By the time Molly Chapman and her psychiatrist decided she should try electroconvulsive therapy, they had already tried everything else.
Chapman, a 27-year-old photographer who lives in St. Louis, Missouri, was diagnosed with severe bipolar disorder when she was 14. Over the years, she struggled with her condition, which is characterized by a combination of elevated moods and depression. Chapman has a subtype of bipolar that’s classified as “unspecified,” and she dealt with both rapid cycling and mixed states: frequent, intense mood swings that ranged from dizzying heights (mania) to deep sadness, along with periods where she felt euphoric, agitated and sad all at once. She also battled severe anxiety and attention deficit hyperactivity disorder, and self-medicated with illicit drugs.
Chapman’s illness caused the honors student to drop out of high school and college multiple times. She finally sought treatment after she turned 21. “I started on medication, but nothing really worked,” Chapman recalls. “I went through every combination I could think of — that the doctors could think of, even — with antidepressants, antipsychotics, sleep medication, anti-anxiety medication, seizure medication — all of these. I did that for years.”
In 2013, Chapman’s depression worsened. During this period, she severed relationships with friends, quit her part-time job and stopped taking photographs. She wouldn’t leave her house for weeks at a time. She attempted suicide. And her mania caused racing thoughts that were “so bad it physically hurt it to just be awake. My brain was on fire.”
Last fall, Chapman visited her psychiatrist, and the two began to discuss other options. Chapman had done prior research on electroconvulsive therapy, or ECT — a psychiatric treatment that electrically induces seizures in patients to relieve severe depression. She suggested it to her doctor, and he agreed she should give it a try.
One early morning that November, Chapman’s mother drove her to the hospital for her first procedure. For the next month and a half, Chapman visited the hospital three times a week to receive ECT. Nearly a year later, she’s able to reflect on the experience’s realities — which, she says, are a far cry from the controversial portrayal the public sees on television and in movies.
What is ECT?
Most people have heard about ECT at one point or another — and most of the time, it’s an unfavorable stereotype, experts say. Critics recall the treatment’s nearly 80-year history; many years ago, ECT was administered without routine anesthesia or muscle relaxants, and occasionally caused bone fracture or dislocation. And movies like “One Flew Over the Cuckoo’s Nest,” the 1975 blockbuster in which the actor Jack Nicholson receives a barbaric, brain-frying course of ECT at the hands of the domineering Nurse Ratched, tarnished its reputation for years, says Edward Shorter of the University of Toronto, a social historian of medicine and author of “Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness.”
The film, he says, “was a cinematic success but a public health disaster.” Due to public misperception, the advent of antidepressants and the pro-therapy, counterculture philosophy of the 1960s, the procedure fell out of favor for decades until it underwent a resurgence in the 1990s. But ECT, as practiced today, is very different from the way it was when it was first invented, says Charles Kellner, a researcher, professor and chief of geriatric psychiatry at Mount Sinai School of Medicine in New York. It’s a “short, simple procedure that is done under brief general anesthesia and muscle relaxation,” he says. “It’s dramatically effective for our patients with the most serious forms of psychiatric illness. For them, it can literally be lifesaving.”
In ECT, a psychiatrist stimulates the patient across the scalp with a very small electrical current, Kellner says. The current induces a brain seizure, which lasts about 30 to 60 seconds. The seizure, experts say, produces changes in the chemistry and functioning of the brain. This can help alleviate deep-seated depression, melancholia and catatonia.
ECT can be given during a hospital stay, but it’s often done on an outpatient basis. An individual arrives at the hospital like he or she is going in for a minor surgical procedure, and is greeted by a psychiatrist, anesthesiologist, psychiatric nurse and other recovery nurses. The patient is put to sleep with an anesthetic and given a muscle relaxant to prevent movement.
The patient is under anesthesia for about eight minutes during the entire procedure, and he or she is given oxygen to breathe before and during ECT. The anesthesiologist injects the anesthetic, followed by muscle relaxant medication when the patient is fully unconscious. Then, a foam or rubber protective device is put into the patient’s mouth, and the electrical stimulus is delivered to induce a brief seizure. The muscle relaxant almost completely prevents any muscle movement during the seizure. Once it wears off, the patient awakens from the anesthesia and is taken to a recovery area. About 20 to 30 minutes later, he or she is ready to go home.
Chapman, who had seen “One Flew Over the Cuckoo’s Nest,” says the idea of ECT was initially “a little bit daunting.” But after she consulted several reputable medical sources, she says, she “saw that it was not at all what I thought it would be. It wasn’t going to be this excruciating torture method that I was fearing.”
In fact, Chapman says, the first two or three times she received ECT she woke up without realizing the doctors had completed the procedure. She was then wheeled into the recovery room, and her mother came to pick her up. The entire process, she says, took about two hours.
Like Chapman, most patients receive a course of three ECT treatments a week until depression lifts — usually a total of six to 12 hospital visits, Kellner says. Some patients continue to get maintenance ECT, receiving a treatment ranging anywhere from one session per week to one every few months.
How Does ECT Work?
For years, physicians haven’t had a clear-cut answer as to why seizures help relieve depression. “It clearly rejigs the electrical wiring of the brain in some way that is comparable to cardioversion — when somebody’s having a heart attack and their heart stops, you get them going again by putting the paddles on their chest,” Shorter says. “ECT is the kind of cerebral version. But why it is that electricity rejigs the wiring of the brain is [not totally known].”
However, Kellner notes, there’s a good amount of both basic and clinical science about how ECT works and how it causes changes in the brain. Sophisticated neuroimaging techniques have shown scientists that ECT changes and re-regulates neuronal circuits that are disregulated during depression, he says. He also notes that there’s “good evidence” ECT is neurotrophic — it causes a release of chemicals into the brain that stimulate nerve growth — and neurogenic, meaning it stimulates the growth of new neurons. “It also clearly releases the neurochemicals that control our moods in a way that’s similar to, but more powerful than, the antidepressant medications,” he says.
What Are the Side Effects of ECT?
After she had ECT, Chapman experienced short-term memory loss. A friend had recently passed away, and she couldn’t remember he’d died after waking up from the procedure. Also, she says, the span of time before and after she received treatment “is still fuzzy.” She can’t remember it in great detail — although she does remember that she’d forget performing “really ridiculously silly” actions, like placing a chair in the middle of her living room. “It wasn’t like I forgot who my mom was, or where I lived or what my name was,” she says. “It was just short-term, little things.”
Chapman also experienced nausea and exhaustion, and was prescribed medication for frequent headaches. All these side effects are normal, Kellner says.
“There’s no medical procedure that is without side effects,” Kellner says, naming the risks and reactions of general anesthesia. “And then ECT, depending on the technique, can cause a light amount of erasing of recent memory. Most [memories] come back, some of them don’t. Again, what people have to understand is that this is a serious treatment for a very serious illness. We are not dealing with trivially ill people here. We are dealing with life-threatening illnesses.”
Max Fink, a noted ECT researcher and professor emeritus of neurology and psychiatry at Stony Brook University in New York, calls ECT’s side effects “transient.” He likens the exhaustion patients feel after ECT to “running a race or going to an activity center, depending on your age. The older you are, the more likely you are to be confused — sometimes for an hour or two, sometimes for the day.” He adds that studies indicate there’s no evidence patients undergo permanent cognitive loss after ECT. The American Psychiatric Association also says there’s no evidence of brain damage.
Vocal opponents of ECT, however, disagree with this notion, and say memory loss can reach back years. They also point to studies that suggest ECT is as effective as a placebo effect (other studies have found that approximately 75 percent of patients see a change in their condition).
Who Gets ECT?
It runs the gamut, but ECT is mostly performed on people like Chapman, who have deep-seated, treatment-resistant depression, as well as those who have severe mania or catatonia.
Although there aren’t any official numbers, ECT is performed on approximately 100,000 people a year, according to Mental Health America, a community-based mental health network that focuses on support, education and advocacy. ECT can be done across the age spectrum, experts say — although it’s more common among older patients and in women, and rarely used with children. (In Texas and Colorado, it’s illegal for it to be given to anyone under 16.) It can also be safely performed on people with serious medical problems or illnesses, as well as pregnant women who can’t take antidepressants. Before getting ECT, patients might need to have blood tests or an electrocardiogram — a heart-rhythm test — to make sure they’re physically up for the treatment.
Most of the time, Kellner and Fink both note, a patient’s circumstances resemble Chapman’s — they are referred for ECT after they’ve unsuccessfully tried several types of therapy or medication. However, they caution, ECT shouldn’t be viewed as only a last-resort procedure; there are many patients who are psychotic, have a high risk of suicide or are severely ill from either depression or catatonia. In these instances, waiting several months before referring a patient for ECT can be fatal.
“One of the most important functions of ECT is to get people who are acutely suicidal out of that desperate state,” Kellner says. “And it can actually do that very quickly.”
Nevertheless, experts say, it’s important for patients to know that ECT won’t cure their underlying psychiatric illness. Nor does it mean they’ll be treatment-free for the rest of their lives. Although ECT is an effective weapon against depression, serious depressive illnesses are lifelong and recurring. Patients will most likely still need medication or therapy to prevent future lows and highs. There’s a chance of relapse, and they still might need “maintenance” ECT — a single, monthly outpatient treatment — as a prophylactic measure to prevent future depressive episodes. And while ECT shows promise for most patients, it isn’t guaranteed to work for all of them.
Chapman says her psychiatrist was supportive — but realistic — about ECT. “He said, ‘This is definitely a valid option; this is like a miracle [treatment] for some people. But I don’t want you to go into it thinking that’s what’s going to happen for you, because it doesn’t always work that well. Nor does it always work as quickly as people would like.'”
While she still has depressive episodes, Chapman says the ECT did make a difference. Her mood lifted, and she felt like her brain had emerged from a fog. “It did help — especially right away,” she says. “When I started it, I was in a place where I didn’t think I was going to make it to the next day. It gave me a lot of hope. I started feeling like I wasn’t drowning quite so much. After probably two sessions, I started seeing that this could be different — that I could survive.”
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Electroconvulsive Therapy: What It Is, How It Works and Who It Helps originally appeared on usnews.com
