beck Depression Inventory to evaluate depressive symptoms in 143 consecutive epilepsy patients from outpatient clinics. Patients who were seizure free for more than 6 months were considered not intractable. Thirty-six percent were neither intractable nor depressed, 43% had intractable epilepsy and were not depressed, 10% had intractable epilepsy and were depressed, and 11% did not have intractable epilepsy and were depressed. Patients with epilepsy have a higher prevalence of depression than does the general population, but the intractability of the seizure disorder does not seem to be an independent risk factor for the occurrence of depression. No relation occurs between the severity of depression and monthly seizure rate.

            • Rob Lindeman says:

              The analogy between uncontrolled epilepsy and ECT is the following: More seizures, less depression. ECT requires numerous repeats to be effective. Would you make the same argument if the evidence suggested that depression was minimal or absent in people with uncontrolled epilepsy? Check out the article I linked. They actually measured depression in uncontrolled epilepsy. It does not correlate with seizure frequency.

              Yes, going to court is coercive. Is that trick question? Please let’s not descend into arguments about the definition of coercion.

              Children cannot give consent, so they cannot be coerced legally. Yet I coerce children daily, several times per day. I at least am honest enough to admit that I do it. I “get away with it” because children cannot give consent. Now, do I coerce parents? I try not to, but it happens, hard as I try. Coercion is stitched tightly into our training. It shouldn’t be. It’s time to un-stitch it.

              Your demented freezing lady deserves compassion, a warm blanket and a cup of tea. I’d take her home. (GASP! You mean you wouldn’t let the benevolent State take over? After all, they are the experts! And they have more compassion than individuals!)

            • purplesque says:

              “They actually measured depression in uncontrolled epilepsy. It does not correlate with seizure frequency.”
              Of course it doesn’t; it likely correlates with the total disease burden and a thousand other things that happen when you have a chronic debilitating illness.

              “Coercion is stitched tightly into our training. It shouldn’t be. It’s time to un-stitch it.”
              Again, I agree with you. But, I’m honest enough to admit that the way things stand right now, I DON’T have a better solution. And neither do you.

              “Your demented freezing lady deserves compassion, a warm blanket and a cup of tea. I’d take her home.”
              Really? And set her up in your guest bedroom? How about the young guy who’s hearing voices telling him to kill himself and his children? Are you going to take him home as well, since he won’t be able to give informed consent, and pretty much all safe options involve “coercion”? Or should we let everyone who is too sick to give an informed consent stay where they are, and let nature take its course?

              How many old women have you taken home from your practice, Dr. Lindeman? You practice pediatrics in what seems to be a private setting. Try practicing psychiatry in the community setting where the people are extremely sick and often have NO ONE in the community to look for them- at least I’m honest enough to admit I can’t take them all home. And I choose not to let them die on the street.

          • purplesque says:

            So how, then, would you explain the bigger improvement compared with sham ECT, which would also include general anesthesia?

            My focus in this article is to tell people that ECT is not the hair singeing, zombie creating tool of coercion that it is made out to be.

            You point about MOA is well taken- I will edit the article to reflect this. I would also LOVE to see the trials with active placebo- who do you think will pay for them? Big Pharma?

            • Rob Lindeman says:

              The larger improvement with sham ECT may very well be due to the fact that in the placebo arms, the subject does NOT wake up confused and amnestic. That’s not much of a control. BTW. I’ve downloaded bar charts from the meta-analysis of ECT vs. Sham at psychiatry on-line. Those are some hefty placebo effects. Let’s see some studies where both arms are controlled with agents that confuse and steal memory.

              A trivial example, but I’ve had CF patients complain that they don’t think Xopenex works. What they were probably telling me is that they don’t feel the kick they feel with Albuterol because Xopenex is a racemer of Albuterol that doesn’t give cardiac side-effects.

              Big pharma will never fund studies using active placebos as controls because they suspect (or know for certain) that the therapeutic effects will go away.

            • Rob Lindeman says:

              “*Edited. There is no definitive answer to exactly how ECT works, but there are several well documented changes in the brain. The small seizure releases several neuro-chemicals in the brain. It also modulates the activity of several brain centers, such as the frontal cortex, prefrontal cortex, and cingulate cortex.”

              Better. If I were your editor, I might have suggested you remove the qualifiers “definitive”, “exactly”, and “small”. We don’t know how ECT works. Period.

              It’s a generalized seizure. “Small” by what standard? Do you mean “brief seizure”? I understand that you are trying to sell ECT to an understandably reluctant public. I’m just begging for clarity and truth.

              Regarding modulated activity, even if it were true, your use of Latinate anatomical terms is a tactic we (doctors) have used for too long to mystify clients and generally get them to do what we want them to do.

              I’m aware that several pathological studies have purported to show absence of evidence of neuronal loss or death after ECT (and another compelling one that shows that shock speeds neuronal cell turnover, so go figure). So let me ask you this: How is it that generalized seizures kill brain cells but ECT-induced seizures don’t?

            • purplesque says:

              “Better. If I were your editor, I might have suggested you remove the qualifiers “definitive”, “exactly”, and “small”. We don’t know how ECT works. Period.”

              I disagree. We have no definitive answer, but we have a pretty good idea. (Yes, the chemicals and the modulation- I’m happy to say ‘increase or decrease’ if you think that is more accurate.) I’m a psychiatrist- I use Lithium. I use psychotherapy. So, there are a LOT of treatments I use without a definitive answer to how they work, but research shows that they do.

              I do mean “brief” seizure when I say “small”. Not sure why that makes it unclear, or a lie.

              Re: lack of confusion with sham ECT, if subjects are getting general anesthesia, they are waking up at least a little confused. For a more “active” placebo effect, you would have to induce a seizure, no? How do you propose designing a better active placebo study?

              Re: brain cell death, I would say the brevity of the ECT induced seizures may make a difference in brain cell death. Oh, and the fact that patients are oxygenated and anesthetized may have something to do with it, too.

            • Rob Lindeman says:

              But it’s compelling to speculate as to why ECT needs to be repeated several times in order to “work”. I say because it takes several whacks at neurons before you kill enough of them to alter the brain enough so that the person feels different. What say you?

              We have a type of control for seizures in ECT. We have people with epilepsy. People with uncontrolled epilepsy should be more depressed than well-controlled epileptics. Yet they are. Why? And people with well-controlled epilepsy should be more depressed than poorly controlled epileptics, yet they’re not. Why not?

              As for your argument about efficacy: I don’t mind your using any modality you want so long as two conditions are met: the client is fully-informed and gives consent, and you do not lie to him about the mechanism of action of the therapy. If you don’t know, say so. Oh and there’s a third. No coercion. Ever.

            • Rob Lindeman says:

              Sorry: people with uncontrolled epilepsy should be LESS depressed, not more. Second half of the syllogism is worded correctly, I think

            • purplesque says:

              Your turn to lose me.

              ECT would more resemble controlled epilepsy, if at all. How is uncontrolled epilepsy akin to ECT? And are you saying that a chronic debilitating illness like uncontrolled epilepsy would have no effect on someone’s quality of life, and therefore their mood? Really, Rob.

              “I don’t mind your using any modality you want so long as two conditions are met: the client is fully-informed and gives consent, and you do not lie to him about the mechanism of action of the therapy. If you don’t know, say so. Oh and there’s a third. No coercion. Ever.”

              I actually agree with you wholeheartedly.

              As for the “coercion” part, we’ve talked about this before. What are your solutions for people who are unable to give informed consent d/t mental/physical illness? Is going to court to get a court ordered treatment “coercion”? How else would you propose we treat someone who is extremely sick and can’t consent to treatment? Do you treat your pediatric patients even though the young ones can’t give informed consent? What were you going to do with my demented old lady found freezing on the highway? Oh, yes, send her to the ER. Where someone else (an ER doc, maybe a psychiatrist) would be in charge of “coercing” her into a safe place while you sit in your armchair and bemoan the state of medicine.

  2. Zotta says:

    I knew someone who improved a little from ECT and became less suicidal(after nothing else worked). She had to write a number on a piece of paper by her bed. After ECT she’d wake up, call her mother and say, “Where am I?” But now her memory is completely fine, as far as I know.
    I never saw her happier than when she had her first child, although not always the right choice for everyone, least of all me:) I really enjoy children a lot, though.

    • purplesque says:

      Thank you, Z. The memory loss from ECT can be persistent and is often distressing. Getting a clear informed consent from all patients who have capacity to do so is extremely important. I’m glad your acquaintance is fine now.

  3. LG says:

    Very informative post. Thank you.

  4. Drag says:

    “You’re mixing electricity with water!” – Choosing such an idiosyncratic comment first in order to misrepresent and belittle “antipsychiatry”, puts you in a bad light imo.

    “Meta-analyses…show that ECT is more effective than any other treatment used for severe major depression” – Why do you totally omit any mention of the quandry that, all else being equal, nearly all responders remit (fall back into major depression) within a few months?

    “The trope of a poor, mentally ill person being given ECT against their will is just that, a trope.” – Sure about that are you? In the UK (and you elsewhere cite a UK review) the official regulator has warned that psychiatrists are too readily assuming that patients are able to give informed consent to ECT. They previously warned that psychiatrists were too readily using loopholes to give ECT without consent or second opinion under emergency procedures.

    • purplesque says:

      “Choosing such an idiosyncratic comment first in order to misrepresent and belittle “antipsychiatry”, puts you in a bad light imo.”
      I have plenty of others where that came from. I chose the less inflammatory ones, actually.

      “Why do you totally omit any mention of the quandry that, all else being equal, nearly all responders remit within a few months?”
      Because depression is a relapsing remitting illness, and ECT is still effective. People on antidepressants remit, too.

      “In the UK..the official regulator has warned that psychiatrists are too readily assuming that patients are able to give informed consent to ECT. They previously warned that psychiatrists were too readily using loopholes to give ECT without consent or second opinion under emergency procedures.”
      I have no first hand knowledge of ECT in the UK. Can you link to that warning, please? I have never seen ECT being done as an emergency procedure in the US. I would have to find out what the emergency was before I can give my take on that.

      • Drag says:

        I think comparing ECT efficacy to antidepressant medications is problematic because, at least in the UK, ongoing or ‘maintenance’ ECT is no longer recommended, due to poor evidence of additional benefit given the extra risks and adverse effects.

        The regulator I mentioned is the Care Quality Commission, e.g. http://www.cqc.org.uk/sites/default/files/media/documents/mhac_biennial_report_0709_final.pdf pointing out the emergency powers were meant to be very rare for extreme cases of e.g. dehydration, severe suicide risk etc, but in fact a quarter of the time where there were doubts about consent doctors were giving ECT under those powers. Apparently about 1000 people a year in England alone are given ECT without consent. Googling found this blog on first page which I have absolutely nothing to do with but has several posts indicating that the stats are routinely under-reported and buried here and in various countries, and i noticed this on a different creepy form of coercion in Denmark http://ectstatistics.wordpress.com/2012/04/21/ect-and-coercion-in-denmark/

        Gather ECT is used without consent in US hospitals too, and has occasionally been on community outpatients.

        • purplesque says:

          “I think comparing ECT efficacy to antidepressant medications is problematic because, at least in the UK, ongoing or ‘maintenance’ ECT is no longer recommended.”
          In the US, it is. And I have no idea how that it makes it a problem to compare ECT to medications.

          I read that 200 some page report, Drag. :) All I can see is that the UK government put an act in place that says you can’t do ECT without informed consent in a patient who has capacity unless it’s an emergency. I believe that is the status quo in US. Further more, the report states that there was a concern that there would be an increased use of emergency ECT once the act was in place, but, in fact, THERE WASN’T. The number of emergency ECTs stayed the same.

          In my personal opinion, there are very, very, very few instances where ECT may qualify as an “emergency” treatment. Acute dehydration mentioned in the report may be one. Would I, personally, use ECT as an emergency treatment? Probably not, but that is my take on it.

          “Gather ECT is used without consent in US hospitals too, and has occasionally been on community outpatients.”
          Again, references? Only three US states even collect ECT data- not sure where you gathered this from.

          • Drag says:

            “I have no idea how that it makes it a problem to compare ECT to medications” – No idea why a high remission rate is more an issue for a one-off treatment than one that can be ongoing?

            “I read that 200 some page report” – Right but we were only discussing ECT (a handful of pages). You have cherry-picked a stat covering 3 months after a change in law in 2008 but I repeat, it states that nearly a quarter of involuntary ECT is under emergency procedures regardless of capacity to consent.

            Their next report states “We were concerned to find that a third of the 1,339 patients referred for a second opinion in 2009/10 were given at least one application of ECT under urgent treatment powers…” ( http://www.cqc.org.uk/public/reports-surveys-and-reviews/reports/mental-health-act-annual-report-2009/10/download-mental-h ) [I NOTE THAT A THIRD IS MORE THAN A QUARTER.....................]

            Their review of 2010/11 states “We are concerned about cases we have seen where doctors appeared to assume capacity too readily.” ( http://www.cqc.org.uk/public/reports-surveys-and-reviews/reports/mental-health-act-annual-report-2010/11/consent-treatment )

            “Only three US states even collect ECT data- not sure where you gathered this from.” – Well that’s a damning fact for you isn’t it? I mean you just blogged that the idea of “poor, mentally ill” people being given ECT against their will is a fiction, yet in many parts of the world we just don’t know? But simply Googling or Wikipedia’ing suggests that US states are administering ECT against patients’ wishes, whether based on emergency procedures or capacity thresholds (and as the first report I linked says “There is a danger that the threshold becomes whether or not professionals are prepared to recognise as valid a patient’s resistance to treatment”)

            • Drag says:

              meant recur/relapse

            • purplesque says:

              “No idea why a high remission rate is more an issue for a one-off treatment than one that can be ongoing?”
              ECT is NOT a one off treatment in the US.

              “Well that’s a damning fact for you isn’t it? I mean you just blogged that the idea of “poor, mentally ill” people being given ECT against their will is a fiction.”
              NO. I based it upon my 6 years training in three different institutions across US, where I saw >200 ECTs. Only one was court ordered, none as an “emergency” procedure.

              “But simply Googling or Wikipedia’ing suggests that US states are administering ECT against patients’ wishes”
              Gee, I wonder where Google or Wikipedia are getting that information, given that NO ONE is collecting it. For the record, I wish they did.

              Here’s an idea. A more constructive use of your time may be starting a petition to mandate anonymous reporting of all ECT treatment, as well as audits of informed consent. An idea that both sides of the fence might agree to? I certainly would.

  5. I didn’t comment on this earlier because I really don’t know enough about ECT to say it’s bad or good. Robert Pirsig, author of “Zen and the Art of Motorcycle Maintenance” writes at length about his bout with mental illness, which was eventually treated with electroshock therapy. His view was largely negative: it “cured” him, but it also erased parts of his memory, which he claims gradually returned in fragments on his journey across the western U.S.

    I will admit it sounds scary, but I also recall struggling with crippling depression, and the days where I could barely respond to greetings by friends. I was lucky in that my condition responded to medication. If it had not, I think I would want to try the therapy recommended by my doctor. I never want to live in darkness again.

    • Lurkertype says:

      Back in his day, the voltages were much higher and there was no anesthesia/muscle relaxant, plus I think the shocks were given more often.

      Losing some memory — generally temporarily — seems a small price to pay to be able to function again. The man who went from immobile to walking and smiling, that’s a beautiful story. Severely depressed people don’t always have memories that are good (in both quality and quantity) anyway.

      Purp, you are ever so much more patient (no pun intended!) than I; I would have ignored and blocked the “doctor” who seems to know nothing and care less about psychiatry. I pity his patients, frankly; I wouldn’t take a child to him. That’s the sort of stuff I normally only hear from,,, how does one say this delicately… persons who believe as a certain recently-divorced couch-jumping movie star do. Everyone I’ve known who’s had general anesthesia has been confused and had a touch of amnesia afterwards, so I don’t know what he’s complaining about there.

      Thanks for being so compassionate to those who bear the brunt of such heavy illnesses. You are a better person than I am, I think, and certainly a better cook. :) If I ever go completely round the bend (“completely’ has been under debate for decades now, LOL), I hope you or someone like you is there to do what’s needed.

      Namaste, girlfriend!

      • purplesque says:

        Thank you, Lurkertype.

        The memory loss with ECT is more than just the effect of anesthesia, but when struggling with crippling depression, some people choose to take that risk. Informed consent is key- my only goal in writing this post was to try and present a counterpoint to all the anti-ECT rumors floating around on the internet.

    • purplesque says:

      HG, I wish more people had the balanced opinion that you do- instead, they choose to accept the media portrayals and the internet rabble rousing as the truth. Pirsig’s experience seems fairly common- I suspect it was a while ago, though, and the procedure itself has changed a lot since then. The persistent memory loss is quite common and often distressing- I think it’s best to get a comprehensive informed consent and give people a lot of time to make up their mind where possible.

  6. phantomxii says:

    Perhaps we should all take to calling you Nena. Nothing wrong with being confused with the “99 Red Balloons” chick. ;-)

    Very interesting post. I admit that the impact on memory, and the possible need for repeated treatments, seem like daunting caveats to ECT. Perhaps acceptable, yes, for someone who is functioning barely if at all, since it could at least alleviate their suffering. But if that patient needs repeated treatments, each causing memory difficulties, mightn’t ECT interfere with larger, longer-term improvements in functioning—such as being able to live independently or get a job, things that require some amount of learning and memorization?

    By the same token, it seems ECT would be problematic, say, for someone who manages to muddle through a more-or-less-functional existence despite crushing depression that hasn’t responded well to meds or talk therapy. That patient might feel better, but losing a significant amount of accrued knowledge and insight in a professional environment can be devastating to job performance (and might in turn damage any gains in self-worth). And they’d have to hope the boss was enlightened and sympathetic to the need for a medical absence, and understood why one’s job aptitude would be hampered afterward. Perhaps the U.S. has tried to make it illegal to fire someone for being sick, but companies that want to unload an employee can always find some other trumped-up cause. (Particularly in a difficult job market, it seems companies aren’t motivated to hire or keep people with problems when there are so many applicants to choose from. Short-sighted, yes, but so are a lot of companies.)

    I’m absolutely not taking a stance against ECT; I’m just pondering the impracticality for some patients. There seems to be a rather large gap between medication, which can presumably be worked into the routine of ordinary, functioning life, and the disruptiveness of ECT.

    • purplesque says:

      “…mightn’t ECT interfere with larger, longer-term improvements in functioning—such as being able to live independently or get a job, things that require some amount of learning and memorization?”
      A valid question. The inability to retain/learn new information after ECT is temporary and resolves in a few weeks. It is the retrograde amnesia- mostly forgetting events during/around the time of ECT- that is problematic for most people. In my experience it does not interfere with independent living (activities like paying bills, doing household chores, groceries, self care), but could it be problematic for someone in school/ in a job requiring memorization/learning of new skills? Yes.

      “it seems ECT would be problematic, say, for someone who manages to muddle through a more-or-less-functional existence despite crushing depression that hasn’t responded well to meds or talk therapy.”
      Yes. I would never offer ECT to someone who manages to be functional- my personal opinion is that it should be restricted to the severely depressed- the actively suicidal, the catatonic, the psychotic.

      And therein lies what has always been my beef with ECT- if it is done without an adequate informed consent or for indications that are less severe or when alternative treatments haven’t been tried. This, unfortunately, is true for all procedural treatments- including surgeries of all kind. This is where we need reform.

      (On a lighter note, please don’t call me Nena! I did not want to cramp the good doctor’s style above by mentioning he got my name wrong. You are held to higher standards. :D)

  7. phantomxii says:

    Only kidding! I have no actual intention of perpetuating such misnomers. :-)

    I think generally I agree with what you’re saying. I’m curious about your comment that “I would never offer ECT to someone who manages to be functional- my personal opinion is that it should be restricted to the severely depressed- the actively suicidal, the catatonic, the psychotic.” I may be stumbling over diagnostic distinctions that I don’t understand, but can’t someone be severely depressed yet functional at the same time? I’m thinking, anecdotally, of people who appear to be doing fine in life and don’t have any cataclysmic problems—except for depression itself, often missed by others, which ends in suicide. Perhaps these have to be considered case-by-case, but if the outcome is suicide, surely something severe is in play? Or is it not that simple?

    • purplesque says:

      “…can’t someone be severely depressed yet functional at the same time?”
      Yes. By DSM criteria, to be diagnosed with major depression, one must have “clinically significant distress or impairment in social, occupational or other important areas of functioning”. Further, one can have mild, moderate or severe major depression- is one person’s moderate another person’s severe? Of course. In my experience, people who are higher functioning in general tend to continue to function even when severely depressed.

      It is straightforward to offer ECT to those who are actively suicidal, psychotic or catatonic. Could there be functioning yet still severely depressed people who would benefit from ECT? Yes. That is where I would defer to a ‘case by case’ assessment- my own approach is more conservative, but there is no absolute answer. So, yes, it’s complicated.

      Re: the anecdotal person who’s doing fine until they kill themselves? That has more to do with missed suicidality- they never saw someone, they saw someone but weren’t screened for suicide risk, they were screened for suicide risk but denied it at the time. Like a patient once said, “why would I tell you if I were planning to kill myself?” As a psychiatrist, I am trained to always screen for suicidality no matter how well someone seems. Can I prevent all suicides? As much as I HATE to say this, no, I can’t.

      • phantomxii says:

        You can’t prevent them all, but your vigilance will make a difference.

        Sad to say, some admit their suicidal intentions but aren’t taken seriously—whether by family, friends, overwhelmed/undertrained professionals, whoever. Maybe routine training should be offered to the public in suicidality response, just as training in CPR is offered. But then, even with those resources available, a lot of people still don’t know CPR!

        Anyhow, thanks for an interesting post, and your thoughtful responses on this rather voluminous comment thread.

        • purplesque says:

          Coincidence- this issue of TIME has a cover story on military suicides. Apparently, military familes are trained to watch for/act when a loved one becomes suicidal. Sadly, some times that is not enough.

          Thank YOU for a genuine discussion of the challenges of mental health diagnosis and treatment. This is what we need.

    • purplesque says:

      Right. Judging by the author’s picture, this was at least 50 years ago. Or are we fighting past injustices now, leaving the present to fend for themselves? Oh, I forgot, you’re taking them all home.

      I had also linked to a personal testimony by Dr. Sherwin Nuland, speaking as an ECT patient. Here it is again. Or is that not relevant, because GASP! ECT worked for someone. http://www.youtube.com/watch?v=oEZrAGdZ1i8

      • Rob Lindeman says:

        I loved Sherwin Nuland’s book on Ignaz Semmelweiss. It should be recommended reading for anyone (present company included) who feels compelled by the evidence to speak out against the status quo, even when doing so gets one’s head bashed in (and I’m not referring to ad hominem attacks at blog posts!)

        I understand the practice using Tu Quoque when needing to defend an indefensible argument. My wife uses it all the time. It’s easier than admitting that present day ECT comes to us bearing the scars of an horrendous history. It’s a worthy cautionary tale, just in case there are any traces of old-school paternalism left in the modern psychiatrist; and of course of course, there are none ; )

        • purplesque says:

          Recommendation taken; I will get the book as soon as my head is unbashed.

          Is Tu Quoque a fancy latinate term? Because I have no clue what it means. :D

          Present day ECT bears the scars of a horrendous history. I agree. Is that enough to completely disregard, nay, ridicule and slander what may be a life saving treatment for some? Your call, doc.

          • Rob Lindeman says:

            Tu Quoque roughly translates as “So’s your old man”. The forum matters, of course. I’m speaking to you as a colleague, not as a lay person. If you’re going to engage in arguments, it’s good to know these terms.

            I don’t dispute that Sherwin Nuland or anybody else emerged from ECT in better shape. Many people emerged from pre-frontal lobotomy greatly improved (See Jack El-Hai’s masterful biography of Walter Freeman). Just because a therapy has an horrendous history and was forced upon unwilling clients does not mean that it does not sometimes “work”. Snake oil sometimes works. That’s not my point.

            Purplesque (I’m observing the “No N-word rule” here), we’ve deviated from the reason I jumped in here, to wit, you told un-truths to your readers regarding the MOA of ECT. You corrected that, and I’m grateful. I expect you’ll do the same to your patients.

            • purplesque says:

              At no point did I tell an un-truth. Mentioning neurochemicals and modulation of brain pathways wasn’t a complete explanation of the MOA, and I corrected that when you pointed it out.

              You, on the other hand, just compared ECT to snake oil and pre-frontal lobotomy. So your intent was just to correct me on the MOA? I’m not the one who needs to learn about how to engage in arguments, Rob. Unless the point is simply to win at any cost.

            • Rob Lindeman says:

              Hoo-boy: Analogy, not equation. Do you really want to argue about how to argue? Doing so undermines the arguments you’re actually making.

              Neurochemicals and modulation are less than explanation for the MOA of ECT: It is speculation at best, and un-truth at worst. If you tell this story to your patients, you should mention that it’s only speculation.

  8. purplesque says:

    “If you’re going to engage in arguments, it’s good to know these terms.”
    “Do you really want to argue about how to argue? ”
    “Doing so undermines the arguments you’re actually making.”

    p.s. There are links to actual studies (!) agreeing with my speculations above on UpToDate.

  9. I didn’t want to enter an argument between two doctors, but when someone says:
    I understand the practice using Tu Quoque when needing to defend an indefensible argument. My wife uses it all the time

    I hear “old-school paternalism.” And I don’t envy that person’s wife.

    (Yes, that is an ad hominem attack, but the poster opened himself up big time there.)

  10. Zydecohogg says:

    Three years ago I was very suicidal, had been hospitalized five times over the course of a year, and tried just about every psychiatric medication available, and was getting no better. Prior to this, I had experienced dysthymia for many years, which was manageable with medication and therapy. I finally decided to undergo a series of ECT treatments which I believe saved my life. After just a couple of treatments, my friends were amazed at the difference in me. Don’t get me wrong, it was a long climb out of that hole, but I at least had a rekindled the will to begin to crawl out. I experienced some memory issues, but that has improved over time. Honestly, I’m not especially interested in how ECT works, and I wouldn’t recommend it unless all other avenues had been exhausted, but for me it brought me back from the brink.

    • purplesque says:

      Thank you, Zydecohogg. It is hard to share experiences with crippling depression, but success stories like yours serve as a counterpoint to the knee-jerk phobia ECT generates at times. Thank you again, and I hope you are well.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s