Perhaps the most maligned and misunderstood treatment in all of psychiatry is electroconvulsive therapy (ECT). Jack Nicholson’s zombie-like performance in One Flew Over the Cuckoo’s Nest seems to have left an indelibly negative impression of ECT in the public mind, despite overwhelming evidence of ECT’s efficacy and safety. For example, a recent meta-analysis revealed “a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus TCAs, and ECT versus MAOIs.”11
ECT, overall, is a very safe procedure when used for appropriately selected patients and carried out using optimal techniques, such as unilateral, nondominant electrode placement. This is so, notwithstanding rare cases of significant and enduring memory impairment.12 Recently, at the Annual Meeting of the Massachusetts Psychiatric Society, Mrs Kitty Dukakis pleaded with the audience to consider ECT early in the course of severe, refractory depression. For Mrs Dukakis, ECT was literally a lifesaving treatment and well worth the trade-off of some mild and isolated memory deficits.
Psychotherapy has also been given short shrift in most discussions of what psychiatry has to offer. Yes, I know: the use of psychotherapy has declined considerably in outpatient psychiatric practice in the past decade.13 But tens of thousands of psychiatrists still provide psychotherapy, and we have excellent evidence that all the major types of psychotherapy “work” for a variety of nonpsychotic disorders.14 We need to reinforce the importance of psychotherapy training, particularly in residency programs, as Dr Cynthia Geppert and I recently stated.15
Yet all these literature citations do not really capture the day-by-day, crisis-by-crisis accomplishments of psychiatrists and other mental health professionals. Flawed healers though we are, we try to do “good” each day simply by showing up and doing our best to help those who struggle with serious illness. I tried to capture this in a poem (please see below) about working with a severely disturbed patient with borderline personality disorder.16 I will let the poem speak for itself, and hope that it says something encouraging about the work we do.
1. Pies R. The “McDonaldization” of psychiatry: psychiatric knowledge is not the equivalent of “fast food.” May 2009. http://psychiatrictimes.blogspot.com/2009/05/mcdonaldization-of-psychiatry.html. Accessed January 4, 2010.
2. Pies R. Doctor, are you “drugging” or medicating your patients? Antipsychiatry and the war of words. July 2009. http://psychiatrictimes.blogspot.com/2009/07/doctor-are-you-drugging-or-medicating.html. Accessed January 4, 2010.
3. Health care reform for Americans with severe mental illnesses: report of the National Advisory Mental Health Council. Am J Psychiatry. 1993;150:1447-1465.
4. Effectiveness of psychiatric treatment. Psychiatric Highlights. 1993;1(2). http://www.calpsych.org/publications/psychhighlights/psaug93.html. Accessed January 4, 2010.
5. Kirsch I, Deacon BJ, Huedo-Medina TB, et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008;5(2):e45. http://www.ncbi.nlm.nih.gov/sites/entrez. Accessed January 4, 2010.
6. Pies R. Devil or angel? The role of psychotropics put in perspective. http://psychcentral.com/blog/archives/2008/03/02/devil-or-angel-the-role-of-psychotropics-put-in-perspective/#ref. Accessed January 4, 2010.
7. Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010;303:47-53.
8. Bipolar diagnostic spectrum scale. http://www.psychiatrictimes.com/clinical-scales/bsds. Accessed December 28, 2009.
9. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163:1905-1917.
10. Ghaemi SN. Hippocratic psychopharmacology for bipolar disorder: an expert’s opinion. Psychiatry MMC. http://www.psychiatrymmc.com/displayArticle.cfm?articleID=article195. Accessed January 4, 2010.
11. Pagnin D, de Queiroz V, Pini S, Cassano GB. Efficacy of ECT in depression: a meta-analytic review. J ECT. 2004;20:13-20. http://focus.psychiatryonline.org/cgi/content/abstract/6/1/155. Accessed January 4, 2010.
12. Fink M. Convulsive therapy: a review of the first 55 years. J Affect Disord. 2001;63:1-15.
13. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962-970.
14. Andrews G, Harvey R. Does psychotherapy benefit neurotic patients? Arch Gen Psychiatry. 1981;38:1203-1208.
15. Pies R, Geppert CM. Psychiatry encompasses much more than clinical neuroscience. Acad Med. 2009;84:1322.
16. Pies R. Creeping Thyme. Richmond, VA. Brandylane Publishing; 2004.