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David Baxter

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Stigma overshadows ECT's effectiveness
by DR. MICHAEL EVANS, Globe and Mail
August 21, 2007

Leon Rosenberg, a former dean of medicine at Yale University, had just attempted suicide by overdose. He was admitted to hospital and prescribed electroconvulsive therapy, or ECT.

"However groggy I still was, I registered surprise," he later wrote. "I thought that ECT had been abandoned years before."

Dr. Rosenberg, now professor of molecular biology at Princeton University, was saved by ECT, he wrote in his 2003 book Brainsick: A Physician's Journey to the Brink. Unlike several of my patients who have also been rescued by this treatment, Dr. Rosenberg talks openly about it at public events and cocktail parties.

He admits that it is a conversation stopper, but the story of ECT is a fascinating one, full of medical stigma, mystery and debate.

ECT's unusual status as an overlooked but effective treatment was highlighted last month in the Journal of the American Medical Association.

The journal published a review showing that ECT remains, by a considerable margin, the most effective treatment we have for severe depression. It works better than pills and better than talk therapy - although most people in this situation would be getting all of the above.

In the recent review, investigators found that ECT produced a marked drop in suicide and depression relapse rates, especially with maintenance therapy in which patients visit regularly as outpatients.

Yet, despite a cultural fascination with health and even mental health, we don't talk about ECT. As the JAMA investigators conclude, "despite well-documented efficacy and safety, ECT is widely stigmatized as a last-resort treatment."

If ECT was a new high-tech treatment to fix your elbow or your bladder, this would be a very different story.

The societal view of depression, in my opinion, for all our societal advances, remains oppressive. Those on the outside still see it as not really a disease but a weakness. Those on the inside see it as a chronic disease like any other, but with a twist.

Dr. Rosenberg wrote that his suicide attempt was "the end result of mental illness in the same way I view a heart attack as the end result of coronary artery disease. Both are potentially lethal, both have known risk factors, both are major public health problems, both are treatable and preventable, and both generate fear and grief."

But, in the end, there is a crucial difference.

"The shame associated with them differs greatly," Dr. Rosenberg wrote. "Heart attack victims are consoled ('Isn't it a pity?'); suicide victims are cursed ('How could he?')."

There are some real differences between treating the brain and other organs. Therapeutic decisions in psychiatry do seem more intricate than with other illnesses. My patients considering antidepressants fret significantly about starting or continuing these medications. ECT, despite its effectiveness, adds another level of complexity.

The therapy, of course, has a long and checkered history dating back to Roman times, when electric eels were applied for headaches. The viewpoint of the general public is mostly informed by Jack Nicholson's scenes in One Flew Over the Cuckoo's Nest.

After some success in the 1930s, ECT was used on too wide a spectrum of patients and, according to compelling testimony, was used occasionally not to treat but to "control" troublesome patients.

ECT technique has evolved and been simplified.

Patients are asleep, and while an observer may see a toe quivering or a hand clenching, convulsions are no longer part of the treatment.

Memory loss seems the side effect of most concern to patients. With current ECT, it is usually transient, but any unauthorized withdrawal from the memory bank is a travesty. The medical community has occasionally shown insensitivity to this, but researchers are now attempting to better delineate the cause and effect.

What is crucial to making a decision about starting a treatment such as ECT is where you are at. The experience of surgeon and best-selling writer Sherwin Nuland during the 1970s reflects the impact of depression and the deferral of ECT, and the extraordinary value of saving just one brain from itself.

"From my late 30s until my early 40s, I underwent a period of depression that gradually deepened into an intensity that I finally required admission to a mental hospital, where I stayed for more than a year," Dr. Nuland wrote.

"Neither medication, psychotherapy, the determined efforts of friends nor the devotion of the few people whose love never deserted me had even the most minimal beneficial effect on my worsening state of mind."

Dr. Nuland had been scheduled for a lobotomy by the time he went for ECT. The ECT worked.

The story of electroconvulsive therapy is far from over, but thus far it has been a fascinating mix of misinformation, media and success. It is really a lesson in perspective: We discount a therapy that has proven effectiveness because of its image, yet every day embrace unproven therapies that have benefited from a public-relations makeover.

The disheartened mind can be a terrible place to be.

The Japanese say: "Fall down seven times, get up eight." I, for one, feel better having ECT to help some get up that eighth time.

Michael Evans is an associate professor at the University of Toronto and staff physician at Toronto Western Hospital.
 

Meg

Dr. Meg, Global Moderator, Practitioner
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I actually saw ECT being administered about two months ago. It was really interesting and gave me a new perspective on it.
 

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