Don’t be Shocked — Electroshock Therapy Works!

Palla (sxc.hu)

Think of Jack Nicholson’s portrayal of McMurphy in the movie One Flew Over the Cuckoo’s Nest. It brought electroconvulsive therapy (ECT) and the controversy surrounding it to the cultural forefront back in the 1970s. Well, the subject is once again in the news. Many people, including patients and psychiatrists, believe that ECT can be an invaluable tool in the recovery from clinical depression, while others criticize it as unsafe, extreme and even unhelpful.

Earlier this year, a cadre of influential mental health organizations, including the American Psychiatric Association and the National Alliance on Mental Illness, teamed up to urge that the FDA downgrade the risk rating of ECT devices to medium-risk from high-risk, a move that would put them in the same risk category as syringes and surgical drills. After reviewing the request, an FDA advisory committee in March recommended against taking this action — not because the procedure is known to be unsafe but because there’s little research that proves it is safe, particularly long term. Proponents of ECT argue that this will make it difficult for many patients who would benefit by having access to ECT, with some saying that such a ruling even may make the treatment unavailable altogether.

 SAFETY TESTING HASN’T BEEN DONE

 Though ECT has been around in one form or another since the 1930s, you may be surprised to learn that it has never undergone rigorous clinical trials. Because of its long history of use, it was grandfathered into FDA regulations in 1976, when the agency was given more authority to regulate medical devices. At the time it was categorized as “high-risk,” primarily because of the memory loss and other cognitive problems suffered by recipients. But keeping it in that category going forward may mean that manufacturers would be required to perform expensive and time-consuming tests to prove safety — which device makers claim they cannot afford.

As agency officials ponder their decision, I put in a call to Charles Kellner, MD, a professor of psychiatry at Mount Sinai School of Medicine and a leader in ECT research. He told me that the technology does have some history of abuse — such as when patients at psychiatric hospitals received ECT simply for not being cooperative… or when ECT was used as a punishment for troublesome inmates in prison — and acknowledged that as a result there is a stigma surrounding it. But he believes that evidence shows today’s version of ECT is safe, painless and effective for people with severe depression who have found no relief from other therapies.

 IS ECT DANGEROUS?

 About 100,000 American adults undergo ECT each year. It’s typically prescribed for patients who haven’t been helped by medications and psychotherapy, and 60% to 90% are helped by the treatment. It’s believed that ECT works by triggering changes in brain chemistry that reverse at least some of the symptoms of serious mental illness, often within days.

The main criticism of ECT is that it causes memory loss — and it does — but Dr. Kellner cited three reasons he believes the concern is exaggerated…

  • Modern techniques, such as lower doses of electricity and application to only one side of the brain, have greatly reduced memory loss in comparison to past methods of administration.
  • The memory loss that does occur varies greatly by individual and is usually only temporary — typically lasting for a few weeks.
  • When you have a potentially life-threatening disease that can lead to suicide — the eleventh-leading cause of death in theUS– the vast majority of psychiatrists believe that the benefits outweigh the risks.

WHAT PATIENTS EXPERIENCE

 ECT can be administered on an outpatient basis and typically involves six to 12 treatments over three to five weeks, each costing $1,000 to $2,000. Some insurance companies pay for the treatments, others don’t.

Each treatment begins with the patient being given a muscle relaxant… a foam bite block… and general anesthesia through an IV line, which renders the patient unconscious and unaware during the procedure. An electrode pad is placed on his/her forehead, through which a mild electrical current is passed, triggering a seizure that lasts about 45 seconds. The patient wakes up within 10 minutes or so, is taken to a recovery area to be monitored for any problems (such as increased heart rate and blood pressure) and goes home, usually about an hour after the treatment. Many patients experience temporary confusion and disorientation, which typically doesn’t last more than a few hours and usually just a few minutes. Other possible transitory side effects include nausea, vomiting, headache, jaw pain and muscle aches or spasms.

 TAKE THE BAD WITH THE GOOD?

Serious depression is often a lifelong illness, Dr. Kellner noted, and although ECT alleviates current symptoms, it cannot cure the underlying disease. Therefore, if they are not already taking it, patients also are given antidepressant medication to prevent the next depressive episode. Some 20% of patients also receive prophylactic maintenance ECT — a once-a-month repeat treatment to forestall future occurrences of depression.

Dr. Kellner compares ECT to serious medical interventions in other health crises — for example, coronary bypass for people with heart disease and chemotherapy for those with cancer. They’re not easy or risk-free treatments, but they can and do save lives. He pointed out that many people fail to understand that severe depression also threatens survival — and for patients with this disease, ECT can likewise be lifesaving.

Source:  Charles Kellner, MD, professor of psychiatry and director of the division of geriatric psychiatry, director of the ECT Clinical Service, Mount Sinai School of Medicine, NYC. He is a leader in the field of electroconvulsive therapy research. Dr. Kellner is the coprincipal investigator of a multisite study of maintenance ECT for geriatric depression and has led the collaborative ECT research group, Consortium for Research in ECT (CORE), in the performance of NIMH-sponsored multisite research protocols.

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