Wednesday, February 09, 2011

Shock Value

Electroconvulsive therapy, or ECT, is considered to be a highly effective treatment for depression. The story goes that roughly 90% of patients respond. The down-side is that it requires general anesthesia with all it's attendant risks, and patients may suffer from headaches, and memory loss. The memory loss is often mild, but there are cases where it is profound and very, very troubling. As with any psychiatric treatment ---or so it seems-- there are those who say it saved them and those who say it destroyed them. Because the risks aren't minor, the procedure is expensive and often done on an inpatient unit, and people generally don't like the idea of having an IV line placed, being put under, then shocked through their brain until they seize, only to wake up groggy and perhaps disoriented with a head ached, it's often considered to be the treatment of last resort, when all else has failed. This makes the 90% response rate even more powerful.

I'm no expert on ECT. I haven't administered it since I was a resident and I don't work on inpatients where I see people before and after. I've rarely recommended it, and then I've been met with a resounding, "NO." My memory of it was that it worked, and that most people didn't complain of problems. One woman read a novel during her inpatient stay. I asked if she had trouble following the plot (ECT in the morning, novel reading in the afternoon) and she said no.

The FDA has been looking at the safety and efficacy of the machines used to perform ECT. It's a fairly complex story where the FDA advisory panel was considering whether to keep ECT machines categorized as "Class III" machines which would now require machine manufacturers to prove their efficacy and safety. A reclassification as Class II (and therefore lower risk) would not require this stringent proof.

On Medscape, Fran Lowry writes:

If the FDA decides to follow the advice of its Neurological Devices Committee, it means that the 2 companies that currently manufacture ECT machines would have 30 months to submit a premarket approval to show that the devices are safe and effective.

ECT has been in use since before the FDA enacted new, more stringent laws for device approval, and psychiatrists fear that the logistics of conducting new trials will pose insurmountable problems for the manufacturers.

They also doubt whether data from any new trial would be sufficient to convince a subsequent advisory panel of the efficacy and safety of the devices, long considered by the APA to be life-saving.

"It hasn't been yanked from the market right now," said Sarah H. Lisanby, MD, head of psychiatry, Duke University, Durham, North Carolina, and chair of the APA Task Force to Revise the Practice of Electroconvulsive Therapy.

"But the continued availability of this life-saving treatment in the long term lies in the hands of the FDA right now. We're pleased it wasn't taken off the market instantly, but if new trials are going to be required, it's not clear who will fund them and whether they will in fact even be done. This is the concern," she told Medscape Medical News.

David Brown has an excellent article in the Washington Post-- see "FDA panel advises more testing of 'shock therapy' devices."

(As an unrelated aside, since Roy claims that "everyone" is my neighbor , I'll mention that David Brown is also my neighbor. )

In surfing, I found a strong anti-ECT sentiment on many blogs. There were also those who said it helped them, but theirs was a quieter rant. I particularly enjoyed Electroboy's rendition of his treatment for mania.

If you have thoughts or stories, by all means....

Thanks to Bob Roca for the heads up on the FDA hearings.


moviedoc said...

Keep in mind that a single ECT device, which may be purchased for not much more than the cost of treating one patient for one year with a drug that is still on patent, can remain in use for many years, treating hundreds or thousands of patients. The market for these devices is relatively small, especially compared to Pharma. Where would the 3-4 companies that make them ever get the money to conduct the research?

Vanessa Gentleman said...

The literature continues to support positive evidence in favor of ECT as a viable treatment option for treatment-resistant major depression. Through my own research, I have personally witnessed great successes with ECT.

Alison Cummins said...
This comment has been removed by the author.
Alison Cummins said...

“Electroconvulsive therapy, or ECT, is considered to be a highly effective treatment for depression.”

Dinah, that kind of language is what I expect to see in an article explaining an imaginary treatment. “Touch Therapies are so-called as it is believed that the practitioners have touched the clients’ energy field.” “In homeopathy, a substance that causes specific symptoms in a healthy person is believed to relieve those same symptoms in a sick person.”
“In traditional Chinese medicine, internal disharmony is believed to cause blockage of the body’s vital energy, known as qi, which flows along 12 primary and 8 secondary meridians.” “The craniosacral practitioner claims to gently work with the spine and the skull and its cranial sutures, diaphragms, and fascia. In this way, the restrictions of nerve passages are said to be eased, the movement of cerebrospinal fluid through the spinal cord is said to be optimized, and misaligned bones are said to be restored to their proper position.”

Do you believe that ECT is science-based? Because then you can just go ahead and say “Electroconvulsive therapy, or ECT, is a highly effective treatment for depression.”

The cautious, indirect language you use suggests you think it’s plausible that ECT is imaginary.

Is this what you are trying to communicate?

Anonymous said...

I see no hedging in the word considered. Read the article about lymph node removal in breast cancer and it is clear that science does not equal whatever the opposite of imaginary is. Science based treatments, anything scientific, is always nothing more than what some people consider to be effective, or an accepted explanation of what is true or real. The only reality is that often new studies will come out to highlight the flaws of old ones, some treatments will work for some people and not for others. I think that is where Dinah is coming from if I read her right. As for imaginary, there is a lot to be said for the placebo effect. If the placebo works for someone, my guess is that they do not consider it imaginary at all. As far as ECT is concerned, I know one woman for whom it worked for a time until it stopped working.Everything stopped working for her.

Kate Seldman said...

I haven't heard back from you and wanted to reach out one last time. We're actively building up our mental health section, and I believe that our audience would be interested in what you have to say.

We're not selling you (or anyone) anything, we'd simply like to publish your content.

So please let me know if you have (or don't have) an interest in becoming a contributor on Opposing Views.

Thanks for your time and consideration.

Kate Wharmby Seldman
Health and Entertainment Editor
Opposing Views

Dinah said...

" considered to be...."
1) Reflects that it's been years since I've done ECT and I've very few patients who've had it so I didn't feel comfortable asserting that it's great when I don't have first hand recent experience.
2) Is a measure of respect for the fact that some people feel they were injured by it.

Our treatments help some of our patients some of the time.

"Science" is numbers and statistical significance. It's important, but it doesn't matter if it helps 90% of people if you're in the 10% that didn't get helped.

Moviedoc, it's not completely clear (from what I read) that the existing literature will not be sufficient to establish efficacy and safety. I imagine there will be an outcry if ECT becomes unavailable.

Sarebear said...

I read an article and some of the source material for it that they referenced recently since I found myself interested, on this exact issue.

I seem to remember thinking that the proposal to reduce the classification had merit until I came to a couple points of just how much looser the restrictions or maybe not restrictions, but SOME aspect of implementing and regulating ECT, would be, and it alarmed me quite highly. Going down to a class II opens up a whole mess of issues that is unfortunate because it sounds like if they don't go to class II, the machines might not meet a certain standard? It's just there's so many implications of going to class II beyond what are mentioned here. If I could remember what alarmed me, I'd mention it. Maybe I'll go find the info and reread it again.

On a completely different note, I used to feel I'd never consider a treatment as severe sounding as ECT. Now, after years of depression which the doc doesn't even seem to care to address (ok, so I know she's trying to get the mania under control first) and, struggling with mania that I can't seem to tolerate more than low to moderate levels of medication for (Depakote and muscle tremors, I ain't bumping this med up like she suggested I might want to), so after struggling with the depression and mania (didn't know ECT could treat that btw) I'd now possibly consider it.

moomag said...

In the early to mid nineties, I had two separate treatments with lasting 15 sessions, the other 6. The first set of treatments pulled me far enough out of a debilitating depression in which I was actively suicidal. The memory loss was horrible, but most came back. What didn't I really didn't remember anyway. The second was useless and I ended treatment after having a serious reaction to the anesthesia, which I had told the doctor I had had previous problems with. Would I have it again? If my family and I felt it was warranted I would as a last resort. Thankfully with medication I have been symptom free for many years, and hopefully would never need it again, but if I was in the throes of another depressive episode like the first one, as a last resort, yes I would.

Sunny CA said...

In California ECT can be given to patients without their consent which I find scary and horrible considering the side-effects of losing memory.

I went to the blog of Dr. Shock last year (I think there used to be a link on this site) and found a series of video tapes of Rachel Star before and after ECT which clearly document the brain damage and memory loss she suffered (if one watches the whole series of videos she taped). I just watched her 1-year-later tape in which she details forgetting how to read, forgetting how to write, not being able to hold text in her mind when she started to read again, writing gibberish, forgetting people's faces, forgetting how to use numbers, forgetting the last 2 years, forgetting movies she has seen, etc. She sounds like a brain damage victim. Dr. Shock finds her "very impressive" presumably because she is still enthusiastic about ECT (perhaps because she can't remember what she lost). I would rather die than lose that much of my memory.

Sarebear said...

um, yikes.

Anonymous said...

when I was hospitalised with severe depression and was suicidal, I decided that I would even agree to ECT without an anaesthetic. luckily I didn't need it but i would have agreed if it had been offered as i was desperate. PS I'm a Dr with mental health experience and have seen good responses to ECT

Anonymous said...

In this season of bleak, gray, cold weather, this is a link to one of my favorite "authorities" on this topic.

Anonymous said...

Regarding the post directly above, try this LINK

Retriever said...

Several relatives have been helped by it. But, most recently, one was forced out of the hospital while still undergoing at least six weeks of ECT (after a couple in the hospital). During that time, the patient had to be driven to and from a hospital an hour arway from their home, and the family was billed the extortionate rates charged by the anesthiologists which they had to pay up front (some $14,000 over the course of treatment). Althought the hospital billed the insurance company directly, the family ended up having to request reimbursement which took months to get (while paying interest on credit cards). It is a hideously expensive treatment. Furthermore, during the entire time the patient was undergoing this treatment (which admittedly helped somewhat, but only by the very last week), their memory was completely shot, and they were unable to function, drive, interview for work, read or write, or do much of anything except sleep. Admittedly, their suicidal depression had been so severe for the year previously that the family were already used to having to have someone in the house making sure the patient was safe at all times (a nearly successful attempt, and many threats in the year subsequently). But tho it was effective, it absolutely is NOT something that most people can do while going back to work or normal life. This may perhaps reflect the severity of the particular person's depression? But it was our impression that the person was functioning better (tho depressed) before the ECT than during it. The memory problems persisted in severe form for at least six months and the patient (a college student) was not able to even concentrate on a book, let alone enroll in an academic course for a year. Clinicians argued that one had to put priorities straight. But the person in question had been a brilliant student, and has not been the same since.

It is,IMHO, a treatment only to be used in extremis, and the particular patient feels that it was worth it, but that the recuperation year was hell.

Anonymous said...

CORRECTED LINK to Anonymous just above

Anonymous said...

Sunny, Mind Freedom is fighting for someone who is being forced to undergo outpatient ECT in Minnesota against her will. Thanks to their efforts, Ray Sanford, another Minnesota resident was freed from the court order to have involuntary outpatient ECT. To be blunt, I feel that forcing someone to have ECT against their will is torture.

You also said,

"I would rather die than lose that much of my memory."

To address Dinah's points - I am too lazy to look up the research but if I remember correctly, high effectiveness rate does not last very long.

When you say that memory loss is often mild, on what scientific study are you basing that on? Also, how is that tested and for how long?

If I remember correctly, Harold Sakeim after initially admitting that memory loss was non existent with ECT, admitted it was alot worse than he initially thought. In my opinion, he was still underplaying it.

You might want to ask the woman who had no trouble reading a novel during a hospital ECT stay if she could follow the plot a year from now as an FYI.


Anonymous said...

A good link:

Cut and paste into your browser. This corrects the Anon Link 2 posts above.

Judith Kastenberg said...
This comment has been removed by the author.
Sunny CA said...


Yes, I said:

"I would rather die than lose that much of my memory."

I would like to add that I am not depressed, and do not say that out of depression, but because I consider part of my essence to be my sharp mind and stored memories of loved ones and my life's history. I think when we lose our memories we lose who we are. It reminds me of one of those awful science fiction movies where the hero is having his mind altered by the aliens. I DO think there can be a profit motive on the part of the clinicians which makes it alarming to me that the very same psychiatrist who can declare a psychiatric inpatient too ill to release can order ECT against the patient's will as well.
When I listen to or read some of the stories and hear the ECT patient describe having been on lots of different medications and all those medications not doing any good, I wonder if they might have felt better just by quitting the psyche drugs and taking a vacation in a lakeside cabin with good food and long walks. There was a New York Times first person account by a former journalist who had lost his ability to report and write following ECT. Watch the series of Rachel Star's videos on her website and form your own opinion. I found a mid-1980's study of autopsy's of brains of people who died either during ECT or shortly thereafter in which all the brain damage was detailed by neurologists. The brain damage is not imaginary, it is being covered up.

Anonymous, why can't the woman who is being required to have ECT as an outpatient just leave the state?

I do not understand a medical community that thinks it is OK to wipe out huge areas of people's memory by destroying parts of their brain. How is this any measure of successful treatment? It is like cutting off the feet of people who complain of foot pain. So what if they no long can walk? Their feet are no longer a problem.

Anonymous said...

I had some number of ECT treatments. Maybe 8 or so. Don't know because my memory loss became too severe and the series ended early (or so I was told later). My psychiatrist called the memory loss "moderate" and "more than we like to see". Six months later I felt my brain was working again, but in its usual depressive fashion. A year later, I gave myself a seizure as a side effect of a suicide attempt -- and you know, I felt pretty good (but quite delerious) afterwards.

My point? Seizures help. The experience of being so "out of it" -- I remember struggling to dial a phone -- is itself traumatic, even if you bounce back in 6 months or so. Second, the effects might well be short-lived. I honestly don't know if I'd do it again, but feel more motivated than ever not to have to consider it.

moviedoc said...

A few more facts about ECT: There are TWO kinds of memory loss. The patient may never remember much about what happened during the time they were treated. Usually this is not a big problem. More disturbing would be an inability to recall events from prior to treatment or to "lay down" new memories after treatment.

The most dangerous part of ECT as currently practiced may probably still be the general anesthesia. The treatments are relatively safe.

ECT represents hope for those who cannot tolerate meds or for whom meds and psychotherapy do not work. Then there's rTMS and VNS.

Anonymous said...

Hi Sunny,

As an FYI, I quoted you about memory and meant to say I agree with you. Sorry, insomnia was at work.

Like you, I am not depressed in the least but dealing with memory loss while on psych meds and then in withdrawing from them, was one of the scariest issues I have ever dealt with.

At a previous job, one time I asked a boss about a procedure that I had literally forgotten how to do. It was so elementary. He was very kind but I can't tell you how embarrassed I was.

What was scary was I didn't realize this was something I should know how to do and figure out without asking him.

Multiply this several times over at at a worst intensity which is what many ECT folks deal with and I would reach the same conclusions about wanting to die.

You have done a great job in summarizing the issue. Great analogy about comparing ECT to cutting off the feet of people who complain about foot pain.

That is a good question about the woman being forced to have outpatient ECT as to why she can't move.

I was one of those folks who definitely felt better quitting psych meds. I didn't have treatment resistant depression but the horrific side effects led me to this decision. Things aren't back to being 100% but making this move was one of the best decisions I have made in my life.

Movie Doc, you never mention supplements as alternatives and I am curious as to why. Yesterday, when I was researching things for insomnia, I was amazed at all the reviews of people on 5htp who claimed that drugs did nothing for their depression but that this was magical.

Of course, anecdotal experiences do not make for a study. But to be honest, I don't exactly see great studies for ECT and the options you are mentioning.

As an FYI, there was a recent study that showed that sAME was a possible effective alternative. Also, various studies have shown that high EPA fish oil has helped some people with depression.

I also recall a small study in which for people experiencing treatment resistant depression found relief when high EPA fish oil was added to Prozac.

By the way, I don't think supplements are the magical solution that some alternative med folks think they are. But I am just stunned that these options aren't considered by more mainstream medical professionals

One thing that I found impressive about an out of state psychiatrist I wanted to consult with when my insomnia was at its worst was he seemed to be very knowledgeable about conventional and alternative approaches. Fortunately, it didn't get to that point where I felt the need to go see him.

As far as ECT giving hope to people, I don't doubt what you are saying. But I guess I am having trouble reconciling that with Sunny's post about memory loss.

Would that journalist who lost his ability to write following ECT still say that it gave him hope?


PS - I wanted to thank the shrink rappers for allowing dissenting viewpoints and letting comments get posted right away. It is greatly appreciated.

Anonymous said...

I have chronic, treatment-resistant major depression, first appearing about age 7. I am currently on a drug cocktail including parnate, an MAOI (remember that drug, Shrinkrappers?) as a last resort class after trying every other antidepressant drug class. FYI, I live in Australia. 10 years ago, I'd just completed my PhD and was about to start a research career. 6 years ago, I was desperately depressed and suicidal. Since then, I've had about 100 ECT treatments, the most recent course of about 25 from Dec '09 through May '10. ECT has saved my life, but cost me my self and I often struggle with the loss of who I thought I was. I thought I was an intellectual, an award-winning scientist, a researcher. Over the last 6 years, the treatments (or perhaps the illness?) have cost me my cognitive skills to the point that my boss pulled me into his office and told me he couldn't pay me a researcher's rate any longer because "you just can't think the way I need you to think any more". That was devastating. I have lost so many memories that I often am unaware that I haven't remembered something significant that everyone else in the family thinks I should. My research career is over - I can only recall the outline of my PhD research. I have difficulty laying down new memories - my kids are used to me saying "sorry, you know mum has a stuffed-up memory". Would I have ECT again? Reluctantly, yes. The last time I had a significant breakdown my kids were present and their devastation at the prospect that they might never see me again was the only thing that stopped me from acting on my desire to die. If DBS was available in Australia for depression, I would stick my hand up straight away. I am a mere shadow of the person I used to be, but my kids say they love and need me, even if I don't value my life myself.

manchester fat acceptance said...

my mother had ECT. it briefly helped to keep her alive by reducing her symptoms slightly, but she never really recovered from her depression and 7 years later she committed suicide (after multiple attempts). not sure yet whether her extra years of torment were worth it for her or for her family.

she retained most of her memory, except for the recent events just prior to the ECT (in fact she unfortunately forgot that she consented to treatment, so she became convinced that the ECT was against her will).

the ECT itself caused very little problems, but she had significant memory issues (brain damage, essentially) from suicide attempts (she also did some intentionally milder overdosing for the purposes of wiping her memory in order to dissociate - even on a weekly basis or more often).

ECT didn't seem to cause harm, but it didn't really seem to help either.

Sarebear said...

I would imagine that a patient that is so badly off that someone wants to force them into ECT, is having so many problems functioning that moving would involve far too many detailed tasks for them. I know the concept of moving for me is just too daunting for me, and yet with my husband still out of work, we may have to eventually move in with my parents, and I don't know how I can cope with all that's involved with it.

I literally don't feel capable, AT ALL, of what's required.

So it's a bit disingenous to say well why doesn't she just move, then? Depression robs you of alot. Simple things aren't so simple.

Anonymous said...

Recently a few papers ran a story about a cranial stimulator device sold by Fisher Wallace. Here's a link:

Sounds similar to ECT, but maybe it is a safer, cheaper alternative?

clairesmum said...

as a nurse, i have seen some terrific improvement in function in elderly clients struggling with depression. they were already in a nursing home due to combination of multiple illnesses and care needs, so memory loss impact was less apparent.
as someone who had had depression off and on since age 13, i would consider ECT if i couldn't get a drug combo to work. as you get older and have other health problems, sometimes ECT is better tolerated and less likely to disrupt physiological functions than multiple drug cocktails do.
Read the book by Kitty Dukakis on her experiences w/ ECT - she is the wife of former governor of Massachusetts Michael Dukakis. There is a coauthor to the book (MD or researcher) who covers the scientific parts and she writes about her own experiences and impact of ECT on self and family.

Anonymous said...


Older women are the target market for ECT and over represented in the population of people getting it. I am sure it's all to do with being particularily indicated rather than them just being generally more compliant and less likely to refuse.

Anonymous said...

They shut the ect program down at a hospital in my state because so many people who turned 65 and were covered by Medicare suddenly needed ECT.

Several years ago I was told I needed ECT, and I said no. I'm glad I didn't do it. The risk of memory loss was not worth it to me. I was told I had recurrent major depression, treatment resistant, and ECT was supposedly my only hope. It wasn't my only hope. I just needed a different practitioner. I shudder to think what would have happened to my brain if I lived in Minnesota or another state where they can give it by force. I'm sure the whole forced treatment thing really helps lift a depressed person's spirits.

Anonymous said...

Update on Elizabeth Ellis, the Minnesota resident being forced to have ECT against her will. Because she didn't report for a session last month, a judge has authorized a sheriff to pick her up any day to bring her to the institution to have it.

Needless to say, I am speechless that we are engaging in techniques that were common in Soviet Russia to force ECT on someone against their will.


Sunny CA said...

You make a valid point about a depressed person's inability to move, but I had read the MindFreedom site in which Elizabeth said:
"Elizabeth added, "I'm in very good mental health. I'm active, eating, sleeping, doing everything. I'm in deep appreciation of MindFreedom for putting out alerts."

Her husband Robert (see photo of the couple above) agreed: "Elizabeth doesn't need electroshock. She's been fine, active. We've been doing things together. She's pretty sharp, but her memory is still off from the electroshock. I'm angry and upset about this court order for her to have forced outpatient electroshock."

I was thinking more along the lines of hopping into a car and heading to the next state for a vacation rather than a whole scale move, but options such as a visit to friend or relative out of state ought to be considered in my opinion.

The anonymous PhD researcher who posted, in my opinion is an example that argues against shock treatments not for them.

Anonymous said...

""Her husband Robert (see photo of the couple above) agreed: "Elizabeth doesn't need electroshock. She's been fine, active. We've been doing things together. She's pretty sharp, but her memory is still off from the electroshock. I'm angry and upset about this court order for her to have forced outpatient electroshock."""

She probably wishes she had moved or fled somewhere because she has now been forcibly institutionalized and faces months of ECT.

Psychiatrists and mental health workers who visit this blog - I would love to hear from you as to how situations like this create trust in the mental health system. Even people I know who feel they benefited from psych treatment find these involuntary commitment laws extremely frightening.

Please understand that I am not looking to attack or flame anyone. I am just speechless as to what has happened and am trying to make sense of it all.


Anonymous said...

AA, that's horrible. I cannot believe they can do that to people. Do they honestly believe terrorizing people is helpful for depression? Sickening.

Sarebear said...

If she's functioning that well, why would they order it?

Anonymous said...

Hi Sarebare,

You said,

""If she's functioning that well, why would they order it?""

Are you asking out of curiosity or because you feel there is another side of the story? I just want to make sure my response is appropriate.



Sunny CA said...

I am really sorry. I followed the link to the MindFreedom website to read more, and used the links there to write to the Minnesota senators for help. This should not happen to anyone. Ever.

Anonymous said...

To Sunny Ca,

I agree - the loss of my cognitive skills and the memory problems are not a good advertisement for ECT. However, I would not be here posting without having had ECT. It is like being on a tightrope over a bottomless pit - every day I think about letting myself fall in permanently, the cost has been extraordinary, but there is a small skerrick of selflessness left that reminds me of my kids. I don't know for sure if ECT is what dragged me back onto the tightrope. I do know that high doses of medication wasn't helping. Frankly, life sucks, and if I didn't have kids, nothing would keep me teetering on the tightrope. I think euthanasia should be available for untreatable mental illness as well as terminal physical illness.

P.S. I retain anonymity because if I were to ever recover enough cognitive ability to do research again, the stigma of depression might prevent an employer from giving me a chance.

Steven M. Schwartz said...

I have had 19 ECT treatments in 4 years and just finished a course. Myself personally ECT works well, will no side effects at all. This is not to say that everyone will have such experiences. I blog about it because the anti-ECT noise online is over shadowing the good outcomes. You can read my story here.

and my personal blog here:

Carole said...

I have had 3 series of ECT. The third one included maintenance treatments for a period of 18 months (every other week, then every three weeks and finally every 4 weeks for several months). I would do it again. My memory losses were small and when reminded I usually could recall most of them. I have more memory loss from my extended period of major depression than from ECT.

I vote in favor of ECT as a possible treatment, especially for those who are suffering from suicidal intentions. I know for me, ECT saved my life.

Dinah said...

I would like to use a few of these comments for a chapter in our book on involuntary ECT. No names. But a couple that highlight the spectrum of concerns about both efficacy, memory, and the mix of good and bad. Please let me know if you object to this. I was interested in the comments by Sunny CA, the anonymous Australian researcher (no mention of location), and Carole,