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Shock and Disbelief - Page 3
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Keeping It Boring
cLean Hospital has the sprawling lawns and architectural mien of a small New England college. Its forty-two buildings, almost all made of brick, are spread out over 242 acres. Adirondack chairs grace the lawns. Even early in the morning people are strolling about, and it is impossible to tell which are patients and which are staff members.
As at most hospitals, ECT at McLean is administered early on Monday, Wednesday, and Friday mornings—a cycle that allows patients to spend at least two days resting between treatments. In a typical year doctors at McLean give about 2,000 ECT treatments to about 200 patients. The diagnosis for almost all of them is some form of acute depression. Most have experienced what psychiatrists gently call "suicidal ideation." On the April morning that I visited to watch a treatment, Michael Henry, the head of McLean's ECT programs, was scheduled to treat sixteen patients, all of whom fit into those two categories. Henry seems to display all the qualities one hopes for in a psychiatrist. He has soft, comforting features; indomitable patience; and a voice that remains calm even when the situation calls for some emotion.
I arrived at the hospital before 8:00 a.m. and was met in the reception area by a staff member in the hospital's public-affairs office. (This was the first time that a reporter was to be allowed to watch an ECT procedure at McLean.) A few minutes later I was shown into the treatment room, which looked like a small operating room but was less intimidating. With the middle of the room dominated by the table on which the patient lay, there was little space for the small crowd that had assembled: Henry, the anesthesiologist, a nurse, a third-year medical student, another staff member, and me.
The patient appeared to be in his late fifties, with gray hair and a touch of stubble. He was wearing jeans, a purple long-sleeved shirt, and white tennis shoes. He seemed unalarmed by the treatment that was to come, but his countenance betrayed the anguish of what Henry had told me was a depression whose manifestations included somatic hallucinations—illusions of movement and disease in different parts of the man's body. A year earlier the patient had gone through a course of ECT for similar episodes. That course had shown positive results, but the patient had recently relapsed and opted for more ECT. The treatment he was receiving that morning was his sixth in this course. I later asked Henry how many the man was to have. "That depends on him," he said. "We let the patient decide. We are very reluctant to push ECT."
The treatment began when the anesthesiologist injected a muscle relaxant and a general anesthetic into the patient's arm. The nurse inflated a blood-pressure cuff around his right ankle, which would prevent the relaxant from reaching his right foot and thus would provide a place where Henry could observe muscle contractions. She gently rubbed his hand as he went under. The anesthesiologist fit a plastic mask attached to a turnip-shaped bag over the patient's mouth and proceeded to squeeze oxygen into his lungs. Manually aided respiration has become standard procedure in ECT; it helps the patient not only to breathe once the muscle relaxants have paralyzed his diaphragm but also to rise from the anesthesia with a minimum of discomfort and memory loss.
Henry rubbed conductive jelly on two electrodes and placed both on the left side of the patient's head. Unilateral ECT, as this is called, is now the most common form. For years researchers debated whether this method was less effective than bilateral ECT, which involves placing one electrode on either side of the head, thus causing the seizure to affect both hemispheres of the brain. It has recently become clear that the difference in effectiveness is negligible but that unilateral ECT causes much less serious aftereffects.
Henry walked over to the ECT device, which looks like a large stereo receiver, and pressed a button. The patient's right foot seized, as though experiencing a sudden itch or a slight muscle spasm, and after ten seconds that was it. The procedure was gracefully mundane—anticlimactic, I couldn't help thinking. As we walked out, Henry said, "We try to keep it as absolutely boring as possible. The less interesting the better."
He could have been speaking for nearly all his fellow practitioners of ECT. Henry understands full well that the treatment's reputation is more complicated. Despite all the improvements in patient care, despite all the subtle tweaks and the impressive monitors affixed to the devices, ECT, Henry says, is still fundamentally the same treatment it was sixty years ago. The theory has remained fixed: shock a patient with enough electricity so that he'll have a seizure, and he'll probably get better. It's a blunt idea, medically speaking, and when pills that silently alter neurochemistry are the frame of reference, it is tough to warm up to something so primitively straightforward—even if for some reason it seems to work.
A number of ECT's most dedicated practitioners express a distaste for engaging in public efforts to bolster its reputation. One reason they give is that such undertakings would require pressing patients into service as witnesses. "We are here to do good by patients," Henry told me, "not to create poster children." In any event, among ECT practitioners there is considerable apprehensiveness about the media. In 1995 USA Today ran a three-part story about ECT that began with the death of a seventy-two-year-old woman during treatment; understandably, the article's publication had serious repercussions for patients' willingness to undergo ECT. In 1980 The Atlantic Monthly ran an article titled "Electroshock: The Unkindest Therapy of All," which Max Fink likened to Mein Kampf.
A skeptical press is symptomatic of a larger phenomenon. Psychiatrists assume that anti-ECT activists represent a fringe viewpoint on mental illness, whereas the evidence suggests that the anti-ECT outlook is actually close to the public's. In 1999 the Office of the Surgeon General released its first ever report on mental health. The report cited estimates that two thirds of all cases of mental illness in this country go unreported. One of the main reasons the report gave for this is a widespread disbelief in the biological origin of psychiatric disorders. Despite the fact that major depression ranks second only to heart disease in the nation's "disease burden" (a measure that takes both mortality and morbidity into account), and despite the great scientific leaps that psychiatry has made, the report found the stigma associated with mental illness to be overwhelming: many people do not even accept that mental function is the work of a physical organ—a basic tenet of psychiatry. This suggests that the main obstacle ECT proponents face may be not proving its inherent usefulness but proving that the brain is an organ like any other, capable of breakdown.
When the Surgeon General's report came out, it included a statement about ECT: "First-line treatment for most people with depression today consists of antidepressant medication, psychotherapy, or the combination ... In situations where these options are not effective or too slow ... electroconvulsive therapy (ECT) may be considered." This wasn't the original wording. Two months earlier a consumer-rights activist had leaked the section dealing with ECT, which had called it a "safe and effective treatment for depression." A torrent of protests flooded the Surgeon General's office. CCHR sent a sixteen-page document denouncing what it saw as a categorical endorsement of ECT. Linda Andre held meetings with an administrator working on the report. In the end the statement was softened.
However, the central message of the report—that there exists an enduring, peculiar, and unfortunate double standard involving the "physical" and the "mental" illnesses—was not mitigated. The predominant belief in the United States, the report indicated, is that it is all right to be subject to infection, degeneration, and microscopic revolts from the neck down. But a moral culpability is attached to whatever afflicts our minds. The double standard extends to treatment. We concede that coping with diseases of the body may of necessity bring about painful, even dangerous, side effects. We concede that we must weigh risks and benefits. But with psychiatric treatments, especially ECT, any possibility of harm is deemed wanton and intolerable. The discrepancy in attitudes is a strange one. According to Joseph Coyle, the chairman of the Department of Psychiatry at Harvard University, 15 percent of severely depressed patients commit suicide. It is a lethal disease. ECT doctors often draw a parallel with cancer: the treatments for cancer can be as damaging as the disease itself, they point out, yet there are no anti-chemotherapy lobbyists.
More important than questioning why anti-ECT lobbyists persist is asking what psychiatrists might do to counter the criticism. The answer from some is that they are already doing all they need to do. ECT use seems to be on the rise, even if slowly, and psychiatry's professional organizations are continually refining treatment guidelines. Greater advocacy efforts seem not to be on anyone's agenda, perhaps for fear of luring ECT's detractors into even louder denunciations.
Elsewhere on the Web
Links to related material on other Web sites.
"A bright spot on the horizon: Transcranial magnetic stimulation in psychiatry"
An introduction to transcranial magnetic stimulation. By Matthew Kirkcaldie and Saxby Pridmore, mental health researchers at the University of Tasmania.
There is still the possibility that a more benign method will be found to produce therapeutic seizures in the brain. Clinical trials are under way at hospitals worldwide for a treatment known as transcranial magnetic stimulation, which in one of its forms uses a strong magnetic field to create a seizure that is much more precise in intensity and placement than an ECT seizure. Convulsive TMS could drastically reduce memory loss, and thus could be an advance in convulsive therapy as marked as the move from Metrazol to electricity, sixty years ago. But it is likely to be years before TMS is fully developed and finds its way into treatment rooms around the country. In the meantime, patients must continue to seek out hospitals that offer ECT. And ECT will continue to offer benefits that other treatments do not.
As for Michael Henry's patient, he underwent six more treatments and was released, in good condition and well oriented.
Photograph by Arthur Tress.
Copyright © 2001 by The Atlantic Monthly Group. All rights reserved.
The Atlantic Monthly; February 2001; Shock and Disbelief - 01.02; Volume 287, No. 2; page 79-90.