Brain Stimulation: Electroconvulsive Therapy

Electroconvulsive therapy, also known from times of old as "shock therapy," is on the rise—albeit a relatively quiet one. Considering its beginnings as a crude and violent procedure, it's not surprising that ECT's comeback isn't loudly publicized. The treatment, which involves inducing a controlled seizure, is most often administered to patients with significant psychiatric illness—depression, mania, and bipolar disorder—and is one form of brain stimulation therapy for people whose symptoms don't respond to medications. Kitty Dukakis, actress and wife of 1988 presidential candidate Michael Dukakis, has spoken candidly in recent years about her reliance on the treatment, the only one that significantly alleviates her bouts with severe depression. Many clinical trials are currently investigating ECT to better understand why it seems to work against major depression—it puts 60 percent to 80 percent of people who try it into remission—and researchers at the National Institute of Mental Health are investigating the therapy's potential in treatment of schizophrenia that does not respond to common medications. Still, the treatment suffers stigmatization—in part due to its association with mental illness but also due to its checkered past since its inception in the late 1930s.

Today, ECT is far gentler than in the days evoked by the 1962 novel and later film One Flew Over the Cuckoo's Nest, which depicted it as a cruel treatment for psychiatric illness; in those days, fractures were a common result of seizure-related convulsions. The treatment usually takes place in a hospital setting a few times per week over the course of a month or less, in a series of six to 12 sessions. Anesthesia is administered, so the patient feels no pain and doesn't experience bodily convulsions. An overnight stay is typically required. (While ECT for depression is often covered by insurance, a copayment of several hundred dollars per session might be required.) Still, many are deterred who might benefit, says Mehmet Dokucu, psychiatrist and director of the Cancer Psychiatry Service at the Feinberg School of Medicine at Northwestern University.

To be sure, ECT is not a first-line treatment. "The vast majority of mental illness can be treated without resorting to ECT or [other] brain stimulation," explains Vaughn McCall, a Wake Forest University psychiatrist and researcher who administers ECT to patients, primarily for depression. And a newer brain stimulation therapy might be tried first. Transcranial magnetic stimulation (TMS) is a brain stimulation technique that does not require anesthesia or induce seizure. Dokucu, who prescribes medications and also administers both TMS and ECT to patients, says that if drugs have failed, he may offer TMS first and follow with ECT if necessary because "ECT is more aggressive and invasive."

McCall has given ECT to his patients for over 20 years and says he has seen it help patients desperate for relief. It can make a big difference to people with "moderate to severe symptoms who are miserable and not performing," he has observed. "If you are depressed enough that your marriage is strained or you might lose your job," and medications and psychotherapy have failed, ECT might be a solution, he says. Older people are often candidates, since their independence may be at stake.

ECT is more preservation therapy than cure, as symptoms return over time. And while patients typically try the treatment because antidepressants failed to help, the role of such drugs after or during an ECT series is not entirely clear. McCall was lead researcher in a study published this month in the Archives of General Psychiatry that suggested that certain antidepressants used in conjunction with ECT better alleviated symptoms of depression and also lessened the most predominant side effect of ECT: memory loss. (Other potential side effects include headache and delirium.)

The mechanism linking ECT to memory is not well understood, but about one third of patients experience a significant loss. The ability to remember should come back after treatment, but specific memories might not. Research suggests that factors contributing the most to cognitive problems are the use of a high electrical dose and the placement of electrodes on both temples, rather than just on the side of the head associated with the patient's nondominant half of the brain. The difficulty for practitioners—as well as fuel for debate—is that when both temples are used, a patient might not require as high a dose of electricity to achieve the necessary rejiggering of brain circuitry. Both McCall and Dokucu favor placing electrodes on one side of the patient's head. McCall's recent research has found that administering ECT on one side of the head in higher doses offered equal or more effective depression relief compared with placing electrodes on both sides of the head with a moderate dose—and the single-side placement also spared memory loss.

When considering ECT, McCall suggests posing a few questions to the psychiatrist who administers the treatment. Ask about track record. "You want to hear that they have at least a 60 or 70 percent success rate," he explains, and that "in the immediate post-ECT period, symptoms will have been driven to nil." And because practitioners differ in the way they administer the treatment, he says, it's important to ask: "What technical approach will you use to help preserve my memory?" His preference would be a high-dose, one-sided approach.