A Shockingly Effective Treatment for Depression

Jan. 29, 2008 — -- I have been taking care of many severely ill patients with depression and bipolar disorder over the past month, patients hospitalized on the mood disorders service at Johns Hopkins Hospital. Three of these patients have had outstanding responses to ECT, or electroconvulsive therapy, also known as "shock" therapy.

Two of them came in hopeless, intensely miserable, and preoccupied with ending their lives, while the third came in with a depression so severe that it shut her down entirely — she was mute, not able to respond to my questions or even recognize that I was in the room with her.

The three of them all look happy and cheerful now, and feel very grateful for having been made well again.

The challenges that their depressions created in their lives — disruption at work and school, and damaged family and social relationships — now seem surmountable, given their new energy and confidence.

While in the minds of some patients and their families ECT remains scary and controversial, the reality is that it is the most effective treatment for clinical depression, and it is a well-studied, safe medical procedure.

I know it looks cruel and punitive as it is depicted in the 1975 movie "One Flew Over the Cuckoo's Nest," but that's Hollywood — that's fiction — rather than an accurate rendering of ECT as we use it in psychiatry today.

The most important thing to know about ECT is that it works 75 percent to 80 percent of the time in treating people with depression, while any given antidepressant medication works about 60 percent of the time.

As with most of our treatments in psychiatry, we do not know precisely how ECT works, though we have some clues.

We know that ECT causes a seizure — an electrical storm — in the brain, and that this seizure is necessary for ECT to have its therapeutic effect. The seizure seems to reboot the emotional machinery of the brain, in the same way that pressing Ctrl-Alt-Delete on the computer can sometimes provide a fresh start when the digital computer brain is stuck.

Sparking Hope

ECT has been around longer than any other modern psychiatric treatment — since 1938, when it was developed in Italy. Because it seemed to work, and because there was so little available to treat the severely mentally ill, ECT spread around the world very quickly.

While the treatment was initially used in patients who were awake and alert, and was thus potentially frightening, by the late 1950s it was being applied with modern anesthesia techniques that included both sedating medications to put patients to sleep, and muscle relaxants so that the seizure was physically only very mild. At the same time, anesthesiologists began to monitor the patients' breathing, heart rate and blood pressure to ensure the maximum level of safety.

Treatment is typically administered three times a week over two to four weeks. Each treatment involves electricity being administered to the head for one or a few seconds, which results in a seizure lasting 20-90 seconds. While the seizure is happening in the brain, there is very little evidence of it in the body, because of the muscle relaxant medication, as noted above. The patient is usually awake within a few minutes, groggy for 30-60 minutes, and feeling back to normal after that.

While minor side effects can occur, like headaches, upset stomach and muscle aches, all of these can be managed with medications. Most patients do very well with the treatments.

The side effect of greatest concern is memory problems. In the same way that rebooting the computer can cause the loss of whatever the computer brain was working on at the time, so ECT commonly causes loss of memories around the time of the treatment. It is important to consider the context here. I have had patients tell me that this was not bothersome because they did not particularly want to recall the horrible feelings they had that led to the necessity of ECT.

On the other hand, the memory problems can extend further, leaving gaps in the period up to six months before ECT and up to two months after it. This effect is more pronounced in people undergoing a form of ECT called "bilateral" ECT, in which the electricity is run through the whole brain, than in the form called "unilateral," in which it is run only through the right side. For this reason, unilateral is the form generally used. For those who experience this memory loss, the memories generally return gradually, over a period of about six months.

Patients typically find they are able to compensate for memory gaps using strategies such as taking more written notes, or relying on friends or colleagues to remind them of things.

Many patients have described how memory difficulties are a price worth paying for relief from devastating and debilitating depression. Kitty Dukakis, wife of former presidential candidate Michael Dukakis, is among them. She relates how ECT changed her life for the better in her book "Shock: The Healing Power of Electroconvulsive Therapy."

The other important downside to ECT that patients need to be aware of is that while it restores many patients to wellness, it does not necessarily keep them well. There is a need for continuing treatment to give people the best possible chance of staying depression-free.

One study showed that either putting patients back on antidepressant medications, or continuing to do occasional ECT treatments (called "maintenance" ECT), led to two-thirds of patients staying well over the next six months. The rate of wellness over that period in patients with no treatment was only 16 percent.

ECT is far from perfect, but it is the most effective treatment we have for serious depression. I wish you could see the bright and optimistic looks on the faces of the three women whom we brought back from the brink this month.

Dr. James Potash is an associate professor of psychiatry and co-director of the Mood Disorders Program at the Johns Hopkins School of Medicine in Baltimore. If you have questions or comments, please e-mail at moods@jhu.edu. To participate in our genetic and clinical studies, call 1-877-MOODS-JH.