Wednesday, November 12, 2008

ECT Reminiscences

There are so many melodramatic frissons surrounding the phenomenon and experience of electroconvulsive therapy that it is worth discussing the procedure soberly and straightforwardly. After eight years I stopped administering the treatment last year, but not because of any appalling epiphany: as with most aspects of ECT, the reality is more prosaic than the myth.

I stopped because the practice of ECT (particularly in solo fashion) is time-consuming, tedious, and emotionally draining; I was ready to do something else. It can also be very rewarding, not in the sense of reimbursement (not very good, which is why ECT services are hard to find in some areas), but because at least a subset of severely ill people can be significantly helped by ECT. As a non-practitioner now I can write this with no conflicts of interest, unless one wishes to dismiss these reflections as exercises in retrospective self-justification (if so, so be it).

Like many treatments in psychiatry, ECT is both overused and underused. It is overused because there are some conditions that don't respond well to ECT but that are so refractory that both patients and doctors grow desperate. It remains underused because available antidepressant treatments, both medications and psychotherapy, persist in being only mediocre in their effectiveness. Severe and treatment-resistant depression remains a scourge, and for many ECT offers the only way out (to my mind suicide is not a way out).

The biggest drawback of ECT is not side effects, but rather, on average, modest and sometimes time-limited efficacy. To be sure, it is better than medications, but in some cases that is not saying much. And responses to ECT are as heterogenous as depression itself. Some people have a curative course of ECT and do well for two or three decades before another episode. Some people improve signficantly but relapse within weeks. Others, a minority fortunately, do not improve at all.

In the course of eight years I heard far more complaints about residual depressive symptoms than about side effects. The latter do occur, and headaches and short-term memory loss can be reasons not to proceed with ECT. These days this decision is almost always made on a voluntary basis; forced ECT is rare in this country, although in some cases (e.g. catatonia) it can be necessary and life-saving.

Those who advocate a complete ban on ECT or who argue that its use is always illegitimate have no understanding of severe depression. People who have the concentration and motivation to blog about this issue are not likely, in the course of that activity at least, to be in the kind of depressive episode that would prompt consideration of ECT. For eight years I had more referrals than I could handle of those who had lost virtually all capacity for energy, pleasure, or reasonable function, and who had already tried available psychotherapy and medication treatments. Not all, but some at least, ended up being very grateful for ECT. I can honestly say that no one I treated said they regretted ever having the procedure; maybe they were just sparing my feelings though.

ECT is a woefully inadequate procedure, and like, say, chemotherapy, it must be superseded eventually by something more...civilized. But the desperate times of both depression and cancer can call for desperate measures at times.


Anonymous said...

Electrodes and voltage applied to the psychotic's head does lend itself well to hollywood interpretation: the drama, the barbarism, the horror!!!--all very pretty on screen. But in reality, it's probably not that exciting (or is it?..)

Do you think it might become obsolete--superceded by deep brain stimulation (DPM)?

DPM is a lot more sanitary, high tech, and convenient (and not so 'hollywood'); thus, it might gain more positive public acceptance.

John J. Coupal said...

ECT and chemotherapy seem to be the use of a sledgehammer to repair a Swiss watch.

We still know so little about brain/mind chemistry that an ECT assault on the brain that brings relief to the patient and caregivers is still a wonder to behold.