Comeback for Shock Therapy?

Its unsavory reputation may be changing

The scene in which Actor Jack Nicholson receives an electric shock treatment in the 1975 film One Flew Over the Cuckoo's Nest reinforced the notion that shock therapy is a cruel and barbaric anachronism. Partially as a result of the movie, the popular image of electric shock, which had been steadily fading in the U.S., grew even dimmer. Now shock treatment is regaining popularity, defended by many psychiatrists as a safe, humane and often dramatically effective method for treating some forms of mental illness, particularly depression.

Electroconvulsive therapy (ECT) dates back to 1938, when Italian Psychiatrists Ugo Cerletti and Lucio Bini, searching for a treatment for schizophrenia, used electricity to induce convulsions in a disturbed patient. Afterward, his condition improved. In the ensuing years, ECT became a common treatment for severe psychotic illnesses, both in Europe and the U.S.

With the introduction of strikingly effective antipsychotic drugs such as chlorpromazine and imipramine in the 1950s, the popularity of shock treatment began to wane. The decline was hastened by growing worry about the safety and efficacy of ECT and by charges that it was being used excessively and indiscriminately in institutions that were little more than "shock mills." Between 1972 and 1977 in New York State, for example, use of ECT dropped by 38%. Across the nation, according to a 1978 report by the American Psychiatric Association, one-third of psychiatrists have reservations about the practice.

But dropping ECT apparently leaves a gap in the psychiatric arsenal. Neither psychotherapy nor medication seems to help 20% to 30% of people with extreme depression--those who suffer excessive weight loss, insomnia, loss of sex drive and energy, or threaten or attempt suicide. Other patients, for example, the elderly or those with heart conditions, cannot tolerate the medications. Drugs also tend to act more slowly and sometimes produce unpleasant side effects, notably tardive dyskinesia, uncontrollable facial and body contortions caused by lengthy use of antipsychotics. Says Dr. Stuart Yudofsky of the New York State Psychiatric Institute: "I'm not pushing the therapy. I don't work for the electric company.

But 80% of the depressions that do not respond to drugs do respond to convulsive therapy."

Proponents of ECT also point out that modern techniques are far removed from the horror of Cuckoo's Nest. Says Yudofsky, "The only way you physically know a seizure is taking place is that sometimes you see a finger wiggling slightly." The patient is injected with a short-acting anesthetic, then a muscle relaxant to prevent the sudden muscular contractions that in the past occasionally caused fractured bones or chipped teeth. An electrocardiogram is sometimes used to monitor the heart rhythm and oxygen is administered to prevent possible brain damage after the shock.

In an ECT session, electrodes are attached to one or both sides of the head, and 80 to 100 volts applied for as much as one second. That produces enough current to light a 100-watt bulb and causes a brain seizure, which can be traced on an electroencephalogram. Patients regain consciousness within minutes but may be groggy and confused for a while. Usually six to ten ECT sessions are given within a two-to-three-week period.

Despite years of experience and large numbers of patients (an estimated 100,000 people undergo treatment in the U.S. each year), no one is exactly sure how ECT works. According to one theory, the seizure affects the hypothalamus, a portion of the brain regulating production of the body's mood-controlling substances. What is known is that patients often do not recall either the treatment or any events immediately before it. But critics of ECT, even as it is practiced today, say that it can also cause permanent brain damage, including a loss of memory of events in the more distant past. Still, any evidence of long-term memory loss is conflicting and anecdotal. For example, Ernest Hemingway was convinced that ECT ruined his writing career by wiping out his store of experiences. Marilyn Rice, a former Government economist, claims the treatments obliterated her expertise and forced her early retirement.

Critics also charge that patients --some of whom are really incapable of giving informed consent--are coerced into agreement. Says Psychiatrist Lee Coleman of Berkeley, Calif: "I've never seen a single case when valid consent was given." But some patients claim the pressure comes mostly from family and friends who urge them not to undergo treatment. Says one Los Angeles college student, 22, who failed to respond to drugs and agreed to have ECT: "The hospital patients thought I was crazy to do it." Still, to protect the patients' rights, several states have rules governing use of ECT. California's model statute calls for seconding opinions by doctors and an attorney and a 24-hour delay between the time permission is given and treatment is started.

The widespread ambivalence about the return of electroconvulsive treatment was evident at a psychiatric conference this fall in Britain. While demonstrators picketed outside the meeting carrying placards reading ECT WAS APPROVED IN BUCHENWALD and CONTROL PSYCHIATRY WHILE YOU STILL HAVE A MIND TO, doctors inside reported that fully half of ECT patients questioned in a survey feared the treatment less than going to the dentist.

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