The changing face of electroconvulsive therapy
(January 2008 Issue)

Hospitals around New England have administered electroconvulsive therapy for decades, usually as a treatment of last resort. According to David A. Solomon, M.D., Rhode Island Hospital uses ECT on an inpatient basis. (photo by Tom Croke)

By Ami Albernaz

It's a procedure shrouded in mystery, saddled by a stigma that many claim should have faded long ago. Electroconvulsive therapy (ECT) has changed significantly over the years and many who administer it today in hospitals and medical centers around New England claim it is the most effective treatment for severe depression.

The common idea of ECT as a coerced, excruciatingly painful treatment was forged by the 1962 book "One Flew Over the Cuckoo's Nest" and the 1975 movie it inspired. Since then, the treatment has dwelled largely in the shadows of public awareness, drawn out from time to time by accounts of ECT-induced memory loss or, conversely, Kitty Dukakis's 2006 book "Shock: The Healing Power of Electroconvulsive Therapy," in which the former first lady of Massachusetts, a longtime sufferer of depression, credits ECT with saving her life.

Hospitals around New England have administered ECT for decades, usually as a treatment of last resort. In 2003, David A. Solomon, M.D., and Rendueles Villalba II, M.D., of Rhode Island Hospital wrote in Medicine and Health Rhode Island that "ECT is the most effective treatment available" for major depression. Recent studies of patients who have suffered depression show a 75-80 percent remission rate following ECT, compared with a 45-50 percent rate following drug therapy. Though ECT is most commonly used for depression, it is also used for bipolar disorder, psychotic disorder, schizophrenia and catatonia.

Because ECT is generally a last-line treatment, patients are typically referred by psychiatrists or primary care doctors. In terms of mental disorders, "ECT is the apex of medical intervention," says Bill Nash, Ph.D., an Essex Junction, Vt., psychologist. "It's one thing to refer patients for medication and another to refer them for an extreme medical procedure. Typically, when a patient's depression is so severe that they require ECT, they have been working with a psychiatrist for quite a long time. Consequently, this medical decision is usually left up to the physician."

As practiced today, ECT is administered on an inpatient and outpatient basis. Brief, controlled electrical impulses are delivered to the brain, either on both sides of the brain (bilateral ECT) or one side (unilateral ECT). The current triggers a small seizure, which is thought to alleviate depression. Patients are unconscious during the treatment, while a muscle relaxant prevents convulsions from the seizure.

At Rhode Island Hospital, the treatment is administered only on an inpatient basis. As such, "a whole month may go by without treating anybody," Solomon says. Following a course that averages six to 12 treatments, with three treatments per week, patients are prescribed either a maintenance ECT course - with procedures spaced farther apart - or drug therapy. Solomon says that while both treatments seem equally effective as maintenance, ECT can be crucial in bringing patients to a point at which they can benefit from medication.

"It's important to remember that there's a difference between acute treatment to get well, and staying well," he says.

Perhaps the most common side effect of ECT is memory impairment. Charles Welch, M.D., head of the Somatic Therapies Service at Massachusetts General Hospital, where ECT is also administered, describes three types of impairment. There is disturbance in the ability to remember new information, which he says afflicts nearly everyone receiving the procedure, though it generally dissipates within two to four weeks of the last treatment.

Then, there is difficulty in remembering events that occurred within the past few months, which afflicted Ms. Dukakis, Welch's patient. Following her course of treatment, Welch says, she could not recall having traveled with her husband to Paris a few months earlier. To try to jog her memory, the couple returned to Paris, dining in the same restaurants and staying in the same hotel they had during their previous trip - but to no avail.

"It's a mysterious side effect," Welch says. "Some people don't get it at all, while others do, pretty significantly."

The third type of disturbance, affecting memories of events longer past, is rare, Welch says. "ECT is relatively undisruptive to those kinds of those types of memory," which might pertain to one's profession. "Most people can go back to work pretty soon after the treatments."

Traditional wisdom attributed a greater likelihood of memory disruption to bilateral ECT as opposed to unilateral, though bilateral ECT was also deemed more effective. This view, Welch says, has started to change. "If you look at the data, what it says is that for about 95 percent of people, unilateral is just as effective if it's done correctly," he says. The critical factor, he says, is the intensity of the electrical impulse. Almost all of the treatments administered at MGH are unilateral, while Rhode Island Hospital might deliver either, depending on the severity of depressive symptoms and degree of concern about side effects.

In Barre, Vt., the Central Vermont Medical Center is seeking state approval to administer ECT to a small group of patients. Peter Thomashow, M.D., says that being able to offer the treatment would be a great benefit to patients who have to travel far from home to receive it. "The selection of patients is going to be very rigorous. They will have gone through other treatments," he says. Staff at the medical center has been trained to use new machinery, which will allow for greater control of the procedure in an effort to reduce side effects.

At institutions where ECT is offered, consent procedures tend to be strict. After patients are referred for ECT by a primary psychiatrist or a primary care doctor, they are given a thorough explanation of the procedure. "You need to have an unhurried discussion about all the risks and side effects, as well as the available alternatives," Welch says. "Then you finish up a consent form that summarizes all those points, but the document does not replace the thorough discussion with patients."

Such consent procedures contradict the image people may have of Jack Nicholson being forcibly wheeled in for treatment. In addition to consent, practitioner competence is key when it comes to the ethics of ECT, says Gerald Koocher, Ph.D., co-author of the textbook "Ethics in Psychology" and past president of the American Psychological Association.

"Not all physicians have the skill to make appropriate use of ECT and one would hope that those without the requisite training would refrain from using it," he says.

Given the treatment's efficacy for some patients, Solomon says it is time to reconsider ECT anew, in light of the refinements made to the procedure. "When ECT was first developed, there were mistakes as people were learning how to use it, no different from any other medical procedure," he says. "There's no way to get something absolutely correct the very first time. I'd say ECT is no different."

Leading Stories | Columns | Book Reviews | Hospital Directory
Residential School Directory | Advertising | Classifieds | About Us