Today's post brought back memories (perhaps?) for this blogger, but this article is even-handed and not sensationalistic. However, the bottom line on ECT is not very precise. If this is a (fair & balanced) description of a therapy in search of an explanation, so be it.
[x Dallas Fishwap]
Texas Sees Resurgence In Use Of Electroconvulsive Therapy
By Doug J. Swanson
Tag Cloud of the following piece of writing
Electroshock therapy never enjoyed much in the way of good public relations, and the low point may have come with the 1975 film "One Flew Over the Cuckoo’s Nest."
In the movie, a handcuffed patient played by Jack Nicholson undergoes punitive electroshock with a writhing, torturous convulsion. Some psychiatrists blame that dramatic depiction — it helped Nicholson win an Oscar — for the procedure’s fall from medical favor.
But nearly 40 years later, the procedure is on the rise in Texas. Electroconvulsive therapy, as it is now called, thrives as a treatment for some forms of mental illness, especially severe depression.
The number of ECT treatments in Texas has increased 67 percent since 2001, according to figures compiled by the state health department. ECT was used 14,176 times in Texas on 2,243 patients between September 1, 2012, and August 31, 2013, the last available reporting year. The state’s figures do not include military and veterans’ hospitals.
Doctors who administer ECT say they do so for a simple reason. “It is effective,” said Ahmad Raza, a psychiatrist who performs the procedure at Zale Lipshy University Hospital in Dallas. “ECT works in very severe or profound depression. … I don’t think there’s any question about that.”
Zale Lipshy recorded more ECT treatments — 2,324 in the last reporting year — than any other provider in Texas. “We are very well-known for ECT,” said Raza, a professor at UT Southwestern Medical Center. “There are psychiatrists who never refer a patient for ECT to anyone but us.”
ECT no longer causes patients to thrash and contort like Nicholson’s character because they are sedated. In addition, doctors say they have learned to fine-tune treatment, and the overall technology has improved.
But those who oppose ECT say it has always caused, and continues to inflict, serious brain damage and long-term memory loss.
“It’s devastating to the fragile brain,” said Peter R. Breggin, a New York psychiatrist. “There’s no place for ECT. It should be stopped.”
Breggin publishes a brochure, titled No One Should Be Given Shock Treatment, that urges relatives of patients receiving ECT to “immediately intervene to stop it, if necessary with an attorney.”
The increase in ECT, however, does not surprise Breggin. “I have no reason to suspect it’s not gone up hugely,” he said. “Psychiatry has always increased the use of abusive treatments unless stopped.”
Most common patient
Doctors who perform ECT attribute its growing use to its success. Various studies have shown that 64 percent to 87 percent of patients with major depression respond to ECT.
In Texas’ last reporting year, 87 percent of patients were found to have moderate, severe or extreme symptoms before ECT. After ECT, only 19 percent of the patients were determined to have such symptoms.
ECT opponents note that the medical professionals who administer the treatments are the same ones who measure the results and report them to the Texas Department of State Health Services. The state requires no independent assessment.
According to state reports, most ECT patients are white, female and over 45.
In standard treatment, electrodes are attached to the patient’s head. For about eight seconds or less, a burst of electricity passes through the brain. The current induces an epileptic seizure that lasts perhaps a minute.
Within a few hours, doctors say, the symptoms of illness have abated and the patient often returns to normal activity. “It is the safest treatment in psychiatry,” said Dr. Max Fink, an internationally known proponent of ECT.
ECT has been employed in varying forms for 76 years. In its early days, electroshock was sometimes neither safe nor well-regulated.
Poorly calibrated current caused unanesthetized patients to clench their jaws until their teeth cracked. Some suffered broken bones, including fractured spines.
There were significant abuses by practitioners. Electroshock was used on young children to stop their tantrums. Some mental hospitals employed electroshock to punish uncooperative patients. Others applied it to elderly patients dozens of times for no demonstrable reason other than to generate revenue.
A 1949 Dallas Morning News account of electroshock at the Austin State Hospital — overcrowded and “rat-infested” — said the procedure had “all the outward horror of an electrocution.”
Patients were “laid head to foot in assembly line style” in a hospital hallway, the story said, with each receiving treatment as others watched. “The charge of electricity convulses the patient; the body becomes rigid, eyes dilate, face flushes and sometimes there is nosebleed and frothing at the mouth.”
The development of psychotropic medications in the 1960s and ’70s helped push ECT into the background. Its unsavory reputation helped, too.
Fink, a New York psychiatrist who has written widely on ECT, acknowledged that it still may live in the shadow of past abuses and primitive procedures. He blames much of the lingering suspicion on depictions of ECT in popular culture, in particular "Cuckoo’s Nest."
“That set the tone,” Fink said. “The public perception of this treatment has been tarnished by the movies, the press and the politicians.... This treatment, compared to many medical treatments, has a tremendous stigma.”
Under current standards, patients are fully anesthetized during ECT. A muscle relaxant keeps them from thrashing. Blood pressure and heart rate are monitored throughout.
The language used with patients has been moderated as well. The word “shock” is rarely, if ever, used. The room where the procedure takes place is commonly called the “ECT suite.”
“It’s basically like any other medical treatment,” Fink said. “If you use some guidelines, the risks drop to zero.” He recalled one patient saying that ECT was “easier to take than going to the dentist.”
Dr. John Breeding, an Austin psychologist and active critic of ECT, scoffed at that.
“That’s just stupid,” he said. “They’re not selling the old epileptic seizures and bones breaking and teeth cracking. But in terms of danger, it’s actually worse.... The amount of electricity that’s used now is actually more. That’s one of the tragic ironies.”
Effectiveness
The American Psychiatric Association and the American Medical Association have recognized the procedure’s effectiveness. It is covered by Medicare and many insurance plans.
In 2011, the Food and Drug Administration published a survey of 17 medical studies on ECT. The FDA said the studies generally concluded that ECT “is probably more effective than some anti-depressants.”
The studies also found, the FDA said, that “there is no evidence to suggest that ECT causes brain damage.”
But the debate is hardly settled in medical circles. A British study published in 2012 in Proceedings of the National Academy of Sciences found that ECT “has lasting effects on the functional architecture of the brain.”
ECT worked, the study said, by causing a “decrease in... connectivity” between different parts of the brain.
And a 2010 survey of studies, published in the European journal now called Epidemiology and Psychiatric Sciences, came down strongly against the procedure.
The authors cited brain damage, memory loss and a slightly increased risk of death. “Given the strong evidence,” they wrote, “the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified.”
Even those who advocate for ECT acknowledge that its effectiveness can be temporary.
Some studies have found that the benefits of ECT last only a few days. Many patients must undergo repeated treatments. In Texas, the average number of treatments per patient in the last reporting year was 6.32.
“It doesn’t last,” said Austin psychologist Breeding. “You have a 100 percent relapse rate within six weeks.”
Continuing debate
The continuing debate over the treatment — and its increased use — has produced a collection of vocal patient-activists, pro and con.
“For me, it was absolutely lifesaving,” said Julie Hersh of Dallas.
Hersh said she attempted suicide three times in 2001. Medication did not alleviate her severe depression. “Nothing was working,” she said. “I tried tons of different anti-depressants.”
She underwent five ECT sessions over two weeks. “For me, ECT was instantly effective,” she said. “In 24 hours, I went from feeling like I deserved to die to [thinking] I can work this out.”
In 2007, she said, “I started to slip.” She had seven more treatments.
Her memory loss from treatments has been minimal, she said. Immediately after ECT, “I could not remember how to get to the YMCA, for example, even though I’d been there a million times.”
The only memories she permanently lost with each treatment, she said, “were the two weeks before ECT, during ECT and two weeks after ECT.”
Hersh has written a book about her experience, Struck by Living (2011). She also lectures widely about ECT.
Evelyn Scogin, a teacher in Austin, has spoken before state and federal panels about receiving ECT, but hers is a different story. “ECT destroyed my life,” she said.
She had been on 10 different psychotropic drugs, Scogin said, which only deepened her depression. In 2005, she said, she underwent about 40 ECT treatments over a six-month period.
“They would send me home from the hospital so disoriented I couldn’t stand up,” she said. “I soiled my clothes.”
Her memory loss was devastating, she said. “I not only lost all memory for the time it happened. The last three or four years of teaching, I don’t remember any of it.”
Scogin, 57, said she later suffered from paranoia and a loss of language skills. “I would try to write,” she said, “but what I had written made absolutely no sense.”
Physicians who administer ECT said few patients must undergo more than a dozen treatments to see improvement.
But one Collin County woman said she has had 45 ECT treatments since 2011, and is still receiving them. “The treatments are a godsend,” she said. “They don’t fix you.... They lift the cloud so I can go to therapy and talk about my life.”
The 48-year-old woman, who suffers from depression, spoke to The News on the condition of anonymity. She said that although ECT has “saved my life,” it does cloud her memory.
“I used to have a wonderful memory,” she said. “But when I go home tonight and my husband asks me to describe you or what you’re wearing, I won’t be able to tell him.”
The woman receives outpatient treatment at Green Oaks psychiatric hospital in Dallas. “It’s in and out, kind of like cattle,” she said of the process. “You’re in there probably seven or eight minutes.... You wake up, they put you in a wheelchair and they wheel you out.”
Insurance covers all but a $30 co-pay, the woman said. Total charges to her insurance company are about $4,000 per treatment, she said.
A spokeswoman for Green Oaks said hospital officials and physicians would not comment. According to state figures, Green Oaks administered 1,736 ECT treatments in the last reporting year, the fourth-highest total in the state.
At Zale Lipshy, spokeswoman Jeanne Forbis said the hospital could provide “no typical or average cost for the procedure because it is based on the particular needs of the patient.”
Breggin, the ECT critic, noted that it requires relatively inexpensive equipment and, compared to many other procedures, little in the way of special training for doctors.
“It’s a fabulous money-maker,” he said. “Shock treatments keep psychiatric units in a profit-making mode.”
Memory loss
Most proponents of ECT acknowledge that the procedure does cause some memory loss, though advocates say such problems are usually temporary. Texas requires that patients be assessed by a physician for memory impairment before and after ECT.
State health department figures for the last reporting year show that 45 percent of Texas patients demonstrated some memory degradation before ECT treatment. But two to four weeks after the procedure, 56 percent exhibited memory loss.
Figures reported by Zale Lipshy, however, do not comport with state averages. For the last five years, Zale Lipshy said, only one patient — out of 1,036 — has been found to have worsened memory problems after ECT.
“There’s a good reason for that,” said Raza, the UT Southwestern professor. “We are a leading research center for ECT.”
Zale Lipshy screens patients carefully, Raza said. In addition, he said, Zale Lipshy uses the unilateral method of ECT, which involves placing one of the electrodes on the crown of the patient’s head instead of the temple. Some studies have shown this technique to result in less memory loss.
Texas law does not specify the type of tests to be used to gauge post-ECT memory problems. Raza said he typically uses two tests, one of which is the Montreal Cognitive Assessment. Those who take it engage in simple tasks such as identifying a line drawing of a camel, for example, or repeating a list of five unrelated words.
“These are good screening tests,” Raza said, though they are “by no means perfect.”
Raza said he does more extensive memory testing for those who might require it, such as a physician who will return to work soon after ECT.
Jerry Boswell, president of the Citizens Commission on Human Rights of Texas, said he is skeptical of Zale Lipshy’s figures. “If a hospital is claiming no memory loss, I would want an outside independent agency investigating their claims and interviewing their patients,” he said. The state health department does not conduct independent investigations into such questions.
CCHR, which is affiliated with the Church of Scientology, pushed hard for the 1993 legislation that requires medical providers to report ECT statistics to the state health department. Texas is the only state that keeps a close official count of ECT procedures.
Because of an overall lack of reporting, no one can say for certain how many ECT procedures are performed nationwide.
The most commonly used estimate is 100,000 patients annually. “That’s based on my imagination,” psychiatrist Fink said.
He said he arrived at that figure via extrapolation from a limited sample of patients. “The actual number is not known.”
That’s not the only mystery surrounding ECT. Even those who recommend its use say scientists have been unable to determine exactly how ECT works.
“It is a very difficult thing to study,” Raza said. “The mechanism to this day is not known.” Ω
[Doug J. Swanson is an investigative reporter for The Dallas Morning News. He also is the author of several books — the most recent being Blood Aces: The Wild Ride of Benny Binion, the Texas Gangster Who Created Vegas Poker (2014). Swanson received a BA (journalism) from The University of Texas at Austin; he also was a Knight Fellow in Journalism at Stanford University.]
Copyright © 2014 The Dallas Morning News
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