Date: Fri, 2 Dec 1994 12:37:27 -0500 From: NAME Subject: ECT article (long) To: Multiple recipients of list MADNESS The following article appears in the November 14, 1994 issue of New York magazine. SHORT SHARP SHOCKS by Gene Stone. It's still popularity feared and reviled. But these days, it's kinder and gentler-and widely used. Electroshock therapy is jolting thousands of patients out of suicidal depressions FULLY CLOTHED EXCEPT FOR HIS FEET, LYING FLAT ON A table, Ralph Thomas, a 40-year-old hardware salesman, is waiting for electricity to course across his brain at 100 volts. His hands are trembling. Warm drops of sweat form on his forehead and roll onto his cheek; an orderly flicks them off with his finger. "Everything ready?" a nurse asks. The doctor nods and pushes a button. Ralph Thomas is at a hospital in Queens undergoing electroconvulsive therapy (ECT), the psychiatric treatment that used to be called shock therapy. Electrodes are placed on a patient's temples, and between 75 and 150 volts are shot across the brain to induce a seizure. For reasons not yet understood, the seizures work on the brain like a powerful drug, yanking patients out of severe depressions. After years of publicity so bad that ECT became synonymous with the image of depraved doctors running around will loose electrodes in their hands, the treatment is slowly, and very quietly, regaining respectability. Not that it doesn't have critics who still call it a grotesque torture responsible for brain damage and memory loss, as rendered in the movie One Flew Over the Cuckoo's Nest, in which the Jack Nicholson character is given unwanted and uncalled-for shocks. ECT's opponents have been powerful enough to pass ordinances prohibiting the use of the treatment in some cities-including Berkeley, California (although the court later overturned the ban). On the other hand, a 1987 Harvard Medical School Mental Health Letter cited evidence that ECT is "a safe and sometimes uniquely effective treatment." In a March 1993 editorial, The New England journal of Medicine stated that ECT was "an important method of treating certain severe forms of depression." And the National Alliance for the Mentally Ill, currently the country's largest organization for the rights of people with neurobiological disorders, strongly opposes limiting access to ECT. No other treatment in modern psychiatry engenders such contention. Depending on who is asked, ECT is defined as either a gift from Heaven or a hell on earth. THE NOTION OF INDUCING A SEIZURE AS A REMEDY FOR MENTAL distress dates back to the late eighteenth century, when scientists noticed that convulsions caused by the injection of camphor or other chemicals had a remarkably salutary effect on mental patients. But it wasn't until 1938 that electricity was used to generate such convulsions. An Italian scientist who tried it on several patients noticed that it relieved their depression. Shock therapy quickly became a psychiatric fad, prescribed for any and all mental disturbances with little idea as to the proper dosage or how it actually worked. Ted Chabasinski, a Berkeley lawyer and a leader in that state's anti-ECT movement, recalls undergoing ECT at Bellview Hospital in 1944, when he was 6 years old, as a result of a diagnosis of schizophrenia. His foster parents objected strenuously to the idea, but they were unable to stop the doctors from proceeding with the treatments. "It made me want to die," Chabasinski says. Afterward, he couldn't remember his friend's names or how to find his way around his own neighborhood; the social worker told his parents that this kind of memory loss was a symptom of his illness, and he was institutionalized for ten years. Chabasinski, who eventually went to college and law school, has devoted much of his life to fighting ECT's usage. Supporters admit that ECT was mishandled when it was first used. Patients in the early fifties received as many as 100 treatments, rather than the 6 to 12 currently recommended. The amount of electricity shot through their brains was also greater, and the wave forms of the stimulus was different. (Treatments were once given as often as three times a day; now the current standard is three times a week.) Formerly, patients weren't given anesthetics or muscle relaxants, nor were they monitored with EEGs and EKGs, as they now are. ECT is currently used to treat schizophrenia, mania, and (for 80 to 90 percent of ECT patients) depression. Depressed patients are generally not given shock treatments until they have tried_and found no relief from_psychotherapy and such antidepressants as Prozac or Zoloft. "ECT is seldom the first treatment tried, because of its bad publicity," says Dr. Richard Weiner, director of Duke University's ECT program. "Back in the fifties, it was abused. Now the pendulum has swung the other way, and it's underutilized." Dr. Weiner guesses that approximately 45,000 patients a year undergo the treatment; others estimate the figure at more than 100,000. One of the few states to keep actual figures is California, where in 1990, 2,671 courses of ECT were given. ECT's foes, to prove its overuse, tend to exaggerate the numbers; its allies, to demonstrate its underuse, minimize them. SEVERAL MONTHS BEFORE RALPH THOMAS WAS BORN, his mother, despondent over her pregnancy and a victim of depression herself, tried to abort her baby by taking pills and jumping out a window. It didn't work. Ralph was born into a morose middle-class family in Queens that didn't want him. His parents paid him little attention, so his sister, older by eighteen years, became his surrogate mother. Constant teasing by his peers added misery to Ralph 's unhappy childhood, and in his teens he began to suffer stinging depressions that lasted several months at a time. He eventually found a good job, married, and had children of his own; but the depression never abated, even with the help of psychotherapy and antidepressants. In the summer of 1993 his condition reached a crisis point. Waking up in the middle of each night, he became so obsessed with suicide that he couldn't return to sleep. Ralph had two recurring fantasies: cutting out his heart with a long, sharp knife, and electrocuting himself by throwing an appliance into a bathtub full of water. His family sent him to Hillside Hospital, in Glen Oaks, Queens, hoping that something else could relieve his anguish. Ralph's intense suicidal thoughts and his past failure to respond to other treatments led his doctor, Alan Mendelowitz, to recommend ECT. "When he came into my office, Ralph looked like an F.L.K.," says Dr. Mendelowitz. "A funny-looking kid." Ralph's height, weight, and facial appearance are average, but his bearing is unusual. "He seemed different from the average guy," says Mendelowitz. Ralph's gait is awkward, his conversation marked with inappropriate giggles, as though he were responding to internal jokes only he could hear. Just before going into his second session, Ralph told his doctors, "I'd like to die. But first I'm going to be zapped." The coincidence of his electrical-suicide fantasy and his electric-shock therapy isn't lost on him. As he waits his turn, Ralph tries to calm himself down by pacing around his ten-by-fifteen-foot room and making jokes. He says he doesn't find it any comfort that the name shock therapy has been softened to convulsive therapy. "Who wants to have convulsions?" he asks. ECT is a perplexing and inexact treatment, and not simply because its underlying mechanics aren't understood. For many years, ECT testing lagged behind other disciplines'-in part, says a doctor who performs the therapy regularly, because of a lack of adequate funding for research. (Research money is often provided by drug companies; it is this doctor's belief that drug companies resist ECT because it would hurt drug sales.) But according to Dr. Harold Sackeim, chief of the Department of Biological Psychiatry at Columbia-Presbyterian Medical Center and a consultant for the APA's Task Force on ECT, the situation has changed considerably in the past decade, as more doctors have come to recognize ECT's effectiveness. Several major research studies are now being conducted at Columbia-Presbyterian, including a $4-million study on the prevention of relapse. For the most part, biological psychiatrists and psychopharmacologists don't believe that depression can be relieved for the long term. They don't claim to rid a patient of the source of his depression; rather, they try to address individual episodes. Thus, the studies so far conducted on ECT haven't dealt with long-term success as much as with whether ECT causes death (mortality from treatment is very low) and brain damage. The few studies that indicate the possibility of brain damage are dated, and therefore highly mistrusted by experts because ECT methodology has changed. The most recent American Psychiatric Association task force report-from 1990-calls ECT "often the safest, fastest and most effective treatment" for severe depression. Both critics and advocates do agree that the average ECT patient suffers memory loss. Opinions as to how much loss takes place vary widely. Most ECT doctors say that memories acquired around the time of the therapy may well disappear forever, although Weiner maintains that some of his patients' memories have actually improved after ECT. The treatment's opponents claim that the risk of having a lifetime of memories wiped clean is always present, and they can and do produce people to testify to this result. Advocates counter with the argument that hundreds of thousands of people over the past five decades have undergone successful ECT treatments, including Thomas Eagleton, Vladimir Horowitz (who continued to play hundreds of keyboard pieces from memory), and most recently Dick Cavett, who has publicly acclaimed ECT's effectiveness. In New York City, hospitals like Columbia-Presbyterian, Gracie Square, Mount Sinai, New York Hospital (the Payne Whitney Clinic), and New York University conduct ECT sessions regularly. "We've administered ECT to thousands of patients at Columbia-Presbyterian," says Dr. Sackeim. "Without doubt, ECT is the most effective antidepressive we have. We see improvement rates that are exceptional-up to 80 and 90 percent." It's unlikely anyone would undergo ECT today unless by consent. But opponents say that the consent forms, which vary from hospital to hospital, are either too lax or too abstruse-and besides, few people have the capacity or knowledge to say no when confronted by an authority figure. (An exception is a New York woman who became depressed in 1991 and failed to respond to drugs. Her doctor and her husband urged her to undergo ECT, but she refused to sign her consent form. Eventually, her doctor took her to court. After listening to his arguments, she changed her mind, and ECT ended her depression. "I know it sounds strange," she says, "but I'm grateful my doctor took me to court.") After the orderly walks Ralph to the ECT area, he sits in the crowded waiting room, brooding. Today, about a dozen people wait with him. The alarmed screams of a woman recovering consciousness following her treatment are highly audible through the wall, but the patients choose to ignore her. Dr. Samuel Bailine, the physician in charge of ECT at Hillside, emerges from the ECT room to apologize. "That doesn't usually happen," he says. He seems abashed. "She woke up scared. Sorry." Ralph stares pensively at the other patients. One of them, a tall, bearded 34-year-old in a New York Jets jacket, first underwent the therapy three years ago. He is now on maintenance ECT (a fairly new concept) and comes to Hillside every Friday. "If we had known how terrific ECT was," his mother says, "we would have done it sooner. It saved his life." A half-hour later, it's Ralph's turn. The orderlies lead him into the ECT room, which is large and unpleasantly bright. ("We have to light it like this," Dr. Bailine explains. "Otherwise we wouldn't be able to watch the monitors.") After being placed on the table, Ralph is hooked up to the $8,000 ECT machine, which resembles an old stereo receiver component. A doctor cleans Ralph's brow with alcohol and then applies conducting jelly to the electrodes to help the current flow from the metal to the skin. Ralph is also given intravenous water, along with a short-acting barbiturate and a muscle relaxant. While waiting for the barbiturate to kick in, the anesthesiologist supplies Ralph with enough oxygen to guarantee that his brain is not oxygen-deprived during the seizure, and places a bite block in his mouth. The staff is also monitoring Ralph's brain waves, the oxygen saturation of his blood, and his heart rate-his pulse is currently 75. Then they turn the machine on. During the seizure, which lasts half a minute, Ralph's body remains inert, except for a small curling motion in his toes. Only the monitors reveal Ralph's raging internal state; his pulse charges up to 130 before dipping down to 70. Then it's over. As Ralph starts to awaken, saliva drips from his mouth. He's conscious, but his eyes are closed. "Ralph!" an orderly says. "It's over." Ralph's eyes open. They look panicky. "It's over," the orderly repeats. Ralph shows no sign of understanding. "Do you remember me?" the orderly asks. "No." "Where are you?" "Don't know." Ralph has no memory of the past few hours. The questions revealed to him and his doctors how little he can recall. He looks more and more frightened. "Where are you?" "Hospital," Ralph finally says. The orderly helps Ralph to his feet and leads him to a small room, where he offers him orange juice in a polystyrene cup. Ralph's hands shake as he drinks. "Have you eaten today?" the orderly asks. ECT patients aren't allowed food the morning of the treatment; Ralph's last meal was dinner the previous night. "Yes," Ralph says. The orderly asks another question: "How old is your kid?" Three," Ralph replies. The boy is 7. An hour later, back in Ralph's room, Dr. Robert Colucci, a 33-year-old resident handling Ralph's case, asks more questions. "What month is it?" Ralph doesn't know. "Are you hungry?" Now Ralph remembers that he is. "Why are you here?" "Depression," Ralph says. "Do you feel less depressed?" "No," Ralph says. Dr. Colucci soon leaves, and Ralph walks to the common dining area for a kosher lunch of stuffed cabbage and potatoes. "Hey, Ralph, you want to play cards?" an- other patient asks. Ralph giggles and shakes his head. He carefully eats all his food, then announces that his head aches and he wants to sleep. In a few hours, he's in a better mood. "I can remember everything now except going in for the ECT," he says. "Otherwise, I'm fine." He goes back to sleep. DR. BAILINE, WHO IS OVERSEEING RALPH'S TREATMENT, has a wife, a daughter, and a home in Port Washington; when he came to Hillside in 1970, he was already interested in ECT, and he has been administering the treatment ever since. It's hard to portray him as the hard-hearted villain the anti-ECT forces believe he is. A short, graying man, Bailine projects warmth and concern, and he talks about each of his patients with a combination of scientific fascination and genuine sympathy. "I got into ECT when I was still a resident," he says, "because I was impressed with its dramatic, clear-cut response." At Hillside he now supervises electroshock treatments for 10 to 20 patients a day, three days a week-about 200 patients a year. The number has increased steadily over the past few years. Bailine has heard few complaints. "Yes, some people have memory loss after ECT," he says. "And yes, some of them become very confused. But I think it's a temporary state. Anyway, I find that patients who don't get ECT but have severe depression are also confused and don't bother remembering things." After all, he says, there aren't any objective tests proving that ECT causes loss of memory for more than three to six weeks after treatment. "I don't believe those stories that all the anti-ECT people keep telling," he says. "I just don't believe they were wonderful before and aren't now." Like Ralph Thomas, most of the patients undergoing ECT at Hillside have tried other treatments unsuccessfully and have been recommended by their doctors for this therapy. Bailine seldom follows up on individual cases after they have left the ECT unit, but so many patients are referred to him by the same doctors that he assumes the treatments are successful. The day before Ralph's third session the ceiling falls in-literally-at the Hillside ECT unit. A sudden snowfall has caused the roof to collapse, and the treatments are postponed for a day. When the sessions resume, Ralph is confused and somewhat disoriented, and says that he feels no better than before his ECT started. "And I still get headaches right after they zap me each time," he says. He frowns, and tears form in his eyes. "They hurt pretty bad. " ARE YOU A SCIENTOLOGIST?" ASKS DR. MAX FINK, A psychiatrist and founding editor of Convulsive Therapy, the principal journal for ECT practitioners. Groups that tend to attack any form of psychiatry, such of the Church of Scientology, are also opposed to ECT, which has proved to be a fairly easy target because of the public's lack of knowledge and ECT's poor job of self-promotion. Dr. Fink and several other ECT practitioners refuse to be interviewed. "Fink's been burned by the media too much," says another doctor. "And by his foes." Once while Fink gave a speech, protesters appeared carrying a frying pan filled with brains. "Oh, they weren't even human," an anti-ECT activist says dismissively. Incendiary charges and countercharges fly back and forth. "She's just making money by suing her physician," says one doctor about a prominent anti-ECT advocate. "That doctor's on the board of the company that makes ECT machines_he earns millions," responds an anti-ECT woman. "You know," two prominent anti-ECT people charge, "it costs a journalist $40,000 to watch someone get ECT." "Those anti-ECT people?" confides a well-known Manhattan psychiatrist. "They're nuts. All nuts." At least 500 unhappy former ECT patients are members of an organization called the Committee for Truth in Psychiatry, which believes that patients are inadequately informed about the potential hazards of ECT, and lobbies state and federal legislators on the issue. It's headed by Linda Andre, a frail, intelligent Manhattanite in her early thirties who, ten years ago, underwent ECT at New York Hospital. "It ruined my life," she says. "I lost my memory, and I lost myself." Much of Andre's time is devoted to "fighting for people to be told the truth about ECT," so others won't have to experience the mental anguish she says she endures every day. Another former patient, Selma Lanes, 64, lives in an Upper East Side apartment cluttered with books and pictures. A children's-book writer and editor, Lanes was first struck by a debilitating depression a dozen years ago. She tried antidepressants unsuccessfully, attempted suicide while taking Prozac, and was hospitalized several times. In the spring of 1991, her doctor told her about ECT, and although she was apprehensive, she agreed to try it. "It got me out of my depression," she says. However, she discovered a side effect: Her memory had been decimated. "I went back to work, and I couldn't remember where anything was or who anyone was. I only knew my secretary's name when someone else said it out loud. I was terrified." Lanes left her job to go on permanent disability. However, a year later her depression returned, and when no other medicine or therapy helped, she agreed once more to undergo ECT after her doctor promised that any memory loss would be temporary. But her memory became even worse this time. She now loathes her doctor and tells horrible stories about her life. "I couldn't remember that my best friend had cancer," she says. "I can't even remember which relatives are alive and which are dead." ECT doctors and proponents discount such experiences, claiming that they represent an insignificant minority of the hundreds of thousands of successful ECT recipients. Some go further and suggest that many of these people, who are being treated for mental illness, continue to suffer and, looking for an easy outlet, blame their ECT. The amount of sympathy each side of the issue holds for the other is minimal. RALPH'S FOURTH, FIFTH, AND sixth sessions are relatively uneventful. Again, directly after each treatment his memory is impaired, but over the next few, hours, as far as Ralph can tell, it returns in full, except for the details of the session itself. Also, after each session he still gets headaches that last for the rest of the afternoon. Ralph isn't sure the ECT is working. "I still have lots of negative thoughts," he says. "But I have some nice ones, too." Most psychiatric remedies provide results in slow but tangible increments, and a patient shows gradual improvement over time. But ECT works dramatically: There may be no variation whatsoever in the patient's mood for ten sessions, but a change after the eleventh. For Ralph, improvement comes after the seventh session and Dr. Colucci is surprised by the good results. He had previously worked with only one other ECT patient, a man who became quite confused and couldn't remember his own family for several weeks. "After that, I was totally against ECT," Colucci says. But his supervisor suggested that he not judge the therapy by that one incident. Ralph's improvement has caused him to modify his opinion. "Come see," he says the day after the last treatment. "Ralph's a new man. He's not depressed anymore. His thoughts are much happier. Even his sleep patterns have changed-he doesn't wake up until morning now. And he doesn't think about suicide at all." Ralph confirms it. "I feel good," he says simply. "I don't want to hurt myself now. I really don't. I'm not sure why I thought that way." One need only glance at Ralph to notice the improvement. His funny-looking-kid gait is still evident, but he's more relaxed and open. While he talks, his eyes, which used to roam about aimlessly, now look straight ahead, and his shoulders don't droop as dramatically as they did before. But most important, over the course of the next hour he talks about the circumstances that brought him to the hospital. His tone is now regretful instead of suicidal. He no longer feels pulled along by circumstance; he thinks he can change his life for the better. And for the first time, he is looking forward to leaving the hospital and rejoining his family. The doctor is startled ' Ralph's memory, which shows no sign of deterioration. "Frankly," Colucci confides, "Ralph is one of the few patients I've ever heard of who hasn't been affected by at least some memory loss." A day after the seventh session, Ralph is asked the same 25 questions he had been asked before ECT. He provides almost identical answers to all of them. Colucci believes that the improvement in Ralph's mood justifies the termination of his treatment, and after consulting with his superiors, he releases his patient. Asked if he would ever like to undergo ECT again, Ralph shakes his head. "I didn't like the headaches," he says. "And I don't want to be that bad off again that I'd need it. But I would recommend it for someone else." Still, there's a chance that Ralph's treatment isn't over. Although ECT provides permanent relief for some patients, for others the results are only temporary, and depression can return in as little as a few weeks. No one can predict whether a patient will receive long-term or short-term benefits. In the meantime Ralph will start taking antidepressants, and Hillside will carefully monitor his moods; if he relapses, Colucci may ask Ralph to undergo more ECT. For now, however, Ralph is content. He has to remain in the ward a few days more for observation, but his progress has been so good that he expects to be released shortly. Putting on a light-blue Windbreaker, he heads down to the ward's common area.