Recently, actress and writer Carrie Fisher told Oprah Winfrey that she receives electroconvulsive therapy (ECT) regularly to treat depression caused by her bipolar disorder. Taken aback, Winfrey asked, "They still do that?"
Yes, they do. About 100,000 people in the United States receive electroconvulsive therapy, better known as electric shock treatment, every year for severe mental illness, but that number may be surprising to those who thought ECT went out of favor with the advent of better psychotropic drugs.
Robert K. Dolgoff, a psychiatrist and medical director for mental health services at Alta Bates Medical Center in Berkeley, Calif., says Winfrey's surprise is understandable. Unlike the 1960s and '70s, when the "One Flew Over the Cuckoo's Nest" novel and film offered a dramatic portrayal of mental illness and barbaric treatments like the lobotomy, there is hardly anything in popular culture today that depicts a portrait of the treatment. That's because, Dolgoff says, the procedure is simply boring.
"The people just lie there. There's no convulsing or twitching. They're asleep," he says. "No one makes movies about that."
ECT has a long history as a treatment for people with mental illness. It is also arguably one of the most controversial medical procedures performed today. There are no shortage of ECT critics, including some Bay Area activists who rallied in the 1980s to ban the practice in Berkeley through the voter-approved 1982 Measure T, which was eventually overturned in the courts.
For some former ECT patients, who call themselves survivors, ECT is a brutal treatment that wipes out important parts of memory. For others, the treatment is one of last resort, a lifesaver when medications and therapy fail to lift often lethal depression.
David, a 40-year-old small-business owner in San Francisco, spent about 10 years working to lift what he calls "bone-shattering depression" with 50 to 55 combinations of up to 10 different psychiatric drugs. David is a fictitious name used to protect his anonymity
"At times, my depression got to the point where it was almost a psychopathic level," he says. David says that he was diagnosed with chronic major depression.
He sought out ECT in 2006, saying he was desperate for relief. After four sessions, David reports he had positive results. The chronic depression lifted. He felt content and, for the first time, had peace of mind.
"It was black and white before and after," he says. "I felt like a person. It was a resounding success. I do believe it restructured my brain for the better."
David reports slight memory loss, which is not uncommon Dolgoff says. Usually, the doctor says, the memory loss is minimal and almost always temporary. Actress Fisher jokes about her memory loss in her blog, saying that her outgoing telephone message asks callers to clearly identify themselves in case she forgets who they are in between treatments.
ECT was developed in 1938, and its use became widespread in the 1940s and 1950s. Today the procedure is regulated more strictly than in decades past by a set of patients' rights laws. In California, patients are rarely given ECT without their consent. Forced ECT has to be approved by a judge and it takes several weeks, if not months, to get in front of a judge. Minors in this state are not allowed to have ECT, regardless of their mental state.
ECT basically uses bursts of electricity in the brain to produce a mild seizure. Dolgoff says it is not known for sure why it works, but doctors believe it releases neurotransmitters in the brain and stimulates parts of the brain that are underactive. It is most effective, Dolgoff says, on patients who are severely depressed or catatonic, catatonia being rare.
"ECT is not a good treatment for mild depression. They don't need it. There is some risk in ECT. Why would you take a risk if you had other treatments that you could do instead?" he says, adding that interest in the treatment has increased in the past 10 years, partly because of less stigma associated with mental illness and partly because patients are reporting that it works.
"It's been a long time since 'One Flew Over the Cuckoo's Nest' so people have gotten over the fear of ECT," he says.
Dolgoff notes that although slight and temporary memory loss is associated with ECT, memory loss is also a side effect of depression. Cognitive function actually improves in some people after ECT, he says.
Assurances that memory loss is temporary is not good enough for San Francisco's Leonard Roy Frank, the nation's most vocal opponent of ECT. Frank has been working for nearly four decades to raise awareness of the ill effects of ECT, compiling facts and quotes about the treatment in his free online book "The Electroshock Quotationary" found at www.endofshock.com.
Frank, 78, was in his 20s when he was committed to a Bay Area mental hospital in 1962 right before the Cuban Missile Crisis. His parents were concerned that he was not working, that he had become a vegetarian and that he had grown a beard. He says he was labeled schizophrenic.
Frank received several ECT treatments against his will and suffered severe, permanent memory loss, which he believes is brain damage.
"Permanent memory loss is the surest indicator of brain damage," Frank says. "That's the heart of our critique of ECT. Psychiatrists deny brain damage, but if it's permanent memory loss, short term or long term, that's an indication of brain damage."
Frank, who is not a doctor, also believes that psychiatry is an illegitimate medical practice and that mental illness is more of a social problem than an actual disorder.
The treatment is different now than it was 40 years ago. The electrical current that goes into the brain is weaker, and patients are anesthetized during treatment.
Frank and his opinions get under the skin of Amy Lutz, a Villanova, Pa., resident who spoke in favor of ECT in front of an FDA panel in Washington, D.C., in January.
Lutz's 12-year-old son, Jonah, suffers from autism and rapid-cycling bipolar disorder. Lutz has spent most of Jonah's life trying to control extremely aggressive behavior. He broke his teacher's nose when he was 6, and Lutz was terrified that he'd go after his younger brothers and sisters and perhaps hurt or kill them. Jonah was institutionalized for most of 2008 while doctors tried to control his behavior with various combinations of medications.
It wasn't until Jonah attacked his elderly grandfather on Halloween 2009 - which led to Jonah's arm being broken while he was restrained - that Lutz considered ECT for her son. She says she was worried the fate of Kent State University professor Gertrude "Trudy" Steuernagel, who was killed in 2009 by her 19-year-old mentally ill son, might befall her family.
"I thought 'That's not going to be me,' " she says.
On March 17, 2010, Jonah started ECT sessions.
"Jonah's aggression is gone," Lutz says. Before ECT, Jonah averaged learning seven new skills a month in school. In December 2010, the school reported he learned 52 new skills. He was able to ride on an airplane for the first time and go with the family to Disneyworld in January.
Lutz says Jonah still squawks when he doesn't get his way, but he's not violently aggressive, putting his fist through windows and attacking people every day. He's also no "zombie" she says.
"A lot of people blame ECT for things that are probably not the fault of ECT," Lutz says. "For the vast majority of people who get ECT, it is beneficial and not harmful. Jonah's entire quality of life depends on him getting ECT."
Frank, Lutz says, was likely falsely incarcerated and should not have been given ECT.
"What happened to him is truly horrible and should not happen," she says. "But the people who are leading the anti-ECT movement (like Frank) were never sick when they got the treatment. Of course ECT can't help them if they weren't sick to start with. I would love to see what Leonard Frank would say I should do with my kid."
South Carolina certified psychiatrist and neurologist Mark George, honored by U.S. News & World Report in 2009 as one of 14 "pioneers of medical progress," says ECT is the field's most effective treatment for major depression.
"It is a lifesaver for people who are terribly, terribly depressed, who haven't responded to medications, who are unsafe and who are thinking of harming themselves or others," he says.
He says it's wrong that the psychiatric community has denied in the past that ECT has no adverse side effects, and it is wrong that people like Frank were forced into treatment.
"That's a bad thing that psychiatry did," he says.
As for the brain damage issue, George believes that the brain is already damaged when people are in the throes of depression.
"They are distorted, they can't do pen and paper tests, they can't think normally. Their brain is really stunned," he says. "(ECT) really doesn't cause permanent brain damage in terms of structure of the brain."
What's exciting about the continued use of ECT for depression, George says, is the cross-pollination the procedure is having with other treatments for major psychiatric disorders. George has been researching the brain for more than 20 years and focuses on transcranial magnetic stimulation, a gentler alternative that doesn't require anesthesia but stimulates the brain with intense magnetic pulses. Deep brain stimulating electrodes are also being researched as alternatives to ECT.
"We want to get something as good as ECT without memory effects," he says. "We're not there yet. Right now we need ECT profoundly. But ECT is part of this flowering of new technology of getting into the brain."