Kitty Dukakis' Book: in Praise of ECT

It may come as a surprise, especially given its low repute in the popular mind since the 1980s, but electroconvulsive therapy (ECT) is making a comeback, both as a recommended treatment for depression and in public awareness.

That is, at least, one of the theses of a new book titled Shock: The Healing Power of Electroconvulsive Therapy. Its authors are Kitty Dukakis, former first lady of Massachusetts and wife of one-time presidential candidate Michael Dukakis, and Larry Tye, a medical reporter who spent 15 years at the Boston Globe and now runs a fellowship program for medical journalists.

"Twenty-five years ago ECT seemed on its way to the same dustbin of discredited remedies as mustard plaster, bloodletting, and lobotomies," Tye wrote, adding the following quotation from a 1981 book by British psychiatrist Robert L. Palmer, MD: "It is my personal prediction that the widespread practice of ECT will not last for another forty years, not indeed to the end of the century. Perhaps even by the end of this decade, ECT for severe depressive states will probably have been replaced by more effective and selective drugs. ECT will pass into history and will be judged in that perspective."

From 1975 to 1980, Tye added, "ECT usage nationwide had tumbled a dramatic 46%. At state and county mental hospitals, once the epicenter of electroconvulsion, the decline was a whopping 74% and the number of patients treated in 1980 a trifling 1221."

ECT was widely used to treat a broad spectrum of psychiatric illnesses throughout the 1940s and 1950s. The technique fell into disfavor in part as a result of lurid portrayals in films such as The Snake Pit and One Flew Over the Cuckoo's Nest and in part because the pharmaceutical industry began producing an array of psychotropic drugs that were aimed at the same patient population.

"In the 1970s, convulsive therapy was rejected around the world," said Max Fink, MD, professor of psychiatry and neurology emeritus at Stony Brook University. "Following the release of Cuckoo's Nest, students stormed the schools and even forced professors to resign. In the 1980s, [ECT] disappeared in Western Europe." Fink began using ECT in 1952 and is credited by Tye as "the first and foremost among the revivalists" who have kept the procedure alive.

Today, however, "more than 100,000 Americans a year get ECT for ailments ranging from mania to catatonia, with ten to twenty times that many worldwide" Tye wrote. ECT "is now as ordinary as a hysterectomy and twice as common as knee replacement surgery. And it all is happening just enough out of sight that it has taken many medical professionals by surprise."

This history and the evolution of ECT compose one part of Shock. Tye carefully traces the use of ECT, examining the medical evidence in its favor-studies have shown it to be 20% more effective than tricyclic antidepressants, 45% more effective than monoamine oxidase inhibitors, and "clearly superior to" some SSRIs-as well as the causes of the decline and reemergence of ECT.

"Not all of electroshock's traumas came at the hands of writers and moviemakers," Tye writes. "Shock doctors undermined their own credibility and their therapy's by prescribing it for conditions where it does not work." In the days before evidence-based analysis gave providers the tools to evaluate the effectiveness of their treatments, ECT was used for almost any condition remotely con nected to mental functioning--head injuries, neuroses, schizophrenia, even stammering--as well as asthma and psoriasis.

Dukakis' experience
Alternating with Tye's chapters on the scientific and historical view of ECT are Dukakis' first-person accounts of her own struggles with amphetamines, alcohol, and depression. In 2001, after years of psychotherapy, hospitalizations, and support groups, Dukakis underwent her first ECT treatments at Massachusetts General Hospital.

"Next thing I know I am waking up," she wrote. "I vaguely recall the anesthesiologist having had me count to ten, but I never got beyond three or four. I remember Charlie Welch and his ECT team, but am not sure I got the treatment. One clue is a slight headache. . . . Another is the goo on my hair.. . . There is one more sign that I did in fact have my first session of seizure therapy: I feel good-I feel alive."

Dukakis recounts the benefits of her experiences with ECT with the zeal of a religious convert. "It is not an exaggeration to say that electroconvulsive therapy has opened a new reality for me," she wrote.

In an interview with Psychiatric Times, she added, "I would much rather have a pill than have to go to the hospital [for treatment].

That's not an outrageous statement. For those of us who have taken them and failed-the medical record shows that there are 18 different medications I have tried-ECT is a wonderful last resort."

It is likely that Dukakis' testimonial will have a significant effect on the popularity of ECT. Following the release of Shock, she and Tye have been interviewed widely on television and radio and the book has been the sub ject of major articles in newspapers and magazines.

But it also raises the issue of how ECT is prescribed. Often today ECT is, as Dukakis described it, the last resort. But given its proven effectiveness, does that make sense?

"Sometimes there is a difference between what is and what should be," said Sarah H. Lisanby, MD, who chairs the American Psychiatric Association's committee on ECT and related electromagnetic techniques. "We strive to find the least invasive treatment that will be effective for the patient. For some patients, that is ECT. But it is not uncommon to see patients who have been depressed for as long as 5 years in the current episode and who have gone through as many as 10 medication trials. You have to ask, why wasn't ECT recommended earlier? The more the profession is educated about the risks and benefits of ECT, [the more] people will appreciate that it may be useful earlier in the process than we currently use it."

The Question of Memory Loss
In their interviews-and in the book itself-Tye and Dukakis have been frank about the risks as well as the benefits of ECT. The biggest risk, and for many patients the scariest, appears to be memory loss.

"A study in Britain, involving 166 patients who had finished ECT a year or so before, found that 'a striking 30% felt that their memory had been permanently affected, although the majority meant by that [that] they had permanent gaps in their memory around the time of treatment, not that their ability to learn new material was impaired,"" Tye wrote.

He added, "ECT doctors call mem ory losses tragic yet rare. . . . ECT critics call them brain damage.""ECT is remarkably safe," countered Fink. "The issue of memory loss is an exaggeration. Here's an analogy: Have you ever heard of surgeon who was able to work without [causing] bleeding? There's no such thing as a seizure without acute memory loss. Why keep arguing about memory loss?

"Every study has shown that if you have a patient who is severely depressed or psychotic and you do a memory test today, then do a memory test after the last ECT treatment, there will be a decrement in memory during that period. But if you examine them 4 to 8 weeks later, they say their memory is better than it was when they were ill."

Dukakis, who writes extensively about her memory loss following ECT and who had to pause during an interview to look up her own phone number, disagrees with Fink's assessment. "It's tragic in a way. He has pooh-poohed this memory loss every step of the way. He's wrong. He's just wrong. Of all the patients we talked to who had ECT, I have not met one who has not had some experience with memory loss," she said.

In Tye's chapter about memory loss, he cited a study by Harold A. Sackeim at Columbia University that found that in 38 of 306 ECT patients studied, "memory and other cognitive deficits lasted six months, which was the time limit of the study."

He also wrote about Anne Donahue, a Vermont state legislator who claims to have lost 6 years' worth of memories following ECT. Responding to a critic who called Donahue's claims "a personal conviction," Tye noted, "it might be tempting to accept [the] brushoff except that Donahue has undergone repeated EEG tests, taken neuropsychological exams at leading medical centers, and compiled evidence suggesting her memory issues are related to both her underlying depression and her ECT treatment." Tye also quotes one neurologist who wrote, "I agree with Anne's assessment that these EEG changes and her retrograde amnesia are likely permanent sequelae" of her ECT.

Lisanby agrees. "Memory loss is a recognized side effect of ECT. The degree depends on how the treatment is given. The decision to use ECT is a clinical one, and it depends on the context. The patient and the physician have to weigh the benefits. It is the most effective and most rapidly acting treatment we have. When there is a need for immediate response, it is rapidly effective in serious conditions. But there are recognized serious side effects, amnesia being one of them.

"The approach with any medical treatment is to be straightforward about the risks and the benefits," she added. "That should apply to all treatments, including ECT."

Dukakis offered what may be the definitive response to those who are overly defensive about the issue of memory loss: "The control ECT gives me over my disabling depression is worth this relatively minor cost. It just is. It's a quid pro quo, like everything we do in life. It is also easier to accept the losses of memory since I was warned to expect them and since most of the memories come back."

Lisanby, who is the director of the Brain Stimulation and Neuro modula tion Division in the Department of Neuroscience at the New York State Psychiatric Institute and associate professor of clinical psychiatry at Columbia University College of Physicians and Surgeons, said she is recommending Shock both to patients who are contemplating undergoing ECT and to physicians.

"It is important for us as physicians to hear about the patient's experience of ECT," she said.