Psychology: The Leap of Faith

Anything that was fun just wasn’t fun anymore. You just can’t do anything. You’re paralyzed.” These are the words of a woman, currently in her sixties, describing the depression she has endured off and on for most of her life; her words are a fairly accurate description of depression, a condition that affects 9.4 million Americans . As one can imagine, many drug companies, notably Pfizer – the maker of Prozac - , make a large amount of money trying to cure this condition. The cure for depression that many seem to forget about is shock therapy, a cure that has been around since 1934.

Shock therapy, also known as Electroshock and Electroconvulsive Therapy (ECT), is a now painless procedure in which a machine sends electrical currents through a person’s brain in an attempt to cure them of a mental illness. Because of the controversy inherent in running electrical currents through mental health patients, and because of its past misuses, ECT remains a treatment that many consider barbaric and somewhat frightening; however, the procedure has changed drastically since it was first introduced in the mid 30s. The real problem with ECT is that though shock therapy has been shown to work and seems to be fairly safe, doctors and scientists alike still do not know what exactly ECT does to the brain or why ECT works.

The procedure of ECT has, in fact, been a guess and check procedure since the invention of shock therapy, when physicians discovered that patients afflicted with dementia praecox, a debilitating mental disease, were sometimes cured of their disorder upon developing epileptic seizures. This discovery was followed by the work of a man named Ladislas Meduna, who noticed while working at the Hungarian Psychiatric Institute in the early 1930s that humans who had dementia praecox had lower amounts of neuroglia in their brains than a normal human would, and that humans who suffered from epilepsy had higher amounts of neuroglia in their brains than a normal human would; neuroglia support and assist neurons, the main cells of the brain. From this observation he concluded that patients who had dementia were often cured with the increase of neuroglia in their brains as a result of epilepsy. Later, in 1934 while working in a mental hospital, Meduna injected patients who had “incurable” mental diseases with camphor-in-oil, a substance known to cause seizures; after several mental health patients were cured, Meduna published his findings in 1937. His method of inducing seizures was improved upon with the advent of ECT, and within fifteen years electroshock became a common treatment for patients of many differing psychological disorders.

It has been awhile since that time when ECT was first invented, and different people have come up with a few theories as to why epileptic seizures can cure so many mental illnesses. One of theories is based upon the secretion of hormones, which are chemicals the body uses to regulate functions such as sleep cycles and mental states; patients with psychological disorders often have hormone levels that are either too high or too low for their body to function normally. For example, a person suffering from depression will have adrenal glands, organs in the body that produce hormones, that create too much of the hormone cortisol; the common symptoms of depression such as sleeplessness, fatigue, and impaired cognitive ability are all related to processes controlled by cortisol. The electrical currents that are run through the patient’s brain during ECT stimulate the hypothalamus, a hormone producing part of the brain, to release hormones which cause the pituary gland, another hormone producing organ, to release its hormones which repress the production of cortisol. After a few treatments the hormones begin to interact normally, and the patient’s eating, sleeping, mood, and muscle activity become normal again. It is not known yet which substances, hormones or otherwise, control functions such as mood, emotion, thought, and muscle activity; so this theory remains a theory. There is as yet no proven explanation as to what ECT does or why it works.

Because ECT is poorly understood, it is usually only used as a last resort when all other treatments have failed or the symptoms of whatever condition the patient has become so severe the patient can no longer tolerate the condition. If such a last resort scenario occurs, the doctor will describe the benefits, procedures, and risks of ECT to the patient; the law also requires that the patient sign a legal consent form before the patient can receive shock therapy. No other psychiatric treatment requires such consent, not even psychotropic drugs with known risks. The patient can also choose to drop out of the treatment process at any time, and many states mandate that the patient sign a consent form before each treatment. Involuntary treatment is usually only legal when the procedure is necessary to save the patient’s life; when a patient’s condition is so severe that he requires supervision to prevent him from harming himself, or the patient requires a nurse to feed him and prevent him from dying from lack of food and water, a judge can enforce involuntary treatment. Sometimes family consent can authorize emergency treatment.

After the legal issues have been dealt with, a blood count, an electrocardiogram (a test of the patients heart), and blood chemistry tests are performed on the patient. The physician in charge of the shock therapy examines all medications taken by the patient; the physician may alter the amounts and types of medications the patient consumes in order to avoid complications. Than an anesthesiologist must find out about all the previous times the patient has been anesthetized so that he can decide how the patient should be anesthetized. Women able to bear children undergo pregnancy tests, since certain drugs administered during ECT could damage the fetus. An examination of the patient’s teeth is also required to insure that his or her teeth are suitable for the mouth guard used in the procedure.

When it is finally time to perform the actual procedure, the patient puts on a surgical gown, and empties his bladder. He goes to a treatment room where he lies down on a stretcher, and a needle is inserted into one of the patient’s veins. The needle is used to medicate the patient during the procedure. Adhesive electrodes are then attached to the patient; some measure heart rate, some measure blood pressure, some measure motor movement, some measure brain activity, some measure the oxygen and carbon dioxide level in the patient’s blood, lungs, and exhaled air, and some apply the electric current. An oxygen mask is then placed over the patient’s mouth and nose; through this mask the patient breathes one hundred percent oxygen during the entire treatment. The anesthesiologist administers a sedative to the patient, and as soon as the patient’s muscles stop twitching a muscle relaxant is administered. A machine then passes a painless electric current through the patient’s body while the anesthesiologist holds a mouth guard in the patient’s mouth, which prevents tongue biting and damage to the teeth and jaws of the patient.

Usually within three minutes the patient can breathe on his own, and after he wakes up he is asked his name, the date, and his current location. In less than fifteen minutes the patient is usually able to answer these questions with some degree of accuracy, and within thirty minutes he is fully aware of himself and his surroundings. Some patients become perturbed after regaining consciousness; such a patient is usually given a dose of Valium or Ativan. After the treatment, patients can perform most activities; however they should not drive until the effect of the anesthetics completely wears off. Also, important decisions such as marriage or divorce should not be made immediately after treatment; if decisions such as these need to be made immediately, a trustworthy adult should supervise the patient.

Most patients derive only limited benefit from one treatment of ECT, so physicians almost always prescribe multiple treatments; however, patients rarely have ECT performed on them daily or twice daily except in emergency situations such as someone who is suicidal. Most patients receive two to three treatments a week, and a complete course of treatment takes a minimum of six months usually. Such a schedule is not sufficient for some patients; they begin what is called “continuation ECT”, and this is usually done on a biweekly basis with a minimum of six treatments.

I question this procedure. How do physicians know how many treatments are sufficient? The only way to tell would have to be a reviewing of past successes and failures; what this means is that the only way a physician can know the safe amount of treatments for an individual patient is to try what has worked in the past and hope for the best.

I interviewed someone who had experienced shock therapy to get a first hand account of the treatment; for the purposes of privacy I will call her Susan. She is now an old woman in her sixties, but a physician had performed shock therapy on her in the early seventies, so she would have been in her forties when she had experienced ECT. At the time, Susan had been experiencing depression that she says was brought on by the overwhelming pressure of taking care of her eight children; she says she never did anything for herself, and it finally caught up with her. In her words, “Anything that was fun just wasn’t fun any more. You just can’t do anything. You’re paralyzed”. She had very little energy at the time, and often could not even get out of bed. She saw a psychiatrist on her sister’s recommendation, and he recommended she go to a hospital where she would be closely monitored. During Susan’s stay, she received no group therapy or any sort of treatment, and talked to a physician only 15 minutes a week. After a month there, she left, and it was after she left the hospital that she received shock therapy. She received a total of twelve treatments, which she said did not help to alleviate her depression. She also lost eight months of her memory, and to this day can not remember her son’s graduation; to this she simply stated “It doesn’t bother me…it was worth a try.” She had not received any medication up to this point, and it was not until three years after the treatments that she began taking antidepressants and sleeping pills, which she says helped. Though her depression returns sometimes, Susan said that these days she feels “really good.”

Like all treatments, ECT does not have a one hundred percent success rate; according to the American Psychiatric Association, “Clinical evidence indicates that for uncomplicated cases of severe major depression, ECT will produce a substantial improvement in at least eighty percent of patients”, so it is not a complete surprise that the treatment did not work for Susan. The memory loss she described, however, still occurs even today. According to Dr. Harold Sackeim, a leader in the field of performing shock therapy, patients may experience memory loss, from a “few months before to a few weeks afterwards”; rarely does the memory loss extend further back. However, many patients have reported long gaps in their memory even with recent treatments of ECT.

On the other hand, the benefits of ECT are just as difficult to ignore as the risks. Memory loss is minimal for modern day shock therapy due to the now-constant monitoring of oxygen inhaled and exhaled by the patient , and the changeover from sinusoidal currents to square wave currents; the percent of people who die from the procedure is about one tenth of the percent of women who die from giving birth. In a study of hospital patients in a large urban area, 0.8 percent of those patients who underwent ECT attempted suicide, while 4.2 percent of the patients being treated solely with antidepressant drugs attempted suicide. In another study, 190 patients underwent bilateral ECT and 156 (72 percent) were deemed recovered. Dr. Harold Sackeim, while on the program Sixty Minutes, claimed that “The medical community recognizes universally that ECT is the most effective antidepressant we have.” ECT can also cure a wide range of mental diseases, including depression, mania, schizophrenia, catatonia, parkinsonian rigidity, and neuroleptic malignant disorder.

In light of both sides of the argument on whether or not to use ECT, I think the National Mental Health Association summed it up best when they said that shock therapy involves “serious risks”, and they urge “increased, rigorous, and objective research on ECT”. They recommend ECT only “after all other treatment approaches, such as medication and psychotherapy, have either failed or have been seriously and thoroughly rejected”. Not only is ECT potentially unsafe, physicians will not know the truly correct way to perform shock therapy until its effects are understood. As it stands, an effective treatment is “seizures in duration of at least 25 seconds in the motor convulsion, 30 to 50 seconds in the heart rate increase, and 30 to 150 seconds in the EEG are now presumed to be effective.” Such a guess and check method of psychiatry is not safe for the patient, especially when ECT involves the passing of electric currents through a patient’s brain. Until shock therapy is truly understood, physicians are putting their patients at risk when they subject them to ECT.

Works Cited

American Psychiatric Association. Professional page. 6 Jun. 2002. American Psychiatric Association. 6 June 2002.

Fink, Max. Electroshock: Restoring the Mind. New York: Oxford University Press, 1999

Sixty Minutes. Host Bob Simon. CBS. Cablevision, Massachusetts. 4 Mar. 2001.